I

Abstract of thesis entitled

“An evidence based education program on using breast self examination to screen

breast diseases”

Submitted by

Lam, Tanny

for the degree of Master of Nursing

at The University of Hong Kong

in August 2015

Breast Cancer is the most common cancer of women in worldwide. In Hong Kong,

breast cancer has become the most common cancer among females since 1993. The

early detection of the breast cancer leads to better survival rate. Breast

self-examination (BSE) is a simple, cost-free and friendly way to screen breast

diseases. The easy friendly technique allows the middle class or low income family to

approach the preventive measures of breast diseases.

This dissertation is aimed to develop an evidence-based protocol for a program of

teaching women on using breast self-examination. The Scottish Intercollegiate

Guidelines Network was used as a critical appraisal tool to state the levels of

evidence and grading of the recommendation in the guidelines.

The guideline is proposed in the breast care centre of a private hospital in Hong Kong.

Target population is female aged over 20 with all background including those are

II

pregnant, breastfeeding or after mastectomy. They will attend a one hour education

program of knowledge on breast cancer and proper BSE skills.

A thorough communication plan is developed to facilitate effective communication

and implementation of the guideline between stakeholders in the administrative,

managerial, and operational level. A pilot period measuring knowledge, job

satisfaction, and confidence level of staff as well as the satisfaction level of the

subjects before refined guidelines is implemented for five months. Effectiveness of

the guideline would be determined by increase in number of women performing

regular BSE, staff knowledge, satisfaction and confidence level, increase in breast

knowledge and satisfaction level of participants, balance of income and overall

expenditure.

III

“An evidence based education program on using breast self examination to screen

breast diseases”

by

Lam Tanny

R.N., B.N.

A thesis submitted in partial fulfillment of the requirements for

the Degree of Master of Nursing

at the University of Hong Kong.

August, 2015

IV

DECLARATION

I declare that this dissertation represents my own work, except where due

acknowledgement is made and that it has not been previously included in a thesis,

dissertation or report submitted to this University or to any other institution for a

degree, diploma or other qualifications.

___________________________________

Lam, Tanny

V

ACHKNOWLEDGEMENTS

I would like to take express my gratitude to my supervisor, Dr. Denise Chow, whose

enlightenment, guidance and patience has enabled me to complete my dissertation.

Her valuable experience and support helped me to pass though the whole master

studies and journey of dissertation.

It is a pleasure to thank my colleagues and classmates who showed their support and

encouragement during my study in the Master of Nursing degree course. I must also

express my deepest gratitude to my family for their patience and continuous support

throughout my study.

VI

CONTENTS

CHAPTER 1: INTRODUCTION

1.1 Background ………………………………………………………………………..……………………….….. 1

1.2 Affirming Needs ……………………………………………………………………………..……………….. 3

1.3 Objectives & Significance ………………...……………………………….…………………………….. 8

CHAPTER 2: CRITCAL APPRAISAL

2.1 Search & Appraisal Strategies ……………………………………………………....................... 11

2.1.1 Identification of studies

2.1.2 Data Extraction

2.1.3 Appraisal Strategies

2.2 Results…………….………………………………………..………………………………..…………………… 13

2.2.1 Search Results

2.2.2 Study Characteristics

2.2.3 Methodology Issues

2.3 Summary & Synthesis …………………………………………………………….……………………….. 19

2.3.1 Summary

2.3.2 Synthesis

CHAPTER 3: TRNSLATION AND APPLICATION

3.1 Implementation Period …………………………………………..…..……………………………..... 24

3.1.1 Transferability of the findings

3.1.2 Feasibility

3.1.3 Cost-benefit ratio of the innovation

3.2 Developing a EBP guideline…..……........………..……………………………….………….….. 32

CHAPTER 4: IMPLEMENTATION PLAN

4.1 Communication plan with potential users...……………….…………………….…………… 37

4.1.1 Identification of the stakeholders

4.1.2 Process of Communication

4.1.3 Pilot Study Plan

4.2 Evaluation Plan……………………………………………………………………………………………… 43

4.2.1 Patients Outcomes

4.2.2 Healthcare provider outcomes

4.2.3 System outcome

4.2.4 Nature of clients to be involved

4.2.5 Sample size

VII

4.2.6 Timing and frequency to take measurements

4.2.7 Data analysis

4.2.8 Criteria for Determining Guideline Effectiveness

APPENDICES

Appendix I: Evidence Table ………………………………………………………………………………….. 50

Appendix II: Quality Assessment of the Randomized Controlled Trial ………………….. 52

Appendix III: Budget Plan of the Education Program on BSE…….…………………………... 56

Appendix IV: SIGN Grading System 1999-2012…………………………………………….…....... 57

Appendix V: Quality of the Identified Studies………………………………………..……………... 58

Appendix VI: Summary of the Breast Self Examination (BSE) Education Program … 59

Appendix VII: Communication Plan with Timeline………………………………………………… 60

Appendix VIII: Take-home Pamphlets with Attached Schedule……………………………… 61

Appendix IX: Patient Survey………………………………………………………………………………….. 62

Appendix X: Staff Survey……………………………………………………………………………………….. 63

Appendix XI: PRISMA 2009 Flow Diagram…………………………………………………………….. 65

REFERENCES ……………………………………………………………..………………………………………..… 66

1

CHAPTER 1

INTRODUCTION

1.1 Background

Breast Cancer is the most common cancer of women in worldwide. It has a high

modality not only in developing countries, but also in developed countries (World

Health Organization, 2014). Nevertheless, the survival rate was found to be higher in

well-developed countries than less developed countries. According to Coleman et al.

(2008), the difference may due to the well-developed health care system which can

screen the diseases in early stages and provide better techniques for treatment.

The early detection of the breast cancer leads to better survival rate. It was found

that patients in stage 0 and stage 1 got 100% 5-year survival rate while 73% survival

rate was noted in stage 3 (American Cancer Society, 2014a). However, the early

stage of breast cancer can be asymptomatic. Once the symptoms such as breast pain

or nipple discharge occur, they may already indicate the spread of cancer cells.

In Hong Kong, breast cancer has become the most common cancer among females

since 1993. In 2011, there were 3419 newly diagnosed cases while there were just

1152 in 1993. Some patients were even below 20. The warning rising trend has

shown the necessity of teaching the public of effective preventive measures to

breast cancer (Hong Kong Department of Health, 2013)

2

In Chinese society, people used to neglect the importance of preventive care. They

do not perceive the primary care of breast screening is a necessity. In comparison

with the western women, Chinese women were less likely to participate in

prevention activities (Kwok et al., 2009; Kwok & Sullivan 2007). Knowledge, attitudes

and belief were contributed to the phenomenon (Chen, 2009). Under this

phenomenon, even though mammography and clinical examination are available to

screen breast diseases in many hospitals and clinics, they look expensive and

time-consuming to the general public. In the other hand, breast self-examination

(BSE) is a simple, cost-free and friendly way to screen breast diseases (Lam et al.,

2008). Smith (2003) has found that regular BSE can help early detection of breast

cancer with palpable breast lesions. The easy friendly technique allows the middle

class or low income family to approach the preventive measures of breast diseases.

The early detection of breast tumour can definitely relieve the pain and complication

brought along with treatment of breast cancer such as chemotherapy, radiotherapy

and lymphoedema (Michealson et al., 2003). Teaching of the BSE technique can be

done by health professionals to the public. Though the education program, we can

raise breast awareness among women (Shen et al., 2005).

3

1.2 Affirming Needs

Studies (Eskelinen & Oilonen, 2010; Micheal et al., 2009) have shown that women

under stress are more prone to have breast cancer. In Hong Kong, most of women

have to work even after marriage. Therefore, the potential of getting breast cancer is

higher with the large amount of women labour force. This has shown the need to

promote ways to have early detection of breast disease. And the program should be

flexible which allows women to take part in after the busy working hour.

According to the Legislative Council Secretariat of Hong Kong (2014), the

Government is trying to promote the development of private hospitals which help to

relieve the burden of Hospital Authority. Not only in secondary healthcare services,

but also the primary healthcare services. It is because preventive care is the best way

to promote patient’s outcome and save the expenditure of government. Therefore,

private hospitals in Hong Kong have the mission, especially for those not-for-profits

ones to promote the primary healthcare services in Hong Kong.

A not-for-profit private hospital in Hong Kong has a Breast Care Centre which

cooperates with wards in the hospital to provide a variety of screening and surgical

opinions to inpatients or out patients. The service provided is mainly focused on the

secondary care. It includes advanced practice nurse individual counseling service on

post-operative wound care and some education talks on latest breast cancer

4

treatment by doctors. However, there is lack of primary health education programs in

the Centre. Only pamphlets for health promotion and occasional health talks are

available in the Centre. The burden of APN and doctor are so heavy that she needs to

spend most of her time on individual service but not group education. Besides, there

is no noted protocol or evidence-based guidelines present in the centre as a

reference for breast health promotion. There is a need to establish a reliable protocol

to ensure the consistence of the education program and relieve the burden of

doctors and other health care staff. In order to balance the expenditure in the private

hospital, a low cost program fee should be charged but not discouraging the

participants.

