RESEARCH PROPOSAL

Effect of a Brief Online Educational Module on Mammography Knowledge, Confidence, and Screening Recommendation Intentions Among Medical Students

TITLE PAGE

1. INTRODUCTION AND BACKGROUND

1.1 Burden of Breast Cancer and the Role of Screening

1.2 Medical Students as Future Counselors

1.3 Guideline Complexity as a Knowledge Challenge

• The USPSTF (updated April 2024) recommends biennial mammography beginning at age 40 for average-risk women aged 40-74 (JAMA 2024;331(22):1918-1930).
• The American Cancer Society recommends annual mammography starting at age 45 (with option starting at 40), transitioning to biennial at age 55.
• The ACR/SBI recommends annual mammography from age 40.
• The NCCN 2024 guidelines stratify recommendations based on risk score.

1.4 Online Education as a Scalable Intervention

1.5 Rationale for This Study

2. PROBLEM STATEMENT

3. AIM AND OBJECTIVES

3.1 Primary Aim

3.2 Specific Objectives

1. To assess baseline (pre-intervention) knowledge of mammography among medical students.
2. To develop and deliver a brief, self-paced online educational module on mammography screening.
3. To measure changes in mammography knowledge scores from pre-test to post-test.
4. To evaluate changes in self-reported confidence in discussing mammography with patients.
5. To assess students' intentions to recommend appropriate breast cancer screening in clinical scenarios.
6. To identify baseline demographic and academic predictors of mammography knowledge.

4. RESEARCH HYPOTHESES

• H1 (Primary): Medical students who complete the online educational module will demonstrate a statistically significant improvement in mammography knowledge scores compared to their pre-test scores.
• H2: Students will report significantly higher self-confidence in discussing mammography with patients after the module.
• H3: Students will demonstrate significantly higher intention to recommend appropriate screening at post-test compared to pre-test.
• H0 (Null): The online educational module will produce no significant change in knowledge, confidence, or screening recommendation intention.

5. STUDY DESIGN

5.1 Design

1. A pre-test questionnaire (baseline)
2. The online educational module
3. A post-test questionnaire (immediately after module completion)
4. An optional 1-month follow-up questionnaire (knowledge retention sub-study)

5.2 Study Timeline

6. STUDY POPULATION

6.1 Target Population

6.2 Inclusion Criteria

• Currently enrolled medical students (any year of study)
• Willing to provide informed consent
• Access to internet and a device capable of completing an online survey
• Ability to read and comprehend the module and questionnaire in English

6.3 Exclusion Criteria

• Students who have completed a formal rotation in radiology or breast oncology within the past 3 months (to reduce ceiling effects)
• Students who fail to complete either the pre-test or post-test (incomplete data)
• Students who complete the post-test without engaging with the module (tracked via platform analytics)

7. SAMPLE SIZE CALCULATION

• Expected mean knowledge score improvement: 15% (based on analogous online module studies, e.g., PMID: 39087993)
• Standard deviation of difference: estimated at 20%
• Significance level (alpha): 0.05 (two-tailed)
• Power: 80%

• n = (1.96 + 0.84)^2 * 400 / 225 = approximately 50 participants minimum
• Accounting for 20% non-completion/attrition: target n = 65 students

8. SAMPLING AND RECRUITMENT

• Sampling method: Purposive sampling via direct outreach to medical school class representatives and student societies, supplemented by snowball sampling through student WhatsApp/email groups.
• Recruitment: The study link (Google Forms / REDCap platform) will be distributed via email and social media platforms used by medical student associations.
• Incentive: Participants will receive a certificate of participation and a summary of current mammography guidelines upon completion.

9. THE EDUCATIONAL MODULE

9.1 Module Development

9.2 Platform

9.3 Estimated Duration

9.4 Module Content

9.5 Instructional Design Features

• Narrated slide format with visual diagrams
• Embedded knowledge check questions (formative, unscored) after each section
• Downloadable guideline summary card
• Aligned with principles of adult learning theory (Knowles) and the Health Belief Model

10. DATA COLLECTION INSTRUMENT (QUESTIONNAIRE)

10.1 Questionnaire Structure

Domain A: Mammography Knowledge (Primary Outcome)

• 20 multiple-choice questions (MCQs) covering:
  • Epidemiology of breast cancer
  • Indications and contraindications for mammography
  • Screening age and frequency per major guidelines
  • Interpretation of results (BI-RADS categories)
  • Sensitivity, specificity, limitations
  • Risk-based screening
• Scoring: 1 point per correct answer; total score = 0-20
• Knowledge score converted to percentage

