Abstract / Summary
In rural multi-ethnic settings, multilevel barriers and facilitators to breast and cervical cancer screening have been widely reported, but their patterns across the full screening journey and variation in local service-improvement priorities remain less understood. We therefore used a screening-journey perspective to identify multilevel barriers and facilitators and compare priorities between two geographically close sites. Both were in rural areas with relatively low socioeconomic development and operated under the same government-led screening programme, but differed markedly in ethnic composition. We conducted a two-phase exploratory study in Gansu Province, informed by human-centred design (HCD). In Phase 1, semi-structured interviews with 103 participants from five stakeholder groups were analysed thematically. After theme development, barriers and facilitators were mapped onto a socio-ecological model–screening journey matrix comprising five socio-ecological levels and three screening stages. In Phase 2, participatory stakeholder workshops were conducted in Dongxiang (ethnic minority–concentrated; n = 16) and Lintao (Han-majority; n = 11). Individual ratings and group discussions were used to prioritise the barriers and 28 service-improvement suggestions derived from Phase 1. Fourteen barrier themes and 11 facilitator themes were identified, most in the pre-screening stage; four barrier themes and six facilitator themes spanned at least two stages. Suboptimal education and information delivery ranked first at both sites, while bodily and privacy concerns and screening beliefs and cognitive biases also ranked highly. At Lintao, on-site service and workflow barriers, time–role conflict, and result-related fears and screening avoidance ranked higher, whereas at Dongxiang, gaps in result communication and follow-up support and non-adherence to recommended follow-up ranked higher. Off-peak scheduling and clear explanation of results ranked highly at both sites; mobile screening vans ranked first at Dongxiang, whereas free add-on tests ranked first at Lintao. Barriers were concentrated at individual and interpersonal levels, whereas corresponding service-improvement themes were concentrated at community and organisational levels. Improving screening participation and continuity requires particular attention to pre-screening barriers while maintaining support across the screening journey. Service improvements should be adapted to local contexts and address individual and interpersonal barriers through action at the community, organisational, and policy levels.