Rajiv Gandhi University of Health Sciences s5

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA. PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

MS. AMBIKA G. T 1 NAME OF THE CANDIDATE I YEAR M.Sc. NURSING STUDENT,

AND ADDRESS N.D.R.K. COLLEGE OF NURSING

B.M ROAD HASSAN,KARNATAKA

2 NAME OF THE N.D.R.K. COLLEGE OF NURSING, B.M. ROAD, INSTITUTION HASSAN, KARNATAKA.

COURSE OF THE STUDY MASTER OF SCIENCE IN NURSING 3 AND SUBJECT (COMMUNITY HEALTH NURSING)

4 DATE AND ADMISSION TO 18/07/2011 THE COURSE

“EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON WARNING SIGNS OF BREAST CANCER AND 5 TITLE OF THE TOPIC BREAST SELF EXAMINATION AMONG HOME MAKERS(35-50 YEARS) IN A SELECTED URBAN AREA AT HASSAN” “A STUDY TO EVALUATE THE 5.1 STATEMENT OF THE EFFECTIVENESS OF STRUCTURED TEACHING PROBLEM PROGRAMME ON WARNING SIGNS OF BREAST CANCER AND BREAST SELF EXAMINATION AMONG HOME MAKERS (35-50 YEARS) IN A SELECTED URBAN AREA AT HASSAN”

6. BRIEF RESUME OF THE INTENDED WORK

1 INTRODUCTION

“Think what cowards men would be if they had to bear children women are altogether a superior species”

- GEORGE BERNARD SHAW

Every year we celebrate women’s International Day, inspiring the women of today to stride a head in life. While women have made progress in most off the field but still her tends to in inexplicably neglect her own health. Women are the basic foundation of a society and its wealth. So it is very important to take care of a women’s health. If we will train a man and we train an individual, if we train a woman and we can build a nation.1

The global commission on women’s health established in 1992 under the auspicious of the WHO emphasized “Health security for women throughout the life span” in mainly concerned with the reproductive and sexual life of the women. During the period of reproductive life many changes occurs in a women’s body as a results of hormonal influences and adaptation to the physiological process.1

Breast problems are significant health concerned to women. In a women’s life time there is a one in eighth chance that she will be diagnosed with breast cancer. Whether benign or malignant intense feeling of shock, fear and denial often accompany the initial discovery of a lump or change in the breast. These feelings are associated both with the fear of survival and with the possible loss of a breast. Throught history the female breast has been regard as a symbol of beauty, sexuality and motherhood. The potential loss of breast or part of a breast may be devastating for many women because of the significant psychological, social, sexual and body image implications associated with it.2

Breast self examination is a procedure performed by an individual to physically and visually examine herself for changes in the breast under arm areas of the body. Breast self examination is an important component of health promotion and maintenance. Providing education and encouraging the women to perform breast self examination is recommended to decrease the mortality rates from breast disorders. Performing monthly breast self examination was first advocated by the Colombia University surgeon Cushman experts recommended the women over age of 20 perform a monthly breast self examination.2

2 Breast self examination is a single very low cost, non invasive adjuvant screening method for detection of early breast cancer. It is a useful measure when mammography screening is not available in the rural and poor urban areas. There is an evidence woman who correctly practices breast self-examination monthly or more likely to detect lump at the early stages of its development and early diagnosis has been reported to influence early treatment and to yield a better survival rate. Breast self examination is also help full to detect other breast problems such as change in appearance and other conditions.2

Mary periard and Brenda knaack (2003) found that the group had received the teaching on breast self examination has significantly more knowledge used better techniques and the women were able to correctly identify more lumps in a breast more than those who did not receive the teaching.3

A study was conducted by Shapley M, Mansell G,Jordan IL,On 2010.The aim of the study was to identify symptoms, signs, and non-diagnostic test results in unselected primary care populations that are highly predictive of cancer. Fourteen bibliographic databases were searched, using terms for primary care, cancer, and predictive values. Reference lists of relevant papers were hand-searched. Data were extracted and the quality of each paper was assessed using predefined criteria, and checked by a second reviewer. The result of the Twenty-five studies were identified. PPVs of 5% or more in specific age and sex groups were reported for rectal bleeding, change in bowel habit, and iron deficiency anaemia and colorectal cancer; haematuria and urological cancer; malignant rectal examination and prostate cancer; haemoptysis and lung cancer; dysphagia and oesophageal cancer; breast lump and breast cancer; and postmenopausal bleeding and gynaecological cancer.The conclusion says that Robust evidence was found for eight symptoms, signs, and non- diagnostic test results as strongly indicative of cancer for specific age and sex groups in unselected primary care populations.4

