Mobile Mammography Unit of the PoH
Prefecture of Heraklion
Greece

The Problem

The main problem before the initiative was that many women living in the prefecture of Heraklion and specially women living in the countryside, between the age of 40 and 70 years, were not submitted to a mammography test. The main reasons that had discouraged women from using this important tool of preventive control were mostly economic, social, geographic, lack of advising and awareness.
Regarding economic reasons, women should move from their place using their own expenses and their own means, but the fact is that many women living in the countryside are not used to move on their own, without the company of their relevants and this comprises a severe social problem. Other social reasons that had discouraged women from preventive control are on the one hand the illiteracy and on the other hand the psychological burden, as breast cancer constitutes prejudice, especially to small societies in the countryside. As far as geographic reasons are concerned, as women should cover great distances up to 100 Km within the prefecture’s borders or more than 100 Km for women coming from other prefectures of Crete, as Heraklion concentrates high level of health infrastructure in Crete. Last but not least, is the lack of advising, awareness and mobilization.
Generally speaking, it is very difficult for women, who come from poor families or women of old age, to move from a provincial city or village to a pubic central health unit in order to go through breast cancer screening and diagnosis through the mammography test. At the same time the work load of public hospitals is sufficiently high and as a result, there is a substantial delay in the assignment of the appointments. This long waiting list discourages women from being tested and as a consequence, very few women, who can afford to choose a private clinic, are able to go through an expensive mammography test.
The Prefecture of Heraklion, loyal to its commitment for the development of actions in the vital area of social policy, set as a priority the creation of a mobile mammography unit, which makes tours across the prefecture of Heraklion since July 2008. This unit also moves to other prefectures of Crete and to other neighboring remote islands (i.e. Kastellorizo, Santorini) . Breast cancer constitutes for women the most frequent form of cancer and the second cause of death from cancer in Western societies. It is a fact that the early diagnosis, which is achieved with the mammography, is the best way to treat the illness. In the region of Crete there was no mobile mammography unit. Therefore the Prefecture of Heraklion created such a unit. This is the first time a regional local authority in Greece operates a mobile mammography unit.

Solution and Key Benefits

 What is the initiative about? (the solution)
Considering that the 30% of malignant breast tumors are detected with regular mammography tests, the main achievement of the initiative is the detection of breast cancer in a very early stage, at which the illness is curable and the treatment is more effective. It is remarkable, that this initiative has raised the awareness of women and has made an increasing number of women, who had never been through the test, to change attitudes and have an annual examination .
In particular the achievements and key benefits of the initiative are the reduction of mortality from breast cancer in the female population of Heraklion prefecture at 30% and the early diagnosis of breast cancer with a tumor of less than one centimetre in diameter, in frequency 15/10000. Since the start of the initiative in July 2008, the mobile mammography unit has visited all the 26 Municipalities of Heraklion three times so far. It has done 100 visits in total (88 in the rural areas and 12 visits in the Heraklion area). The unit has done 3,950 mammograms so far. From the 3,950 mammograms that have been analysed by the doctors, 480 women were referred to the hospital for further examination (ultrasound), 28 biopsies were carried out and 15 cases of breast cancer were diagnosed that were life-threatening for women. From the 3,950 women who had a mammogram, the 40% of women were having this examination for the first time in their life.
In the future, when a significant amount of scientific data, that concern breast cancer, will have been collected, it could be used and analysed for further medical research by the medical doctors of Venizeleio Hospital. From this amount of data, it is expected that useful and productive conclusions can be drawn.
The group that has benefited from the initiative is mainly women between the age of 40 and 70 years old, who live in the Heraklion prefecture, other prefectures of Crete and other neighboring remote islands (i.e. Kastelorizo, Santorini). The mission of the mobile mammography unit also serves the tasks of doctors in the Local Health Centres and the Regional Infirmaries of Heraklion prefecture, as it helps in better medical prevention for the population served by them. Moreover, this initiative generally accomplishes a remarkable social work, improving the health level of the prefecture population.
Another key benefit, steaming from the initiative concerns the administrative decentralisation, especially actions such as making mammograms at womens’ places of residence, free of charge (for insured and uninsured women), reduction of public hospital workload as a significant number of women are tested at the mobile mammography unit, reduction of the appointment waiting time, non-involvement of Social Security Organizations’ services and stuff. According to the sector of employment, women are secured in various Social Security Organizations that are government owned services. Complicated bureaucratic processes are frequently required for women who want to have examinations and particularly the expensive ones, such as the mammograms.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
The solution was proposed by the Prefect herself – as former Member of Greek Parliament representing the Heraklion prefecture and former Member of Prefectoral Council, who had addressed the problem and had developed the vision for its resolution. When she became the Prefect, she started its implementation, in collaboration with the responsible Directorate of Public Health, that constitutes a department of the Prefecture of Heraklion, the Venizeleio Hospital and 26 Municipalities of the Heraklion prefecture.
The institutions that participated in the development of this initiative were on the one side the Prefecture of Heraklion and on the other side Venizeleio Hospital of Heraklion (www.venizeleio.gr), which has the essential scientific expertise and know-how.
The initiative of the mobile mammography unit is based on the collaboration of existing infrastructure (Venizeleio Hospital, Local Health Centres and Regional Infirmaries) with the utilisation of relevant economic and human resources.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The Prefecture of Heraklion ensures the information of women between the age of 40 and 70 by distributing the leaflet and by announcements on the press and the internet. Women are also informed by the Municipalities, the Health Centres and the Regional Infirmaries so that all women can have a mammogram free of charge.
The strategy of the Prefecture of Heraklion is based on the collaboration among the Prefecture of Heraklion, Municipalities of Heraklion prefecture, Health Centres, Regional Infirmaries and Venizeleio Hospital. The collaboration is considered vital, as it ensures the best operation of the unit and its continuation in the future, as well as the achievement of the initiative’s objectives.
The coordination of the initiative and the proper and early planning of the unit visits make the above tools appropriate to reach the goals of the initiative.
The administrative decentralization was the main strategy that was used for the implementation of the initiative, paying special attention to making the mammograms at womens’ places of residence and generally the transportation of all the relative processes to the countryside.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
After the supply of the van and the medical equipment (year 2007), the van was transformed into a mobile mammography unit and medical devices and instruments were safely placed on it (April 2008). At the same time, many communications were made with the relevant institutions and organizations and the appropriate licenses were granted to the Prefecture of Heraklion by the qualified Ministry of Health. Afterwards, the appropriate personnel was employed and the unit was finally set in operation (August 2008), according to the reported plan, as it is described below step by step:

