The Israeli national program for early detection of breast cancer: Women as the target population

Objective and Methods: This paper presents a series of three consecutive initiatives aimed at enhancing adherence to mammography (MM) screening in Israel. The first initiative was a field experiment inviting women to a pre-scheduled appointment, interviewing them afterwards. The second initiative, built on the first stage of mailed invitation to MM, recruited primary care medical personnel into further enhancing the adherence of nonattending women. The medical personnel called their nonattending patients, inquired into their reasons for nonattendance and encouraged attendance. The third initiative was undertaken in response to medical personnel's requests for tools in the above-mentioned individual inquiry. It consisted of a qualitative study in search of women's motives and perceptions (personal constructs) regarding MM, employing a salutogenic perspective. Results: The mailed invitation initiative resulted in increasing the rate of adherence to MM from 16% of self-screenees to 45%, and establishment of a national policy of initiated MM appointment. The implementation of the first and second initiatives together resulted in a national average of 56% MM adherence. Conclusions: The above sequence demonstrates that change can be achieved within a relatively short period of a decade. The two-stage model suggested here - a first general appeal to all the target population by means of a mailed personalized message and then an individual approach to the nonadherent women by medical professionals is (1) relatively cost-effective, using the time resource of medical personnel sparingly, targeting only the nonadherent, (2) mobilizes medical staff as opinion leaders to diffuse the innovative concept of a screening test, and (3) capitalizes on the long-term therapeutic relationship between the woman and her attending physician (or nurse), enabling them to tailor the message to the personal barriers of the woman or to tie the message to the woman's concerns and own constructs. The diffusion of the relatively innovative procedure of screening tests from policy level to users requires a management/policy commitment, action research to shape the interventions, as well as monitored implementation.