Cl cox et al (2008) conducted longitudinal clinical trial study on a secondary analysis of a behavioral intervention. Supporting breast self examination in female childhood cancer survivors”. A samples of 149 females survivors (aged 12-18 years) a median of 11 years after diagnosis of leukemia or lymphoma (59%) or solid tumor (41%) was analysed using paired t test, Wil Coxon signed rank test, repeated measures analysis of variance and analysis of

3 covariance. Study concluded that survivors least likely to perform BSE are fearful about cancer and are not motivated to change health behaviors. There should be an exploration of survivors fears about cancer and late treatment effects to address misconceptions, use modeling techniques with return demonstrations to ensure competency in BSE.5 Nurses are playing a pivotal role in teaching the patient to identify the problems. Breast self examination is an that should be perfect for nurses who can promote monthly breast self examination by supporting realistic believes about screening and cancer as well as demonstrating breast self examination so that they can do it themselves without consulting physician.

6.1 NEED FOR THE STUDY

“You may be disappointed if you fail, but you are doomed if you don’t try”

- Beverly Sills

Today, cancer is one of the leading causes of mortality and morbidity in the developed and developing countries. In females, breast cancer is the most common form of cancer. There were 1.7 million breast cancer cases diagnosed worldwide and 4,65,000 women died due to breast cancer in 2007.1In India the incidence are 19.1 per 100000 population and death rate is 10.4 per 100000 population.6

In the absence of an exact aetiological agent for breast cancer, the most appropriate way of controlling it is by early detection and treatment. Mammography is the method of choice, but its use is limited due to the high cost and unavailability. Considering this, breast self-examination is an ideal method which can be performed by every woman at her leisure time.7

A prospective controlled trial of BSE was initiated in 1985 in Leningrad and Moscow under the auspices of WHO, in order to establish the value of this potentially cost-effective technique. More than 62,000 women aged 40-64 years had been enrolled in the BSE and control groups. The study demonstrated the feasibility and effectiveness of the BSE

4 educational programme as measured by the frequency and technique of performance of BSE and a substantial increase in the number of cases of breast abnormalities detected.8

Various studies conducted in different areas emphasised the effectiveness of STP on BSE. A study was conducted to assess the knowledge and effect of PTP regarding breast cancer and BSE among working women in Pune. The STP on breast cancer and BSE was found to be effective in increasing the knowledge of women.

A study conducted by LEPECKA – KLUSKEL et al (2007) on breast self examination among polish women reveal that the significance of breast self examination is closely connected with professional background of the response and actual conducting of breast examination. Greater involvement in educational activities of medical personnel only improve the present situation.10

A wide range of literature suggests that BSE is simple and effective in the early diagnosis of breast cancer. The lack of knowledge and skill is a barrier to BSE practice. Studies have shown that STP is one of the most effective teaching strategies which can be used for improving the knowledge and skill of the people.

Reviewing of the literature and discussion with experts in the field of research made the investigator realise that breast self-examination is the best way for early detection of breast cancer and home makers are the persons who empower and disseminate the knowledge to others. So the researcher felt the need of teaching home makers regarding BSE.

6.3 STATEMENT OF THE PROBLEM:

“A study to evaluate the Effectiveness Of Structured Teaching Programme on Warning Signs of Breast Cancer and Breast Self Examination among home makers(35-50years) in a selected urban area at Hassan.”

5 6.3 OBJECTIVES OF THE STUDY:

1. Assess the pre test knowledge of Home makers in urban area regarding Warning Signs of Breast Cancer and Breast Self Examination prior to the administration of Structured Teaching Programme on Warning Signs of Breast Cancer and Breast Self Examination.

2. Develop and administer Structured Teaching Programme regarding Warning Signs of Breast Cancer and Breast Self Examination among the Home makers of urban area at Hassan.

