Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

PROFORMA SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. Name of the Candidate and Address Ms. DEEPA. S,1st YEAR M.Sc NURSING,ROYAL COLLEGE OF NURSING,7th MAIN ROAD, 1st BLOCK, UTTARAHALLI,BANGALORE- 560 061.

2. Name of the Institution Royal College of Nursing, Bangalore.

3. Course of study and subject 1st year M.Sc Nursing, Medical Surgical Nursing.

4. Date of admission to course01-06-2009.

5. Title of the Topic:

“A Quasi Experimental Study to Assess the Effectiveness of Self Instructional Module on Knowledge of Positive Life Style Modification among Patients with Gastro Intestinal Cancer at Selected Hospitals in Bangalore.”

6. Brief resume of the intended work:

6.1 Need for the study6.2 Review of literature6.3 Objectives of the study6.4 Operational definitions6.5 Hypothesis of the study6.6 Assumptions6.7 Delimitations of the study6.8 Pilot study

6.9 Variables

Enclosed Enclosed Enclosed Enclosed Enclosed Enclosed Enclosed Enclosed Enclosed

7. Materials and methods: 7.1 Source of data- Data will be collected from GI cancer patients who are admitted at selected hospitals in Bangalore. 7.2 Methods of data collection- Structured questionnaire. 7.3 Does the study require any interventions or investigation to the patients or other human being

or animals? No. 7.4 Has ethical clearance been obtained from your institution? Yes, ethical committee’s report is here with enclosed

2

8. List of References Enclosed

Rajiv Gandhi University of Health Sciences, Karnataka,

Bangalore.

PROFORMA SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. Name of the Candidate and Address Ms DEEPA. S,

IST YEAR M.Sc NURSING,

ROYAL COLLEGE OF NURSING,

7TH MAIN ,ROAD,1ST BLOCK,

UTTARAHALLI ,

BANGALORE- 560061

2. Name of the Institution Royal College of Nursing,

Bangalore- 560061.

3. Course of study and subject 1st year M.Sc Nursing,

Medical Surgical Nursing.

4. Date of admission to Course 01/06/2009

5. Title of the topic

“A Quasi Experimental Study to Assess the Effectiveness of Self Instructional Module

on Knowledge of Positive Life Style Modification among Patients with Gastro Intestinal

Cancer at Selected Hospitals in Bangalore.”

1

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“Cancer is a disease where the patient can contribute a great deal of help himself if he or she

can retain their morale and their hopes.”

George Carman

Cancer has afflicted humans throughout recorded history. It is no surprise that from the dawn

of history people have written about cancer. Some of the earliest evidence of cancer is found among

fossilized bone tumors, human mummies in ancient Egypt, and ancient manuscripts. Cancer was once

a word that people were afraid to speak in public, and people rarely admitted to being a cancer

survivor. The growth in our knowledge of cancer biology has led to remarkable progress in cancer

prevention, early detection, and treatment in recent years.1

The age old fear of cancer still persists; indeed relatively the image of cancer has grown more.

The cold knife and the hot rays really produce cures. Heartily a third of all patients with cancer are

now being saved as judged by the fact that they are still alive after five years of diagnosis. The fear of

cancer has doubtless been aggravated by the very necessary effort to combat it; educational

campaigns have been aimed at leading the public to recognized symptoms and to seek diagnosis early

enough for surgery or treatment to be effective.2

Gastro intestinal cancers accounted for 18.6% of new cases of diagnosed in the United States.

This represents to a total of 226,600 new cases and 129,800 cancer deaths. Progress has been made in

treating some of the GI cancers. But others remain difficult to control. Symptoms of many these

2

cancers are vague and non specific until advanced disease develops, which makes treatment difficult

and long term survival rates low. However prevention and early detection can reduce the impact of

the disease and prolong survival.3

Nurses have an important role to play in the prevention, early detection, diagnosis, and

treatment of GI cancers. In some instances, prevention and early detection are not possible, but

knowledge of the course of disease may improve the patient’s quality of life.

6.1 NEED FOR STUDY

“If you clean your body, your diet, your thoughts, your mind, your spirit, and your closest

environment, your body naturally cures cancer.”

Cancer rates could further increase by 50% to 15 million cases in the year 2020, also this

report provides healthy life style and public health action by governments and health practices could

stem this bend and prevent as many as one third of cancers worldwide (world health organization,

2000). There were 270,000 cases of gastrointestinal cancer anticipated in the United States in 2007,

with more than 134,000 deaths from gastrointestinal malignancies.4

Americans one in five will be at least 65 years older by the year 2030, and the incidence of

cancer is 11 fold higher in persons over 65; about 3.5% of American population is cancer survivors.

