Introduction

Breast self-examination (BSE) is a simple, low-cost, non-invasive screening method used to detect early breast cancer1. It involves women examining and feeling their breasts to identify changes as early as possible. BSE has the potential to save lives and is recommended for all women over the age of 202. Through regular practice, women can become familiar with their breasts, enabling them to recognize normal features and detect changes such as thickening, lumps, spontaneous nipple discharge, skin changes, or dimpling3.

Breast cancer (BC) is a global health concern and one of the leading causes of morbidity and mortality among women. According to the Global Burden of Cancer, there were 18 million new cancer cases and 9.2 million cancer-related deaths in 2018, compared to 14.1 million cases and 8.2 million deaths in 2008. After lung cancer, breast cancer is one of the most frequently diagnosed malignancies worldwide, accounting for about 11% of all cancer cases4,5. Lower breast cancer survival rates are associated with the absence of early detection programs, late-stage presentation, limited diagnostic and treatment facilities, and inadequate access to professional care6.

Although breast cancer is a global public health issue, its incidence is rising more rapidly in developing countries, with rates increasing by up to 5% annually7. Most women in low-income countries present at advanced clinical stages, which limits treatment options and leads to high mortality rates. Delays in detection and treatment in underdeveloped countries stem from patient-, provider-, and system-related barriers8.

In Ethiopia, breast cancer is the leading cause of cancer morbidity among adult women, accounting for one-third of all female cancer cases and one in five of all cancer cases nationwide. An estimated 16,133 new cases and more than 9,000 deaths occur annually. Women in Ethiopia typically present for breast cancer screening at later stages and have a significantly shorter life expectancy compared to those in Western countries9,10,11. Currently, only one radiotherapy center located at Black Lion Specialized Hospital provides oncologic services nationwide12. Approximately 10,000 Ethiopian women are diagnosed with breast cancer each year, with many more cases going unreported, especially in rural areas where women often seek care from traditional healers13. Due to late presentation, limited resources, low awareness of symptoms and prevention, and strong traditional beliefs, breast cancer remains highly lethal in Ethiopia14.

A study conducted among female students in Ethiopia found that although women were aware of various breast cancer screening techniques, they did not regularly practice BSE despite recognizing its importance15. While early detection methods like mammography remain largely inaccessible due to inadequate diagnostic and therapeutic infrastructure, BSE remains a practical and essential alternative16.

Most studies in Ethiopia have focused on health professionals such as nurses, physicians, and health extension workers, while relatively few have examined BSE among university or college students17.

Increasing knowledge and practice of BSE may help reduce complications and mortality related to breast cancer18. Despite the recognized benefits of BSE in early detection, most cases in Ethiopia continue to present at an advanced stage, and evidence on the knowledge and practice of BSE remains scarce in the study area. Therefore, the objective of this study is to assess the knowledge and practice of breast self-examination and its associated factors among female undergraduate students in Jigjiga City.

Methods

Study setting and design

An institution-based cross-sectional study was conducted in Jigjiga colleges from April 17 to May 17, 2023. Jigjiga is the capital city of the Somali Regional State, located 630 km east of Addis Ababa, the capital of Ethiopia. It is one of the six council city administrations in the Somali Regional State (SRS)19. According to the woreda-based plan, the estimated population of Jigjiga in 2020 was 763,509, of whom 335,944 (44%) were female and 427,565 were male. Additionally, 22.5% of the populations were urban dwellers20. The majority of the population belongs to the Somali ethnic group (97%) and is Muslim by religion (98%)21. Residents of Jigjiga are primarily agro-pastoralists, with farming and livestock as their main sources of income, alongside small businesses and government employment22.

There are more than ten colleges in Jigjiga City, including both public and private institutions such as Rift Valley College, Jigjiga Health Science College, City Medical and Business College, Jigdam College, Horn International College, East Africa College, Liberty College, Ilays College, Liban HSC, Jigjiga Medical and Business College, Jigjiga Polytechnic, and Iimaan College. These institutions collectively enroll approximately 4,340 female students23. According to the 2020 annual report, Jigjiga City has one referral hospital, one general hospital, one primary hospital, three health centers, and ten health posts24.

Study population and eligibility criteria

The source population consisted of all undergraduate female college students in Jigjiga City attending classes during the academic year. The study population was a randomly selected group of undergraduate students from this source population. Female students were included if they were actively enrolled during the academic year. Exclusion criteria were: postgraduate students, non-regular students, and undergraduate students with a known diagnosis of breast cancer, a history of breast surgery, loss or functional limitation of the upper extremities that prevented performing BSE or students who had withdrawn from their studies.

