Rajiv Gandhi University of Health Sciences Banglore, Karnataka

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGLORE, KARNATAKA

PROFORAMA FOR REGISTRATION OF SUBECT FOR DISSERTATION

MS.PUNAM RASAILY

M.SC NURSING, IST YEAR

OBSTETRICAL AND GYNECOLOGICAL NURSING

YEAR 2013-2015

PADMASHREE INSTITUTE OF NURSING

BANGLORE-560060

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGLORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

MS. PUNAM RASAILY I Year M.Sc NURSING 1 NAME OF THE CANDIDATE Padmashree institute of nursing, AND ADDRESS Kommaghata, Kengeri Hobli, BANGALORE-560060

2 NAME OF THE INSTITUTION Padmashree Institute of Nursing, Bangalore

st 3 COURSE OF STUDY AND 1 year M.Sc Nursing, Obstetrics and Gynecological Nursing SUBJECT

th 4 DATE OF ADMISSION 17 July 2013 Effectiveness of awareness package on 5 TITLE OF THE STUDY knowledge and attitude regarding risk factors for breast cancer and the practice on Breast Self Examination among adolescent girls at selected college, Bangalore.

6. BREIF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION 2

Globally, cancer emerged as the No.1 killer in 2010. Today, it ends more lives than AIDS, malaria and tuberculosis combined. Developing countries such as India face the brunt of the incursion. They report more than half of new cancer cases and two-thirds of deaths,

1 compared with 15 percent of cases in 1970 .

Breast cancer is the most commonly occurring female cancer in the world with an age standardized incidence rate (ASR) of 39 per 100,000, which is more than double that of the second ranked cancer (cervical cancer ASR=15.2 per 100,000). Breast cancer accounts for 23% of all newly occurring cancers in women worldwide and represents 13.7% of all cancer deaths. It is the most frequent cancer in both developed and developing regions (estimated 690,000 new cases in each region) as well as the most frequent cause of cancer death in these regions (280,000

2 deaths in developing countries) of the world .

Age adjusted incidence rate in India amounts to 15-29 per lakh population per year and is ever increasing. In the developing countries of Asia, the health care burden on account of breast cancer has been steadily mounting. It is expected that in the coming decades these countries would account for majority of new breast cancer patients diagnosed globally. India with a population of 1.2 billion is the most populous democracy in the world. India is a pluralistic, multilingual, and multiethnic society. It includes over 15 native languages with more than 70

3 dialects. Over 100,000 new breast cancer patients estimated to be diagnosed annually in India .

According to statistics available with the Kidwai Memorial Institute of Oncology (KIMO), the authorized hospital to register incidence of cancer in Karnataka, breast cancer amounts to 27% of all cancers suffered by women in the state (a majority of them from urban areas), whereas cervical cancer amounts to 13%. The average age of a breast cancer patient is 50, but younger women too are getting this disease fast. The ICMR studies put Bangalore at No. 1

4 when it came to age adjusted rate of breast cancer in India .

According to National Cancer Registry programme, the incidence of breast cancer, estimated that in 2008 there were 115251 new cases of breast cancer with an age standardized incidence rate of 22.9 per 100000. It is estimated that by 2030 the number of new cases of breast

5 cancer in India will reach just under 200000 per year (Ferlay J, 2010) . Bangalore is now the

breast cancer capital of the country. According to Population Based Cancer Registry (PBCR) report 2013, the city tops the chart with 36.6 new cases for every one lakh population having the disease6.

Breast cancer awareness programs are more concentrated in the cities and have not reached the remote and rural parts of the country. Women often do not present for medical care early enough due to various reasons such as illiteracy, lack of awareness, and financial constrains ,lack of an organized breast cancer screening program, paucity of diagnostic aids, and general indifference towards the health of females in the predominantly patriarchal Indian society do not help early diagnosis of breast cancer. A multidisciplinary approach to early detect breast cancer

7 detection is essential .