There are now over 10 million survivors in the United States and a great deal of attention is now

being directed to assist and support them after a diagnosis of cancer is made.5

Cancer is an important public concern in the United States and throughout the world, among

men the most common cancer is gastro intestinal cancer. Body weight and chronic medical condition

3

play more dominant roles in determining physical and mental health factors related to the initial

gastrointestinal cancer diagnosis. These factors will modify their levels of quality of life.

Gastro intestinal cancer is the first leading cause of cancer related deaths in men and second

among women in Iran. Gastrointestinal cancers are among the leading sites of cancer leading causes

of cancer related deaths. Gastrointestinal cancer incidence rates are much lower in India than

elsewhere, and it can occur to both sexes.6

The incidence rates of most digestive cancers in India are moderate or low. Certain forms of

chemotherapy plus supportive care improve both survival and quality of life in patients with

gastrointestinal cancer.

During the clinical experience the investigator found that most of the patients with

gastrointestinal cancer face difficulty in life style modification after cancer, due to lack of knowledge

and insufficient guidelines and modules. Hence the investigator felt that there are needs to make a

self instructional module with goal of making the patients gain sufficient knowledge about positive

life style modification.

6.2 REVIEW OF LITERATURE:

4

A literature review is a written summary of the state of existing knowledge on a research

problem. The task of reviewing research literature involves the identification, selection, critical

analysis and written description of existing information on a topic.7

A case control study was done in Division of epidemiology and Biostatics on stomach cancer

in Mumbai. Stomach cancer incidence rates are much lower in India than elsewhere, but the stomach

remains one of the 10 leading sites of cancer in both sexes in most of the metropolitan registries. The

purpose of the study was to identify the association of tobacco and alcohol use, occupational hazards,

diet, consumption of beverages like tea and coffee, the living environment, cooking media and

literacy with stomach cancer. The study included 170 stomach cancer cases and 2,184 hospital

controls interviewed during the period 1988-1992. Tobacco chewing, bidi or cigarette smoking and

alcohol drinking did not emerge as high risk factors for stomach cancer. Consumption of dry fish at

least once a week compared to never or once a every 2 weeks showed a 12-fold excess risk (OR =

12.4, 95% CI 7.0-22.1, p < 0.0001) for stomach cancer among the nonvegetarian food items

considered. A protective effect of tea consumption (OR = 0.4, 95% CI 0.2-0.9, p = 0.03), showing

59% reduction in risk, was identified, which could be of use for possible control and prevention of

this cancer.8

A hospital based case control study was done in Department of Gastroenterology, Coimbatore

on Risk factors for oesophageal cancer in Coimbatore, southern. The risk factors predisposing to

cancer in southern Indian patients are not known. The aim of the study was to determine the role of

smoking, alcohol and their combination, and diet factors in the etiology of cancer of the oesophagus.

Risk factors like alcohol consumption, smoking, tobacco chewing, and pre-illness diet details in 90

patients with cancer of the oesophagus were compared with those in age- and sex-matched control

subjects. The results showed that risk for oesophageal cancer was 3.5 times higher with alcohol

5

consumption, 2.5 times higher for tobacco users, and 2.8 times higher each for betel nut chewers and

smokers. The calculated odds ratio for the social habits and diet factors was significant amongst cases

of cancer oesophagus. The study concluded that alcoholism, smoking, and chewing of tobacco are

factors predisposing to oesophageal cancer in southern India.9

A study was conducted in College of Medicine University of Arizona regarding the obesity as

a risk factor for subsequent short interval development of adenomas. 2565 Subjects with base line

adenomas and follow up colonoscopy data were drawn from two randomized trials designed to

prevent adenoma recurrence. The results showed that obesity as a risk factor for subsequent short

interval development of adenomas particularly among men and persons with a family history of GI

tract cancer.10

A study was conducted in Department of Epidemiology University of Washington on low fat

dietary pattern and risk of cancer. The results showed that low fat dietary pattern intervention did not

reduce the risk of cancer.11

A study was conducted on Department of Physiological Science University, California USA,

regarding the prevention of cancer through life style changes. The study suggested that the life style

factor including smoking, the typical high fat refined sugar diet and physical inactivity account for

