SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECTS

FOR DISSERTATION

SUBMITTED BY:

VAISAKHY.K.G

Ist YEAR M.Sc. NURSING

OBSTETRICS AND GYNAECOLOGY NURSING

2012-2014

NAVODAYA INSTITUTE OF NURSING

MANDYA

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

1

BANGALORE, KARNATAKA.

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1. NAME OF THE CANDIDATE

AND ADDRESS

VAISAKHY.K.G

#290/290, CHENNAPPANNA DODDI

CROSS, MALAVALLI MAIN ROAD,

GUTHAL HAMLET,

MANDYA-571401

2 NAME OF THE INSTITUTION NAVODAYA INSTITUTE OF NURSING

MANDYA

3COURSE OF STUDY AND SUBJECT M.SC NURSING

OBSTETRICS AND GYNAECOLOGY

NURSING

4 DATE OF ADMISSION TO COURSE 15-06-2012

5 TITLE OF THE STUDY A study to assess the Effectiveness of

Power Point Presentation(PPT) assisted

teaching programme on the importance of

breast self examination in prevention of

breast cancer among school teachers in

selected schools of Mandya

6. BRIEF RESUME OF INTENDED WORK

INTRODUCTION:

2

“When you are fighting for your life, you must be sure to know, your enemy

and have at your disposal the most effective weapons”

-Peter Teeley

The mother is the panacea (universal remedy) for all kinds of calamities

Mahabharata. The experience of transformation into motherhood is a privilege

reserved exclusively for women. Breast self examination has been universally

accepted by the experts as a very simple, significant and effective method of early

detection of breast cancer. As with all other types of cancer early detection and a high

index of suspicion are the keys to combating the menace of cancer.1

The breast cancer is most common cancer in women world wide. And its

incidence is increasing in the most countries involved in breast self examination have

an impact on early detection of breast cancer, treatment and symptom management.

Nurses serve as advocate for women with the disease. In many countries nurses are

far to influence breast cancer care. 2

Breast self-examination (BSE) is a screening method used in an attempt to

detect early breast cancer. The method involves the woman herself looking at and

feeling each breast for possible lumps, distortions or swelling.BSE was once

promoted heavily as a means of finding cancer at a more curable stage, but

large randomized controlled studies found that it was not effective in preventing

death, and actually caused harm through needless biopsies and surgery. Breast

awareness is an informal alternative to structured breast self-examinations. 3

Breast self-examinations are based on an incorrect theory of cancer

development, which assumes steady growth of the tumor. According to breast cancer

specialist Susan Love, "Breast cancer doesn't work like that...it's sneaky. One could

examine yourself every day and suddenly find a walnut".4

According to a meta-analysis in the Cochrane Collaboration, two large trials in

Russia and Shanghai found no beneficial effects of screening by breast self-

examination "but do suggest increased harm in terms of increased numbers of benign

3

lesions identified and an increased number of biopsies performed." They concluded,

"At present, screening by breast self-examination or physical examination cannot be

recommended."5

Although breast self-examination increases the number of biopsies performed

on women, and thus revenue for the breast cancer industry, it does not

reduce mortality from breast cancer. In a large clinical trial involving more than

260,000 female Chinese factory workers, half were carefully taught by nurses at their

factories to perform monthly breast self-exam, and the other half were not. The

women taught self-exam detected more benign (normal or harmless lumps) or early-

stage breast disease, but equal numbers of women died from breast cancer in each

group.6

Because breast self-exam is not proven to save lives, it is no longer routinely

recommended by health authorities for general use.4&5 It may be appropriate in women

who have a particularly high risk of developing breast cancer. Some charitable

organizations, whose donations depend on promoting fear of breast cancer, still

promote this technique as a one-size-fits-all, universal screening approach, even in the

low-risk women who are most likely to be harmed by unnecessary invasive follow-up

procedures.6 Among groups promoting evidence-based medicine, awareness of breast

health and familiarity with one's own body is typically promoted instead of self-

exams. 7

A variety of methods and patterns are used in breast self-exams. Most methods

suggest that the woman stand in front of a mirror with the torso exposed to view. She

looks in the mirror for visual signs of dimpling, swelling, or redness on or near the

breasts. This is usually repeated in several positions, such as while having hands on

the hips, and then again with arms held overhead. 8

The woman then palpates her breasts with the pads of her fingers to feel for

lumps (either superficial or deeper in tissue) or soreness. There are several common

patterns, which are designed to ensure complete coverage. The vertical strip pattern

involves moving the fingers up and down over the breast. The pie-wedge pattern starts

at the nipple and moves outward. The circular pattern involves moving the fingers in