Sample size determination and sampling procedure

The sample size was calculated using the formula for a single population proportion, assuming a 5% margin of error and a 95% confidence interval (Z = 1.96). A prior study conducted at Mekelle University reported a prevalence of knowledge and practice of BSE at 59.5% and 37.2%, respectively. Prevalence rates for personal and family history of breast cancer were 3.3% and 6.3%, respectively. Since the knowledge prevalence yielded the largest sample size, it was used for final calculation25:

n= (z/).p(−)/, Where: P = the prevalence of BSE practice among students, d = Margin of error.

Z α/2 = Z-value for 95% confidence level, which is 1.96, n = the required sample size, N = 1.96*0.595(0.405)/0.05^2. Considering 10% non-response rate, the total sample size was 407.

Jigjiga City has 12 colleges with a total of 4,340 female students. For this study, five colleges with 2,005 female students were selected through simple random sampling. From these colleges, two departments comprising 638 female students were further selected using simple random sampling. Proportional allocation was applied based on the number of students in each selected department and academic year. Finally, participants were selected through simple random sampling using student rosters provided by the departments.

Study variables

Dependent variable

  • Breast Self-examination knowledge and practice.

Independent variables

  • Socio-demographic factors such as; age, marital status, ethnicity, academic year, and prior residence.

  • Knowledge-related factors such as; awareness of breast cancer signs and symptoms, BSE techniques, risk factors, and information sources.

  • Family-related factors such as; family history of breast cancer, parental education, maternal BSE practice, family income, and occupation.

Operational definitions

  • Good knowledge: A score equal to or above the mean on 15 knowledge questions related to BSE26.

  • Poor knowledge: A score below the mean on those same questions26.

  • Good practice: Performing BSE at least once per month, one week after menstruation26.

  • Poor practice: Not performing BSE monthly and/or not timing it correctly26.

Data collection tools and procedures

Structured questionnaires were used to assess knowledge and practice of BSE among female students. These questionnaires were adapted from previously published studies and were initially prepared in English. They were then translated into Af-Somali and back-translated into English to ensure consistency. The questionnaire consisted of four sections: socio-demographic characteristics, family history of breast cancer, knowledge about BSE, and BSE practice. Data collection was conducted by three trained health professionals, one data entry clerk, and one supervisor. Data collectors were selected based on their proficiency in the local language and prior data collection experience. A pilot test was conducted before the main study. Interviews were carried out with eligible female undergraduate students using interviewer-administered questionnaires.

To ensure data quality, the data collectors (BSc Midwifery professionals) received two days of training from the principal investigator on the objectives of the study, ethical considerations, consent procedures, and data collection techniques. Supervisors and data collectors also participated in a one-day orientation session. All completed questionnaires were reviewed immediately by supervisors and the principal investigator for completeness and consistency.

Data processing and analysis

After collection, data were cleaned, coded, and entered into EpiData version 7, then exported to SPSS version 26 for analysis. Descriptive statistics, including frequency tables and graphs, were used to summarize the data. Binary logistic regression was performed to assess associations between independent variables and the outcome variables. Variables with a p-value < 0.2 were included in the multivariable logistic regression model. The final model included variables that remained significant, with results reported as adjusted odds ratios (AORs) with 95% confidence intervals and p-values < 0.05. Model fitness was evaluated using the Hosmer–Lemeshow test, and multicollinearity was checked using variance inflation factors (VIF).

Results

Socio-demographic characteristics of study participants

A total of 407 participants were included in the final analysis. More than half of the participants were aged 15–19 years (209; 51.4%), while one-third were aged 20–24 years (135; 33.2%). Regarding marital status, more than two-thirds were single (310; 76.2%), and 90 (22.1%) were married. Concerning previous place of residence, 310 (76.2%) were from urban areas, while 97 (23.8%) were from rural areas. The vast majority of respondents (358; 99.7%) were of Somali ethnicity. About half (206; 50.6%) reported a family monthly income between 5,000 and 10,000 Ethiopian Birr. With respect to parental education, most participants’ fathers (179; 44%) and mothers (205; 50.4%) were illiterate (Table 1).

Table 1 Socio-demographic characteristic of female undergraduate students in Jigjiga City, (n = 407).
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History of breast problems

Among the participants, 21 (5.2%) reported a family history of breast cancer, and 87 (21.4%) reported a personal history of breast problems other than breast cancer. Nearly half (180; 44.2%) knew someone diagnosed with breast cancer. In addition, 273 (67.1%) had no knowledge of breast self-examination (BSE) methods, and 312 (76.7%) had never discussed BSE (Table 2).