According to American Cancer Society (2014b), women at the age over 40 is

recognized as the high risk group of breast cancer. They are recommended to have

breast cancer screening every year. Nevertheless, a local study (Lui et al., 2007)

revealed that there is a low participation rate in breast diseases screening since

Hong Kong has no population screening which organized by the government that all

women after certain age are invited to participate. People have to pay for the

screening in private clinics or hospital.

In order to reduce the modality of breast cancer, we have to raise the awareness of

breast cancer among women and encourage them to have regular breast diseases

5

screening. The knowledge deficit on the risk factors of breast cancer and

mammography contribute to the high modality rate of breast cancer in Hong Kong.

However, a study (Chua et al., 2005) showed women in Hong Kong neglected the

importance of regular screening and they were not familiar with the skills of breasts

self examination (BSE) which is an effective technique to screen breast diseases

(Norman & Brain, 2005). The sensitivity of detection was not related to patient age,

menopausal status, the size of breast, the depth of lesion. The accuracy of self

detection has no relationship with family history of breast cancer, pervious hormonal

therapy, breastfeeding status and use of contraceptive pills. Patients could detect as

small as 0.5mm lesion by palpation (Lam et al., 2008). Some studies (Baxter, 2001;

Kartic, Lang & Budak, 1996) argued that teaching BSE might leads to many

unnecessary biopsies and increases in medical expenses. Nonetheless, more than

75% of malignant breast lesion could be detected by patients themselves with

self-examination (Coates et al., 2001; Lam et al., 2008). Compared with the expenses

spent on the breast lesion biopsies and treatment on breast cancer (e.g.

chemotherapy, surgery, etc.), patients have to spend much more when they are

diagnosed of breast cancer. The treatment also brings along with the pain and side

effects (e.g. nausea, loss in appetite, lymphoedema, hair loss).Thus, regular BSE

practice leads to early diagnosis of breast cancer can promote better patient

6

outcomes. In the education program, they were taught with the nature of breast

lesion and the presenting symptoms of abnormal breast cancer such as mastaglia.

There would be an enhancement on knowledge of breast diseases and breast

awareness among public by teaching BSE (Liu et al., 2010).

A study showed (Secginli & Nahcivan, 2011) that the accessibility and the

convenience are the two main reasons for people to have health screening. However,

for BSE, people can perform by themselves at anywhere. In the long run, as

healthcare professionals, we should provide BSE education problem so as to

promote a better patient outcome. A local study showed that people were more

satisfied with service in private clinics than in GOPCs (Wong et al., 2010). Education

program held by private sectors are more preferable by patients. Organizing BSE

education program can also promote the clinical screening examination in the

hospital which the service are available nearby.

The better prognosis of patients with breast cancer has no doubt to relieve the

clinical workload of healthcare staff and the burden of hospital. Therefore, the BSE

practice can benefit not only the patients, but also the nursing staff and the hospital.

Nonetheless, there are limited studies reviews on the effectiveness of breast self

examination education program on increasing the BSE practice for women over 40s.

7

In the reviews of recent high quality studies, an evidence-based guideline is aimed to

be established to provide BSE education program in a local private hospital.

8

1.3 Objectives & Significance

Research question:

In the women over 20 years old, is the education program on breast self examination

(BSE) can increase the number of women having regular BSE

Research hypothesis:

Women will perform regular breast self examination (BSE) after the BSE education

program

Inclusion criteria:

1. Female aged over 20

2. Women with all background including those are pregnant, breastfeeding or after

mastectomy

3. No financial difficulties on paying the program fee

Exclusion criteria:

1. Male clients

2. Clients with financial problems that cannot support their program fee

(Referrals to government clinic will be given)

9

Since we perceived the need of the evidence-based education program on using

breast self examination to screen breast diseases, this dissertation is aimed to:

1. Increase the number of clients to perform regular BSE

2. To systematic evaluate the latest significant evidence on using breast

self examination to screen breast diseases

3. Develop an evidence-based protocol for a program of teaching women who

are over 20 on using breast self-examination

4. To evaluate breast self examination education program to increase

proficiency of BSE by follow up the clients

The dissertation tried to critique the latest evidence by using literature review on the

effectiveness of teaching women to have breast self examination. In order to

increase the popularity of using BSE among women and increase the public

awareness of breast cancer, a plan of implementation and evaluation on the

education problem in a local private hospital would be developed. From the patients’

perspectives, learning BSE allows them to detect the breast lesion effectively by

themselves and have better patient’s outcome. It is also beneficial to the

development of education program in the Breast Care Centre. For healthcare

professionals, we can teach and answer the enquiry on BSE comprehensively. An

10

evidence based protocol allows the consistence on the content of education program

based on latest high qualities studies. That means, we would not waste time to make

individual counselling on BSE but group education. This results in decrease in daily

workload. In long term, the development of BSE education program will be

corresponded to the direction of development of primary health care service in the

hospital. So the evidence-based guideline would benefit the development of hospital

11

CHAPTER 2

CRITCAL APPRAISAL

2.1 Search & Appraisal Strategies

2.1.1 Identification of studies

In order to identify the latest significant studies, three electronic databases including

‘Pubmed’, ‘Ovid’ and ‘Cochrane Library’ were used on 10th November, 2014. Used

search keywords were ‘breast diseases’ and ‘self examination’ which only

included those full-texts English randomized controlled trials conducted in the last 10

years. Duplicated studies were then eliminated. Results were screened on its titles

and abstracts thoroughly to match the aim of our dissertation.

Inclusion criteria:

1. Design of the studies must be randomized controlled trials

2. The intervention was the breast self examination education

3. The outcome measure included breast self examination

4. The target participants were women who were physically capable to perform

breast self examination

Exclusion criteria:

1. Studies in languages other than English

2. Studies concerning mammography and clinical breast examination

12

3. Studies measuring the level of knowledge on breast cancer.

2.1.2 Data Extraction

The full texts of the eligible studies were reviewed and 5 studies were found to be

able to fulfill the criteria above. In order to make further analysis, data were

extracted in the table of evidences (Appendix I) which included the study design,

characteristics of patients, intervention and comparison, length of follow, outcome

measures and effect size.

2.1.3 Appraisal Strategies

The tool for critical appraisal used in this dissertation was the Scottish Intercollegiate

Guidelines Network (SIGNS) (2012). Checklists included 2 parts which the internal

validity was assessed in the first part while the overall assessment of the study and

the level of evidence were assessed in the second part. This tool concerns mainly on

the study question, the randomization of samples, concealment method, methods of

allocation, intention to treat, and analysis tool. The less bias noted in the study, the

higher would be the level of evidence. The level of evidence would then be shown in

the table of evidence in the appendix I. Therefore, the SIGNS checklist which shown

in Appendix II is a convincing methodology to rate the quality of the study.

13

2.2 Results

2.2.1 Search Results

The search was done from 21st July 2014 to 10th November 2014. 28 randomized

controlled trials were found from the latest 10 years in the three electronic

databases chosen. By briefly screening on the title and their abstracts, applying the

inclusion and exclusion criteria, only five good quality studies were noted. They were

extracted by screening on participants, interventions and outcome measures with

the elimination of duplicated findings. The excluded studies included the education

focused on the importance of mammography, dietary advice as the only preventive

care, or teaching knowledge on several cancers in a single program. The following

flow chart illustrated the steps of search and screening in the selected three

electronic databases (figure 1).

14

Figure 1. Flow chart of search

Database

Steps

PUBMED Ovid(MEDLINE, Embase,

Joanna Briggs Int EBP)

Cochrane Library

1. Keywords:

‘breast diseases’ AND

‘self examination’

801 181 2

2. Limit to RCTs 71 114 2

3. Limit to full texts 31 32 2

4. Limit to latest 10

years

28 8 1

5. Apply selection

criteria

5 2 0

6. Elimination of

duplicated studies

5

Number of eligible

studies 5

15

2.2.2 Study Characteristics

The five eligible studies were conducted from 2009 and 2011 in China (Liu et al.,

2010), Turkey (Secginli & Nahcivan, 2011; Gucuk & Uyeturk, 2013), the United States

(Lindberg et al., 2009) and Iran (Hajian et al., 2011). All five RCTs included breast self

examination in the intervention where there was also a comparison program

without BSE technique education. The comparison group used varies which included

dietary intervention of breast cancer, preventive care of various cancers, general

healthcare information except breast health, etc. The control group of Gucuk &

Uyeturk (2013) included education of the importance of BSE and BSE practice but no

proper instruction of BSE technique by health professionals. BSE practice was

included in outcome measures of all 5 studies. The target participants of four studies

were women around 40 while one focused on those women with family history of

breast cancer. The chosen length of follow up was different. The length of follow up

also varied. Two studies (Liu et al., 2010; Lindberg et al., 2009) followed up the

subjects after 12 months whereas others were followed up ranged from 3 to 6

months after. Two of the studies (Secginli & Nachivan, 2011; Gucuk & Uyeturk, 2013)

also included BSE proficiency apart from BSE frequency as the outcome measures. As

a result, a summary of study characteristics was elaborated in the table of evidence

(Appendix I).