4

concentric circles from the nipple outward. Some guidelines suggest mentally

dividing the breast into four quadrants and checking each quadrant separately. The

palpation process covers the entire breast, including the "axillary tail" of each breast

that extends toward the axilla (armpit). This is usually done once while standing in

front of the mirror . 9

For pre-menopausal women, most methods suggest that the self-exam be

performed at the same stage of the woman's menstrual cycle, because the normal

hormone fluctuations can cause changes in the breasts. The most commonly

recommended time is just after the end of the period, because the breasts are least

likely to be swollen and tender at this time. Women who are postmenopausal or have

irregular cycles might do a self-exam once a month regardless of their menstrual

cycle. 10

Cancer is a disease that can take years to develop, yet it can plunge you and

your family into upheaval the instant it takes the doctor to deliver the news no one

wants to hear : “ what we have found is a malignancy,”. In many cultures, the breast

plays a significant role in a women’s sexuality and self identity.

The female breast has been regarded as a symbol of beauty, feminity, sexuality

and motherhood. The potential loss of a breast or a Part of a breast may be devastation

for many women because of the significant psychologic, social, sexual and body

image implications associations associated with it.11

Bill Clinton, former President of the US, named October as the National

Breast Cancer Awareness Month and the third Friday in October as the National

Mammorgraphy Day in the US. The rest of the world, including India, followed soon

in adopted it. Approximately 80 thousand new cases of breast cancer were reported in

India, and the incidence is rising. One in 22 women in India are likely to develop

breast cancer of all cancer death in women. It is the number one cause of death in

women in their 40’s.12

The issue of importance here is Early Detection. Breast Self Examination is a

simple technique that women can use to assess for changes in their breast that may

signal breast cancer. Women in the 20’s should begin BSE. The women should

5

become familiar with the normal appearance and fell of her breast to be confident of

her ability to perform BSE.

6.1 NEED FOR THE STUDY

Childbearing is known to protect against breast cancer, whether or not

breastfeeding contributes to this protective effect is unclear. Individual data from 47

epidemiological studies in 30 countries that included information on breastfeeding

patterns and other aspects of childbearing were collected, checked, and analyzed

centrally, for 50302 women with invasive breast cancer and 96973 controls. Estimates

of the relative risk for breast cancer associated with breastfeeding in parous women

were obtained after stratification by fine divisions of age, parity, and women’s age

when their first child was born, as well as by study and menopausal status. Women

with breast cancer had, on average, fewer births than did controls (2.2 vs2.6, fewer

parous women with cancer than parous controls had ever breastfed (71% vs 79%), and

their average lifetime duration of breastfeeding was shorter (9.8 vs 15.6 months). The

relative risk of breast cancer decreased by 4.3% (95% CI 2.9- 5.8; p<0.0001) for each

birth.13

Multiparity, young age at first childbirth, and breast-feeding are associated

with a reduced risk of breast cancer in the general population. We performed a

retrospective cohort, all of whom carried a mutation in BRCA1 or BRCA2.