Breast cancer associated morbidity and mortality can be reduced through early detections by means of screening programs as it not only increases the chances for successful treatment and cure of the disease but also improves chances of survival and lessens the need of invasive treatment .In-fact, many in a study done in India reveal that five-year survival rate was 56% among patients diagnosed with breast cancer at a later stage in comparison to 85% for cases diagnosed early . Implementation of the preventive measures has been acknowledged as the main tool in the fight against breast cancer worldwide. Globally, breast self-examination (BSE), clinical breast examination (CBE) and mammography are the recommended screening test for early detection of breast cancer. Due to lack of access to diagnostic facilities, especially for women in low resource settings, it is essential to empower them with BSE as a primary modality

8 for screening . 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 and 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

9 overhead . 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 menstruation, because the breasts are least likely to be swollen and tender at this time. Women 4

who are postmenopausal or have irregular cycles might do a self-exam once a month regardless

10 of their menstrual cycle .

WHO says though scientists have concluded that breast self examination is not an effective method of reducing mortality from breast cancer and the vast majority of changes found during breast self-examination are not cancerous, in many countries it may be the only alternative and women should be encouraged to be aware of what is normal breast and recognize changes in their breast, size, shape, skin and nipples as soon as possible by self-examination once in a month or two basis. National Cancer Control programs should not recommend mass screening by breast self-examination and physical examinations of the breast. Rather, programs should encourage breast awareness and early diagnosis of breast cancer11.

6.2 NEED FOR THE STUDY

According to the Globocan data (2008) breast cancer is the most common cancer amongst women and 1 in 8 women in the US and has a chance of developing breast cancer in their life time. In India, the overall incidence of breast cancer is less as compared to the US approximately 1 in 30 women. In the year 2008, there was about 1, 82,000 breast cancer cases reported in the US, whereas in India, 1, 15,000 new cases were diagnosed. This implies that, though, because of India's population, the percentage of total women affected seems less, the breast cancer burden in India has almost reached about 2/3rds of that of the US and is steadily

12 rising .

India has higher burden of breast cancer in urban areas being 1 in 22 in a life time compared to rural areas where the risk is relatively much lower being in 1 in 60 women developing breast cancer in their lifetime. The average age of high risk group is 43-60 years

13 unlike in the western women aged 53-57 years are more prone to breast cancer .

Breast cancer is the top cancer in women both in the developed and the developing world. The incidence of breast cancer is increasing in the developing world due to increase life expectancy, increase urbanization and adoption of western lifestyles. Although some risk

reduction might be achieved with prevention, these strategies cannot eliminate the majority of breast cancers that develop in low- and middle-income countries where breast cancer is diagnosed in very late stages. Therefore, early detection in order to improve breast cancer

14 outcome and survival remains the cornerstone of breast cancer control .

According to national breast cancer various predisposing f actor are associated as the risk factor for breast cancer such Gender, age, race, family history and genetic factors, personal health history, menstrual and reproductive history, certain genome changes, dense breast tissue , lack of physical activity, poor diet, overweight or obese, lack of awareness drinking alcohol,

15 radiation to the chest and combined hormone replacement therapy (HRT) .

WHO promotes breast cancer control within the context of national cancer control programmes and integrated to non communicable disease prevention and control. A national cancer control programme is a public health programme designed to reduce the number of cancer cases and deaths and improve quality of life of cancer patients, through the systematic and equitable implementation of evidence-based strategies for prevention, early detection, diagnosis, treatment, and palliation, making the best use of available resources16.

Many studies have shown that screening for breast cancer can reduce mortality from the disease. Mammography has come to be regarded as the screening method of choice, but evidence suggests that breast self examination (BSE) is at least as effective in reducing mortality. Mammography detects many non-infiltrating and small, non-palpable tumors, but we do not know whether these would ever cause symptoms or threaten the woman's life. It is doubtful whether the time gained by early mammographic detection confers any survival benefit over breast self examination detection. Breast self examination has substantial advantages over

17 mammography in terms of human and economic costs .

Breast Self- Examination (BSE) can be a valuable tool in diagnosing breast cancer at an early stage. It is important to remember that everyone’s breasts are different and that changes can be related to aging, menstrual cycle, pregnancy, menopause or hormone use. Normal breast tissue feels lumpy and uneven. It is normal for a woman’s breast tissue to become swollen and tender right before or during her menstrual period. Nine out of 10 breast masses are detected

through BSE. Eight out of every 10 breast masses are not cancerous, but that does not lessen the importance of performing BSE monthly. Regular BSE will help to identify changes that require

18 further evaluation and possible treatment .

Breast self examination (BSE) can detect 40% of breast lesions. The knowledge and practices of women toward breast self examination for early detection were observed to be inadequate in respondents but there was a significant improvement after the intervention. Health education programs through various channels to increase the awareness and knowledge about BSE are the need of the hour. Mass media cancer education should promote widespread access to

19 information about early detection behavior .