Domain B: Confidence (Secondary Outcome)

• 5-item Likert scale (1 = not at all confident to 5 = extremely confident)
• Items: confidence in explaining mammography to patients, recommending appropriate screening, discussing results, addressing concerns, identifying high-risk patients
• Composite confidence score = mean of 5 items

Domain C: Intention to Recommend Appropriate Screening (Secondary Outcome)

• 3 clinical vignette-based questions presenting patient scenarios (e.g., a 40-year-old woman with no risk factors; a 35-year-old with BRCA1 mutation; a 55-year-old with dense breasts)
• Students select the most appropriate screening recommendation from 4 options
• Scored 0-3 (1 point per correctly recommended action)

Domain D: Demographic and Background Information (collected at pre-test only)

• Year of medical study (Year 1-6 or equivalent)
• Gender
• Prior exposure to mammography teaching (yes/no)
• Prior clinical placement in breast/radiology (yes/no)

10.2 Questionnaire Validation

• Content validity: Expert panel review (3 radiologists, 1 breast oncologist, 1 medical educationist) using Content Validity Index (CVI target: >0.80 per item)
• Face validity: Review by a sample of medical students from a non-participating institution
• Pilot testing: 15 students will complete both pre- and post-test instruments to assess item clarity, difficulty index, and discrimination index
• Reliability: Cronbach's alpha calculated for the knowledge domain and confidence scale (acceptable threshold: alpha >0.70)

10.3 Platform

11. OUTCOME MEASURES

12. DATA ANALYSIS PLAN

12.1 Descriptive Statistics

• Continuous variables: mean ± standard deviation (SD) or median [IQR] as appropriate
• Categorical variables: frequencies and percentages
• Baseline characteristics tabulated by year of study

12.2 Primary Analysis

• Paired samples t-test (parametric) or Wilcoxon signed-rank test (if normality violated) to compare pre-test vs. post-test knowledge scores
• Effect size reported as Cohen's d (small: 0.2, medium: 0.5, large: 0.8)

12.3 Secondary Analyses

• Paired t-test / Wilcoxon for confidence scores (pre vs. post)
• McNemar's test or Wilcoxon for vignette-based intention scores (pre vs. post)
• Subgroup analyses by year of study (ANOVA / Kruskal-Wallis)
• Subgroup analysis by prior mammography exposure

12.4 Predictors of Baseline Knowledge

• Multiple linear regression: dependent variable = pre-test score; independent variables = year of study, gender, prior clinical exposure, prior teaching exposure

12.5 Software

• IBM SPSS v29 or R (version 4.3 or later)
• Significance level: p < 0.05 (two-tailed)
• All tests with 95% confidence intervals

13. ETHICAL CONSIDERATIONS

14. LIMITATIONS

1. No randomized control group: The single-group design cannot exclude the effect of test-retest learning (students may recall questions from the pre-test). Mitigation: some post-test MCQs will be paraphrased or presented in different contexts.
2. Self-selection bias: Students who volunteer may have higher baseline interest in screening, potentially inflating baseline scores and underestimating true effect.
3. Hawthorne effect: Awareness of being studied may affect engagement with the module.
4. Social desirability: Confidence and intention scales rely on self-report; actual clinical behavior is not measured.
5. Short follow-up: Knowledge retention beyond 1 month is not assessed in this design.
6. Generalizability: Results may not generalize across all medical schools if curriculum content differs substantially.

15. SIGNIFICANCE AND EXPECTED CONTRIBUTIONS

• Curriculum development: Provides evidence to support integration of a standardized digital mammography module into undergraduate medical training.
• Scalability: An online module requires minimal instructor time and can be deployed across multiple institutions simultaneously.
• Patient outcomes (downstream): Better-informed physicians are more likely to engage in evidence-based, guideline-consistent screening counseling, potentially improving breast cancer detection rates.
• Template for future studies: The validated questionnaire and module design can be adapted for other cancer screening topics (cervical, colorectal, lung).