Information on reproductive factors was obtained from a questionnaire. At the time of

interview 853 subjects were classified with breast cancer. Data were analyzed by

using a weighted cohort approach. There was no statistically significant difference in

the risk of breast cancer between parous and nulliparous women an increasing number

of full-team pregnancies was associated with a statistically significant decrease in the

risk of breast cancer (Ptrend = .008); risk was reduced by 14% (95% confidence

interval [CI] = 6% to 22%) for each additional birth. In BRCA2 mutation carriers,

first childbirth at later ages was associated with an increased risk of breast cancer

compared with first childbirth before age 20 years, HR = 2.68 [95% CI = 1.02 to

7.07]; > or 30 years, HR = 1.97 [95% CI = 0.67 to 5.81]), whereas in BRCA1

mutation carries, first childbirth at age 30 years or later was associated with a reduced

6

risk of breast cancer compared with first child birth before age 20 years (HR = 0.58

[95% CI = 0.36 to 0.94]). 14

Nurses must have expertise in the assessment and management of not only the

physical symptoms but also the psycho social symptoms of breast cancer. As health

teaching is an important nursing role, nurses should educate women about the

importance of routine screening. Nurses play an important role in promoting BSE,

women report increased frequency of BSE when taught by a nurse.

The word “cancer”, spells doom for the patient and disaster for the family.

Majority of the women have myths and misunderstandings regarding breast self

examination. As knowledge is power, instead of living on the shadow of myths and

misconceptions, the researcher plans to throw on their knowledge breast self

examination. Hence, as a first step the present study is planned to assess knowledge of

School Teachers, why school teachers because “One woman can educate a family but

a teacher can educate a society”. So, the investigator is interested to administer a PPT

Teaching Programme and plans to examine its effectiveness on imparting the

knowledge regarding the importance of Breast Self Examination in the prevention

early detection breast cancer.

6.2REVIEW OF LITERATURE

The literature was reviewed and is presented under the following headings.

i. Studies related to general information and prevalence breast cancer.

A study analyzed the expression of the basal cytokeratins (CKs) 5/6 and 17 in a

case series from Central Sudan and investigated correlations among basal CK status,

ER, PgR, and Her-2/neu, and individual/clinicopathological data. Of 113 primary

breast cancers 26 (23%), 38 (34%), and 46 (41%) were, respectively, positive for

CK5/6, CK17, and combined basal CKs (CK5/6 and/or CK17). Combined basal CK+

status was associated with higher grade (P < .03) and inversely correlated with ER (P

< .002), PgR (P = .004) and combined ER and/or PgR (P < .0002). Two clusters based

on all tested markers were generated by hierarchical cluster analysis and k-mean

clustering: I: designated "hormone receptors positive/luminal-like" and II: designated

7

"hormone receptors negative", including both basal-like and Her-2/neu+ tumors. The

most important factors for dataset variance were ER status, followed by PgR, CK17,

and CK5/6 statuses. Overall basal CKs were expressed in a fraction of cases

comparable to that reported for East and West African case series. Lack of

associations with age and tumor size may represent a special feature of basal-like

breast cancer in Sudan.15

A study on cancer incidences in urban Delhi - 2001-05 was conducted in the

Delhi population based cancer registry collects data on new cancer cases diagnosed

among Delhi urban resident population. The sources for cancer registration are more

than 162 government hospitals/centers and 250 private hospitals and nursing homes.

During the period 1st January 2001 to 31st December 2005 a total of 54,554 cases

were registered of which 28,262 were males and 26,292 were females. The age

adjusted (world population) incidence rates were 116.9 per 100,000 for males and

116.7 per 100,000 for females. The leading sites of cancer among Delhi males was

lung (ASR: 13.8 per 100,000) followed by oral cavity (ASR: 11.4), prostate (ASR:

9.0) and larynx (ASR: 7.9). In females, breast (ASR: 30.2 per 100,000) was the most

common site of cancer, followed by cervix uteri (ASR: 17.5), ovary (ASR: 8.5) and

gallbladder (ASR: 7.4). The incidence of prostate cancer in males and ovary cancer in

females in Delhi were the highest among the Indian registries, while larynx among

males was the second highest and the gallbladder cancer in females was the highest

among Indian metropolitan cities.16

ii. Studies related to knowledge regarding importance of breast self examination

on early detection and prevention of breast cancer.