Breast cancer accounts for 19-34% of all cancer cases among women in India. Early detection and prompt treatment offer the greatest chance of long-term survival and breast self- examination (BSE) seems to be a important viable optional substitute for early detection of cancer. Pre-experimental one group pretest post-test design was carried out among 40 degree female students by using cluster sampling method from selected colleges of Udupi district. The data analyzed showed that majority (52%) of them was in the age group of 18-19 years and 72% of them were had average knowledge on BSE in the pretest score. Out of 40 participants only one student was performing BSE occasionally20.

The important resources of dissemination of breast cancer knowledge to women are the health-care professionals, educational institutions and media. Among the healthcare professionals, female nurses comprise the group most suited for this purpose. In India a substantial number of nurses are women and culturally, women patients are reluctant to go to male health care providers for problems such as breast diseases. The nurses can play an important role in educating women through specially designed educational programs in the clinical setting, as well as, through community outreach strategies that suit our social and cultural setting. In addition, they constitute an important source of information within their social

21 networks .

According to the world health organization, dramatically one-third of the cancer deaths could be decreased if detected and treated early. In world context nearly 400000 lives could be

saved every year. WHO has suggested that education to help people recognize early signs of cancer and seek prompt medical attention for symptoms, screening helps to identify early cancer or pre-cancer before signs are recognizable, these two components of early detection have shown

22 to improve cancer mortality .

The above instances provoked the researcher to conduct the study on awareness on risk factors for breast cancer. Also, the researcher clinical experience in Obstetric Gynecology, has provided to oversee many of the adolescents to have inadequate knowledge on prevention of Breast cancer and Breast Self Examination. Thus, the researcher wanted conduct study on “A study to assess effectiveness of awareness package on knowledge and attitude regarding risk factors for breast cancer and the practice on breast self examination adolescent girls at selected college, Bangalore.”

6.3 STATEMENT OF PROBLEM

A study to assess effectiveness of awareness package on knowledge and attitude regarding risk factors for breast cancer and the practice on Breast Self Examination among adolescent girls at selected college, Bangalore.

6.4 OBJECTIVE:

 To assess pre-test level of knowledge and attitude regarding risk factors for breast cancer and the practice on breast self examination among adolescent girls.  To assess post- test level of knowledge and attitude regarding risk factors for breast cancer and the practice on breast self examination among adolescent girls.  To assess the effectiveness of awareness package on knowledge and attitude regarding risk factors for breast cancer and the practice on breast self examination among  To correlate knowledge and attitude regarding risk factors for breast cancer and practice on breast self examination among adolescent girls  To associate pretest level of knowledge and attitude regarding risk factors for breast cancer and the practice on breast self examination among adolescent girls with their selected demographic variables

6.5 OPERATIONAL DEFINITIONS:

Effectiveness:

It refers to the extent to which the awareness package improve knowledge and attitude on risk factors for breast cancer and improve practice in breast self examination among adolescent girls

Awareness package:

It refers to providing Information Education Communication activity prepared by investigator regarding risk factors for breast cancer and breast self examination for duration 45 minutes using flash cards. Investigator will demonstrate breast self examination for the adolescent girls with the use of video.

Knowledge:

It refers to the level of understanding of adolescent girls regarding risk factors for breast cancer and breast self examination which is measured by structured questionnaire.

Attitude:

It refers to the opinion expressed by the adolescent girls regarding risk factors for breast cancer and breast self examination which is measured by Likert scale.

Risk factor for breast cancer: it refers to predisposing factors for breast cancer such as family history of breast cancer, previous history of breast cancer, elderly prim mother, early menarche, late menopause, nulli para, poor breast feeding, obesity, oral contraceptives, alcoholism which may lead to malignant neoplastic condition of breast.

Practice on breast self examination:

it refers to the skill obtained by adolescent girls in practicing breast self examination which is measured by using check list 9

Adolescent girls:

It refers to the girls, age between 17-19 of years and studying in college.

6.6. ASSUMPTIONS

 Adolescent girls may have inadequate knowledge and poor attitude regarding risk factors for breast cancer.

 Adolescent girls may have inadequate practice regarding breast self examination, awareness package improve their practice on breast self examination.