the majority of the cancer. Adopting a diet low in fat and high in fibre rich starch food, which would

also include an abundance of antioxidants combined with regular aerobic exercise might control

insulin resistance, thus reduce the risk for cancer.3

6

A study was conducted in National Office for Cancer Prevention and Control, China

regarding Incidence and mortality of gastric cancer in China. In China, based on two national

mortality surveys conducted in 1970s and 1990s, there is an obvious clustering of geographical

distribution of gastric cancer in the country, with the high mortality being mostly located in rural

areas, especially in Gansu, Henan, Hebei, Shanxi and Shaanxi Provinces in the middle-western part

of China. Despite a slight increase from the 1970s to early 1990s, remarkable declines in gastric

cancer mortality were noticed in almost the entire population during the last decade in China. These

declines were largely due to the dramatic improvements in the social-economic environment,

lifestyle, nutrition, education and health care system after economic reforms started two decades ago.

Nevertheless, gastric cancer will remain a significant cancer burden currently and be one of the key

issues in cancer prevention and control strategy in China. It was predicted that, in 2005, 0.3 million

deaths and 0.4 million new cases from gastric cancer would rank the third most common cancer. The

essential package of the prevention and control strategy for gastric cancer in China would focus on

controlling Helicobacter pylori (H. pylori) infection, improving educational levels, advocating

healthy diet and anti-tobacco campaign, searching for cost-effective early detection, diagnosis and

treatment programs including approaches for curable management and palliative care.12

A study was conducted Department of Preventive Medicine in Korea regarding the

relationship between intake of vegetables and fruits in carcinoma sequence. The sample consists of

162 cases with colo-rectal cancers and 2576 control were collected from Mercy Hospital. The results

of the study showed that the relationship between fruits and vegetables may reduce the

developmental steps of GI carcinoma.13

7

A study was conducted regarding Supportive care in cancer regarding nutrition in cancer

patients. The study reported that medical history, physical examination, estimates of daily oral intake,

weight changes and an approximate consideration of the nutritional requirements according to the

stage of disease must be assessed.14

A study was conducted in two major Military Centres in South Western United States

regarding the change in exercise tolerance, activity and sleep patterns and quality of life in patients

with cancer, participating in a structured exercise programme. The sample consisted of 62 patients.

The study reported that patients with various type and stage of cancer can safely use exercise to

realise significant improvement in sleep patterns and quality of life.15

A study was conducted in Cancer Institute, Chinese Academy of Medical Science Beijing

regarding the nutritional intervention trials in Linxian, China: Supplementation with specific

vitamin/mineral combinations, cancer incidence and disease specific mortality in the general

population. The sample consists of individuals of ages 40-69 were recruited in 1985 from four

Linxian communes. The subjects were randomly assigned to intervention groups according to a one

half replicate of a 24 factorial experimental design. The results showed that cancer was the leading

cause of death, with 32% of all deaths due to oesophageal or stomach cancer. The findings indicated

that vitamin and mineral supplementation of the diet of Linxian adults particularly with the

combination of beta carotid, vitamin E and selenium, may effect a reduction in cancer risks in

Linxian population.16

8

A qualitative study was conducted on returning to work following cancer into the experience

of returning to work following cancer. This study reported that more advice is required from health

professionals about returning to work, along with reasonable support and adjustments from

employers to ensure that cancer survivors are able to successfully reintegrate back into their work

force.17

A study was done on Low-fat dietary pattern and risk of colorectal cancer: the Women's

Health Initiative Randomized Controlled Dietary Modification Trial in Department of Epidemiology,

University of Washington, and Seattle. The objective of the study was to evaluate the effects of a

low-fat eating pattern on risk of colorectal cancer in postmenopausal women. The Women's Health

Initiative Dietary Modification trial, a randomized controlled trial conducted in 48,835

postmenopausal women aged 50 to 79 years recruited between 1993 and 1998 from 40 clinical

centres throughout the United States were the participants. Participants were randomly assigned to

the dietary modification intervention (n = 19,541; 40%) or the comparison group (n = 29,294; 60%).

