Christou et al. BMC Public Health 2010, 10:373 http://www.biomedcentral.com/1471-2458/10/373 Table 3 Barriers to cancer screening uptake as well as follow-up and treatment in Indigenous populations Socio-cultural and behavioural barriers Individual barriers Structural barriers Access barriers Poor knowledge and awareness of cancer and screening services Low levels of health literacy Language/literacy barriers Low perceived risk Negative attitude Worry or fear of cancer Fatalism regarding cancer Low priority of screening Perceived self efficacy Lack of appropriate health information Presence of co-morbidities History of racism and distrust in medical institutions Discomfort with mainstream services/alienating hospital environment Absence of holistic, culturally appropriate cancer services Poor coordination of services, from screening to follow-up and treatment Lack of transportation Distance barriers/rural residence Frequent moving, changing address Child care commitments (family responsibilities) Inflexible clinic schedules Lack of Indigenous staff Difficulties negotiating/ communicating with providers and organizations due to language/ literacy or cultural differences Lack of health promotion material in Indigenous languages Economic Cost of seeing a GP including transport Unsure of potential costs of follow- up and treatment Costs for travel and accommodation to hospital Provider-related Lack of understanding of cultural needs Poor identification of Indigenous status Lack of appropriate resources Indigenous people other than an evaluation conducted following the pilot program in 2004 which interviewed only 15 people - 8 participants and 7 non-participants [82]. However, a study of Italian migrants in Australia found similar issues and beliefs to Indigenous Austra- lians - fatalism, English proficiency, fear of cancer and finding out they have cancer, inadequate knowledge and misconceptions of causes of bowel cancer [83]. Weber Page 11 of 21 [84] also explored uptake of cancer screening in Austra- lian migrants and found a significantly lower participa- tion rate in bowel cancer screening among Asian men, although as the authors noted, the NBCSP had not begun in Australia at the time of the survey [84]. This highlights the importance of identifying the needs and preferences of minority groups so as to appropriately target them for bowel cancer screening. To successfully target messages, educational resources and interventions for increasing uptake requires understanding of the cur- rent knowledge, attitudes and beliefs of the community of interest. Potentially, screening could exacerbate inequalities in health as a result of less participation by those of lower SES or ethnic minority groups, including Indigenous populations [8]. A recently completed study in S.A has shown disparities in participation in the NBCSP accord- ing to SES, gender and age [85]. Although many coun- tries are examining ways of increasing participation by disadvantaged groups, only N.Z has taken a serious interest in avoiding increasing health inequalities before implementing any sort of CRC screening program that may negatively impact on the health of the Maori popu- lation [86]. A CRC screening advisory group in N.Z recommended that any screening program if implemen- ted must: adopt a holistic approach to health and well- being; establish partnerships with relevant Maori health organisations; incorporate Maori language in informa- tion and health promotion materials; and ensure partici- pation of Maori in the planning and dissemination of the program [87]. Such an inclusive approach with con- sultation and involvement of the community is likely to have a positive impact on participation and should be explored further in Australia. 2.2 Findings from the evaluation of the bowel cancer screening pilot program A qualitative evaluation undertaken in 2005 of opinions, attitudes and behaviours influencing participation or non-participation in the pilot bowel cancer screening program is the only available review which provides some insight into Indigenous people’s view of the bowel cancer screening program, its associated screening kit, and reasons behind their decision to participate or not [82]. However, only a very small number of Indigenous people were involved (8 participants and 7 non-partici- pants) and the target population of Indigenous people was not considered representative, so the findings need to be interpreted with caution. The main issues that emerged were that lack of aware- ness and knowledge of bowel cancer and related screen- ing options as key barriers to participation. There was a lack of understanding of bowel cancer and the benefits of screening and early detection, with many unable to distinguish bowel cancer from other cancers. Not having