3. Assess the post test knowledge of Home makers in urban area regarding the Warning Signs of Breast Cancer and Breast Self Examination after the administration of Structured Teaching Programme on Warning Signs of Breast Cancer and Breast Self Examination.

4. Evaluate the effectiveness of Structured Teaching Programme on Warning Signs of Breast Cancer and Breast Self Examination among the Home makers in urban area.

5. Associate the post test knowledge of Home makers regarding the Warning Signs of Breast Cancer and Breast Self Examination in urban area with the demographic variables.

6.4 RESEARCH HYPOTHESIS:

H1:-There will be significant difference between the pre test and post test knowledge scores of Home makers who have received the Structured Teaching Programme on Warning Signs of Breast Cancer and Breast Self Examination.

H2:-There will be significant association between selected socio demographic variables and the knowledge of Home makers regarding Warning Signs of Breast Cancer and Breast Self Examination.

6.5 ASSUMPTIONS:

6 1. The study will improve the knowledge of home makers of urban area at Hassan regarding Warning Signs of Breast Cancer and Breast Self Examination.

2. The study will improve the knowledge of home makers regarding selected aspects of Warning Signs of Breast cancer and Breast Self Examination such as basic physical examination.

6.6 OPERATIONAL DEFINITION:

EVALUATE:

The process of judging the value or quality of study regarding Warning Signs of Breast Cancer and Breast Self Examination before and after implementation of Structured Teaching Programme.

EFFECTIVENESS:

It is the significant increase in knowledge of home makers regarding Warning Signs of Breast Cancer and Breast Self Examination.

STRUCTURED TEACHING PROGRAMME:

Structured Teaching Programme refers to systematically developed instructions for a group of home makers regarding Warning Signs of Breast Cancer and Breast Self Examination.

KNOWLEDGE:

It is the awareness of study regarding Warning Signs of Breast Cancer and Breast Self Examination.

WARNING SIGNS AND BREAST SELF EXAMINATION:

Warning Signs are the first requirement is to alert the operator to the solution, and then aid to accurate and prompt diagnosis.

7 Breast Self Examination is one of the effective screening measures and has proven to be effective in discovery of lumps at an early stage.

HOME MAKERS:

Home makers are the women who are manage a house hold while her husband earns the family income.

6.8 CRITERIA FOR SAMPLE SELECTION

INCLUSION CRITERIA:

- Home makers who are managing their houses.

- Home makers who are available at the time of study.

- Home makers who are willing to participate in the study.

EXCLUSION CRITERIA

- Home makers who have been diagnosed as having breast cancer and have undergone mastectomy.

- Home makers who have previous exposure to BSE.

LIMITATION OF THE STUDY:

The study limited to,

 100 home makers of urban area at Hassan

 A period of 4-6 weeks

 A study is limited to only home makers.

6.9 SIGNIFICANCE OF THE STUDY

8  Increase the knowledge of home makers regarding warning signs of breast cancer and breast self examination.

 Pave the way for home makers to gain knowledge regarding selected aspects of basic physical examination.

6.10 CONCEPTUAL FRAME WORK :

“Social cognitive Theory”

6.11 REVIEW OF LITERATURE:

Review of literature is an important step in research. The review of literature on a topic of interest often prepared to put a research problem in context or as the basic for an implementation project. It can help with orientation to what is known about an area of enquiry to ascertain what research can best make a contribution to the existing base of evidence.

Ogletree et al (2004) conducted a study on “Knowledge and intentions of ninth grade girls after a breast self examination progaramme” 255 ninth – grade girls were selected from four public high schools. Displayed a 50- minute video demonstration programme of proper BSE technique. Using a quasi – experimental design, the program was evaluated for changes in knowledge and intention to perform BSE, were given a pre test to determine their knowledge about breast cancer and breast self-examination. A delayed post test was administered between five to six weeks later (n=211). Girls who participate in the BSE education program (treatment group) recorded a significantly higher overall mean knowledge score than girls who did not participate (Comparison group). The result

9 revealed that more girls in the treatment group reported performing BSE in the past month well as a higher intention to perform BSE in the future.11