A randomized population-based study has been carried out since 1985 in

Leningrad in order to evaluate the efficacy of breast self-examination (BSE) in early

breast cancer detection. The population under study covers 120,310 women aged 40–

64 years with no history of breast cancer.About half of these women were exposed to

BSE training (60,221) and 60,098 women constituted the control group. BSE teaching

was carried out on a person-to-person basis and each patient received the BSE

calendar. As a result of examination, 190 breast cancer patients in the BSE group and

192 patients in the control group were detected. Comparisons of patients from both

groups with regard to the size of primary tumor and the incidence of metastatic lesion

8

in the regional lymph nodes showed no differences. The study is ongoing and all

cases of breast cancer in the BSE group will be registered up to 1994 and followed-up

to 1999; information will then be available on the impact of BSE upon breast cancer

mortality.17

A correlational study was conducted to identify attitudinal variables specified

by the Health Belief Model that were related to frequency and total performance

(frequency and proficiency) of breast self-examination (BSE). The probability sample

consisted of 362 women, ages 35 and over, who were initially contacted via random

digit dialing. Data were collected during in-home interviews by trained graduate

assistants and by telephone interview 1 year later. Results supported the ability of past

performance, perceived barriers, and knowledge to predict current total performance

(combined frequency and proficiency). In addition, frequency for breast self-

examination was predicted by past frequency, barriers, health motivation, control,

being taught by a doctor, confidence, having BSE procedure checked, benefits, and

susceptibility. Results lend support to use of attitudinal and experiential variables in

predicting women''s actual behaviors in relation to breast self-examination.18

An indirect behavioral measure for measuring the frequency of breast self-

examination (BSE) in the natural environment was developed and evaluated. BSE was

performed using a lubricant (i.e., baby oil), and then a sheet of absorbant tissue was

applied to the examined area. The tissue, which retained an oil stain, provided a trace

measure of the exam. Results indicated that the measure remedied some of the

weaknesses in verbal report, although for certain subjects it underestimated

compliance.19

Using a questionnaire survey a study analyzed the relationship between the

frequency of breast self-examination (BSE) and the clinical stage and course of breast

cancer in Japanese patients. BSE had been performed monthly by only 5.4% of the

patients (M group), occasionally by 35.4% (O group), and not at all by 59.2% (N

group). There was a positive relationship between more frequent BSE and an earlier

clinical stage, the percentages of Tis/stage 0 and I for the M, O, and N groups being

83%, 44%, and 36%, respectively (P<0.05). The percentages of patients in the M, O,

and N groups who underwent breast-conserving therapy were 42%, 11%, and 19%,

respectively, with patients who had performed monthly, BSE more frequently

undergoing breast-conserving therapy (P<0.05). At a median follow-up time of 34

months, 0%, 3.8%, and 7.6% of the patients from the M, O, and N groups,

9

respectively, had died of breast cancer, the overall survival curve of the M group

being significantly better than that of the N group (P<0.01). This retrospective study

suggests the positive correlation of BSE frequency with earlier detection, and a more

favorable clinical course in Japanese breast cancer patients.20

iii.Studies related to effectiveness of PPT assisted teaching programme.

Studies related to knowledge of teachers regarding the early detection and

prevention of breast cancer

.

M,StJamesRobertsI,AshleyS,TilneyC,BroughamB,EdwardsL,BaldusC,Ro

mer G. Conducted a study on factors associated with emotional and behavioural

problems among school age children of breast cancer patients. To identify factors

linked with emotional and behavioural problems age (6- to 17-year-old) children of

women with breast cancer. Reports of children’s emotional and behavioural

problems were obtained mothers, their healthy partners, the children’s teacher and

adolescents using the Child Behaviour Checklist and Mental Health subscale of the

Child Health Questionnaire. Parents reported on their own level of depression and, for

patients only, their quality of life. Family functional was assessed using the Family

Assessment Device and Cohesion subscale of the Family Environment Scale. Using a

cross-sectional within groups design, assessment were obtained (N=1007 families)

where the patients were 3-36 months post diagnosis. Risk of problems in children

were linked with low levels of family cohesion, low affective responsiveness and

parental over-involvement.21

Zhang YJ, Chen K, Jin MJ, Fan CH. Conducted a study on screening the

risk factors of malignant tumour. Data was analyzed from a survey that conducted on