Table 2 History of breast cancer or problem among female undergraduate students in Jigjiga City (n = 407).
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Knowledge of breast self-examination

Most participants (395; 97.1%) believed that breast cancer affects only females. A considerable proportion did not recognize the benefits of early detection, with 243 (59.7%) responding “no” when asked if early detection improves survival, and 229 (56.3%) believing breast cancer is not curable if detected early. Regarding the timing and frequency of BSE, 265 (65.1%) thought it should begin before the age of 19, 255 (62.7%) did not know how often it should be performed, and 188 (46.4%) did not know the appropriate time to perform it. Knowledge of BSE procedures was also limited: 67 (16.5%) did not know what to look for and 321 (78.9%) did not know how to perform it. The main sources of information were health personnel (101; 24.8%) and colleagues (74; 18.2%). However, 105 (25.6%) did not know the advantages of BSE, and only 60 (14.7%) reported that it is important for early detection and timely treatment (Table 3).

Table 3 Knowledge of breast self-examination among female undergraduate students in Jigjiga City (n = 407).
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Among breast cancer screening methods, clinical breast examination by health professionals was most commonly reported (77; 57.5%), followed by BSE (54; 40.3%), while mammography was the least known (3.2%) (Fig. 1).

Fig. 1
figure 1

Knowledage of Breast cancer screening methods among female undergraduate students in Jigjiga City (n = 134).

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Knowledge level toward breast self-examination

Overall, the majority of participants (290; 71.3%) demonstrated a poor level of knowledge regarding BSE, while only 117 (28.7%) had good knowledge. The mean knowledge score was 7.89 ± 1.761 (Fig. 2).

Fig. 2
figure 2

Level of knowledge breast self-examination among female undergraduate students in Jigjiga City (n = 407).

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Practice of breast self-examination

Most participants (335; 82.3%) reported poor BSE practice, while only 72 (17.7%) demonstrated good practice (Fig. 3).

Fig. 3
figure 3

Level of Breast self-examination practice among female undergraduate students in Jigjiga City (n = 407).

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Factors associated with knowledge of breast self-examination

In the bivariate logistic regression analysis, the following variables were significantly associated with knowledge of BSE at p < 0.25 and were included in the multivariate model: age of participants, maternal educational status, discussion about BSE, knowing someone diagnosed with breast cancer, personal history of breast problems, and source of information.

After adjusting for potential confounders in the multivariate logistic regression analysis, the following factors remained significantly associated with knowledge of BSE at p < 0.05:

Age: Students aged 15–19 years were nearly three times more likely to have good knowledge about BSE compared to older students (AOR: 2.951; 95% CI: 1.224–7.114, p = 0.03). Discussion about breast self-examination: Students who had discussed BSE were more than twice as likely to be knowledgeable compared to those who had not (AOR: 2.420; 95% CI: 1.004–5.833, p = 0.001). Knowing someone diagnosed with breast problems: These students were about six times more likely to have good knowledge (AOR: 6.12; 95% CI: 2.004–10.392, p = 0.02). Source of information: Students who received BSE information from friends or colleagues were almost ten times more likely to be knowledgeable compared to those who received information from mass media or health personnel (AOR: 9.782; 95% CI: 3.34–17.496, p = 0.012) (Table 4).

Table 4 Factors associated with knowledge of breast Self-Examination among female undergraduate students in Jigjiga City, (n = 407).
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Factors associated with the practice of breast self-examination

In the multivariate logistic regression analysis, academic year, family history of breast cancer, and source of information were significantly associated with BSE practice (p < 0.05). Academic level: Fourth-year students were about four times more likely to practice BSE compared to students in lower academic years (AOR: 3.8; 95% CI: 1.43–10.14, p = 0.04). Family history of breast cancer: Students with a family history of breast cancer were four times more likely to practice BSE compared to those without such history (AOR: 4.03; 95% CI: 1.028–7.312, p = 0.011). Source of information: Students who received BSE information from friends or colleagues were about four times more likely to practice compared to others (AOR: 4.105; 95% CI: 1.462–11.525, p = 0.001). Similarly, those who received information from health personnel were more than twice as likely to practice BSE (AOR: 2.394; 95% CI: 1.038–5.520, p = 0.016) (Table 5).

Table 5 Factors associated with practice of breast Self-Examination among female undergraduate students in Jigjiga City, 2023 (n = 407).
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Discussion

Since most healthcare facilities in Ethiopia lack advanced laboratory investigations for breast cancer screening and diagnosis, breast self-examination serves as a cost-effective and feasible alternative. It can be performed in any setting and at any time, making it particularly suitable in resource-limited environments27.