6.7 RESEARCH HYPOTHESES

H1: There will be significant difference between the mean pretest and post test level of knowledge and attitude regarding risk factors for breast cancer and practice on breast self examination among adolescent girls.

H2: There will be significant correlation between knowledge and attitude regarding risk factors for breast cancer and practice on breast self examination among adolescent girls.

H3:There will be significant association between pretest level of knowledge and attitude regarding risk factors for breast cancer and practice on breast self examination among girl with their selected demographic variables.

6.8 REVIEW OF LITERATURE

Review of literature is defined as comprehensive, in-depth systematic critical review of scholarly publication, unpublished scholarly print materials audio visual material and personal communications. The investigator carried out extensive review of literature on selected topics both research and non research in order to gain maximum relevant information and to perform in a scientific manner.

Studies related to knowledge, attitude and practice on breast self examination and breast cancer.

A cross-sectional descriptive questionnaire study was conducted to assess knowledge, attitude and practice (KAP) regarding breast self-examination (BSE) on among students. The study involved a cohort of 203 female dental students. This study findings revealed that the total mean knowledge score was 14.22 ± 8.04 with the fourth year students having the maximum mean score (19.98 ± 3.68). The mean attitude score was 26.45 ± 5.97. For the practice score, the overall mean score was 12.64 ± 5.92 with the highest mean score noted for third year 13.94 ± 5.31 students. KAP scores upon correlation revealed a significant correlation between knowledge and attitude scores only (P<0.05) .The study concluded that the need for educational programs to

23 create knowledge, attitude and practice regarding regular breast cancer screening behavior .

A descriptive study was conducted to assess the level of awareness regarding breast cancer among 864 Kashmiri females. The questionnaire had 18 questions and on the basis on score attained, the subjects were classified as having poor, average or good breast cancer awareness. Out of 864 participants, 703(81.37%) had poor breast cancer awareness and 103(11.92%) had average awareness. Only 58(6.71%) had good awareness about breast cancer. The study concluded that the level of awareness regarding breast cancer in Kashmiri females is very low and there is a need to spread awareness about this disease among the general

24 population .

A cross- sectional study was conducted to determine the level of knowledge regarding breast cancer and to measure breast self-examination (BSE) performance in a group of 80 women aged 40 years and above. Total 80 women were interviewed by means of a structured questionnaire (after obtaining written informed consent) .Further; attitude towards BSE was also evaluated. The study findings revealed that Breast cancer awareness was found to be 52% in this group of women even though 95% women claimed to have heard of the disease. Only 12% of all women had received information about breast cancer. About 38% women had never heard of BSE and among those that had heard of it, 15% were regular while 23% were irregular performers. Thus performance of BSE was found to be inadequate in this group. The study

concluded that inadequate knowledge is the reason for lack of attitude and practice on breast self

25 examination .

A descriptive and cross-sectional study was conducted to assess knowledge on breast self examination among 718 female high school students. The female high school students had insufficient knowledge about breast self-examination and a low percentage of students reported that they had performed breast self examination monthly. The most common reason for not doing breast self- examination was "not knowing how to perform breast self-examination" (98.5%). personal history of breast cancer (68.7%). The study concluded that there is a need to increase knowledge of adolescent females about the risks of breast cancer and benefits of early detection26.

A cross sectional study was conducted to investigate the awareness of BSE among women patient and other female attendees visiting a teaching hospital for 2 months. Total 300 women were studied. A semi structured questionnaire about the awareness of BSE and source of information was administered by the investigator to collect data Mean age of the participants was 26.5 years. About 2% women were aware about BSE. Main information and source was health workers in 50% of aware women. Younger, married women and with more years of schooling were significantly more aware. Awareness about BSE among women of Andhra Pradesh is very poor. The study concluded that knowledge of women about BSE improved through various

27 means like health workers, breast health care programs and targeting girl students .

Studies related to knowledge on breast cancer and its risk factors

A descriptive cross sectional analysis was conducted to assess awareness about breast mass/lump, cardinal symptom of breast cancer among women. Respondents known to symptoms of breast cancer was 47.2% (463). The two main causes of breast cancer according to respondents were late initiation of breast feeding (150, 15.3%) or not practicing breast feeding (166, 16.9%).Late marriage being a risk factor was known only to 55(5.9%) respondents and relation of obesity with breast cancer was known to only 89(9.1%) subjects. The main preventive modality, breast self exam was known by only (324, 33%) subjects. Of those who knew about breast self examination correct methodology was known only to 1/4th of respondents (255,

25.9%). The study concluded that women have knowledge deficits about breast cancer and

28 various factors related to it .

