Mobile mammography unit screening project
King Hussein Cacner Foundation Jordan Breast Cancer Program

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Among the development of centralized services, many challenges are faced such as women’s accessibility to quality breast cancer screening services and usability of mammograms outside the capital Amman (south and middle of the Kingdome); where in some governorates the services are either unavailable or inactivated or non complaint to local and regional international screening standards. In addition to infrastructure challenges access to quality screening services is hindered due to shortage of qualified well trained female medical service providers in remote areas and unfortunately public transportation from and to the mammography units are not easily available either Despite repeated mass social marketing campaigns, the majority of women outside Amman do little to nothing to detect breast cancer early. They face cultural barriers that prevent them from adopting life-saving screening practices. These barriers include fear of diagnosis, negative attitudes about cancer in general and breast cancer in particular (many females prefer not to know), wrong understanding of fatalism, and fear of being abandoned by their husbands, family or society should they be diagnosed with cancer. Such cultural barriers coupled with physical and accessibility barriers represented in travelling time and cost incurred by less privileged women in underserved remote areas make breast cancer screening the least of their priorities as they overlook a life saving test.

B. Strategic Approach

 2. What was the solution?
The Jordan Breast Cancer Program led and supported by the King Hussein Cancer Foundation and Center took the initiative of planning and implementing a breast cancer screening project using one of its mobile mammography units to address the accessibility challenge of less privileged women to quality breast health services. A Mobile Mammography unit is a van that travels to provide women with breast imaging services. It is a successful alternative way to obtain a mammogram to less accessible population. This mobile unit is currently operational in Al Mafraq, one of the underserved governorates of Jordan with a target population of 21,990 women over forty years eligible for screening (as per Jordanian screening guidelines). This community is underserved medically due to infrastructure and human resources challenges, not to mention is currently overburdened with the influx of Syrian Refugees which create an extra burden in all services including health care services. The screening project was planned out in a way to resolve both accessibility issues in addition to identified cultural barriers women in Al Mafraq experience, whereby the unit is conveniently located in their local community eliminating the need for travel and incurring additional costs, in addition; women are granted free screening examination in a very comfortable and private environment operated by female staff only. Other previously mentioned cultural barriers are scientifically addressed through an intensive behavioral change outreach project with targeted home visits conducted in Al Mafraq visiting women from the local community in the comfort of their homes to educate them about breast cancer and the importance and methods of screening. During the home visit women are encouraged to start performing self-breast examinations and go for clinical breast exams and mammograms when necessary. They are educated about breast cancer symptoms, risk factors, early detection examinations by a trained health educator. At the end of the home visit women eligible for screening by mammography are referred to the mobile unit to be screened using state of the art equipment operated by qualified medical and technical personnel of the King Hussein Cancer Center.