The intensive behavioural modification program aimed to motivate and support reductions in dietary

fat, to increase consumption of vegetables and fruits, and to increase grain servings by using group

sessions, self-monitoring techniques, and other tailored and targeted strategies. The results showed

that a total of 480 incident cases of invasive colorectal cancer occurred during a mean follow-up of

8.1 (Standard Deviation of 1.7) years. Intervention group participants significantly reduced their

percentage of energy from fat by 10.7% more than did the comparison group at 1 year, and this

difference between groups was mostly maintained (8.1% at year 6). There were 201 women with

invasive colorectal cancer (0.13% per year) in the intervention group and 279 (0.12% per year) in the

comparison group (hazard ratio, 1.08; 95% confidence interval, 0.90-1.2 the study concluded that a

9

low-fat dietary pattern intervention did not reduce the risk of colorectal cancer in postmenopausal

women during 8.1 years of follow-up.18

A study was conducted in Department of Epidemiology and Public Health, Yale University;

New Haven on religious coping is associated with the quality of the life of patients with advanced

cancer. 170 samples were included in the study. The study reported that religious coping plays an

important role for the quality of life of patients and the types of religious coping strategies use are

related to better or poorer quality of life.19

A study was done in Research in Nursing and Patient Care Services, Boston on psycho

spiritual well being in patients with advanced cancer. The purpose of the study was to examine the

research on psycho spiritual well being in terminally ill cancer patients. Psycho spiritual well being is

an area of interest for researchers for all over the world. Retrieved studies had been conducted in 14

countries by researchers in a variety of psychology and theology. The study concluded that patients

with an enhanced sense of psycho spiritual well being are able to cope more effectively with the

process of terminal illness and find meaning in the experience. The research indicated that health

professionals can play an important role in enhancing psycho spiritual well being, but further

research is needed to understand specific interventions that are effective and contribute to positive

patient outcomes.20

A prospective cohort study was conducted in The National Institute of Environmental

Medicine, Sweden on vitamin A, retinol, carotenoids and the risk of gastric cancer. The objective of

the study was to examine the associations between intakes of vitamin A, retinol and specific

carotenoids and the risk of gastric cancer in prospective Swedish adults. The sample consisted of

10

82002 Swedish adults aged 45 to 83 years who had completed a food frequency questionnaire. The

results showed that during a mean 7.2 year follow up 133 incident cases of gastric cancer were

diagnosed. High intakes of vitamin A and retinol from foods only and foods and supplements

combined and of dietary alpha carotene and beta carotene were associated with a lower risk of gastric

cancer. The study concluded that high intakes of vitamin A, retinol and pro vitamin A carotenoids

may reduce the risk of gastric cancer.21

6. 3 OBJECTIVES OF THE STUDY:

1. To assess the knowledge of GI cancer patients regarding positive life style modifications.

2. To administer Self Instructional Module among GI cancer patients regarding positive life

style modification.

3. To evaluate the effectiveness of Self Instructional Module among GI cancer patients

regarding positive life style modification

4. To find out the association between knowledge score and selected demographic variables.

5. To compare the pre and post test knowledge score levels on positive life style modifications.

6.4 OPERATIONAL DEFINITIONS:

a) Assess: Assess refers to process of the critical analysis and valuation or judgement of the

status or quality of a particular condition or situation.

b) Effectiveness: Effectiveness is a measure of the ability of a program, project or task to

produce a specific desired effect or result that can be qualitatively measured.

c) Self Instructional Module: It is referred to a systematically organized booklet prepared by

the investigator on positive life style modification to be used by the GI cancer patient to gain

knowledge by them.

11

d) Knowledge: It refers to the information and skills acquired through experience or education.

e) Positive Life Style Modifications: The changed practices adopted by the GI cancer patient

which includes nutritional pattern, pain relieving factors, sleeping patterns, occupation, social

life and sexual life, coping with fear and anxiety, coping with body changes and spiritual life.

f) Gastro Intestinal Cancer patients: Persons suffering from uncontrolled growth of ana-

plastic cells that tend to invade surrounding tissues and metastasize to distant gastro intestinal

tract.

6.5 HYPOTHESIS OF THE STUDY:

H1: There will be statistically significant association between GI cancer patient’s knowledge

regarding positive life style modifications and dietary habits.

H2: There will be statistically significant association between GI cancer patient’s knowledge

regarding positive life style modifications and occupation.

6.6 ASSUMPTIONS:

1. GI cancer patients possess some knowledge regarding positive life style modifications.

2. GI cancer patients knowledge regarding positive life style modifications can be measured by

using a structured questionnaire.

3. GI cancer patients knowledge regarding positive life style modifications can be improved by

administering a Self Instructional Module.