16

2.2.3 Methodology Issues

The SIGNS checklists attached in appendix II were used to assess the quality of the

methodology. Among the five selected studies, three studies were high quality (Liu

et al., 2010; Secginli & Nahcivan, 2011; Lindberg et al., 2009) when two of them were

classified in moderate quality (Hajian et al., 2011; Gucuk & Uyeturk, 2013).

All five RCTs addressed appropriate and clearly focused questions. For the

randomization method, all five studies claimed their samples were randomly

allocated. However, two studies (Lindberg et al., 2009; Gucuk & Uyeturk, 2013) did

not clarify the way to achieve randomization while one (Hajian et al., 2011) used

computerized randomization and the other two (Liu et al., 2010; Secginli & Nahcivan,

2011) used random number generation. Regarding concealment method, all five

studies could not achieve it. It might due to the intervention was an education talk

which needed researcher to deliver a designed program so they could not be

concealed during the studies. About the blinding method, only one study (Lindberg

et al., 2009) stated the investigators were blinded during data collection when other

four did not report it. Among five studies, the sample size was similar between

intervention group and comparison group. Also, the demographic factors including

educational level, marital status and the treatment used in control group had no

significant differences. Four studies (Liu et al., 2010; Secginli & Nahcivan, 2011;

17

Lindberg et al., 2009; Gucuk & Uyeturk, 2013) tried to provide a similar duration

education program in the comparison group while one (Hajian, et al., 2011) just

offered information from healthcare provider as routine care but no education.

All relevant outcomes in five studies were measured in a standard, valid and reliable

way. The participants were recognized to have regular BSE practice when they

performed at least monthly which was suggested by World Health Organization. Still,

there were limitations by using questionnaires which were relied on self report. One

study (Secginli & Nahcivan, 2011) investigated the BSE proficiency by using BSE

Proficiency Rating Instrument (BSEPRI) developed by Wood (1994) which measured

both the inspection and also the palpation skills. Gucuk & Uyeturk (2013) did not

state clearly on the model used in assessing the BSE technique accuracy. It just

claimed the participants were scored with their BSE practice under the supervision of

health professionals. Higher scores indicated higher accuracy. The drop out rate of

five studies was more or less the same, around 10% which was acceptable. However,

Gucuk & Uyeturk (2013) didn’t include the drop out rate in the study since they

excluded those subjects if they could not come back for all 3 interviews. Bias existed

here since the subjects didn’t complete the 3 follow up were not counted in the

results and the reasons of drop out were not investigated. None of studies

18

mentioned the intention-to-treat issues in the analysis and there was only one study

(Liu et al., 2010) implemented in more than one site.

19

2.3 Summary & Synthesis

All five identified studies shown significant increase in practicing regular breast self

examination after BSE education program. They all reported that the subjects got

increase in breast cancer knowledge as well. All of them used Health Belief Model in

the study which tried to decrease their barriers to screening and increase their

susceptibility to breast cancer and benefits of BSE and regular screening though

education. If they believe working on BSE can make them healthy, their awareness

on breast cancer would increase.

Four studies (Lindberg et al., 2009; Secginli & Nahcivan, 2011; Hajian et al., 2011;

Gucuk & Uyeturk, 2013) collected their subjects in places they could approach

conveniently. They collected the samples from the first degree relatives of patients

in one hospital, the parents of primary school next to a health care center, members

from a health organization or women recruited in a family practice clinic. They

conducted the studies in only one setting. This limited the generalizability of the

studies. Only one study (Liu et al., 2010) tried to collect samples in 4 different

districts and compared the difference of change in knowledge of breast cancer and

BSE practice in the urban and suburban area after the education program. Thus,

result of the study was more representable to the general public and more feasible

to apply the intervention in other areas.

20

The longer is the length of follow, the more valid is the data represented the

intervention. One of the identified studies (Hajian et al., 2011) followed up the BSE

practice of participants 3 months after the education. It’s difficult to judge if the

subject had regular BSE or not since the length of follow up was really too short. The

other three studies (Liu et al., 2010; Secginli et al., 2011; Lindberg et al., 2009) used 6

months or 12 months as the length of follow up. These outcome data were more

representable as it could show if subjects could have BSE consistently after the

intervention. Gucuk & Uyeturk (2013) and Secginli & Nachivan (2010) had followed

up the samples twice after education program by face to face interview and

telephone call respectively. Reinforcement was given in the first follow up which

allowed the health professionals to correct the misunderstanding and wrong

technique in BSE after they started their BSE practice at home. The follow-up also

could act as a reminder to participants to have regular BSE examination. But the

other three studies provided no follow-up calls for problem-solving.

A good education program should be conducted through multi-media. It would make

the session become more interesting and information taught would be more

memorable to participants. All five eligible studies (Liu et al., 2010; Lindberg et al.,

2009; Secginli & Nahcivan, 2011; Hajian et al., 2011; Gucuk & Uyeturk, 2013)

approached the subjects in group which the contents of the program were similar.

21

They used PowerPoint lecture and video to talk about risks of breast cancer,

importance of regular screening and the technique of BSE. All of them used breast

model for practice of BSE except one (Hajian et al., 2011). A sample of model to

practice could allow share of experiences in learning proper BSE and learnt from the

errors from others. All programs conducted in the study could make around 20%

increases in practicing BSE regularly among subjects.

Small group education can produce a stronger effect on practicing regular BSE than a

large group teaching session. And a follow-up telephone call reminder could also

give effectively remind the subjects to do the practice and answer their enquiry after

they start to practice. There was much larger effect size in one study (Lindberg et al.,

2009) which was more than double, over 46% more in doing BSE. The difference

might due to the individual education session rather than group education in the

other studies. Lindberg et al. (2009) provided a 30- to 45-minute individual

counseling session to teach breast self examination to the participants one by one

while group education in others (Liu et al., 2010; Secginli & Nahcivan, 2011; Hajian et

al., 2011) which lasted at least 1 hour. However, Gucuk & Uyeturk (2013) didn’t

mention the duration of program. The first part of program used to be watching

video about BSE and the second part was the practice with silicon models. This

allowed the instructor to be able to solve the barriers of participants independently.

22

BSE education program could significantly raise the public awareness to breast

cancer. This could be achieved by increasing the knowledge of breast cancer and

susceptibility to breast cancer. Most of the studies (Liu et al., 2010; Hajian et al.,

2011; Lindberg et al., 2009; Gucuk & Uyeturk, 2013) showed the education program

could decrease the perceived barriers to BSE. But this didn't apply on Secginli &

Nahcivan (2011). This study explained it might due to the assessment of BSE

proficiency. Participants might find it more difficult to perform BSE correctly after

the assessment and finally had less confident to do BSE. Still, the study had shown

people have increased in BSE proficiency after the education session. They were

more capable to grasp BSE technique and detect the mass or abnormal tissue by

BSE. Moreover, no matter what we assessed the BSE proficiency or not, education

could help to have stronger perception of confidence in performing BSE, stronger

perception of benefits to BSE.

Gucuk & Uyeturk (2013) provided BSE information and practice for both control and

intervention group. The only difference was the education of proper technique by

health professionals. For intervention group, the palpitation skills were corrected in

the first and second interviews while there was no correction in the control group.

The result was interesting that the increase in regular BSE practice were more or less

the same in both groups. That means, no matter what kinds of ways to reinforce BSE

23

education, the number of people having BSE practice would still increase.

Nevertheless, those in the intervention group had better BSE skills than the control

group. Therefore, education given by health professionals is necessary to ensure the

proper practice. This could avoid the missed palpable breast lesion with wrong

technique.

Apart from knowledge on breast cancers and BSE frequency, researchers also tried

to find out if the intervention could decrease the perceived barriers to mammogram

and clinical breast examination. The results varied among four identified studies (Liu

et al., 2010; Hajian et al., 2011; Lindberg et al., 2009; Secginli & Nahcivan, 2011)

while it was not measured in Gucuk & Uyeturk (2013). They believed the barriers

could be decreased by the accessibility and low price to the examination. These

seem to be the biggest concerns to have clinical breast diseases screening with

advanced medical machines and advices of health care professionals.

In conclusion, education program on using breast self examination was proven

effective in increasing public awareness of breast cancer, regular breast screening,

technique of breast self examination.