84 breast cancer patients and 273 cancer-free controls selected randomly in Jiashan

county. The classification tree model was constructed using Exhaustive CHAID

method and evaluated by risk statistics and the area under the ROC curve. 9 out of

105 effect risks factors were selected, nevertheless, the number of pregnancies, breast

examination, reason for menopause, age at menarche, intake of shrimp, crab, kipper,

kelp and laver etc were also risk factors on breast cancer. The Risk statistics of model

was 0.174, and the area under the ROC curve was 0.872 which was significantly

different from 0.5, suggesting that the classification tree model fit the actuality very

10

well.22

Maria Pavial, Gualtiero Ricciardi, Aida Biancol, Pantisan, Elisa Lan

giano and Ital Francesco AngelillO conducted the study explores knowledge,

attitudes and behavior regarding screening for breast and cervical cancers. All female

teachers in primary and secondary schools in Crotone and in Cassino (Italy) received

a questionnaire on demographic and socioeconomic characteristics, clinical history,

knowledge, behavior and attitudes about breast and cervical cancer and related

screening procedures. A response rate of 65% was achieved. Knowledge on

effectiveness of mammography and Pap test in finding related was widely spread in

the sample. Only about 30% and 50% had respectively undergone their last

mammogram and pap test according to the recommended time interval. Pap smear in

the previous three years was significantly more likely in women in their forties, with a

higher family income and in those who had been examined by a physician in the

previous year. The results strongly recommend continued emphasis of physicians on

education of women regarding mammography and paps mear.23

Roth EH, Ludwig H, Schmitz F, Werner W. Conducted a study on

Retinoscopy. A multi-media teaching program on CD Retinoscopy is a classical

method to determine the refraction of the eye by observing the dynamics of reflexes

and varying the experiment parameters until a specific reflex (neutralization point) is

observed. The video sequences are converted in computed files and together with

computer animations of the germetrical ray tracings, text files audio sequences, they

are stored in a suitable CBT-programma. The CBT-program and the specific files are

stored on CDs or can be distributed on the internet. A collection of retinoscopy

records of patients, some with extraordinary reflex phenomena in also available.

Video and animation procedures are more suitable for matching the dynamic

phenomena on retinoscopy than photographs or drawings as they offer a more direct

basis for understanding of the sometimes difficult processes of retinoscopy.24

Oh PJ, Kim IO, Shin SR, Jung HK. Conducted a study on Development of

Web-based multimedia content for a physical examination and health assessment

course. The multimedia content was developed bases on Jung’s teaching and learning

structure plan model, using the following 5 processes: 1) Analysis Stage, 2) Planning

Stage, 3) Storyboard Framing and Production Stage, 4) Program Operation Stage, and

11

5) Final Evaluation Stage. Consultation with the experts in context, computer

engineering, and educational technology was utilized in the development of these

processes. Web-based multimedia content is expected to offer individualized and

tailored learning opportunities to maximize and facilitate the effectiveness of the

teaching and learning and learning process.25

STATEMENT OF THE PROBLEM:

A study to assess the Effectiveness of Power Point Presentation(PPT) assisted

teaching programme on the importance of breast self examination in prevention of

breast cancer among school teachers in selected schools of Mandya

6.3 OBJECTIVES:1. To assess the knowledge level of School Teachers regarding the importance of

Breast Self Examinations in terms of pretest score.

2. To develop a PPT teaching programme on the importance of Breast Self

Examination in the early detection and prevention of Breast Cancer

3. To assess effectiveness of PPT teaching program by comparing the pretest and

post test knowledge score difference comparing the pre and post test

knowledge scores difference.

4. To determine the association between the selected demographic variables like

Age, Income, Age at Menarche, Marital Status, Age of Marriage, Age of frist

Pregnancy, Parity, Feeding Practices, Age of Menopause obesity,

Socioeconomic status, source of information and the knowledge scores.

6.4. RESEARCH HYPOTHESIS:

H1 : The mean post test knowledge score of school teachers will be significantly

higher than mean pretest score by paired `t` test at 0.01 level.