A case control study was conducted to identify knowledge regarding risk factor for breast cancer. The study consisted 105 hospitalized cases confirmed on histopathology and 210 group matched controls selected without malignancy. Bivariated analyses included odds ratio (or), 95% confidence interval (CI) for odds ratio. Earlier age at menarche< 112 years of age , late age at first full term delivery, null parity , lack of breast feeding were found to be significantly associated with the risk of breast. The study concluded that the knowledge regarding breast cancer is essential in reduction of breast cancer29.

A case control study was conducted to assess risk factor breast cancer. Over a 1 year study period 105 consecutive biopsy or fine needle aspiration cytology confirmed breast cancer patients were interviewed by direct questionnaire method regarding risk factors attending Surgery and Radiotherapy OPD, while taking other 105 patients attending Surgery Department for some other disease as controls. Among the cases, rural residence, illiteracy and low socio- economic status was significantly higher than controls. Late onset of menarche, late onset of menopause, ever OCP usage, breast feeding for 1-2 years and age of 1st childbirth between 20- 30 years were found to be significant protective factors. The study concluded that women should

30 be made aware regarding the modifiable risk factors to prevent breast cancer .

A Case control study was conducted to study the association between breast cancer selected exposure variables and to identify risk factor for breast cancer among 188 participants in which 94 cases and 94 controls groups are selected. All the study participants were between 25 to 69 years of age group. The cases and controls were matched by ± 2 years age range. The study revealed that non vegetarian diet was one of the important risk factors (OR 2.80, CI 1.15-6.81). More than 7 to 12 years of education (OR 4.84 CI 1.51-15.46) had 4.84 times risk of breast cancer as compared with illiterate women. The study concluded that non vegetarian diet is the important risk factor for Breast Cancer and the risk of Breast Cancer is more in educated women

31 as compared with the illiterate women .

A case control study was conducted to identify and quantify various demographic, reproductive, socio-economic and dietary risk factors among women with breast cancer. Pathologically confirmed breast cancer women were selected as case and controls were age- matched women from medicine and surgery wards without any current breast problem or previous breast cancer. A total of 152 cases and 152 controls were enrolled. They were interviewed for parity, breast feeding, past history of benign breast lesion, family history and dietary history with a pre-tested interview schedule after obtaining informed written consent. The significant risk factors were (odds ratios with 95% CI) previous history of biopsy for benign breast lesion 10.4 (1.3-86.3), nulliparity 2.4 (1.14-5.08), consumption of fats more than 30 g/day 2.4 (1.14-5.45) and consumption of oils containing more of saturated fat 2.0 (1.03-4.52).The study concluded that nulliparity, past history of benign breast lesion, high fat diet and

32 consumption of oils with more saturated fats were the risk factors for breast cancer .

A case control study was conducted to study the association between breast feeding and breast cancer risk. Total 1,866 Cases and 1,873 control group were selected for the study. Information was collected through interview method. Odds ratio (OR) and 95% confidence intervals (CI) were estimated by unconditional logistic regression models. Life time duration of breast feeding was inversely associated with breast cancer risk among premenopausal women (p- value of linear trend, 0.02).no such protective effect was observed in postmenopausal women, among whom a protective effect of parity suggested. A reduction of breast cancer risk with prolonged breast feeding was shown among premenopausal women. The study concluded that health campaign focusing on breastfeeding behavior by appropriately educating women would

33 contribute to reduce cancer burden .

7 MATERIALS AND METHODS

7.1 SOURCES OF DATA

The data will be collected from adolescent girls in selected college of Bangalore.

7.2 METHOD OF DATA COLLECTION i. Research design 14

Quasi-experimental, one group pretest and post test research design34. ii. Research Variables

Independent variable:

Awareness package on risk factors for breast cancer and breast self examination.

Dependent variable:

Knowledge and attitude regarding risk factors for breast cancer and practice on breast self examination.

