Abstract
In Brazil, 70% of the population is illiterate or has completed less than eight years of education, and breast cancer is the most common cancer among women.1, 2 Although breast cancer screening and management is covered by the Brazilian Public Health System, overall survival is less than that observed in more developed countries. 3
In 2003, the first Brazilian Organized Screening Mammography Programme was initiated in the region of Barretos, São Paulo State. It enrolled 54,238 women aged 40-69, who were examined in Barretos Cancer Hospital and in a mobile unit. Attendance rates only ever reached as high as 33.1%.
To reach more women, in 2008, a new strategic programme was started in the Jales region of São Paulo, where 64,286 women were examined. This new region has a similar geography, human development index (HDI) and education range as Barretos 4 . A full-time chief nurse was assigned to each municipality while the mobile unit was in the area. In addition, a nurse from Barretos Cancer Hospital was sent one month earlier to the city, aiming to prepare all healthcare professionals responsible for recommendations and registration and to educate and motivate them in relation to breast cancer screening. As well as meeting with local entities to raise community awareness of the importance of breast cancer screening, home visits were also undertaken by community agents. Only women were employed in the mobile units in an attempt to overcome concerns about male workers in this environment. To increase participation, initiatives such as cars broadcasting information in the streets and local radio advertisements were introduced, and symbolic gifts were offered to the participating women.
With this new approach, 61.4% of the eligible population of this region attended. If we include the 20% of women in Brazil who undergo mammography in private clinics, the two-year programme could now be considered comparable in long-term experience with mammography screening programmes in Britain, the Netherlands, and Scandinavian countries 3 . There is very little in the literature regarding cancer screening in developing countries5,6. One of the most effective elements of the success of this programme was the participation of the community agents who, because they live in the poor neighborhoods, better understand the women's message. They are also members of the Family Health Programme covering 100 million individuals (or 50.9% of the Brazilian population 7 ). These agents could play an increased role in breast cancer screening if they were better trained.
In conclusion, this health strategy challenges the paradigm that it takes a long time to modify the resistance of underserved women to undergoing cancer screening. Nevertheless, to achieve sustained and long-term change in the health attitudes in poor populations, we need to continue to involve local healthcare professionals and promote women's education emphasizing the pivotal role of breast cancer screening.