H2: There will be a significant association between the selected demographic

variables-age, Income, Parity, Feeding Practices, Age of Menopause obesity

education, religion, type of family, socioeconomic status, age of menarchae,

12

menstrual history, obesity, source of information and the knowledge of school

teachers by chi-square at 0.05 level.

6.5. OPERATIONAL DEFINITIONS:

KNOWLEDGE

The correct response from the participants regarding importance of breast self

examination in the early detection and prevention of breast cancer elicited through

structured questionnaire schedule.

EFFECTIVENESS

A Significant gain in knowledge as determined by significant difference in pre

and post knowledge Scores

PPT ASSISTED TEACHING PROGRAMME

It refers to an instructional programme regarding Breast Self Examination should be

so organized and administers that the PPT assisted method forms an integral part of

the education programme.

EARLY DETECTION

In this study, it refers to a procedure to accelerate the ability of a woman to

physically examine herself and locate a breast tumor.

PREVENTION

Prevention in an act serving to avert the occurrence of Breast Cancer.

BREAST CANCER

Breast cancer is a malignant proliferation of epithelial cells lining the ducts or lobules

of the breast.

6.6. DELIMITATIONS:1. School Teachers attending in selected schools of Mandya

2. School Teachers in the age group of 30-55 years.

13

3. School Teachers who will be available during the time of data collection.

6.7. ASSUMPTION:

The study assumes that

1. Schools teachers may not have adequate knowledge on Breast Self Examination.

2. Schools teacher will have interest to know more about Breast Self Examination.

6.8. VARIABLES UNDER STUDY:DEPENDANT VARIABLE

Knowledge level of school teachers regarding breast self examination in

prevention of Breast cancer as measured by structured questionnaire schedule.

INDEPENDENT VARIABLE

PPT assisted teaching programme on breast self examination in prevention of

breast cancer

EXTRANEOUS VARIABLE

Demographic variable such as age, income, age at marriage, age at first pregnancy,

age at parity, feeding practices, age at Menopause

7.0. MATERIALS AND METHODS OF THE STUDY

7.1. SOURCES OF DATA:

Date will be collected from School Teachers attending in selected school of Mandya

7.2 METHOD OF DATA COLLECTION

A data collection instrument is a formal document used to collect and record

information such as questionnaire (Polit & Hungler 1999). The tool was prepared

after an extensive review of literature and discussion with the experts, to assess the

14

effectiveness of PPT assisted teaching programme on the knowledge importance of

breast self examination.

7.2.1 RESEARCH APPROACH

An Evaluative research approach

7.2.2 RESEARCH DESIGN

The research design will be Quasi-experimental research design.

Pre experimental one group

Pre test-post test design.

7.2.3. SETTING OF THE STUDY

The Study will be conducted in selected school of the Mandya.

7.2.4. POPULATION:

The population of the study comprises of School Teacher of Mandya

7.2.5. SAMPLE SIZE:

The total sample of the study consists of 50 teacher of selected schools of Mandya

7.2.6. SAMPLING TECHNIQUE

Non probability purposive sampling.

7.2.7. SAMPLING CRITERIA:

INCLUSION CRITERIA

Who are able and willing to participate in the study.

School Teachers in the age group of 30-55 years of age .

EXCLUSION CRITERIA

Who are not willing to participate in the study.

Who are having any complications during the time of study

15

7.2.8.DATA COLLECTION TOOL:

A structured tool will consist of two sections

Part 1-Selected demographic variables such as age, education, Income, Age at

Menarche, Age at first pregnancy, religion, occupation, type of family, socioeconomic

status, age of menopause, pattern of menstruation, obesity, source of information.

Part 2- Structured questionnaire consist of questions related to knowledge of BSE in

the early detection and prevention of breast cancer.

7.2.9. DATA ANALYSIS METHOD

Date analysis will be through Descriptive and Inferential statistics:

1. DESCRIPTIVE STATISTICS

Frequency, mean, Mean percentage, and Standard deviation, to complete

demographic variables.

2. INFERENTIAL STATISTICS:

Paired ‘t’ test to compare pre and post test knowledge scores at 0.01 level.

