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The population-based mammographic screening programme offers every woman in Sweden between 40 and 74 years of age a mammogram with the purpose of early detection of potential breast cancer. The programme is seemingly equal in its setup; however, approximately 20 percent of the women do not participate in the screening. The overall aim of Sweden’s public health policy is to create prerequisites for good and equal health, and health care, a health determinant, falls under the responsibility of the self-governed Regions. Therefore, it is important to analyse regional participation in mammographic screening to develop strategies to reach those who refrain from screening.

The aim of the doctoral dissertation was to describe, explore and understand access to and participation in health care using mammographic screening as an example. Study I was a quantitative cross-sectional study based on individual and aggregated data. The analysis consisted of frequencies of data, multivariate logistic regressions, and pairwise chi-square tests. Study II used group discussions with women participating in mammographic screening for data collection. In Study III, women who had not participated in mammographic screening for at least the last two invitational rounds were interviewed. In Study IV, interviews with regional politicians were conducted. The method of analysis for Studies II and III was qualitative content analysis, and in Study IV a reflexive thematic analysis was performed.

The results show that access to and participation in mammographic screening involve both structural and individual conditions. Municipality of residency as a potential proxy for distance to the mammographic facility is indicated to impact participation, as is age. Getting to and from the facility and taking time off from work are examples of structural conditions. Facilitators for and barriers to participation in mammographic screening are similar for women who participate and women who lately have not. The phases of the screening process are addressed. Psychological preparation before the visit, encounters with the staff, and managing the wait for the results reflect individual determinants. Caring for health is perceived as a shared commitment between politicians and individuals. This responsibility requires information and understanding of the impact social determinants have on the decision to participate in the screening. It also requires resources for the lowering of thresholds for participation.

Encounters with the health care system and the health care systems responsiveness are important for continuous participation in mammographic screening, whereas information and knowledge are pivotal to making well-informed decisions.