Christou et al. BMC Public Health 2010, 10:373 http://www.biomedcentral.com/1471-2458/10/373 manifest until the cancer reaches an advanced stage, thus making screening an invaluable tool for cancer pre- vention [2]. Early diagnosis and intervention can sub- stantially improve treatment outcomes and survival in patients diagnosed with bowel cancer. Commencing with Phase 1 in 2006, Australia imple- mented a large, nation-wide organized screening program for the prevention and early detection of bowel cancer. Population screening programs require high uptake by the target group in order to make an impact on health and benefit the population being screened [8], however, participation by Indigenous Australians in the program has been poor [9,10]. By recognising and addressing bar- riers to screening uptake, significant changes were made to the national cervical cancer screening program to accommodate for Indigenous women’s needs, and we argue that a similar approach is necessary for the National Bowel Cancer Screening Program (NBCSP) [11]. This review provides a descriptive and critical analysis of Australia’s NBCSP in order to identify key character- istics of the program that could inadvertently exclude and impact on participation by Indigenous people and other ethnic minorities. Specifically, it examines organi- zational aspects and socio-cultural barriers facing Indi- genous Australians in accessing and engaging in a program which does not take into account their social and cultural diversity, and healthcare access inequities. While our focus is on characteristics of the program that may discourage and hinder participation by Indi- genous Australian, the issues highlighted are also rele- vant to other ethnic minority and disadvantaged groups and people living in remote locations. Such issues need open discussion in order to catalyse policy and program changes to ensure a more equitable and accessible pro- gram for all Australians. Methods and Results Search strategy and approach This review draws upon the existing literature to iden- tify problematic areas in the Australian NBCSP that need to be addressed to optimize the program for Indi- genous people. The dearth of information available on Indigenous populations in relation to bowel cancer screening particularly in Australia, required that we broaden our examination to studies with minority and ethnic groups and also take lessons from breast and cer- vical screening studies which have been more exten- sively studied in Indigenous populations. We undertook a search of the literature for material relevant to the following research questions: What is the current state of bowel cancer and bowel cancer screening among Indigenous Australians? Page 2 of 21 How is the NBCSP disseminated and what may be influencing Indigenous participation? Are there any aspects of the program which appear problematic and which could be modified to improve participation? Similar to the critical interpretive synthesis approach, the process of literature searching was dynamic and reflexive with themes emerging as the literature was searched. This served to shape the content of the review [12]. In contrast with systematic reviews, where inclu- sion and exclusion criteria are defined at the outset, our approach was more appropriate in the context of limited availability of literature. Yet, our critique drew upon ele- ments of a systematic review, including an initial metho- dical and structured search of the literature using electronic databases to synthesise and appraise the infor- mation available. Peer reviewed journal articles were selected following a search of electronic databases including Proquest, Science Direct, Google Scholar, PubMed, Medline, Informit and ISI Web of Knowledge. Key search terms used included a combination of the following: Indigen- ous or Aboriginal with cancer screening, bowel cancer, colorectal cancer, colon cancer with screening; ethnic or racial minorities and disparities in colorectal or bowel cancer screening. Other search terms included, Native American and Alaska Native, Maori, First Nations, Inuit and Metis, ethnicity or ethnic minorities with colorectal or bowel cancer screening. Additional articles were obtained through citation snowballing. The Australian Indigenous Health InfoNet, the Australian Institute of Health and Welfare, the Australian Bureau of Statistics, Australian and State Cancer Council websites and pub- lished and unpublished government reports also pro- vided useful information and links. Publications were considered for inclusion if they addressed at least one of the above research questions and contained information about colorectal cancer inci- dence, mortality and survival or colorectal cancer screening participation in Indigenous populations and racial/ethnic minority groups. Articles examining knowl- edge, attitudes, beliefs and barriers toward colorectal cancer screening uptake and interventions to improve screening uptake in these populations were also included. Literature was not limited to Indigenous Aus- tralians or Indigenous populations because of the dearth of studies available. As literature on colorectal cancer screening in Indigenous Australians was minimal, papers looking at breast and cervical screening practices were included to identify participation levels, barriers and interventions for increasing uptake. Papers that did not refer to an Indigenous, minority or disadvantaged group were excluded.