24

CHAPTER 3

TRANSLATION and APPLICATION

3.1 Implementation Plan

The systematic evaluation of five identified studies has shown the education

program on breast self examination (BSE) is an effectively way to promote the

practice. Still, the value of program implementation should be assessed in the local

setting before implementation. In order to determine whether the education

program is suitable, the implementation potential including the target setting,

transferability of the findings, feasibility of program and cost-benefit ratio of

innovation should be assessed. A clear illustrated evidence-based guideline could be

then developed.

3.1.1 Target audience/setting

The innovation is proposed in the breast care centre of a Hong Kong private hospital.

The centre provides various services including specialist consultation, surgical

opinions, breast screening and diseases management to clients. One breast care

surgeon, an advanced practice nurse, a registered nurse and a clerk are working in

the centre. In the hospital, there are four multi-purpose rooms with the capacity of

25

30-100 people available which allows healthcare staff or patients to gather for

various functions such as health talks and experience sharing.

Female clients who are financially capable to pay the program fee are all our target

audience. As we know, patients come over private hospitals are mostly financially

independent. No matter if they have any medical history or breast surgery are all

welcome to the program. Both inpatients and outpatients can also join the

education program.

3.1.2 Transferability of the findings

3.1.2.1 Suitability of innovation and similarity between the research studies and the

practice setting

In the target local hospital, the breast care centre used to have 16 to 20

consultations per day, about 70% is inpatients and 30% is outpatients. In 2013,

around 78% inpatients are 20 years old or above and 56% of them are females in a

mixed ward of the hospital. Education program found in literatures were all also held

within the hospital or the medical centres. The clinical settings were very similar.

Therefore, these studies’ findings could be applied on the target centre. Participants

in the identified studies included women aged over 40s (Liu et al., 2010; Secginli &

Nahcivan, 2011), aged over 40-70 (Lindberg et al., 2009; Gucuk & Uyeturl 2013) and

26

those with family history of breast cancer (Hajian et al., 2011). All involved a wide

range of female clients. Therefore, the target population in the research is

comparable to that in the proposed setting. The majority of patients are eligible to

join the program.

3.1.2.2 Philosophy of care

The philosophy of care underlying this innovation is similar to the philosophy

prevailing in the practice setting. The mission of the hospital is providing holistic

healthcare service to patients and the breast care centre was established in a view of

promoting breast health. They have to evaluate the current practice and system

constantly to improve their service. The proposed guideline offers an

evidence-based education program on breast self examination which is aimed to

promote regular and proper BSE practice. The practice will result in early detection

of breast lumps and early detection always leads to better prognosis. More and

more people will come to the hospital for primary breast healthcare rather than

tertiary care. Thus, compared with the people diagnosed of breast cancer in the late

stages, better prognosis is noted with early diagnosis (American Cancer Society,

2014a). Thus, the program could provide more primary healthcare service to general

public. A large number of people could benefit from the innovation.

27

3.1.2.3 Duration needed for the innovation

The program will take a reasonable time to implement and evaluate. One month is

required for training of the nursing staff, preparation of the materials and promotion

of the program within the hospital. A pilot program will follow right after the

preparation period which takes another one month for trail and amendment. Any

problem encountered in the pilot period will be evaluated and improvements will be

made after getting the feedback from audience and nursing staff. After two months

of preparation and pilot, the program will be implemented. Nursing staff is required

to have strict compliance on the proposed guidelines. Evaluation will be done by

following up the participants by telephone three months after and six months after

the program.

3.1.3 Feasibility

3.1.3.1 Administrative part

Nurses play important roles on running this program. Still, implementation of new

program in the target hospital involves approval of chief of service (COS). The senior

clinical manager (SCM) in outpatient department (OPD) who will be the project

director is needed to cooperate with the SCM in wards. A project organization

committee is formed by the project director, the APN and the RN in breast care

28

centre. The project director is in charge of evaluation of the program and has the

right to terminate the program when the outcome of program is undesirable. The

committees are responsible for the program implementation, promotion and follow

up participants. Most importantly, they need to train the trainer to carry out the

innovation.

The innovations require two one and a half hours training session for training the

trainers which involves principle of breast self examination and skills on giving health

talks. During the implementation period, one hour education program will be

conducted twice a week. All the extra time spent on the program training or

implementation will be counted as working hours. Since the program is conducted

after the working hours, it will not affect the daily routine of nursing staff.

As the program will be implemented in a private hospital, service quality and cost

are the biggest concerns. In fact, the hospital is very supportive to the

evidence-based practice and they are willing to change and standardize tools (e.g.

fall precaution charts, nursing care plan forms, etc) using in the hospitals. The great

success of the washing hand campaign and central electronic system are the good

example. In order to gain the administrative support, participants have to pay 30

Hong Kong dollars for the program fee which included two telephone follow ups.

Since the program will be implemented after normal working hour, the daily patient

29

service will not be affected. The program is welcome to all. Females who are not

patients in the hospital may also be attracted. This can increase the reputation of the

hospital and recruited more people to join our health screening.

3.1.3.2 Frontline Staff

The new program may be perceived as an extra workload to the nursing staff. Apart

from the busy daily routine work, they have to spend more time on running the

program. They may think the workload increased with less benefit to them. In order

to reward their effort, a certificate of completion of training session will be given to

them. The frontline staff is given the autonomy in the program and need not to be

released from other practice or activities for this program. Although they need to

work after the normal working hours, these will be counted as working hours.

3.1.2.3 Staff training and equipment

In the proposed program, nurses with well-performed BSE skills are needed to teach

and demonstrate to the audience. A comprehensive teaching material is needed to

train the trainers and also teach the audience. Since the program will be held twice a

week, ten trainers are needed. APN in the breast care centre will be in charge of the

two one and a half hours training-the-trainers sessions.

The teaching video can be found in http://www.mammacare.com/ which was

adopted in one of the identified studies (Liu et al., 2010). And we need two silicon

30

breast models for palpitation skills demonstration which are available in the breast

care centre. And the venue can be either one of the multi-purpose rooms in the

hospital.

In order to evaluate the education program, two follow up sessions will be done to

interview the clients if they perform regular BSE in the past few months after the

program. And researchers, the nurses, will try to answer the enquiries they have

during practicing BSE at home.

3.1.4 Cost-benefit ratio of innovation

General public is more likely to consult private hospitals rather than public hospital

because of the quality of care. The existing BSE education program held in NGO or

department of health is usually held in normal working hours. Since the proposed

education session will be held in private hospital which our target group is mostly

the working women, the program will be held after working hours which allows

them to join after their busy day. The flexibility of time is important to them. And a

small group education of 20 people is provided to ensure the effectiveness of BSE

education. Concentrated education by professional healthcare givers can relieve the

anxiety of performing BSE as well.

31

Currently, there is no BSE related program in the proposed setting. Nevertheless, the

hospital is eager to promote primary health and evidence based practice. The cost of

the innovation implementation will be acceptable as well.

i) material costs

Certain materials should be prepared for the program. Two silicon breast models can

be provided by breast care centre. The IT materials such as desktop and large screen

projector used during the training and program implementation are also available in

every multi-purpose room of the hospital. This could save a lot in preparation

expenses. Still, notes to the trainers and pamphlets with attached schedule to the

audience should be prepared. Details of the estimated material costs are illustrated

in Appendix III.

ii) non-material costs

Although the program will reward trainers with certificate and extra time needed

will be counted as working hours, the extra working hours may become the burden

to the frontline staff. Some unexpected absenteeism may occur. This may affect the

staff morale in the short term. Rearrangement of workforce or staff rotation is

needed to solve the manpower problem and share the workload.

32

3.2 Developing a EBP guideline

An evidence-based protocol is developed after the systemic reviews of five identified

studies. Although it is important to use the proper technique so as to detect the

breast lumps, the proposed evidence-based guideline is easy and friendly. The

recommendations are based on best evidence shown the BSE education program

can promote regular BSE practice. Summary of BSE education program protocol is

presented in Appendix VI.

Title: Breast self examination (BSE) education program

a) The objectives of this protocol are to:

1. Summarize the clinical evidence for education program on teaching BSE.

2. Formulate clinical practice instructions for the education program on BSE based

on the best evidence available.

3. Streamline and standardize the BSE education program provided in the breast

care centre.

b) Who the protocol for:

The protocol is used for supporting teaching proper and regular BSE in education

program held by registered nurses who are trained with BSE education giver

teaching session in Breast Care Centre.

33

c) Target patients:

Female patients who are 18 years old or above.

(Past medical history or breast related surgery is negligible)

d) Recommendation:

The level of evidence and grading of recommendation in the protocol is based on

grading system of Scottish Intercollegiate Guidelines Network (SIGNS) so as to

support the strength of evidence. (Appendix IV, Appendix V)

Recommendation 1

Education session should last about 1 hour.

