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
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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)
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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
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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
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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.
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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).
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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
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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).
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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.
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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
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