A cross-sectional study was conducted by Michael N Okobia, on 2006 in Nigeria. The aim of the study was designed to assess the knowledge, attitude and practices of community-dwelling women in Nigeria towards breast cancer. Statistical analysis software method used to carry out the study. The result of the study shows that mean knowledge score was 42.3% and only 214 participants (21.4%) knew that breast cancer presents commonly as a painless breast lump. Practice of breast self examination (BSE) was low; only 432 participants (43.2%) admitted to carrying out the procedure in the past year. Only 91 study participants (9.1%) had clinical breast examination (CBE) in the past year. Women with higher level of education (X2 = 80.66, p < 0.0001) and those employed in professional jobs (X2 = 47.11, p < 0.0001) were significantly more knowledgeable about breast cancer. Participants with higher level of education were 3.6 times more likely to practice BSE (Odds ratio [OR] = 3.56, 95% Confidence interval [CI] 2.58– 4.92).Conclusion shows that community-dwelling women in Nigeria have poor knowledge of breast cancer and minority practice BSE and CBE.12

A study was conducted by Ali Montazeri, Mariarm Vahadanenia on 2008 in Iran. The aim of the study was to investigate about female knowledge of breast cancer and self- reported practice of breast self-examination in Iran. Structured questionnaire and interviewer method were used for this study. The result of the study was total 1402 women were interviewed. The mean age of respondents was 43.4 (SD = 14.4) years; most were married (85%), and without any personal (94%) and family history (90%) of breast problems. Conclusion says that the women awareness of breast cancer warning signs (painless lump, retraction of nipple, and bloody discharge) and effective screening methods i.e. clinical examination, and mammography were very inadequate. Thus, health education programmes to rectify the lack of women awareness is urgently needed. The primary health care providers should raise awareness about breast care among women and to encourage them to report any unusual changes in their breasts to their family.13

10 A study was conducted by L Linsell A.J, Ramirez,LJL Forbes on 2009 in UK. The aim of this study was to test the efficacy of an intervention to older women with the knowledge, skills, confidence and motivation to detect symptoms and seek help promptly, with the aim of promoting early presentation with breast cancer symptoms. Randomised method is used for this study. Result of the study was out of 867 women aged67-70 years at 1 month, the intervention increased the proportion who were breast cancer aware compared with usual care (interaction arm: 32.8% vs 4.1%; odds ratio (OR): 24.0, 95% confidence interval (CI): 7.7–73.7; booklet arm: 12.7% vs 4.1%; OR: 4.4, 95% CI: 1.6– 12.0). At 1 year, the effects of the interaction plus booklet, and the booklet, on breast cancer awareness were largely sustained, although the interaction plus booklet remained much more effective. It concludes that to older women with the knowledge, skills, confidence and motivation to detect breast cancer symptoms and seek help promptly increases breast cancer awareness at 1year.14

A descriptive study was conducted by G Erten,A Kocer, on 2009 in Turkey. The aim is to determine the practices of nurses and midwives and their attitude toward breast self- examination (BSE). The study was conducted to determine the practices of nurses and midwives and their attitude toward BSE. It tried to cover the total population rather than sampling part of it. However, 15 nurses and midwives. A total of 80 nurses and midwives were included in the study group. This survey was carried out at the State Hospital, all Public Health Cabins, and Family Health Centers, in the rural area of Izmir, The analysis included descriptive statistics, to examine the association between BSE and medical history, knowledge of BSE, and attitude toward BSE. The results of the study indicated that 52% of the sample performed BSE. Approximately 35% of those who performed BSE reported that they acquired information regarding BSE during their work experience. Concludes that a positive correlation was found between nursing work experience and their practice alongside BSE medical professionals. Almost all the nurses and midwives knew how to conduct BSE, but did not prioritize practicing it.15

A experimental study was conducted by Fathia Ahmed Mersal and Nadia Mohamed Taha, on 2011 in Egypt. The aim of the study was to assess the impact of a nursing intervention program leading to health decisions for breast cancer screening among