Grade of recommendation: B

Evidence: The reviews of identified studies showed program lasts about 1 hour

was effective to teach proper concepts and BSE technique to the clients (Liu et al.,

2010; Gucuk & Uyeturl 2013; Hajian et al., 2011). One of studies (Secginli &

Nahcivan, 2011) needed 2 hours because they promoted not only BSE, but also

clinical examination and mammagraphy at the same time. In our case, only BSE is

promoted in the program. So one hour is worth enough.

Recommendation 2

The program should include multi-media approach such as PowerPoint, video,

pamphlets.

34

Grade of recommendation: A

Evidence: The audience feels refreshed with different media approaches. All

studies reviewed used various tools to present BSE (Liu et al., 2010; Gucuk &

Uyeturl 2013; Hajian et al., 2011 ; Secginli & Nahcivan, 2011; Lindberg et al.,

2009). For example, powerpoint lecture about breast diseases, video of BSE

demonstration and pamphlets of key points in the session.

Recommendation 3

The program should include not only general knowledge on breast diseases and

importance of early detection, but also BSE practices with breast models under

supervision.

Grade of recommendation: A

Evidence: All studies have included the knowledge of breast health and breast

cancer. Basic concepts are important for the audience to learn about meaning of

BSE. After knowing the importance of BSE, they had increased motivation to

proceed regular practice. Besides, fake breast models for demonstration and

redemonstration of BSE was effective to teach BSE skills (Liu et al., 2010; Gucuk &

Uyeturl 2013; Hajian et al., 2011 ; Secginli & Nahcivan, 2011; Lindberg et al.,

2009).

Recommendation 4

35

Take home pamphlet with attached schedule should be provided.

Grade of recommendation: A

Evidence: Availibility of take home leaflets were found in all identified studies (Liu

et al., 2010; Gucuk & Uyeturl 2013; Hajian et al., 2011 ; Secginli & Nahcivan, 2011;

Lindberg et al., 2009). They could be treated as reference when participants have

encoutered some common problems when practing BSE. Moreover, three studies

(Hajian et al., 2011 ; Secginli & Nahcivan, 2011; Lindberg et al., 2009) also

provided calender or schedule which was used as reminding patients to have

regular BSE. More participants have shown they had regular BSE practice after the

program.

Recommendation 5

The length of follow up should be at least 6 months after the program

Grade of recommendation: A

Evidence: The longer length of follow up showed higher significance of the

studies. Still, practical situation should be considered. Three studies (Liu et al.,

2010; Secginli et al., 2011; Lindberg et al., 2009) took 6 months or 12 months to

follow up the clients. Hajian et al. (2011) and Gucuk & Uyeturk (2013) followed up

the BSE practice of participants 3 months to 4 months after the education. It’s less

36

representable to say the subject had regular BSE due to the short length of follow

up.

Recommendation 6

Face to face follow up and reinforcement on BSE should be provided after the

program.

Grade of recommendation: B

Evidence: Face to face interview and telephone call follow up were given by

Gucuk & Uyeturk (2013) and Secginli & Nachivan (2010). They had followed up

the samples twice after the program. Reinforcement was also provided in the

follow up to let the nurses help solving the problems clients encountered during

their BSE practice at home. Besides, the follow-up could remind the clients to

have BSE practice.

37

CHAPTER 4

IMPLEMENTATION PLAN

After establishment of evidence-based guidelines with high quality studies, it is

necessary to develop a thorough implementation and evaluation plan before

commencement of the innovation. A communication plan can ensure effective

dissemination of the evidence-based protocol. The chapter of implementation plan

includes identification of the right stakeholder and a pilot testing which can access

the feasibility of proposed program. In evaluation, outcome identification, sample

size and criteria, ways of taking measurement, data analysis will be discussed.

4.1 Communication plan with potential users.

The success of innovation needs effective communication between stakeholders. A

good communication plan is therefore important for the program implementation.

4.1.1 Identification of the stakeholders

The support of stakeholders is necessary for implementation of the innovation. They

can be classified into three categories which are administration, management and

operation.

38

In this innovation, administrative level refers to the senior clinical manager (SCM) of

outpatient department (OPD) who are the highest authority in this innovation. They

have the rights for program approval and termination. They can also make decisions

on manpower arrangement to enhance the implementation of innovation. Other

members in organizing committee are at the managerial level. They are staff working

in the breast centre, the APN, the RN and the clerk who will be in charge of the

program management. In order to implement the innovation successfully, they are in

charge of train-the-trainers, resource allocation, pilot testing, program supervision

and evaluation. All program trainers and helpers belong to the operational level.

They are the main users of the evidence-based guidelines. They have to run the

programs and train our target group. Their skills and cooperativeness will play an

important role on the achievement of program outcome.

4.1.2 Process of communication

A good strategy on communication avoids unnecessary misunderstandings between

stakeholders. It is a key to the success of innovation. The timetable of

communication process is illustrated in Appendix VII.

In order to initiate the change, we should communicate with the administrative

stakeholders at the very beginnings. The significance of the innovation will be

39

presented to the COS and SCM in OPD. It can be shown by the fact that the hospital

has insufficient service on teaching breast self examination (BSE) and the latest

literatures provided evidences of its effectiveness. The approval can be only got after

they know what benefits the program can bring to the hospital and patients’

outcomes. After that, the SCM in OPD will be selected to be the project director

since she will coordinate with workforce and deal with problems on staff allocation.

Then she will form an organizing committee with the staff in breast care centre (BCC).

It is estimated to be completed in one week. Under this committee, ten more

registered nurses in the hospital will be invited to be the ambassadors of the

program. In the next 4 weeks, the committee will launch a train-the-trainers

programs toll ambassadors so as to let them understand the objective and

significance of the innovation. Most importantly, they have to know the proper way

to teach the technique of BSE. They can learn about the troubleshooting skills during

the program. Besides, the committee will have regular meetings for deciding

equipment arrangement and program promotion. A resource manual which will be

kept updated in the BCC and a pocket guide which serves as a reminder will be given

to the members in the project. This can limit the knowledge deficit problems among

those program cooperators.

40

The project ambassadors should be familiar with the guideline before a pilot

program implemented in the following 2 weeks. In the pilot period, two sessions of

one hour education program will be implemented. Each session will include 20

people. Two RNs of program ambassadors will be chosen to teach the program. The

pilot program aims to finds out flaws in the protocol and check if any improvement

can be made before the real implementation. The amended protocol will be used

after pilot program. The short, intermediate and long-term effects are set up for

evaluation on outcomes of patients, staff and system. Patients will be evaluated on

the knowledge of BSE and satisfaction level of the program and any comments for

improvements will be also collected. For the staff outcomes, assessment of nurses’

knowledge level, self-perceived skills and confidence will be conducted. Any

comments for program improvements will also be collected from both patients and

staff. To evaluate the system, comments on tools and resources provided, length of

program will be noted by questionnaires to staff and patients (Appendix IX, X). In

order to sustain the change process, revisions will be made if necessary which are

based on the evidence collected.

Audience of program will be recruited by posters and promotion in the hospitals.

They can be outpatients and inpatients in the hospital. Each attendant can get a

41

pamphlet with an attached schedule (Appendix VIII) which using pictures showing

proper BSE technique and key points needed to remember to practice BSE. The

schedule can be used as a reminder to have regular practice. A small group

education and practicing with silicon breast models can allow more interactions

between audience and trainers. Any enquiry raised can be solved face to face

immediately.

4.1.3 Pilot study plan

A pilot testing will be conducted which aims to screen any potential problems of the

innovation and assess the feasibility of the new evidence-based guideline. Finally, it

can help to evaluate the proposed protocol by feedbacks from coordinators

Revisions on guidelines can be also done with results of pilot study before

implementation of the change in our target setting. It can also avoid unexpected

problems during implementation.

4.1.3.1 Target population

Subjects will be recruited according to the inclusion and exclusion criteria set in the

guidelines. In the pilot program, 40 people will be needed. They can be inpatients, or

42

outpatients. Those women will be welcome to join the pilot BSE education program.

Any problems encountered by nurses have to be recorded.

4.1.3.2 Action plan

The APN in BCC will choose two trained registered nurses as the trainers in pilot

program. They will follow the proposed protocol and hold one session of BSE training

program every week in week 5 and 6. Assessment of patient knowledge level will be

done by giving questionnaires to women before and after the program. (Appendix IX)

Any comments noted would be discussed and evaluated by the committee.

4.1.3.3 Data collection

Pre- and post-program questionnaires including knowledge on BSE, frequency of

practice, comments on program will be used for data collection (Appendix IX). The

program ambassadors, the RNs will help to collect all these data including

demographic data of clients and input into SPSS for data analysis after each session.

Besides, staff morale like staff satisfaction and compliance of the guidelines will be

also taken into account by having questionnaire before and after the innovation.