16. BUDGET (ESTIMATED)

17. REFERENCES (SELECTED)

1. Nicholson WK et al. Screening for Breast Cancer: USPSTF Recommendation Statement. JAMA. 2024;331(22):1918-1930. USPSTF 2024 mammography recommendation
2. Abed ASA et al. Health Belief Model-based educational interventions for knowledge, beliefs, and intentions on mammography: a systematic review. BMC Women's Health. 2025. PMID: 41430199
3. Strom B et al. Challenges in mammography education and training today: perspectives of radiography teachers/mentors and students in five European countries. Radiography. 2018;24(2):154-160. PMID: 29306374
4. Qureshi A et al. Online Educational Module Improves Knowledge of Nurses on Bowel Preparation for Colonoscopy. Gastroenterology Nursing. 2024. PMID: 39087993
5. Wu S et al. Changes in knowledge and awareness for a community-based cancer screening educational program. Arch Public Health. 2023. PMID: 37438840
6. Zafar N et al. Effectiveness of Community Education for Breast Cancer Screening. J Breast Imaging. 2024. PMID: 38412358

APPENDICES (OUTLINE)

Notes on Customization

• Institution-specific language: Replace generic references with your medical school's name, year classification system, and ethics board name.
• Module format: If your institution uses Moodle or Canvas, module hosting is straightforward. Alternatively, Google Sites with embedded Google Forms works as a zero-cost option.
• Questionnaire: Appendix A will need full item development before pilot testing - this is the most time-intensive step and should begin early in Month 1.
• If you need a parallel-group RCT: A waiting-list control design can be added - Group A receives the module first; Group B (control) receives it after the study period. This controls for test-retest effects while ensuring all participants eventually benefit.

RESEARCH PROPOSAL

TITLE

TITLE PAGE

1. INTRODUCTION AND BACKGROUND

1.1 Global and National Burden of Breast Cancer

1.2 Mammography as a Screening Tool

1.3 Knowledge Gaps Among Medical Students

1.4 WhatsApp as an Educational Platform in India

• Requires no institutional LMS or broadband infrastructure
• Works on 4G mobile networks available across urban and semi-urban Jharkhand
• Reaches students asynchronously across campuses
• Is a platform students already use daily

1.5 Justification for This Study

2. PROBLEM STATEMENT

3. AIM AND OBJECTIVES

3.1 Primary Aim

3.2 Specific Objectives

1. To assess pre-intervention (baseline) mammography knowledge among MBBS students (Years 1-Final) in Jharkhand.
2. To develop and deliver a structured WhatsApp-based educational module on mammography screening.
3. To measure the change in mammography knowledge scores from pre-test to post-test.
4. To assess pre- and post-intervention self-reported clinical confidence in discussing mammography with patients.
5. To evaluate pre- and post-intervention intention to recommend appropriate mammography screening using clinical vignettes.
6. To compare knowledge, confidence, and intention scores across academic years (Phase I, II, III/Final).
7. To identify baseline predictors of mammography knowledge (year of study, gender, prior breast cancer teaching exposure).

4. RESEARCH HYPOTHESES

5. STUDY DESIGN

Recruitment
     |
Pre-test Questionnaire (Google Forms link shared via WhatsApp)
     |
WhatsApp Educational Module (delivered over 3-5 days in a dedicated study group)
     |
Post-test Questionnaire (same Google Forms link, sent on Day 6-7)
     |
[Optional] 4-week follow-up short test (knowledge retention, sub-study)

6. STUDY SETTING

• Primary setting: Medical college(s) in Jharkhand, India
  • Examples: Rajendra Institute of Medical Sciences (RIMS), Ranchi; MGM Medical College, Jamshedpur; Patliputra Medical College, Dhanbad; Hazaribagh Medical College
• Mode of intervention delivery: WhatsApp group(s) and/or Instagram/Telegram (social media)
• Mode of data collection: Online questionnaire (Google Forms / KoBoToolbox / REDCap)

7. STUDY POPULATION

7.1 Target Population

7.2 Inclusion Criteria

• Currently enrolled MBBS student at a medical college in Jharkhand
• Owns a smartphone with WhatsApp access
• Willing to provide written/electronic informed consent
• Available to complete both pre-test and post-test within the study period

7.3 Exclusion Criteria

• Interns (completed all clinical phases) - to avoid ceiling effect from extensive clinical exposure
• Students who have completed a dedicated breast radiology posting within the last 3 months
• Students who complete only the pre-test or only the post-test (incomplete pairs excluded from analysis)
• Students who join the WhatsApp group but do not view any module content (tracked via read receipts or a mid-module engagement quiz)