 3. How did the initiative solve the problem and improve people’s lives?
An innovative communication model was followed for behavioral change with a one-to-one approach through targeted home visits. The home visits are conducted by trained educators from the community who are aware of its culture and are sensitive to its needs. JBCP has a thorough selection and training process for these educators recruited from a pool of local volunteers and activists, who undergo training on behavioral change communication skills for disseminating health messages. JBCP was also innovative in the interactive communication tools addressing women of different background and literacy levels. This initiative was also innovative in overcoming one of the main barriers to screening women in remote areas; being the shortage of qualified medical personnel outside the capital. Mafraq like other underserved governorates suffer from the lack qualified female radiologists to oversee screening efforts. To address this, JBCP partnered with the Jordan Health Initiative to electronically link the mobile unit to the King Hussein Cancer Center’s data center in Amman. This electronic solution helps address the shortage of radiologists in the area through the electronic transmission of mammography images to KHCC, enabling the success of screening efforts and saving women of Mafraq the trouble of travelling to Amman for screening in the process.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
To conduct the screening project the following plan was set and implemented: Recruitment of a civil society partner: choosing a partner NGO from the local community experienced in outreach preferably on health issues and aware of the local community needs. JBCP staff screens NGOs and societies working in the targeted area and identifies most suitable partner based on its knowledge and understanding of local community, and outreach capabilities. Recruit of qualified health educators through the identified partner a peer education approach is adopted whereby qualified and interested volunteers and activists from the local community are recruited to be the main outreach arm and lead the home visits in the area. Health educators are women between the ages 25-45 with high school; educational background at the least with excellent communication skills. Training of identified health educators: where they are intensively trained on Breast cancer related issues including symptoms, risk factors, myths and misconceptions towards breast cancer in addition to early detection examination and national screening guidelines. The training workshops also tackle soft skills as educators are trained in effective communication skills and the dissemination of health related messages to the public. Once completed the theoretical training educators proceed to the field training whereby they conduct a home visit under the supervision of JBCP outreach specialist. Depending on the post training assessment only shortlisted educators are cleared to proceed to the home visits implementation phase Execution of home visits: a detailed mapping of the target area is conducted based on which a specific home visits schedule is planned according to which educators reach out to women of the local community knocking on their doors with a life saving message. During the home visit women are educated and encouraged to uptake self breast examination and clinical examination. Throughout the home visit the peer educator uses an interactive information, education and communication kit creatively designed to deliver the early detection message. The toolkit includes flyers interactive boards and other materials that utilize figures, illustrative drawings and simple text messages to be easily communicated with women of different educational backgrounds and literacy levels. The tool kit also includes a breast model that the educator uses in introducing women to the techniques of performing self breast examinations. At the end of the home visit women eligible for screening (40 years of age and above according to the Jordanian national breast cancer screening guidelines) using a specific voucher for a free screening examination on board of the mobile unit. Provision of screening examination on board the mobile mammography unit: women arriving at the unit are welcomed by an administrative coordinator who collects necessary information based on the national registry system developed by the Jordan Breast Program and explains to women that will be receiving a screening mammogram and shall expect her results within a month as per the international standard for screening examinations. A women is led to the private examination room where the highly trained technologists administer the mammography examination as per local and international standards. The electronic system installed also enables staff communication between technical staff at KHCC and technologist operating the mobile mammogram for required giodance. Upon completion the technologist upload mammography images as they are electrobically transmitted to KHCC’s data center in Amman for assessment and reporting. Assessment and reporting: received images at KHCC are assessed by a qualified radiologist based on which women are either cleared with negative findings Otherwise women with suspicious finding are called back for follow up at KHCC in Amman where the necessary examinations are offered. The costs of additional tests are fully covered by the project until a definitive diagnosis is reached.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
This initiative is a model example of the public-private mix approach that gathers (the Ministry of Health, Ministry of Planning and International Cooperation, Ministry of Finance, Mafraq Governor and Municipalities, Local NGOs and CBOs, private sector companies, international donors, in addition to the King Hussien Cancer Foundation and Center and the Jordan Breast Cancer Program); where efforts are successfully geared towards the support of early detection at the national level with specific focus on emphasizing the women’s’ and less privileged populations’ rights in accessing quality health services. The Ministry of Health facilitated the whole process of service delivery through direct involvement of decision makers in both the central and peripheral levels; in addition to MoH medical service providers i.e. nurses, midwives, family medicine doctors and general practitioners and specialists who played a vital role in promoting the early detection examination to women of the local community and informing them of the mobile unit. The implementation of the outreach and social marketing part is facilitated by the local municipalities and governor in addition to local community based organizations (CBOs) and non-governmental grass root organizations (NGOs) led mainly by JBCP’s identified partner Bushra Center for Women Affairs. The King Hussein Cancer Foundation & Center and the Jordan Cancer Program as owners of this projected played a significant role in the operation of the mobile unit and serving the main technical and medical arm in this project; in addition to their fundraising efforts to secure funding for this initiative which reflected in the allocation of financial resource through the budget of (CSR of private companies such as Kingdom electricity and Cisco), USAID Local Currency Allocation and international agencies like Suzan Komen.
 6. How was the strategy implemented and what resources were mobilized?
To see this project through a variety of technical, human, and financial resources were allocated for the project: Human resources: (most involved personnel are not allocated to this project on a full time basis) • A technical breast imaging team involving three technicians and a radiologist to oversee breast imaging tasks, image interoperation in addition to implementation of follow up exams. • A technical support team that involves an electrical engineer, a biomedical engineer and IT specialist, and a driver • A network of over 10-15 educators from the local community of Mafraq • An administrative coordinator on boad the mobile unit Technical resources: • A mobile mammography unit equipped with state of the art digital mammogram machine • A data transmission system connected to both the mobile unit and the King Hussein Cancer Center’s data center Financial resources: This project is funded by the King Hussein Cancer Foundation/Jordan Breast Cancer Program through funds secured by special allocations from the Ministry of Finance and Ministry of Planning and International Cooperation budgets, USAID local currency allocations, and other fundraising efforts with private sector companies through their corporate social responsibility programs in addition to other regional and international partners and donor agencies. All secured funds are used to fund the home visits and the actual screening and follow up examinations (if needed) for target beneficiaries.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Ever since the inception of this project a total of 6,100 home visits were conducted in the targeted area of Mafraq reaching around 18,500 women from the local community with messages about breast cancer and the importance of early detection. A total of 800 women were screened through the mobile mammography unit some of which are still undergoing follow up procedures at King Hussein Cancer Center and finally a total of 4 women presented malignant findings and have been positively diagnosed with breast cancer.