(Appendix X)

43

4.1.3.4 Evaluation of the pilot study

In week 7 and 8, the APN and the RN in BCC will be responsible for the

computerization and analysis on results of the pilot study. Statistical Package for

Social Sciences (SPSS) will be used for statistical analyses. Any comments and

obstacles encountered in the pilot period will be evaluated so as to find out possible

solutions or suggestions for improvement on the guidelines before implementation.

Any refinements on protocol should be approved not only by the managerial

stakeholders but also by administrative stakeholders before the actual

implementation in week 9.

4.2 Evaluation Plan

An evaluation plan including outcomes identification and effectiveness assessment

of the innovation is preferred. It is developed to evaluate the BSE education

programs. Data and comments collected can therefore be used to refine the

guidelines.

4.2.1 Patients Outcome

It refers to assess the clinical benefits of the innovation. In the proposed protocol,

they are the knowledge of breast cancer and the frequency of BSE.

44

The aim of protocol is increasing number of clients practicing regular BSE, this will be

our primary outcome. The frequency of BSE is relying on the self report by clients

during follow up. According to five identified studies (Liu et al., 2010; Secginli &

Nahcivan, 2011; Gucuk & Uyeturk, 2013; Lindberg et al., 2009; Hajian et al., 2011),

there is an increase ranging from 17.8% to 82% in total number of clients having

regular BSE after teaching BSE. The innovation will be considered as successful if

over 50% of clients having regular BSE.

The knowledge of breast cancer will be assessed by five questions on self-perceived

skills before the program and during the follow-up. Higher mark in post-assessment

is regarded as improvement on knowledge. With the references of identified studies,

the program is defined as effective if over 60% of women get increase in breast

cancer knowledge.

4.2.2 Healthcare provider outcomes

Healthcare providers are the main operators of proposed guidelines. The outcome

measurement will be on their satisfaction rate, confidence level, the knowledge and

skills of BSE so as to assess the acceptance or compliance level of staff. The

assessment will be done by questionnaire before and after the program (Appendix X)

Increases in confidence, knowledge and skills are our expected outcomes. For the

45

satisfaction score, over 70% shows positive represents the program is beneficial to

the providers. Any concerns or comments will be also recorded for evaluation.

4.2.3 System outcome

In order to measure system effectiveness, utilization, human resources of the

innovation and costs are the outcome measures. A progress sheet is used for this

evaluation. The trainers have to complete it with their signature after the program. It

includes all the data collected in the program like the knowledge of breast cancer

and the proficiency of BSE practice. On the other hand, if the number of patients

recruited fulfils the target sample size, the utilization of innovation is considered

successful.

The majority of expense in the program is on manpower and photocopying. The

costs spent on the program should be balanced with the income made from the

program fee by participants.

4.2.4 Nature of clients to be involved

In the target setting, women who are over 20 and have no financial difficulties on

paying the program fee can be recruited. They can be pregnant, breastfeeding or

after mastectomy. Both inpatients and outpatients in the hospital are welcome. The

46

eligibility criteria are set up based on the identified evaluation studies. It should be

consistent to the developed guidelines.

4.2.5 Sample size

The sample size is important to decide the significance of study results. In this

innovation, the sample size is calculated by downloading software, ‘Java applets for

power and sample size’ (Lenth, 2010). Since there is only one proportion of sample in

the innovation, ‘actual value’ and ‘null value’ is needed for sample size calculation.

‘Actual value’ is the percentage of clients having BSE after the program

implementation while ‘null value’ is the current percentage of women having regular

BSE. According to a local study (Kwok & Fong, 2014), 33.3% of Hong Kong women

has regular monthly BSE. 33.3% will be used as the null value. The latest studies have

shown at least 17.8% increase in women having BSE after implementation of BSE

teaching program (Liu et al., 2010; Secginli & Nahcivan, 2011; Gucuk & Uyeturk, 2013;

Lindberg et al., 2009; Hajian et al., 2011). 50% will be taken as the actual value. The

sample size required is 63 with the power set to 80% and a level of significant set at

0.05.

47

4.2.6 Timing and frequency to take measurements

Different outcomes require different time and frequency of measurements. For the

outcomes of clients, the demographic data, frequency of BSE, and knowledge of BSE

will be collected right before program. After attending the program, clients will have

a telephone follow-up 3 months and 6 months after which will assess the frequency

of BSE and knowledge of BSE. The telephone follow up will collect the information of

clients on their frequency of BSE practice and also the reinforcement will be given to

clients for reassurance. Any problems encountered in the follow up will be tackled by

the nurses during the phone call. Short-term and long-term outcomes will be

assessed among staff. They will be first assessed after the train-the-trainers program

(week 6). Questionnaires will be distributed to evaluate their satisfaction rate,

confidence level, the knowledge and skills of BSE. After the implementation period

(month 8), those items will be measured again for long-term measurement with the

comparison of assessment before implementation. For the system outcomes,

cost-benefit ratio will be evaluated after the implementation period (month 8) as a

long-term measurement.

48

4.2.7 Data analysis

The data analysis will be conducted by the APN and the RN in BCC after data

collection. Statistical Package for Social Sciences (SPSS) will be utilized to make the

statistical analysis. With the data collected from the questionnaires, descriptive

statistics will be used to summarize the demographic characteristics and satisfaction

rate of clients. Besides, it will be used to summarize the staff outcomes including

their knowledge, confidence and satisfaction. With the reference of the latest

literatures, 50% of people having regular BSE practice are estimated after

implementation of the innovation. Change in percentage of people after attending

the program will be calculated by adopting two-tailed z-test which is used for testing

one proportion. In evaluation, 95% confidence interval will be used in reporting and

the level of significance will be taken as 5% in all statistical tests. Comments and

suggestions obtained should be analyzed by the organizing committee so as to make

refinements on proposed protocol. In order to determinate the cost-effectiveness,

expense spent on the program preparation and operation will be compared with the

income obtained from program fee paid by clients.

49

4.2.8 Criteria for Determining Guideline Effectiveness

Several requirements are set up to determine if the proposed program is effective.

After implementation of the proposed guidelines, number of women having regular

BSE is supposed to increase. Literature reviews have all shown the positive effect of

teaching BSE on percentage of women having BSE regularly. In our proposed

guidelines, at least 20% increase in the percentage of women is expected. At least

70% of women increase in knowledge of breast cancer is also supposed. On the

other hand, the healthcare providers should have increase in their knowledge,

confidence and satisfaction rate. By comparing the post-implementation

questionnaire with the pre-implementation one, 80% increase in BSE knowledge,

70% increase in confidence and satisfaction rate are expected. For the system

outcome, according to the budget plan, a totally amount of HKD9500 will be spent

for the innovation while each participant in the program will be charged with HKD30

(Appendix III). The program is supposed to recruit sufficient number of participants

so as to compensate the expense on program preparation and operation with the

program fee paid.

(9036 words)

50

Appendix I Evidence Table

Biblio

graph

ic

citati

on

Study

type

Evidence

level

Patient

characteristics

Intervention Comparison Length

of follow

up

Outcome measures Effect size

Liu, et

al.,

2010

RCT 1++ Age > 40

never

diagnosed

with breast

cancer

1 hr. program:

1. PowerPoint: breast cancer

& early screening

2. Video of BSE technique

3. Breast model for practice

Lecture:

knowledge and

behavior to

prevent various

kind of disease

12

months

1. regular BSE

practice

2.Knowledge on

BSE

1. Intervention : 25%

increased

Control: 5% increased

(p<0.001)

2. Intervention: 99%

Control: 59% (p<0.001)

Secgi

nli &

Nahci

van,

2011

RCT 1++ Age>40 2 hrs. Program:

1. breast health education,

video

2. BSE instruction, booklet,

calendar

General

information

except breast

health

6

months

1. regular BSE

practice

2. BSE proficiency

1. Intervention: 26%

Control: 9% (p<0.001)

2. Intervention: 69.5%

Control: 27.2% (p<0.001)

Lindb

erg,

et al.,

2009

RCT 1++ 40-70 yrs old 30-45mins individual session:

1. BSE instructions

2. practice with models

3. identify barriers to BSE

Dietary

intervention

12

months

1. regular BSE

practice

1. Intervention: 59%

Control: 12.2%

(p<0.001)

51

Biblio

graph

ic

citati

on

Study

type

Evidence

level

Patient

characteristics

Intervention Comparison Length

of follow

up

Outcome measures Effect size

Gucu

k &

Uyetu

rk

2013

RCT 1+ Age 20-49

Excluded

pregnant and

breastfeeding

women

Education of proper

technique of BSE

Reinforcement in 2

month follow up

Take home

pamphlets about

BSE after breast

cancer education

session

4 month Primary outcome:

1. Knowledge on BSE

Secondary outcome:

2. BSE practice

1. Intervention: 16.8%

Control: 12.7%

2. 17.8% more when

compared with the first

visit (p<0.05)