In this study, 28.7% of female students demonstrated good knowledge of BSE. This finding is comparable to a study conducted at Gonder University28 but lower than findings from other study in Ethiopia13, Bangladesh27, Cameroon29, and Malaysia30. The variation may be due to differences in socioeconomic status, educational infrastructure, or the departments from which students were sampled. Conversely, the knowledge level in this study is higher than that reported at Adama University31, likely because the Adama study excluded health science students, while the current study included both health and non-health disciplines.

Regarding practice, 17.7% of participants reported performing BSE. This is consistent with findings from Gonder University28, possibly due to similar socio-cultural and economic contexts. However, it is higher than results from Eritrea32 but lower than those from Haramaya University33. Differences may be explained by variations in socioeconomic status, cultural practices, education systems, health service access, and public awareness campaigns.

Students who had discussed BSE with their parents were more than twice as likely to have good knowledge compared to those who had not (AOR: 2.420; 95% CI: 1.004–5.833). This is consistent with the study at Gonder University28, and other study in Ethiopia15, suggesting that parental discussions may improve access to reliable health information.

Participants who knew someone diagnosed with breast problems were six times more likely to be knowledgeable about BSE (AOR: 6.12; 95% CI: 2.004–10.392). Similar results were reported in Ethiopia17, Malaysia30, Cameroon29, and Bangladesh27. Personal exposure to the illness may increase awareness and encourage individuals to seek information.

Age was also a significant factor. Students aged 15–19 years were about three times more likely to have good knowledge compared to older students (AOR: 2.951; 95% CI: 1.224–7.114). Younger students may benefit more from peer discussions and educational settings, which promote information sharing.

Furthermore, students who obtained BSE information from friends or colleagues were almost ten times more likely to be knowledgeable than those who relied on mass media or health personnel (AOR: 9.782; 95% CI: 3.336–17.496). This supports findings by Kumarasamy and Veerakumar36, emphasizing the critical role of peer influence and interpersonal communication in shaping knowledge.

Having a family history of breast cancer was also a strong predictor of BSE practice. Students with such a history were four times more likely to perform BSE than those without (AOR: 4.03; 95% CI: 1.028–7.312). Similar findings were reported in Malaysia30, and Gonder University28. A family history may increase perceived personal risk, encouraging preventive behavior.

Academic year also influenced practice. Fourth-year students were nearly four times more likely to practice BSE compared to their juniors (AOR: 3.8; 95% CI: 1.43–10.14). Studies in Tigray Region, Ethiopia25, Libya34 and Turkey35 support this, suggesting that higher academic exposure enhances health literacy and encourage preventive practices.

The source of BSE information was significantly associated with practice. Students who received information from friends or colleagues were about four times more likely to practice BSE (AOR: 4.105; 95% CI: 1.462–11.525), while those informed by health personnel were twice as likely (AOR: 2.394; 95% CI: 1.038–5.520). This finding aligns with studies in Addis Ababa, Ethiopia26, Kumarasamy and Veerakumar36, highlighting the importance of interpersonal and professional communication in promoting preventive health behaviors.

Limitations of the study

This study has several limitations. First, the prevalence of breast self-examination practice was based on participants’ self-reports, which may be subject to recall bias or social desirability bias, potentially leading to underreporting or over reporting. Second, the cross-sectional design does not allow for establishing causality between independent variables and BSE knowledge or practice. Third, the absence of clinical validation of self-reported BSE practice may limit the reliability of the findings. Additionally, the study population was limited to female college students in Jigjiga City, restricting the external validity and generalizability of the results to other populations, such as women outside the academic environment. Finally, students with a prior diagnosis of breast cancer or upper limb disabilities were excluded from participation, which may further limit the generalizability of the findings.

Conclusions and recommendations

In conclusion, the levels of knowledge and practice of breast self-examination among female college students in Jigjiga City were found to be low. Several factors were significantly associated with knowledge and practice, including age, discussion about breast self-examination, knowing someone diagnosed with breast problems, obtaining information from friends or colleagues, academic year, and family history of breast cancer.

Based on these findings, it is recommended that the Jigjiga City Health Bureau collaborate with relevant stakeholders to raise awareness of breast self-examination among college students, particularly those under the age of 19 and those with limited exposure to the topic. Awareness campaigns should utilize audiovisual media, peer-led discussions, and student-focused outreach. Both private and public colleges are encouraged to employ mini-media platforms and youth-friendly programs to disseminate information on breast self-examination. Regular educational initiatives should also be implemented to inform the broader public about the importance of early detection through BSE. Overall, targeted awareness and advocacy campaigns for young females are needed to promote early diagnosis of breast cancer, thereby increasing the chances of successful treatment in Ethiopia.