The benefits of population-based screening for breast cancer are now accepted although, in practice, programmes often fail to achieve their full potential. In this paper, we propose a conceptual model that situates screening programmes within the broader health system to understand the factors that influence their outcomes. We view the overall screening system as having multiple sub-systems to identify the population at risk, generate knowledge of effectiveness, maximise uptake, operate the programme, and optimise follow-up and assurance of subsequent treatment. Based on this model we have developed the Barriers to Effective Screening Tool (BEST) for analysing government-led, population-based screening programmes from a health systems perspective. Conceived as a self-assessment tool, we piloted the tool with key informants in six European countries (Estonia, Finland, Hungary, Italy, The Netherlands and Slovenia) to identify barriers to the optimal operation of population-based breast cancer screening programmes. The pilot provided valuable feedback on the barriers affecting breast cancer screening programmes and stimulated a greater recognition among those operating them of the need to take a health systems perspective. In addition, the pilot led to further development of the tool and provided a foundation for further research into how to overcome the identified barriers.

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Keywords Breast cancer, Cancer screening, Health systems
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Journal Health Policy
Turnbull, E. (Eleanor), Priaulx, J, van Ravesteyn, N.T, Heinävaara, S. (Sirpa), Siljander, I. (Ilona), Senore, C, … McKee, M. (2018). A health systems approach to identifying barriers to breast cancer screening programmes. Methodology and application in six European countries. Health Policy. doi:10.1016/j.healthpol.2018.08.003