11 workers. Setting was conducted in 2 pharmaceutical companies, 2 food processing industries, and a textile factory Sample: a convenience sample 520 women working previous settings, Tools used for data collection included a self-administered assessment questionnaire assessing knowledge, a health beliefs assessment rating scale, an attitude rating scale, a breast self-examination observation checklist, and a mammography card. A nursing intervention program was designed by the researchers based on the results obtained from the study tools and findings of similar research. The results show that the mean age of studied women was 43.2 years, and 56.7% of them had secondary education. Only 5.4% of the women had satisfactory knowledge at the pretest. After program implementation, statistically significant improvements were revealed in women's knowledge about breast cancer and early detection methods. Conclusion says that working women had deficient knowledge, and negative perceptions related to breast cancer and its early detection.16

A study was conducted by U.M.D. Gwarzo, K. Sabitu and S. H. Idris ,on 2003 in Zaria.The aim of this study was to evaluate the effectiveness of breast self examination. self administered questionnaires is used for this study. In the result it was found that despite nearly three quarter of the respondents (87.7%) had heard of BSE, only 19.0% of them were performing this examination monthly. Regarding the sources of information about BSE among respondents, media was found to be most common followed by health workers accounting for 45.5% and 32.2% respectively. Regular performance of BSE was significantly correlated with duration of stay in the University (X2 = 81.9, df = 3, P < .05) and family history of breast cancer(X2 = 17.4, df = 2, P < .05).It concludes that. Public health education using the media could significantly reduce the knowledge- practice.17

A study was conducted by Dr. M.O. Balogun MBBS (Ib), MPH (Ib) and Dr. E.T. Owoaje MBBS, on 2003 in Nigeria. The aim of the study was to assess the knowledge and practice of breast self examination among female traders in a well defined market. A descriptive cross-sectional survey was carried out among a total sample of 281 women in Sango market, Ibadan in, Female traders were interviewed using interviewer administered questionnaires to obtain information on their socio demographic characteristics, items traded, knowledge and practice of breast self examination. the traders had ever checked their breast. The level of awareness of breast self examination was highest among those

12 aged 50-59 years (p = 0.067). Awareness of breast self examination was found to be related to educational attainment. Women who had tertiary education were more knowledgeable about breast self examination. The level of knowledge among female traders in Nigeria is unacceptably low. Efforts should be made to increase level of knowledge and practice of breast self-examination through health education programmes.18

A study was conducted by Kösters JP, Gøtzsche PC,on 2008 in Russia. The aim of the study was to determine whether screening for breast cancer by regular self-examination or clinical breast examination reduces breast cancer mortality and morbidity. Randomised clinical trials, included cluster randomised trials.Data collection and analysis method is used for the study. The result of the study found that two large population-based studies (388,535 women) from Russia and Shanghai that compared breast self-examination with no intervention were included. There was no statistically significant difference in breast cancer mortality between the groups (relative risk 1.05, 95% confidence interval (CI) 0.90 to 1.24; 587 deaths in total). In Russia, more cancers were found in the breast self-examination group than in the control group (relative risk 1.24, 95% CI 1.09 to 1.41) while this was not the case in Shanghai (relative risk 0.97, 95% CI 0.88 to 1.06). Almost twice as many biopsies (3406) with benign results were performed in the screening groups compared to the control groups (1856).19

7. MATERIALS AND METHODS OF STUDY:

7.1 SOURCES OF DATA

Data will be collecting from home makers those who are living in urban area at Hassan.

METHODS OF COLLECTING DATA:

1. Research Design:

Pre-test and Post-test Control group design

Group Pre-test Intervention Post-test

13 A group of home makers living in urban area, 01 X 02 Hassan.

Control group 01 02

Key words:

01=Pre-test knowledge of home makers regarding warning signs of breast cancer and breast self examination.

X=Structured teaching programme on warning signs of breast cancer and breast self examination.

02=Post-test knowledge of home makers regarding warning signs of breast cancer and breast self examination.

2. Research setting:

Urban area home makers, Hassan, Karnataka.

3. Population:

Home makers of pension mohalla in Hassan.

4. Sample:

Home makers who are fulfilling the inclusion criteria.

5. SAMPLE SIZE:

100 Home makers of urban area, Hassan, Karnataka.

6. SAMPLING TECHNIQUE:

Convenient sample technique.

14 8. VARIABLES:

 INDEPENDENT VARIABLE:

Structured teaching programme for home makers.