The procedure that is followed is described below:
1) The secretariat of the mobile mammography unit communicates with the Municipalities, Regional Infirmaries or Local Health Centres and the dates of visit and the itinerary of the mobile mammography unit are determined,
2) The communication and information of the interested women are carried out with announcements by the Municipalities and the Regional Infirmaries at least two weeks in advance of the mobile mammography unit date of visit to each Municipality so that interested women can make their appointments.
Other possible ways of communication, that are used, are press releases in the mass media (newspapers, internet, television, radio etc), as well as at the web site of the Prefecture of Heraklion (www.nah.gr), interviews on the mass media that are occasionally given by relevant persons (Prefect, assistant Prefect, Mayor), two informative leaflets that have been created by the Prefecture and concern the information about the mobile mammography unit and the prevention in breast health, events that occasionally take place, for example on the 8th of March 2009, the International Woman’s Day.
3) The mobile mammography unit visits each Municipality and does mammograms.
4) Afterwards, doctors from the Radiology Department of Venizeleio Hospital receive the films of the mammograms and they make a diagnosis. The expert medical reports of mammograms are recorded by the secretariat of the Prefecture of Heraklion, afterwards they are returned to the medical personnel of each Municipality and finally they are given to women. In case there is need for further examination, women are notified directly by the Venizeleio Hospital or by the Prefecture of Heraklion, in order to immediately go through further medical tests. All this procedure is free of charge for all women.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
The main obstacles that the Prefecture of Heraklion encountered were mainly procedural and were related to the search of financing resources, the specifications of the van transformation into a secure vehicle, taking into account the sobriety of adding instruments with radiation, the engagement of specialised medical personnel etc. The first obstacle was finally overcome and the financing of the mobile mammography unit was implemented by the Prefecture’s own resources. The second obstacle was overrun with the subscription and collaboration of the National Centre of Scientific Research "Demokritos". "Demokritos" which was founded at the end of the 1950’s and its scientific activities take place in eight administratively independent Institutes: Institute of Nuclear Physics, Institute of Nuclear Technology and Radiation Protection, Institute of Materials Science, Institute of Telecommunications and Informatics, Institute of Microelectronics, Institute of Physics/Chemistry, Institute of Biology and the Institute of Radioisotopes and Radiodiagnostic Products. The activities of these Institutes concern the sectors such as: nanotechnology, microsystems, integrated telecommunications and informatics technology systems, modern technologies for cultural heritage, control of environmental pollutants, nuclear technology and radiation protection, accelerative systems technologies and detector devices, generation and characterization of innovative materials, bioactive molecules, natural products and biotechnology, medicines and diagnostics technologies, telemedicine, etc. The third obstacle was overcome with the assistance, cooperation and voluntary offer of the Venizeleio Hospital.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
A. FINANCIAL COSTS
The initiative is within its original budget.
The costs are described below:

Equipment (van, mammographer, furniture): 130,000 €
Maintenance (Aug. 2008 - Nov. 2009): 14,000 €
Consumables (films, chemicals, etc.) Aug. 2008 - Nov. 2009: 9,500 €
Personnel: 66,000 € per year (3 persons)
Transportation costs: 280 € per month
Dissemination (leaflets): 11,000 €

B. TECHNICAL COSTS

The technical equipment of the mobile unit consists of a van equipped with a mammographer. In the van's interior there is an office for secretarial work and a waiting room for the women. In case women need further medical examination, they are referred to the Venizeleio Hospital where they are subject to more tests (ultrasound etc).