4. Effectiveness of Self Instructional Module can be assessed by using a post test.

6.7 DELIMITATIONS OF THE STUDY:

1. The study is limited to GI cancer patients who are above 35 years and below 65 years of age.

12

2. The study is limited to GI cancer patients who are able to read and write Kannada or English.

3. The study is limited to GI cancer patients who are admitted at selected hospitals in Bangalore.

6.8 PILOT STUDY:

The study will be conducted with 6 samples. The purpose to conduct the pilot study is to

find out the feasibility for conducting the study and design on plan of statistical analysis.

6.9 VARIABLES:

A concept which can take on different quantitative values is called a variable.

Dependent variables: knowledge level of GI cancer patients regarding positive life style

modifications.

Independent variables: Age, gender, dietary habits, educational status, occupation, income

and residential area.

7. MATERIALS AND METHODS:

7.1 SOURCE OF DATA:

The data will be collected from GI cancer patients who are admitted at selected

hospitals in Bangalore.

7.1.2 RESEARCH DESIGN:

13

Quasi-experimental design

The research design adopted for this study is quasi experimental in nature. One group

pre test-post test design.

7.1.3 RESEARCH APPROACH:

Evaluative Research Approach.

7.1.4 SETTING OF THE STUDY:

The study will be conducted at selected hospitals in Bangalore.

7.1.5 POPULATION:

GI cancer patients who meet the inclusion criteria.

7. 2 METHOD OF DATA COLLECTION (INCLUDING SAMPLING PROCEDURE):

The data collection procedure will be carried out for a period of one month. This study

will be conducted after obtaining permission from the concerned authorities. The investigator will

collect the data by using a structured questionnaire, before and after administering Self Instructional

Module regarding positive life style modifications

Data collection instrument consist of following sections:

Section A: Demographic data.

Section B: Questions related to the knowledge regarding positive life style modifications of GI

cancer patients.

14

7.2.1 SAMPLING TECHNIQUE:

Sampling technique adopted for the selection of sample is non-probability

convenience sampling.

7.2.2 SAMPLE SIZE:

The sample consists of 60 GI cancer patients who are above 35 years and below 65

years of age, able to read and write Kannada or English and are admitted at selected hospitals in

Bangalore.

7.2.3 SAMPLING CRITERIA:

INCLUSION CRITERIA:

1. GI cancer patients who are able to read and write Kannada or English.

2. GI cancer patients who are admitted at selected hospitals in Bangalore.

3. GI cancer patients who are willing to participate in the study.

4. GI cancer patients who are available at the time of study.

5. GI cancer patients who are above 35 years and below 65 years of age.

EXCLUSION CRITERIA:

1. GI cancer patients who are not able to read and write Kannada or English.

2. GI cancer patients who are not available at the time of study.

3. GI cancer patients who are not willing to participate in the study.

4. GI cancer patients who are admitted at selected hospitals in Bangalore.

15

5. GI cancer patients who are selected for pilot study.

6. GI cancer patients who are below 35 years and above 65 years of age.

7.2.4 TOOL FOR DATA COLLECTION:

A structured questionnaire will be used to collect the data from GI cancer patients who

are admitted at selected hospitals in Bangalore.

7.2.5 DATA ANALYSIS METHOD:

The data will be analyzed by using descriptive and inferential statistics.

Descriptive statistics: frequency and percentage will be used for analysis of demographic

data and mean, mean percentage and standard deviation will be used for assessing the level

of knowledge.

Inferential statistics: Chi-square test will be used to find out the association between

knowledge and selected demographic variables. Paired’t’ test will be used for assessing the

effectiveness of structured teaching programme. Product Moment Correlation Coefficient

‘r’ will be used to find out the comparison of pre and post test knowledge scores.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO BE

CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS?

Since the study is quasi-experimental in nature, investigation or interventions are not

required.

7.4 ETHICAL CLEARENCE:

16

The main study will be conducted after the approval of research committee of the college.

Permission will be obtained from the head of the institution. The purpose and details of the study will

be explained to the study subjects and assurance will be given regarding the confidentiality of the

data collected.

8.LIST OF REFERENCES (VANCOUVER STYLE FOLLOWED)

1. American cancer society. Cancer reference information. The history of cancer. Available

from URL:http://www. cancer .org .

2. Otto. S. E. Oncology Nursing. 4th edition, Missouri: Mosby Publication; 2001. 185-208.

17

3. Barnard . R. J. Prevention of Cancer through Life Style Changes. Evidence Based

Complementary and Alternative Medicine 2004;1(3): 233-239. Available from:URL:

http://www.pubmed.com .