 DEPENDENT VARIABLE:

Knowledge of Home makers regarding Warning Signs of Breast Cancer and Breast Self Examination.

9. PLAN FOR DATA ANALYSIS:

Descriptive Statistics:

It includes Mean, Median, Mode, Frequency, Standard deviation is used for the study.

Inferential Statistics:

Chi-square test is planned to find the association between warning signs of breast cancer and breast self examination with demographic variables and other relevant statistical analysis is used for this study.

10. PILOT STUDY:

10%Population is planned for the pilot study.

11. ETHICAL CONSIDERATION:

1. Has the consent been taken from the home makers?

………Yes. Informed consent will be taken from the respondents.

2. Has ethical clearance being obtained from your institution?

………Yes.

12. LIST OF REFERENCES (Vancouver style):

15 1. www.google.com.

2. Basavanthappa,BT,Medical & surgical Nursing.First Edition.New Delhi:Jaypee Brothers,Medical Publishers 2003.P.785-786.

3. Marry P,Brenda K.Breast self exam and experimental study.The regents of the university of Michigan, 2002,4(1):10-12.

4. Shapley M,mansell G,Jordan IL.Primary care for breast cancer.Keele university,2010:60(578):366-77.

5. Cl cox et al.Supporting breast self examination in female childhood cancer survivors:A secondary analysis of a behavioral intervention:Oncol nurse forms ,2008:35(3):423-36.

6. www.imagins.com/breast health/statistics.asp.Statistics of breast cancer in India.Accessed on(12-10-2010).

7. Singh MM,Devi R, Walia I, Kumar R. BSE for early detection of breast cancer.Indian journal of medical Science 1999;27(6):108-15.

8. Semiglazov VF,Soiseenko VM. BSE for early detection of breast cancer. A USSR/WHO controlled trial in Leningrad. Bulletin of WHO 1987;65(3)391-6.

9. Kadam M. A study to assess the knowledge and effect of PTP regarding breast cancer and BSE among working women in the age group of 20-45years in Pune city.Nightingale Nursing Times 2007 Jul;4(3):7.

10. Lepecka Klusek et al Breast self Examination among Polish Women of Procreative age and the attached significance. Cancer Nursing 2006,30(1):64-686.

11. Ogletre et al Knowledge and intentions of ninth grade girls after health.2004 Nov;74(9):365-9.

12. Michael Nokobia, for knowledge,attitude and practice of Nigerion women towards breast cancer.World journal of Surgical oncology2006,4:11.

13. Ali Montazeri, Mariarm Vahdanenia.Need for greater women awareness of warning signs and effective screening methods.2008.7/1/6.

14. Linsell, A J Ramirez,affect on breast cancer awareness.2009,101.S40-S48.

16 15. G Erten,A Kocer.the practices of nurses and midwives and their attitude toward breast self examination.2009;21:10.

16. Fathia Ahmed Mersal and Nadia Mohamed Taha. Nursing Intervention Program for Early Detection and Prevention of Breast Cancer among Working Women.Journal of American Science,2011;7(1).

17. U M.D Gwarzo, K Sabitu, SH Idris. Knowledge and practice of breast-self examination among female undergraduate students of Ahmadu Bello University Zaria,2003,10.4103/1596-3519.55766.

18. Dr. M.O. Balogun MBBS (Ib), MPH (Ib) and Dr. E.T. Owoaje MBBS (Ib);FWAC(Comm.Hlth)Department of Community Medicine, University College Hospital, PMB 5116, Ibadan,oyo State, Nigeria.

19. Kösters JP, Gøtzsche PC. Regular self-examination or clinical examination for early detection of breast cancer. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD003373. DOI: 10.1002/14651858.CD003373.

20. www.Pubmed.com.

17 SIGNATURE OF THE 13 CANDIDATE

14 REMARKS OF THE GUIDE This study signifies the importance of warning signs of breast cancer and breast self examination, thus will give knowledge to the home makers.

NAME AND DESIGNATION 15 OF Prof. BERNICE MARGARET

15.1 GUIDE

15.2 SIGNATURE

HEAD OF THE 15.3 DEPARTMENT Prof. BERNICE MARGARET

15.4 SIGNATURE

REMARKS OF THE 16 PRINCIPAL

16.1 SIGNATURE