Demographic variable:

Base line information of girls such as; age, educational status , age at menarche, religion, family occupation, family income , and family history of breast cancer and previous knowledge

iii. Setting:

The study will be conducted at Mahesh Pre- University College , Nagarbhavi ,Bangalore 72 iv. Population:

All the adolescent girls studying in Mahesh Pre-University College.

v. Sample:

Adolescent girls who will fulfill the inclusion criteria are considered as sample and the sample size is 60 vi. Criteria for sample collection

Inclusion Criteria:

The study includes adolescent girls:

1. Who are between the age of 17-19years

2. Who are willing to participate

3. Who can read and understand English and Kannada

Exclusion criteria:

The study excludes the adolescent girls:

1.Who are not available during the period of data collection.

2. Who have been previously sensitized with same or similar awareness package programme.

vii. Sampling Technique:

35 Probability-simple random sampling technique . viii. Tools of data collection

Section A:

Demographic variable of the adolescent girl such as: age, educational status, age at menarche, religion, family occupation, family income, family history of breast cancer and previous knowledge

Section B:

Structured questionnaire to assess the knowledge regarding risk factors for breast cancer

Section C: 16

Likert scale used to assess the attitude regarding risk factors for breast cancer.

Section D:

Check list used to evaluate the breast self examination among adolescent girls. ix. Procedure for data collection:

After obtaining permission from the concerned authority and informed consent from samples. The investigator, assess the effectiveness of awareness package on risk factors for breast cancer and practice on breast self examination among adolescent girls.

Phase I:

Pre- test will be conducted to assess the existing knowledge and attitude regarding risk factors for breast cancer and practice on breast self examination among girls with the structured questionnaires, likert scale and check list.

Phase II:

Awareness package program will be conducted regarding risk factors for breast cancer for 45 minutes by utilizing flash cards and breast self examination will be demonstrated by using video at the same day.

Phase III:

Post test will be conducted using the same structured questionnaire, Likert scale and check list on the 7th day.

Duration of data collection : 4 to 6 weeks. x. Plan For Data analysis and Interpretation:

Data will be analyzed through descriptive statistics and inferential statistics.

Descriptive statistics: 17

 Frequency and percentage distribution will be used to analyze the demographic variables.  Mean and standard deviation will be used to analyze the knowledge and attitude regarding risk factors for breast cancer and breast self examination among adolescent girls.

Inferential statistics

 Paired t- test will be use to compare the pre -test level of knowledge and attitude regarding risk factors for breast cancer and practice on breast self examination among adolescent girls.  Karl Pearson’s correlation will be used to assess the correlation between knowledge and attitude regarding risk factors for breast cancer and practice on breast self examination among adolescent girls.  Chi-square test will be used to analyze the association between knowledge and attitude regarding risk factors for breast cancer and practice on breast self examination among adolescent girls with their demographic variables. xi. Projected outcome

There will be significant increase in the level of knowledge and attitude regarding risk factors for breast cancer and able to practice breast self examination following proper technique after administering awareness package.

7.3 Does the study require any investigations or interventions to be conducted on patients or other human or animals?

Yes, awareness package will be administered as an intervention regarding risk factor for breast cancer and breast self examination among the adolescent girls

7.4 Has ethical clearance has been obtained from your institution?

Yes, ethical clearance will be obtained from concerned authorities and informed consent will be obtained from samples, the privacy and confidentiality of the data will be maintained.

8. LIST OF REFERENCES

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7. Saurabh Ram and Biharilal Shrivastav. Breast Self Examination: A tool for early diagnosis of breast cancer; 2012 vol.1,issue. 8. Breast self-examination: Available from: http://en.wikipedia.org/wiki/ 9. Breast digital atlas - Breast self-Examination (BSE):Available from : :http://screening.iarc.fr/breastselfexamination.php 10. global comparison breast cancer in India .Available from: http://www.breastcancerindia.net 11. About Breast Cancer-Welcome to Tata Memorial Centre: Available from: http://tmc.gov.in/cancerinfo/breast/ 12. WHO/Breast Cancer: prevent control: Available from: http//www.int/cancer/detection/breas cancer. 13. Press Release –National Breast Cancer Foundation:Avaailable form: http://nationalbreast cancer.org/press-release 14. WHO/cancer: Available from://www.who.int/cancer 15. Sadler G R, Dhanjal S K, Shah N B, Shah R B, Ko C, Anghel M, Et.al. Knowledge, attitudes and behaviors toward breast cancer early detection. Public Health Nurse. 2001 Sep-Oct; (5):357-363. 16. Guide lines for Breast Self –Examination-Genesis Health System: Available from:http://www.genesishealth.com/services/cancer/treat/breast exam 17. Gupta SK. Impact of a health education intervention program regarding breast self examination by women in a semi-urban area of Madhya Pradesh, India. 2009;10(6):1113- 7 18. Shalini, Divya Varghese, and Malathi Nayak Awareness and Impact of Education on Breast Self Examination Among College Going Girls Indian j palliate care 2011 may-aug 17(2):150-154 19. Vikas Fotedar and Rajeev K Knowledge of Risk Factors & Early Detection Methods and Practices towards Breast Cancer among Nurses in Indira Gandhi Medical College, Shimla, Himachal Pradesh India , DOI http:doi.org/10.7314/apjcp.2013.14 1.117 20. Breast Cancer Statistics/ worldwide breast cancer: Available from: :http://world breast cancer.com/learn breast/cancer.