C. HUMAN RESOURCES COSTS

The unit occupies a technologist-radiologist, a driver and an officer who coordinates the unit activity, accomplishes communication among Health Centres, Regional Infirmaries and the Venizeleio Hospital and records the results. The human resources and expertise of the Venizeleio Hospital are invaluable for the operation of the project.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
The initiative promotes the equality between women who live in the cities and women who live in rural areas, by ensuring the access of the latter to a high quality medical service, therefore it promotes social cohesion.
Currently the initiative focuses on breast cancer screening and diagnosis through the mammography testing all over the Heraklion prefecture. Regarding research, the mammograms and all the medical data of the women examined are being collected by the Venizeleio Hospital. So far the unit has made 3,950 mammograms throughout the Heraklion prefecture. This valuable scientific data, that concern breast cancer, is expected to be analysed and used for further medical research by the medical doctors of the Venizeleio Hospital in the future, when a considerable amount of data will have been collected.
The initiative is an investment in human capital, in the sense that the population health is a main index of human development and well being and a substantial criterion for social and economic development. It secures the health protection of working women and therefore it extends the timeline of their economic productivity and employability. Additionally, there is a gain in man-hours. The mobile mammography unit goes to various places in the Heraklion prefecture so that working women do not need to go far from where they work to do the mammogram. Furthermore, the doctors of the Venizeleio Hospital will use the knowledge acquired for further medical research and are expected to reach conclusions for new programmes in the health field.
The initiative also promotes the administrative decentralization, serving its implementation, paying special attention to the reduction of bureaucratic processes and the saving of human and economic resources in the field of preventive medicine.
There is a positive environmental impact, as the need for transportation is reduced. Women can do the mammogram in their place of residence and they don't need to travel to Heraklion. Regarding the chemical substances used by the equipment in the mammography process, these are being treated in the Venizeleio Hospital by a specialized treatment unit and there are no discharges to the environment.
Since the sort-term results, as far as the mobile mammography unit is concerned, are very encouraging and the response from the public has been very high, the Prefecture of Heraklion is planning the operation of the mobile mammography unit in the future. The initiative has received a lot of publicity as it is the only mobile mammography unit operated by a regional authority in Greece and it carries out a very remarkable work. The Prefecture of Heraklion is also planning to start a new initiative, based on the same idea (a mobile dental unit for children), aiming at pointing out the significance of preventive control.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
The impact of our initiative, especially for the inhabitants, is described as follows:
• Prevention with regard to breast cancer.
• Reduction of the mortality of female population.
• Awareness on this crucial issue
• Better service to citizens who don’t have to go through bureaucratic processes.
• Reduction of hospitals’ workload in the cities and shorter waiting time in the assignment of the appointment.
• Saving of resources in the field of Public Health, reducing the burden of the Social Security Organizations.

The above result in the improvement of the quality of life on a social-economic level, particularly for women living in regions of the Heraklion prefecture located far from the main cities as well as in remote mountainous areas. An important number of women in rural areas had not been regularly submitted to mammography test before the mobile unit went to their area. The main reasons that discouraged women were economic, social and geographic. The initiative brought this process to their home. It helped them understand the importance of preventive control and saved many women who have been diagnosed and referred to the Hospital.
The initiative also promotes the equality between women who live in the cities and women who live in rural areas, by ensuring the access of the latter to a high quality medical service. Therefore, it promotes social cohesion, as it helps remove geographic and social inequality. The above situation derived from the lack of medical centres with mammography units in the Heraklion prefecture and most women had to go to the Heraklion city. As a result there was an inequality in terms of access to health protection services.
The mobile mammography unit has created 3 jobs, as it currently occupies 3 persons (1 technologist-radiologist, 1 driver, 1 administrative staff) and has also offered services to all the 26 Municipalities of the prefecture. It has done 100 visits (88 in rural areas and 12 in the area of Heraklion), since the start of its operation, July 2008 and the mammography test is free of charge for all women. As a consequence, the need for transportation to Heraklion and other urban centres has been reduced, therefore working women (together with all women of the prefecture), have saved many man-hours, and all these without any other administrative and bureaucratic processes.
Based on the results until now, the response from the public has been very high and the initiative appears to be extremely effective beyond the initial expectations. The number of women who get a mammogram has substantially increased in the Heraklion prefecture, as the project raises awareness of the breast cancer issue and ensures that all women have access to a high quality medical service. This initiative constitutes a very constructive health service and it is the first time that such a programme is operated by a regional local authority in Greece.

Contact Information

Institution Name:   Prefecture of Heraklion
Institution Type:   Public Organization  
Contact Person:   Evangelia Schoinaraki-Iliaki
Title:   Prefect  
Telephone/ Fax:   +302813400300
Institution's / Project's Website:   +302810342588
E-mail:   nairakl1@otenet.gr  
Address:   Eleftherias Square
Postal Code:   71201
City:   Heraklion
State/Province:   Crete
Country:   Greece

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