PUTUWA: an initiative that contributed to increasing breast screening participation among Aboriginal women in NSW, Australia

Cancer is a relentless opponent, but medicine has long known that catching it early is the most powerful weapon a person has. For breast cancer, this means looking for changes before symptoms appear, a process called screening. In Australia, a national program offers free mammograms, which are specialized X-rays of the breast, to women starting at age fifty. However, for Aboriginal women, the story is different and more urgent. Statistics show that Aboriginal women in New South Wales are more likely to develop breast cancer at a younger age and are significantly more likely to die from it than non-Aboriginal women. Despite this, fewer Aboriginal women participate in the screening programs. The barriers are not just about knowing the program exists; they are often about whether the medical system feels safe, welcoming, and respectful to their culture. When a healthcare environment feels alienating, even the most vital services can go unused.

In December 2022, a major shift occurred to address this gap. BreastScreen New South Wales, the state's breast cancer screening program, launched a new initiative called PUTUWA. The name comes from the Gadigal language and means "to warm your hands by the fire and gently squeeze the fingers of another person," a gesture of connection and care. This was not just a marketing campaign; it was a fundamental change in how the program operated, designed from the ground up with Aboriginal communities. The project lowered the recommended age for Aboriginal women to start screening from fifty to forty, based on evidence that they develop breast cancer earlier. But the real innovation was in the approach: the program was co-designed with Aboriginal leaders, health workers, and community members to ensure every step, from the invitation letter to the waiting room, was culturally safe and responsive.

To understand if this new way of working actually made a difference, researchers from Inside Policy, an Aboriginal-owned research agency, spent a year and a half studying the project. They looked at the numbers of women who attended screenings and spoke directly with the people who made the program happen. The results were striking. In the two years before the project started, only about eight percent of Aboriginal women aged forty to forty-nine had participated in the biennial screening. After the PUTUWA initiative was fully implemented, that number jumped to over eighteen percent. This was a rise of more than ten percentage points, a significantly larger increase than what was seen in the general population of women in the same age group. For women aged fifty to seventy-four, participation also grew, though the increase was more modest, suggesting that the specific focus on the younger age group and the new invitation strategies had a profound impact on those who had never screened before.

The success of PUTUWA was driven by a combination of practical changes and deep cultural respect. Before the project, the system could only send official invitations to women who had already identified as Aboriginal in their records. This meant many eligible women were never asked to come in. The new initiative worked to fix this data gap and, crucially, partnered with local Aboriginal health organizations to reach women directly. The invitations themselves were redesigned. Instead of standard medical text, they featured artwork and language that reflected Aboriginal culture and strength. A central piece of this visual identity was a design called "Biyani," which represents a healing practice performed by women. This image appeared on posters, websites, and even on scarves that were given to women attending appointments. These scarves were not just gifts; they served a practical purpose, offering modesty and comfort during the screening process, which helped reduce feelings of shame or trauma that can prevent women from returning.

The physical spaces where screenings took place also changed. Screening centers began displaying Aboriginal flags and local artwork, transforming sterile medical rooms into places that felt more like community spaces. Staff underwent extensive training to better understand cultural safety, learning how to interact with respect and how to ask the right questions to identify Aboriginal patients without making them feel singled out. Perhaps most importantly, the program relied on trusted Aboriginal health workers to bridge the gap between the medical system and the community. These workers did not just hand out flyers; they had conversations, listened to concerns, and accompanied women to appointments. They created group booking events where women could attend together, making the experience less intimidating and more of a shared community activity.

The researchers found that these efforts worked together to create a system where Aboriginal women felt seen and valued. The increase in participation was not just a number; it represented women who had previously felt excluded now engaging with life-saving care. The study noted that while the pandemic had disrupted services for everyone, the specific strategies of PUTUWA helped Aboriginal women recover and surpass previous attendance levels faster than the general population in the younger age bracket. The project also highlighted that while the data systems are improving, challenges remain in reaching every woman, particularly those who have never visited a clinic before. The initiative continues to evolve, with a focus on maintaining these partnerships and ensuring that the cultural safety measures become a permanent part of the healthcare system.

Ultimately, the PUTUWA initiative demonstrates that when a health program is built on trust, cultural respect, and genuine partnership with the community, it can overcome deep-seated barriers. The increase in screening participation suggests that Aboriginal women are ready to engage when the door is held open with understanding rather than just an invitation. By lowering the screening age and wrapping the service in cultural safety, the program has begun to change the trajectory of breast cancer outcomes for Aboriginal women in New South Wales. The work is ongoing, but the path forward is clear: continued collaboration, listening to community needs, and ensuring that every woman feels safe enough to walk through the door and warm her hands by the fire.