21. Breast Cancer Statistics/ worldwide breast cancer: Available from: :http://world breast cancer.com/learn breast/cancer. 22. Dolar Doshi, B Srikanth Reddy, and P Karunakar Breast Self-examination. Knowledge, Attitude, and Practice among Female Dental Students in Hyderabad City, India Indian palliate care ; Jan -April 2012 : 18(1),68-73 23. S.A. Salat, A. Rather, S. Ahmad, A.B. Khan Breast Cancer Awareness among Females in a Developing World - A Study from Kashmir; Mar-Apr 2010: Vol. 15, No. 1, pp. 16-21. 24. S Ahuja and N Chakrabart. To Determine The Level Of Knowledge Regarding Breast Cancer And To Increase Awareness About Breast Cancer Screening Practices Among A Group Of Women In A Tertiary Care Hospital In Mumbai, India The Internet Journal of Public2013;Volume 1 Number 1 25. Shalini, Divya Varghese, and Malathi Nayak Awareness and Impact of Education on Breast Self Examination Among College Going Girls Indian j palliate care 2011 may-aug 17(2):150-42 26. Pawan Kumar Sharma, Enakshi Ganguly, Disha Nagda and T Kamaraju Knowledge, attitude and preventive practices of South Indian women towards breast cancer The Health Agenda, Volume 1. Issue 1. January, 2013 27. Pawan Kumar Sharma , Disha Nagda , T. Kamaraju and Enakshi Ganguly Awareness of Breast Self Examination (BSE) Among Women of Andhra Pradesh, India Research Journal of Medical Sciences Year: 2012 | Volume: 6 | Issue: 6 | Page No.: 272-274 28. Ramchandra Kamath, Kamaleshwar S Mahajan, and T S Sanal. A Study on Risk Factors of Breast Cancer Among Patients Attending the Tertiary Care Hospital, in udupi district Indian j community med. 2013 aprl-jun:38(2):95-99 29. Kulkarni, hiwarkar, meshram. Reproductive Risk factors for Breast Cancer: A case control study Online J Health Allied Scs. 2009;8(3): 30. Soumen Das, Santanu Sen, Anindya Mukherjee,Debadatta Chakraborty, pankaj Kumar Mondal Risk Factors of Breast Cancer Among Women in Eastern India: A Tertiary Hospital Based Case Control Study. Asian Pacific J Cancer Prev, 13 (10), 4979- 4981. Volume13_No10/4 31. S.M Balasubramanian,SBRotti,SVivekananda.Risk factors of female breast cancer: A case control study at Puducherry.2013;vol :550,issue:6.page 65-70 21

32. S S.Reshma, A study to assess the effect of reproductive, socio-economic, and dietary risk on the breast cancer, Available from: http://www,ncbi.nlm.nih.gov/pubmed 33. Rae Haining. Breast feeding practice and breast cancer. Journal of gynaecology.2011 may;777-880 34. Polit D F & Beck C.T. Nursing Research: Principles and methods. 7th edition. New Delhi: Philadelphia. Lippincott Williams publications.2004 35. Sunder Rao & Richard. An introduction to biostatistics. 6th edition. New Delhi: Prentice- Hall of India PrivTE Limited; 2004

9. Signature of the candidate :

10. Remarks of the guide :

11.1 Name and designation of the guide : Prof. Mrs. Sundaram M

HOD, Obstetrics and Gynecological Nursing

11.2 Signature :

11.3 Co-guide :

11.4 Signature :

11.5 Head of department : Prof. Mrs. Sundaram M

11.6 Signature :

12.1 Remarks of the principal :

12.2 Signature of the principal :