Background: Breast cancer remains the most common malignancy among women in China. Although a national free screening program has been implemented, screening uptake remains suboptimal, raising concerns regarding equity and policy effectiveness. This study aimed to examine socioeconomic, policy-related, and health perception determinants of breast cancer screening participation using a large multi-province population dataset.

Methods: A cross-sectional survey was conducted in July 2023 using multi-stage stratified random sampling across five representative provinces in China: Sichuan, Yunnan, Hubei, Fujian, and Shandong. A total of 37,883 women aged 18–74 years were included. A structured questionnaire grounded in Andersen’s Behavioral Model was used to collect information on socio-demographic characteristics, enabling resources, health status, and screening behavior. Multivariable logistic regression analysis was performed to identify independent predictors of screening participation.

Results: Overall, 61.2% of participants reported having undergone breast cancer screening at least once. Older age and higher educational attainment were significantly associated with increased screening uptake. Awareness of the national free screening policy emerged as the strongest predictor of participation. Higher household income, a personal history of breast disease, and a family history of breast cancer were also positively associated with screening use. In contrast, students, farmers, and self-employed women demonstrated substantially lower participation rates. The most commonly reported barriers were low perceived necessity and time constraints, indicating persistent gaps in risk perception and health communication.

Conclusion: Breast cancer screening participation in China is shaped by socioeconomic disparities, policy awareness, and perceived need. Strengthening policy dissemination and implementing targeted interventions for underserved occupational groups may improve screening equity and early detection. These findings provide actionable evidence for optimizing population-based screening strategies in rapidly evolving health systems.

Lianxue Zhang is a Master of Public Health candidate at Peking Union Medical College, China. Research focuses on women’s health, particularly the epidemiological characteristics, screening behavior mechanisms, and prevention strategies of breast and cervical cancer. Experience includes participation in large-scale population-based surveys and health policy evaluation studies, with responsibilities in questionnaire design, data management, and statistical analysis. Systematic expertise has been