8. SAMPLE SIZE CALCULATION

• Expected mean improvement in knowledge score: 15% (based on Pereira et al., 2020; Pal et al., 2021)
• Estimated standard deviation of the difference: 20%
• Level of significance (alpha): 0.05 (two-tailed)
• Power (1-beta): 80%

• Adding 20% for attrition (non-response, incomplete data): minimum n = 60
• Target enrollment for subgroup analysis across academic years: n = 100 students

9. SAMPLING AND RECRUITMENT

10. THE WHATSAPP/SOCIAL MEDIA EDUCATIONAL MODULE

10.1 Development Team

• 1 Radiologist (mammography content, imaging interpretation)
• 1 Community Medicine Faculty (screening guidelines, epidemiology)
• 1 Obstetrics & Gynecology Faculty (clinical application)
• 1 Medical Education expert (instructional design)

10.2 Delivery Platform

• Primary: A dedicated WhatsApp group (one per college/batch)
• Supplementary: Telegram channel (for document archiving) and/or Instagram close friends / broadcast list for infographic delivery

10.3 Module Duration

10.4 Content Delivery Schedule

10.5 Content Formats

• Designed infographic cards (created in Canva)
• Short pre-recorded audio explanations (voice notes, 2-3 minutes each)
• Guideline comparison table (image format)
• 1-2 short video clips (<3 minutes, hosted on YouTube and shared as links)
• Clinical scenario-based story posts (text)
• End-of-module downloadable PDF guide

10.6 Instructional Design Principles Applied

• Micro-learning: Content broken into small daily doses to reduce cognitive load
• Health Belief Model: Content frames screening as personally relevant and feasible
• Adult learning theory (Andragogy): Learners understand the "why" before the "how"
• Spaced repetition: Key guidelines reinforced across multiple days

10.7 Monitoring Engagement

• WhatsApp read receipts (double blue ticks) to confirm message delivery and opening
• A short 3-question formative quiz sent on Day 3 (via Google Forms link) to check mid-module engagement
• Students who do not open any messages by Day 3 receive a reminder

11. DATA COLLECTION INSTRUMENT

• Time 0 (Pre-test): Before the module begins (Day 0)
• Time 1 (Post-test): 24-48 hours after Day 5 module completion (Day 6-7)

11.1 Questionnaire Structure

Section A: Sociodemographic and Background Information (Pre-test only)

Section B: Mammography Knowledge (Pre-test and Post-test) - PRIMARY OUTCOME

• 20 multiple-choice questions (single best answer) covering:

• Scoring: 1 mark per correct answer; 0 for incorrect/unanswered
• Total knowledge score: 0-20 (converted to percentage for analysis)

Section C: Clinical Confidence (Pre-test and Post-test) - SECONDARY OUTCOME

1. Explaining what mammography is and why it is used
2. Advising a patient on when to start mammography screening
3. Interpreting a mammography report category (BI-RADS) for a patient
4. Addressing a patient's concerns about radiation or false positives
5. Identifying a patient who needs high-risk screening

Section D: Intention to Recommend Appropriate Screening (Pre-test and Post-test) - SECONDARY OUTCOME

• Vignette 1: A 42-year-old woman from Ranchi with no family history or risk factors asks about breast cancer screening. What do you advise?
• Vignette 2: A 36-year-old woman with a confirmed BRCA1 mutation and no prior screening asks when to begin mammography. What is the most appropriate recommendation?
• Vignette 3: A 55-year-old woman, biennial mammography done 18 months ago, reports no symptoms. Her report showed BI-RADS 3. What is the most appropriate next step?

11.2 Questionnaire Validation

12. OUTCOME MEASURES SUMMARY

13. DATA ANALYSIS PLAN

13.1 Descriptive Statistics

• Categorical variables: frequency (n) and percentage (%)
• Continuous variables: mean ± SD or median [IQR] based on distribution
• Baseline characteristics tabulated by academic year

13.2 Primary Analysis (Knowledge Score)

• Normality testing: Shapiro-Wilk test
• If normal: Paired samples t-test (pre vs. post knowledge score)
• If non-normal: Wilcoxon signed-rank test
• Effect size: Cohen's d (paired version) - small: 0.2, medium: 0.5, large: 0.8
• Significance level: p < 0.05 (two-tailed); 95% CI reported

13.3 Secondary Analyses

13.4 Software

• IBM SPSS v29, R (v4.4), or STATA 17
• All tests two-tailed; alpha = 0.05
• Missing data: Per-protocol analysis (complete pairs only); sensitivity analysis with last observation carried forward if >5% missing