Gucu

k &

Uyetu

rk

2013

RCT 1+ Age 20-49

Excluded

pregnant and

breastfeeding

women

Education of proper

technique of BSE

Reinforcement in 2

month follow up

Take home

pamphlets about

BSE after breast

cancer education

session

4 month Primary outcome:

1. Knowledge on BSE

Secondary outcome:

2. BSE practice

2. Intervention: 16.8%

Control: 12.7%

2. 17.8% more when

compared with the first

visit (p<0.05)

52

Appendix II Quality Assessment of the Randomized Controlled Trial

Liu, et al.,

2010

Secginli &

Nahcivan,

2011

Lindberg, et

al., 2009

Hajian, et al.,

2011

Gucuk &

Uyeturk 2013

Section 1: Internal Validity

1.1 The study

addresses an

appropriate and

clearly focused

question

Yes Yes Yes Yes Yes

1.2 The

assignment of

subjects to

treatment

group is

randomised

Yes Yes Can’t say Yes Yes

1.3 An

adequate

concealment

method is used

No No No No No

1.4 Subjects

and

investigators

are kept 'blind'

about the

treatment

No No Yes No Can’t say

1.5 The

treatment and

control groups

are similar at

the start of the

trial

Yes Yes Yes Yes Yes

53

1.6 The only

difference

between groups

is the treatment

under

investigation

Yes Yes Yes Yes Yes

1.7 All relevant

outcomes are

measured in a

standard, valid

and reliable way

Yes Yes Yes Yes Yes

1.8 What

percentage of

the individuals

or clusters

recruited into

each treatment

arm of the

study dropped

out before the

study was

completed?

9% 12% 10% 10% Unknown

1.9 All the

subjects are

analysed in the

groups to which

they were

randomly

allocated(often

referred to as

intention to

treat analysis)

No No No No No

1.10 Where the

study is carried

out at more

than one site,

results are

comparable for

Yes Does not apply Does not apply

Does not apply

Does not apply

54

all sites

Section 2: Overall Assessment of The Study

2.1 How well

was the study

done to

minimise bias?

Code as follows.

High quality(++)

Acceptable(+)

Unacceptable-r

eject 0

++ ++ ++ + +

2.2 Taking into

account clinical

considerations,

your evaluation

of the

methodology

used, and the

statistical power

of the study, are

you certain that

the overall

effect is due to

the study

intervention?

Yes Yes Yes Yes Yes

55

2.3 Are the

results of this

study directly

applicable to

the patient

group targeted

by this

guideline?

2.4 Summarize

the authors'

conclusions.

And any

comments on

your own

assessment of

the study, and

the extent to

which it

answers your

question and

mention any

areas of

uncertainty

raised above.

Yes

Concealment and

blinding not

mentioned.

Study size and

result was

satisfactory. It

showed the

effectiveness of

BSE education

could raise the

awareness of

public and

increase regular

BSE rate

Yes

The study only

recruited the

subjects in the

primary school

next to the health

care center. This

might not be able

to represent the

situation of general

public. NO blinding

noted in the study

as well.

Yes

The study didn’t

mention clearly

about the

randomization of

the samples. Just

simply mentioned

the samples are

randomly assigned

to the intervention

and control group.

Yes

The study has

stated clearly the

concealment and

the random

allocation of

samples. However,

the length of follow

up was just

3months.

Yes

Bias found since

drop out rate was not

mentioned.

Researcher just

excluded those

subject in study size.

56

Appendix III Budget Plan of the Education Program on BSE

Items Cost (HKD $)

1. Rubber breast model x2 Free

2. Venue booking Free

3. Computer Free

4. Projector Free

5. Notes for training (20 copies, $1 each) $ 20

6. Posters for program promotion

(10 color copies, $2 each) $ 20

7. Pamphlets with attached schedule

(40 color copies, $2 each) $ 800

8. Evaluation form

(200 copies, $1 each) $ 200

9. Manpower

a. Training (1.5hr x2)

APN x1 ($200/hr)

RN x10 ($150/hr)

b. Implementation (1hr x20)

RN x10 ($150/hr)

600

4500

3000

Total 9500

Estimated income

1. Program fee ($30x 20ppl x20) 12000

NET BALANCE 2500

57

APPENDIX IV: SIGN Grading System 1999 – 2012 LEVELS OF EVIDENCE

GRADES OF RECOMMENDATIONS

At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating

overall consistency of results

A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall

consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall

consistency of results; or

Extrapolated evidence from studies rated as 2++

Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

Good practice points

Recommended best practice based on the clinical experience of the guideline development group

1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias

1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias

1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias

2++ High quality systematic reviews of case control or cohort or studies

High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the

relationship is causal

2+ Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the

relationship is causal

2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

3 Non-analytic studies, e.g. case reports, case series

4 Expert opinion

58

Appendix V Quality of the Identified Studies

Reviewed literatures Grading

Liu et al., 2010 1++

Secginli & Nahcivan, 2011 1++

Lindberg et al., 2009 1++

Hajian et al., 2011 1+

Gucuk & Uyeturk, 2013 1+

59

Appendix VI Summary of the Breast Self Examination (BSE) Education Program

An evidence-based guidelines on Breast Self Examination (BSE) education Program

Protocol user: Registered nurses trained with BSE education giver teaching session

by Breast Care Centre.

Target audience: Females who are 20 years old or above.

(Past medical history or breast related surgery is negligible)

Stages Recommendation Grading of

Recommendation

During the program Education session should last about 1 hour. B

The program should include multi-media

approach such as PowerPoint, video,

pamphlets.

A

The program should include not only

general knowledge on breast diseases and

importance of early detection, but also BSE

practices with breast models under

supervision.

A

After the program Take home pamphlet with attached

schedule should be provided. A

The length of follow up should be at least 6

months after the program A

Face to face follow up and reinforcement

on BSE should be provided after the

program.

B

60

Appendix VII Communication Plan with Timeline

Process Task Description Organizers Targets Week Month

1 2 3 4 5 6 7 8 3-------7 10 13

PREPARATION Program Approval APN and RN in BCC COS

SCM (OPD)

V

Organizing

Committee

Formation

SCM (OPD)

APN and RN in BCC

Staff in BCC V

Ambassadors

recruitment

Organizing Committee Registered

Nurses

V V

Train-the-trainers

program

Organizing Committee Program

Ambassadors

V V V V

Program

Promotion

Organizing Committee Clients V V V V

PILOT Pilot Program Organizing Committee and Program Ambassadors

Clients V V

Evaluation Organizing Committee and Program Ambassadors

Clients V

IMPLEMENTATION Program

Implementation

Organizing Committee and Program Ambassadors

Clients V

Follow-up Organizing Committee Clients V V

EVALUATION Patients Outcomes Organizing Committee Clients V V

Staff outcomes Organizing Committee Program

Ambassadors

V

System Outcomes Organizing Committee Hospital V

61

Appendix VIII Take-home Pamphlets with Attached Schedule

Breast Self Examination Training Program

‘Our Breast, Our Care’

Know how your breasts normally look Feel and report any breast change

promptly your health care provider Breast self-exam (BSE) is an option for

women starting in their 20s All information adopted from https://mammacare.com/

**BEAR IN MIND**

*EAST & FAST*

*DO IT MONTHLY

Circle the dates of BSE. *Practice regularly on monthly basis

62

Appendix IX Patient Survey

Questionnaire: Patient evaluation of the knowledge and satisfaction level

Name:_________________ Date:_________________

Age: □20-29 □30-39 □40-49 □50-59 □60-69 □>69

Please read carefully on the following instruction and circle the appropriate number for each statement.

The rating scale is as follows:

1. Strongly disagree 2. Disagree 3.Neutal 4.Agree 5.Strongly agree

Assessment of patient knowledge level

1) I understand the nature of breast cancer 1 2 3 4 5

2) I understand the risk factors and prevention of breast cancer 1 2 3 4 5

3) I am clear about the screening method of breast cancer 1 2 3 4 5

4) I know the needs of having breast self-examination (BSE) well 1 2 3 4 5

5) I know the ways to do BSE 1 2 3 4 5

Assessment of patient satisfaction level towards the program

1) I am clear what the program expected me to learn and achieve 1 2 3 4 5

2) The program is well-organized in helping me to achieve 1 2 3 4 5

3) I am able to practice BSE after the program 1 2 3 4 5

4) I learn more about breast cancer after the program 1 2 3 4 5

5) I learn more about BSE after the program 1 2 3 4 5

6) Appropriate teaching materials (pamphlets, model) were used. 1 2 3 4 5

7) The nurses are knowledgeable and understand patients’ needs. 1 2 3 4 5

8) The program fee is reasonable and worth 1 2 3 4 5

9) The nurses are approachable whenever need. 1 2 3 4 5

10) Overall, I am satisfied with the program 1 2 3 4 5

Other Comments:

1. What are the best things about teaching program?

_____________________________________________________________________________

2. What things related to the conductor’s teaching could be improved?

_____________________________________________________________________________

63

Appendix X Staff Survey

Questionnaire on Evidence-based exercise training program

(Evaluation of nurses’ knowledge, confidence and their satisfaction level)

Please read carefully on the following instruction and circle the appropriate number for each statement.

