Christou et al. BMC Public Health 2010, 10:373 http://www.biomedcentral.com/1471-2458/10/373 transient populations and those living in remote areas or who are homeless, situations more commonly experi- enced by Indigenous than non-Indigenous Australians. The NBCSP pilot evaluation identified this limitation to participation and receipt of test results [9]. Arguably, options are needed that enable those without fixed address to receive a kit by alternative means, thereby giving them similar access. Pilot activities are taking place in some states in Australia exploring alternative mechanisms of delivering kits to Indigenous people [93]. These include distributing kits from Aboriginal Medical Services, opportunistic distribution of kits, and the utili- sation of Aboriginal Health Workers to deliver kits and follow up individuals with kits to encourage them to complete the tests. These innovations are being evaluated. Despite greater flexibility in distribution being needed, there is no national initiative to improve access for Indi- genous people to the NBCSP through alternative target- ing strategies. A mechanism is needed whereby those who are interested in receiving a kit are able to obtain one from their health centre, as occurs in Canada where all people over the age of 50 are able to obtain a free FOBT kit from their health care provider [94]. In Aus- tralia, the possibility exists of broadly promoting cancer screening through mobile vans visiting Indigenous com- munities every two years, as is done for breast and cer- vical screening. This may require addressing logistical difficulties, including the need for the van to stay extra days to give enough time for participants to provide two samples. iii) Role of the General Practitioner In Australia’s pro- gram, general practitioners (GP) have a pivotal role to play. They receive FOBT results of patients who nomi- nate them as their GP, manage patients with a positive test and organise referral for colonoscopy. GPs are also responsible for notifying the central registry of patient outcomes and any referrals for colonoscopies [10,95]. GPs have an important role in encouraging test com- pletion [96], however, their pivotal position in the pro- gram poses several problems which may limit access to the program as well as to follow-up tests. Indigenous people in general have lower levels of utilization and access to GPs, especially regular GPs. This is particularly true in rural and remote regions [91]. In the case where an individual has received the kit and completed the test but has not nominated a GP on the form, it is up to the patient to initiate follow-up of their test results with a doctor or nurse. A problem arises when an indi- vidual has difficulty reading and understanding the letter notifying a positive result and then acting upon it appropriately. This is also a barrier for others like those of CALD background, the elderly and those with disabil- ities. Additionally, many Indigenous people have poorer Page 13 of 21 continuity of care, given the high doctor turnover in many rural areas and in Aboriginal Medical Services (AMSs). This has led to a large reliance on overseas trained doctors [97] who are often referred to by their first name, thus posing difficulties when identifying a participant’s nominated GP. Alternative approaches the program could employ include shifting some responsi- bility from the doctors to the nurses and health workers within clinics and hospitals. The bowel cancer screening test could also be integrated into health services so when a person of the target age presents with another problem, a screening test is administered by a health worker. At present there are no supplies of screening kits available to AMSs or hospitals. Alternative approaches could also be considered, such as in the UK where screening hubs have been established and are responsible for call and recall of the screening popula- tion, issuing and analysing kits, arranging colonoscopies and notifying GPs of patient outcomes [98]. iv) Target age group Despite overall incidence and mortality rates being higher in non-Indigenous people, Indigenous Australians die from CRC at a younger age, before the targeted screening age [10]. For example, in the 45-49 age group mortality rates in Indigenous Aus- tralians was 11.3 per 100 000 compared with 7.8 for non-Indigenous people. In the 50-54 year age group the difference is even more marked with a rate of 24.1 for Indigenous people while in non-Indigenous it is 7.8 [10]. Considering the time taken for a polyp to develop into cancer may be over 10 years [38], it is crucial that Indi- genous Australians are targeted for screening at a younger age than the recommended 50 years. Reasons for an earlier age of onset of CRC are not clear and need to be identified, but may relate to exposure to higher levels of risk factors at younger ages. In 2005/ 2006 it was announced that Indigenous people could participate in the NBCSP from the age of 45 [41], but it is not clear whether FOBT kits are in fact being sent out to Indigenous people at this earlier age. Given that this would require Indigenous status to be reliably iden- tified on Medicare enrolment records, a large proportion of at-risk Indigenous people are likely to be missing out on getting screened earlier. v) Health information systems around recording Indi- genous status For a participant to be identified as Indi- genous in the NBCSP, they as well as their GP and colonoscopist must all record Indigenous status on the appropriate forms including reports that are sent to the central registry. Information on Indigenous status recorded within Medicare is currently voluntary, and a large proportion of Indigenous people are not identified. The lack of recording of Indigenous participation in other screening programs has been noted to affect the ability to determine to what extent screening is making