14. ETHICAL CONSIDERATIONS

15. LIMITATIONS

1. No randomized control group: Cannot exclude test-retest effect (students may recall pre-test questions). Mitigation: some post-test items will use paraphrased stems and different distractor sets.
2. Self-selection bias: Volunteers may be more motivated or already more knowledgeable than non-participants.
3. WhatsApp engagement verification: Read receipts confirm message opening, not actual content engagement. Mitigation: mid-module formative quiz (Day 3) as an engagement checkpoint.
4. Social desirability bias: Confidence and intention are self-reported and may not reflect actual clinical behavior.
5. Single-college limitation: If conducted at one institution, results may not generalize to all Jharkhand medical colleges. Mitigation: multi-college recruitment where feasible.
6. Short follow-up: Long-term knowledge retention and actual counseling behavior in clinical practice are not assessed.

16. EXPECTED OUTCOMES AND SIGNIFICANCE

• Provides the first locally-generated evidence on mammography education among Jharkhand medical students
• Produces a validated, reusable WhatsApp mammography module deployable at zero cost across other Jharkhand or East Indian medical colleges
• The validated questionnaire serves as a standalone assessment tool for future curriculum evaluation
• Informs ICMR / NMC (National Medical Commission) curriculum revision discussions on preventive oncology education

17. STUDY TIMELINE

18. BUDGET (ESTIMATED)

19. REFERENCES (KEY)

1. Nicholson WK et al. Screening for Breast Cancer: USPSTF Recommendation Statement. JAMA. 2024;331(22):1918-1930. USPSTF 2024
2. Pal A et al. Knowledge, attitude, and practice towards breast cancer and its screening among women in India: A systematic review. J Cancer Res Ther. 2021. PMID: 34916359
3. Tomic M et al. Exploring female medical students' knowledge, attitudes, practices related to breast cancer screening: a scoping review. J Med Life. 2023. PMID: 38585536
4. Pereira AAC et al. Effects of a WhatsApp-Delivered Education Intervention to Enhance Breast Cancer Knowledge in Women. JMIR mHealth uHealth. 2020. PMID: 32706726
5. Coleman E, O'Connor E. The role of WhatsApp in medical education; a scoping review and instructional design model. BMC Med Educ. 2019. PMID: 31345202
6. Singh NK et al. Leveraging WhatsApp as a collaborative medical information and knowledge sharing tool - insights from a CME WhatsApp community. BMC Med Educ. 2024. PMID: 39227936
7. Sajan AS et al. Comparing the knowledge and awareness of cervical and breast cancer among medical and nonmedical students of a private institution in South India. J Cancer Res Ther. 2022. PMID: 36412443
8. Ayers JW et al. #MedEd: Medical Education and Knowledge Translation on Social Media. JAMA. 2023. PMID: 37642959
9. Krishnan S et al. Cancer incidence estimates for 2022 and projection for 2025: Result from NCRP India. Indian J Med Res. 2022;156:598-607.
10. ICMR National Ethical Guidelines for Biomedical and Health Research Involving Human Participants. New Delhi: ICMR; 2017 (Updated 2023).

APPENDICES (PLANNED)

Checklist Before Submission

• IEC approval letter obtained
• CTRI registration completed and registration number obtained
• Questionnaire pilot-tested and reliability confirmed (alpha > 0.70)
• WhatsApp group(s) created; admin access confirmed
• Google Forms pre-test and post-test links tested on mobile
• Module content reviewed by at least 2 subject experts
• Informed consent form reviewed by IEC
• Co-investigator responsibilities assigned

RESEARCH PROPOSAL

TITLE

TITLE PAGE

1. INTRODUCTION

2. AIMS AND OBJECTIVES

2.1 Aim

2.2 Objectives

1. To assess the level of knowledge about mammography screening among MBBS students.
2. To evaluate awareness of current mammography screening guidelines and recommendations.
3. To assess students' attitudes toward recommending mammography to patients.
4. To compare knowledge, awareness, and attitudes across different academic years (Phase I to Final Year).
5. To identify factors associated with better mammography knowledge (year of study, gender, prior clinical exposure).