The rating scale is as follows:

2. Strongly disagree 2. Disagree 3.Neutal 4.Agree 5.Strongly agree

Assessment of nurses’ knowledge level, self-perceived skills and confidence

1) I understand the nature of breast cancer 1 2 3 4 5

2) I understand the risk factors and prevention of breast cancer 1 2 3 4 5

3) I am clear about the screening method of breast cancer 1 2 3 4 5

4) I know the needs of having breast self-examination (BSE) well 1 2 3 4 5

5) I know the ways to do BSE 1 2 3 4 5

6) I have confidence in teaching BSE 1 2 3 4 5

7) The skills and instruments used in the program were known 1 2 3 4 5

8) I find no problem on communicating with organizing committees 1 2 3 4 5

9) I am able to cope with difficulties encountered in the innovation 1 2 3 4 5

10) I am able to manage the time and workload caused by the innovation 1 2 3 4 5

Assessment of nurses’ satisfaction level

1) The content of the program is well-organized 1 2 3 4 5

2) The duration of the innovation is appropriate 1 2 3 4 5

3) The timeslots of program are appropriate. 1 2 3 4 5

4) The venues of program are appropriate 1 2 3 4 5

5) The program materials prepared well with clear instructions provided. 1 2 3 4 5

6) The resources provide are sufficient 1 2 3 4 5

7) I achieved what the program expected me to teach 1 2 3 4 5

8) I am able to cope with the program workload and the difficulties

encountered during implementation

1 2 3 4 5

9) I’ve found no difficulties in seeking help from the organizing committee 1 2 3 4 5

10) Overall, I am satisfied with the innovation 1 2 3 4 5

Other Comments:

1) What is the best thing of the program?

_______________________________________________________________________________

2) What is the most difficult thing when you carry out the innovation?

_______________________________________________________________________________

64

3) What do you think the innovation should be improved?

_______________________________________________________________________________

4) Any other comments:

_______________________________________________________________________________

65

Appendix XI PRISMA 2009 Flow Diagram

Iden

tifi

cati

on

Records identified through

PUBMED

(n = 801 )

Records identified through

Cochrane Library

(n = 2 )

Records identified through Ovid

(MEDLINE, Embase, Joanna Briggs Int EBP)

(n = 181 )

Records after duplicates removed

(n = 801 )

Scre

enin

g

Records screened

(n = 32 )

Records excluded

(n = 769 )

Elig

ibili

ty

Full-text articles assessed

for eligibility

(n = 5 )

Full-text articles excluded,

with reasons

(n = 27 )

Studies included in

quantitative synthesis

(meta-analysis)

(n = 5 )

Incl

ud

ed

66

Reference:

1. American Cancer Society. (2014a). Breast cancer survival rates by stage. Retrieved August, 30, 2014,

from http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-survival-by-stage

2. American Cancer Society. (2014b). American Cancer Society recommendations for breast cancer

early detection in women without breast symptoms. Retrieved August, 30, 2014, from

http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-

early-detection-acs-recs

3. Baxter, N. (2001). Canadian Task Force on Prevention Health Care: Preventive health care, 2001

update: should women be routinely taught breast self-examination to screen breast cancer? Canadian

Medical Association Journal, 164(13), 1837-1846.

4. Chan, S.S.C., Chow, D.M.K., Loh, E.K.Y., Wong, D.C.N., Cheng, K.K.F., Fung, W.Y.C., Cheung, P.S.Y.

(2007). Using a community-based outreach program to improve breast health awareness among women in

Hong Kong. Public Health Nursing. 24(3). 265-273.

5. Chen, W.T. (2009). Predicators of breast examination practices of Chinese immigrants. Cancer

Nursing, 32(1), 64-72.

6. Chua, M. S. T., Mok, T. S. K., Kwan, W. H., Yeo, W., & Zee, B. (2005). Knowledge, perceptions, and

attitudes of Hong Kong Chinese women on screening mammography and early breast cancer management.

The Breast Journal, 11(1), 52-56.

7. Coates, R. J., Uhler, R.J., Brogan, D.J., et al. (2001). Patterns and predicetors of breast cancer

detection methods in women under 45 years of age (United States). Cancer Causes Control, 12, 431-442.

8. Coleman MP et al. (2008). Cancer survival in five continents: a worldwide population-based study

(CONCORD). Lancet Oncology, 9, 730-756.

9. Eskelinen, M. & Oilonen, P. (2010). Life stress and losses and deficit in adulthood as breast cancer

risk factor: a prospective case-control study in Kuopio, Finland. In Vivo (Athens, Greece), 24(6), 899-904.

10. Gucuk, S. & Uyeturk, U. (2013). Effect of direct education on breast self examination awareness and

practice among women in Bolu, Turkey. Asian Pacific Journal of Cancer Prevention, 14(12), 7707-7711.

67

11. Hajian, S., Vakilian, K., Najabadi, K. M., Hosseini, J., Mirzaei, H. R. (2011). Effects of education based

on the health belief model on screening behaviour in high risk women for breast cancer, Tehran,

Iran. Asian Pacific Organization for Cancer Prevention. 12(1). 49-54.

12. Lam, W.W.M., Chan, C.P., Chan, C.F., Mak C.C.C., Chan C.F., Chong, K.W.H., Leung M.H.J., Tang M.H.

(2008). Factors affecting the palpability of breast lesion by self-examination. Singapore Medical Journal.

49(3). 228-232.

13. Legislative Council Secretariat. (2014). Development of private hospitals in Hong Kong. Retrieved

August,30, 2014, from http://www.legco.gov.hk/yr11-12/english/sec/library/1112in24-e.pdf

14. Liu, C. Y., Xia, H. O., Isaman, D. M., Deng, W., & Oakley, D. (2010). Nursing clinical trial of breast

self-examination education in China. International Nursing Review. 57(1). 128-134.

15. Lindberg, N. M.,Stevens, V. J., Smith, K. S., Glasgow, R.E., Toobert, D. J. (2009). A brief intervention

designed to increase breast cancer screening. American Journal of Health promotion. 23(5). 320-323.

16. Lui, C.Y., Lam, H.S., Chan, L.K., Tam, K.F., et al. (2007). Opportunistic breast cancer screening in

Hong Kong; a revisit of the Kwong Wah Hospital experience. Hong Kong Medical Journal, 13(1), 106-113.

17. Michaelson, J.S., Silverstein, M., Wyatt, J., et al. (2002). Predicting the survival of patients with

breast carcinoma using tumour size. Cancer. 95(1). 713-23.

18. Norman, P., & Brain, K. (2005). An application of an extended health belief model to the prediction

of breast self-examination among women with a family history of breast cancer. British Journal of Health

Psychology, 10, 1–6.

19. Katic, M., Lang, S., Budak, A. (1996). Evaluation of the general practice program of women

education for breast self-examination. Acta Med Croatia, 50, 185-191.

20. Kwok, C., Fethney, J. & White, K. (2010). Chinese Breast Cancer Screening Beliefs Questionnaire:

development and psychometric testing with Chinese-Australian women. Journal of Advanced Nursing,

66(1), 191-200.

21. Kowk, C. & Fong, D. Y. (2014). Breast cancer screening practices among Hong Kong Chinese women.

Cancer Nursing, 37(1), 59-65.

68

22. Kwok C. & Sullivan G. (2007). Health seeking behaviors among Chinese-Australian women:

implication for the health promotion programs. Health: An interdisciplinary Journal for the Social Study of

Health and Illness, 11(3), 401-415.

23. Lenth, R.V. (2010). Java Applets for Power and Sample Size [Computer Software]. Retrieved 5 May

2015

24. Michael, Y. L., Carlson, N. E., Chiebowski, R. T., et al. (2009). Influence of stressors on breast cancer

incidence in the women’s health initiative. Health Psychology, 28(2), 137-146.

25. Secginli, S., Nahcivan, N.O. (2011). The effectiveness of a nurse-delivered breast health promotion

program on breast cancer screening behaviours in non-adherent Turkish women: A randomised controlled

trial. International Journal of Nursing Studies, 48(1), 24-36.

26. Shen, Y., Yang Y., Inoue, L.Y., Munsell, M.F., Miller, A.B. & Berry, D.A. (2005). Role of detection

method in predicting breast cancer survival: analysis of randomized screening trials. J Natl Cancer Inst,

97(16), 1195-1203.

27. Smith, R.A. (2003). Commentry: Breast self-examination. British Medical Journal, 327(7418),

198-199.

28. Wood, R.Y. (1994). Reliability and validity of a breast self-examination proficiency rating instrument.

Evaluation & The Health Professions, 17(1), 418-435.