 8. What were the most successful outputs and why was the initiative effective?
A scientific based analysis method was created for the assessment of the effectiveness of home visits in improving women knowledge of breast cancer and changing their behavior and practice of early detection examinations whereby before the home visit the educator asks women to fill out the pre visit form developed by JBCP’s M & E department with predesigned questions meant to assess women overall knowledge of breast cancer symptoms, risk factors, early detection methods and frequencies in addition their personal belief of some myths and misconceptions related to breast cancer. After six months of the original home visit a second home visit is carried out whereby the same women are requested to fill out the post visit forms. Both the pre and post visit forms are collected by JBCP’s monitoring and evaluation team for a thorough analysis of women’s retained knowledge of information received during the home visit and more importantly an assessment of the effectiveness of home visits in causing behavioral change among visited women towards breast cancer early detection and their practice of regular screening examinations

 9. What were the main obstacles encountered and how were they overcome?
The accessibility to quality cancer care in remote underserved understaffed areas with a shortage of qualified trained medical and technical specialists to oversee the screening process was a major obstacle at the onset of this project, and as the allocation of specialists from Amman to travel to Mafraq was not a feasible option considering their roles as practitioners within their facilities in Amman, an alternative solution was needed. accordingly the centralization of image interpretation within KHCC through the electronic connectivity was a was a successful alternative introduced by JBCP capitalizing on its partnership with the private sector where this connectivity was fully sponsored by Cisco under the Jordan Health Initiative an initiative established for the improvement of health care through the use of information technology. Implementing the home visits in a conservative community like that of Al Mafraq was a challenge at the beginning where some people were suspicious of this new communication technique and of the aim of these visits to the extent that some even refusing the visit at first. However through clear professional and transparent communication with community members both JBCP staff and recruited educators were capable to address this challenge and those who objected at first became advocates of the project and helped arrange other home visits to their friends, families and neighbors.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The implementation of this project has helped provide quality breast cancer screening and early detection services compliant to local and international standards to less privileged women of Al Mafraq Governorate in the only accredited comprehensive cancer center in the country whereby they are examined using state of the art equipment and under the supervision of highly qualified medical staff of radiologists and technologists. such an impact is highly valuable in an underserved understaffed community that is not only suffering from existing challenges in the medical services provided but is also overburdened with additional demand on medical services imposed by the influx of Syrian refugees to the community. This initiative was also of huge added value to the less privileged beneficiaries targeted in the project offering them free of charge breast cancer examinations that they could not have afforded on their own especially that such an asymptomatic screening test is not on their priority list if not clinically indicated considering their socio-economic situation. So far four cases have been diagnosed and is currently undergoing life saving treatment. The life expectancy of these women would have been dramatically compromised if these women were not offered free breast cancer screening and symptoms were waited upon to present themselves. this project gave these women a chance at early detection, a chance at a life.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
This initiative is one the main initiatives that the Jordan Breast Cancer Program implements to provide quality breast cancer screening services to less privileged women in Jordan and accordingly KHCF/JBCP intend to sustain such an imitative dependant on the availability of funding for that purposes and support of local and international partners of this initiative. On other levels like at the social levels JBCP has developed a wide strong network with local CBOs and NGOs to maintain and sustain working at the grassroots level reaching out to women in their local communities through targeted home visits. Such a project proved to be successful in improving women’s access to breast cancer services in underserved remote areas in the country that the program is currently studying replicating this project in a different remote underserved location where the local community is in need of breast cancer screening interventions. Currently the team is screening potential target areas based on the targeted population and medical services provided in that area.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
One to one communication approach proved to be a more effective tool at behavioral change than the group approach allowing direct customized communication and providing a comfortable private non threatening environment where beneficiaries can make all their inquires, comfortably share their fears and personal concerns and understand the importance of early detection and that can early detection can indeed save lives. Despite the cultural barriers with effective communication and elimination of other barriers like cost, incontinence caused by long transpiration time less privileged women are prone to uptake screening if effectively persuaded and convinced of the importance of early detection. Reaching out less privileged women with quality services is indeed a need in our parts of the world where accesses to health care and health equity are rising priorities. population in a country like Jordan are widely dispersed geographically which imposes additional burdens to the medical industry. Yet mobile solutions have proved worthy of consideration given thorough planning is needed as technical and financial management for such initiatives is a challenge. Technical considerations of working in a mobile environment impose additional operational cost which requires additional fundraising efforts to achieve sustainability both at the financial and high quality technical level. Public private partnership has proven a key element of success for such an intiative where all parties are engaged to serve less priviliged women in underserved remote areas and enhance their chances at quality breast health services which can be a suceesful model to be replicated to in other health/development issues. This public private mix created an enabling environment to overcome technical and financial barriers of operating in a monile environment and maximizing the efficiency of limited resources moralizations in service of less privileged communities.

Contact Information

Institution Name:   King Hussein Cacner Foundation Jordan Breast Cancer Program
Institution Type:   Non-Governmental Organization  
Contact Person:   Nisreen Qatamish
Title:   JBCP Director  
Telephone/ Fax:   009625530800/009625530870
Institution's / Project's Website:  
Address:   10 Saad Bin Abi Waqqas 35102 Amman 11180 Jordan
Postal Code:   11180
City:   Amman
State/Province:   City

          Go Back

Print friendly Page