3. REVIEW OF LITERATURE

4. STUDY DESIGN

5. STUDY SETTING

• Medical college(s) in Jharkhand, India
• Example institutions: RIMS Ranchi, MGM Medical College Jamshedpur, Hazaribagh Medical College, Patliputra Medical College Dhanbad

6. STUDY POPULATION

6.1 Target Population

6.2 Inclusion Criteria

• Currently enrolled MBBS student at a medical college in Jharkhand
• Present on the day of data collection
• Willing to give informed consent

6.3 Exclusion Criteria

• Interns and postgraduate students
• Students who refuse to participate
• Incomplete questionnaires (excluded from final analysis)

7. SAMPLE SIZE

• Z = 1.96 (95% confidence level)
• p = 0.50 (expected prevalence of adequate knowledge - taken as 50% in absence of local data, giving maximum sample size)
• q = 1 - p = 0.50
• d = 0.05 (absolute precision/margin of error)

8. SAMPLING METHOD

• Sampling technique: Stratified random sampling
• Students will be stratified by academic year (Phase I, Phase II, Phase III, Final Year)
• Proportionate number of students will be selected from each year using a simple random sampling (lottery method)

9. DATA COLLECTION TOOL

Structured Questionnaire (Self-administered)

• Age
• Gender
• Academic year / Phase
• Prior teaching on breast cancer (yes/no)
• Prior clinical posting in Surgery/Radiology/Gynecology (yes/no)
• Family history of breast cancer (yes/no)

• Scoring: 1 mark per correct answer; 0 for incorrect
• Total knowledge score: 0-15
• Categorized as: Poor (<50%), Moderate (50-74%), Good (≥75%)

• Scoring: 1 per correct/aware response
• Total awareness score: 0-10

• Total attitude score: 10-50
• Categorized as: Unfavorable (<30), Neutral (30-39), Favorable (≥40)

Questionnaire Validation

10. DATA COLLECTION PROCEDURE

1. Permission obtained from Principal/Head of Department
2. Students assembled during a free period or tutorial hour
3. Purpose of study explained; written informed consent obtained
4. Questionnaire distributed (paper-based) or shared via Google Forms link
5. Students complete the questionnaire independently (approximately 15-20 minutes)
6. Completed questionnaires collected immediately (paper) or submitted digitally
7. Incomplete questionnaires excluded

11. OUTCOME VARIABLES

12. DATA ANALYSIS PLAN

• Software: IBM SPSS v29 or R
• Significance level: p < 0.05 (two-tailed)
• Confidence interval: 95%

13. ETHICAL CONSIDERATIONS

14. LIMITATIONS

1. Cross-sectional design - only measures knowledge at one point in time; no causality established
2. Self-reported data may be subject to social desirability bias
3. Results may not be fully generalizable beyond Jharkhand
4. Recall bias for questions on prior teaching exposure

15. SIGNIFICANCE OF THE STUDY

• Provides the first local baseline data on mammography knowledge, awareness, and attitudes among medical students in Jharkhand
• Identifies specific knowledge gaps that can be targeted in curriculum reform
• Supports the case for including structured mammography teaching in MBBS training
• Forms the foundation for future interventional studies (pre-post educational modules) in the region

16. STUDY TIMELINE

17. BUDGET

18. REFERENCES

1. GLOBOCAN 2022. India Breast Cancer Data. International Agency for Research on Cancer (IARC), WHO.
2. Pal A et al. Knowledge, attitude, and practice towards breast cancer and its screening among women in India: A systematic review. J Cancer Res Ther. 2021. PMID: 34916359
3. Tomic M et al. Exploring female medical students' knowledge, attitudes, practices related to breast cancer screening: a scoping review. J Med Life. 2023. PMID: 38585536
4. Sajan AS et al. Comparing the knowledge and awareness of cervical and breast cancer among medical and nonmedical students, South India. J Cancer Res Ther. 2022. PMID: 36412443
5. Nicholson WK et al. Screening for Breast Cancer: USPSTF Recommendation Statement. JAMA. 2024;331(22):1918-1930.
6. ICMR National Ethical Guidelines for Biomedical and Health Research Involving Human Participants. New Delhi: ICMR; 2017.

APPENDICES (PLANNED)

• Design: Cross-sectional - no intervention, no follow-up, straightforward
• Tool: Structured questionnaire with Knowledge (15 Q), Awareness (10 Q), and Attitudes (10 Q Likert) sections
• Budget: Under ₹1,000 - feasible as a student/resident project
• Timeline: 3 months - achievable within a single academic term
• Sample size: 422 students, clearly calculated