4. American Cancer Society. Cancer Centre. Scientific Report. 2006.

5. Rosen baum. Cancer Facts and Ageing. National Cancer Institute 2007: 100-101. Available

from: URL: http://www.pubmed.com .

6. Luk G. D. Prevention of Gastro Intestinal Cancer. Schweiz Mediziniche Wochenschrioff

1996 May; 126(19):801-812. Available from: URL: http://www.pubmed.com .

7. Polit D F, Hungler B P. Nursing Research; Principles and Methods. Philadelphia: J B

Lippincott Company; 2003.

8. Rao DN , Ganesh B, Dinshaw KA, Mohandas KM. A case-control study of stomach cancer in

Mumbai. International Journal of Cancer. 2002 June;99(5):727-731. . Available from: URL:

http://www.pubmed.com

9. Chitra S, Ashok L, Anand L, Srinivasan V, Jayanthi V. Risk factors for esophageal cancer in

Coimbatore, southern India: a hospital-based case-control study. Indian J Gastroenterol. 2004

Jan-Feb;23(1):19-21. Available from: URL: http://www.pubmed.com.

10. Jacobs .E T, David S. Association between Body Size and Colo Rectal Adenoma. Clinical

Gastro Enterology and Hepatology 2007 August;5(8): 982-990. Available from: URL:

http://www.pubmed.com

18

11. Beresford S. A. Low Fat Dietary Pattern and Risk of Colo Rectal Cancer. Evidenced Based

Nursing 2006 October; (4): 112-113. Available from: URL: http://www.pubmed.com

12. Yang. L. National Office for Cancer Prevention and Control. China 2006.

13. Lee S. Y. The Relationship between Intake of Vegetables and Fruits in Carcinoma Sequence.

Korean Journal of Gastro Enterology 2005 January;45(1): 23-33. Available from: URL:

http://www.pubmed.com .

14. Mercadante S. Nutrition in Cancer Patient. Supportive Care in Cancer 2005 June; 4: 10-20.

Available from URL:http://www.springlink.com.

15. Stacey Y. Change in Exercise Tolerance, Activity and Sleep Pattern and Quality of Life in

Patients with Cancer participating in a Structured Exercise Programme. Oncology Nursing

Forum 2003;30(3): 441-454. Available from : URL: http://www.pubmed.com

16. William J. V, Philip R. T, Chung S. Y. Nutrition Intervention Trials in Linxian, China:

Supplementation with Specific Vitamin/mineral Combination, Cancer Incidence and Disease-

Specific Mortality in the General Population. Journal of National Cancer Institute 1993

September; 85(18): 1483-1491. Available from: URL: http://www.pubmed.com

17. Kennedy F. A Qualitative Study into the Experience of Returning to Work Following Cancer.

European Journal of Cancer Care 2007; 16: 17-25. Available from: URL:

http://www.pubmed.com

19

18. Beresford SA , Johnson KC, Ritenbaugh C et al. Low-fat dietary pattern and risk of colorectal

cancer: Women's Health Initiative Randomized Controlled Dietary Modification Trial. The

Journal of American Medical Association. 2006 February ;295(6):643-54. Available from:

URL: http://www.pubmed.com.

19. Tarakeshwaran. Religiouys Cop[ing is Associated with the Quality of Life of Patients with

Advanced Cancer. Journal of Palliative Medicine 2006 June; 9(3): 646-657. Available from :

URL: http://www.pubmed.com.

20. Tracy A. B, Lauren C, Elizabeth P. Religiousness and Spiritual Support among Advanced

Cancer Patients and Associations with End of Life Treatment Preferences and Quality of life.

Journal of Clinical Oncology 2007 February; 25(5): 555-560. Available from: URL:

http://www.pubmed.com .

21. Susanna C. L, Leif B, Ingmar N. Vitamin A, Retinol and Carotenoids and the Risk of Gastric

Cancer: Prospective Cohort Study. Annals of Oncology 2009 May;20(8): 1434-1438.

Available from: URL: http://www.pubmed.com .

9. Signature of the Candidate.

10. Remarks of the Guide.

11. Name and Designation of

11.1 Guide

20

11.2 Signature

11.3 Co- Guide

11.4 Signature

11.5 Head of the Department

11.6 Signature

12. 12.1 Remarks of the Chairman &

Principal.

12.2 Signature.

21