Non parametric chi-square test will be used to find out the relationship

between selected demographic variable & knowledge score level of the school

teachers.

7.3 DOES THE STUDY REQUIRE ANY INTERVENTIONS TO BE

CONDUCTED ON PATIENTS OR OTHER HUMAN

- YES -.

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM

YOUR INSTITUTION?

Permission will be obtained from:

The research committee.

Authorities of selected schools in Mandya

16

8. LIST OF REFERENCES:

1. Olson, James Stuart 2002. Bathsheba's Breast: Women, Cancer and History.

Baltimore: The Johns Hopkins University Press. . 

2.  Kösters JP, Gøtzsche PC 2003. "Regular self-examination or clinical

examination for early detection of breast cancer". Cochrane Database Syst

Rev (2).

3. Thomas DB, Gao DL, Ray RM, et al. 2002. "Randomized trial of breast self-

examination in Shanghai: final results". J. Natl. Cancer Inst. 94 (19):

1445–57. 

4.  Harris R, Kinsinger LS 2002. "Routinely teaching breast self-examination is

dead. What does this mean?". J. Natl. Cancer Inst.94 (19): 1420–1. 

5.  Baxter N; Canadian Task Force on Preventive Health Care June

2001. "Preventive health care, 2001 update: should women be routinely taught

breast self-examination to screen for breast cancer?". CMAJ 164 (13):

1837–46. 

6. Gayle A. Sulik 2010. Pink Ribbon Blues: How Breast Cancer Culture

Undermines Women's Health. USA: Oxford University Press.

7. Christiance Miaskow.Ski Patricia Buchsel. “Oncology Nursing-Assessment

and Clinical care”.

8. Dr. (Sr) Placida Vennalivally. “Health Action”, Health Accessories for All.

13-15.

9. Bryant, HE; Brasher, PM. Risks and probabilities of breast cancer: short-term

versus lifetime probabilities. CMAJ. 1994 Jan 15; 150(2):211-216.

10. Lila A Wallis. “Text Book of Women’s Health”, Lippincott Raven.

1998.1343-1365.

11. Christiane Miaskow.Ski Patricia Buchsel. “Oncology Nursing – Assessment

and Clinical Care”. Mosby Publishes.1999. 469-489.

12. Dr. (Sr) Placida Vennalivally. “Health Action”. Health Accessories for All.

13-15.

13. Lila A Wallis. “Text Book of Women’s Health”. Lippincott Raven.1998.1343-

1365.

17

14. www.springerlink.com

15. Awadelkarim KD , Arizzi C, Elamin EO, Hamad HM, De Blasio P, Mekki SO and

Osman IBasal-Like Phenotype in a Breast Carcinoma Case Series from Sudan:

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16. Elwali NE , Barberis MC and  Mariani-Costantini R Italian cancer figures, report

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cancer and human papillomavirus infection: No evidence of HPV etiology of breast

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19. Victoria L. Champion .Breast self-examination in women 35 and older: A prospective

study. Journal of Behavioral Medicine. Volume 13, Number 6, 523-

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20. Junichi Kurebayashi , Kojiro Shimozuma and Hiroshi Sonoo. The practice of breast

self-examination results in the earlier detection and better clinical course of Japanese

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21. www.ncbi.nim.nih.gov

22. ‘Br J cancer’ 2006 Jan 16; 945(1) : 43-50 Watson M, ST James Roberts I,

Ashleys, Tilmeyl, Broiyham B, Edwards L. etal. ‘emotiondl and behavioral

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Kanho Hakhoe Chi 2004 oct : 34 (6) : 994-1003

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9 SIGNATURE OF THE

CANDIDATE

10 REMARKS OF THE GUIDE

11 NAME AND DESIGNATION

11.1 GUIDE11.2 SIGNATURE

Ashwini.M.R

HEAD OF THE DEPARMENT

11.5 NAME

11.6 SIGNATURE

Ashwini.M.R

12

12.1 REMARKS OF THE

CHAIRMAN AND PRINCIPAL

12.2 SIGNATURE

19