Christou et al. BMC Public Health 2010, 10:373 http://www.biomedcentral.com/1471-2458/10/373 any symptoms and no family history of cancer were rea- sons given for non-participation. In addition, there were doubts about the efficacy of the test and some had con- cerns about physically collecting the stool samples. Rejection of the kit was often the result of anxiety and confusion. The analysis showed those who completed the kit required much encouragement and support from health workers and GPs as they believed that they did not have the ability to correctly complete the test. Indi- genous participants did not discuss the test with family members nor did they actively seek assistance from health professionals [82]. Indigenous people that partici- pated were perceived to be more proactive, in control of their health, and more literate. Participation was influ- enced by personal experiences such as knowing some- one with CRC, degree of community engagement and access to information in a known language. Participants in the pilot tended to have a better understanding of why they were receiving the kit and the benefits of the screening as they were more likely to have seen promo- tions and media campaigns prior to receiving the kit and so had an idea of what to expect and were not sur- prised when they received it. This was an important trigger for participation, as was contact and encourage- ment from community health workers, the fact the test was free, and a sense of privilege felt for being chosen for participation. However, this latter factor also insti- gated fear and anxiety in some people who felt that they were at risk because they were targeted individually [82]. Additional barriers identified were similar to other screening programs and included a fear of cancer and the belief that cancer essentially means death. This find- ing is consistent with research conducted into the per- ceptions of cancer among Indigenous people [88]. There is often a social stigma attached to cancer among Indi- genous people [17] which may prevent people from uti- lizing screening. Bowel cancer screening has not had a strong advertis- ing campaign to increase public education and aware- ness, so that many people receive the test without being aware of its purpose. Poor knowledge and understanding of the program was highlighted as a major barrier to participation in the pilot [82]. A study [89] assessing tel- evision coverage of CRC concluded that the disease is under-reported in the media relative to other cancers, despite incidence and mortality rates being high. The absence of celebrities speaking publicly of their CRC experience was also noted, with publicity of affected celebrities highly effective in influencing the public’s perception and increasing uptake of screening [90]. The 2005 evaluation report echoed this need for more exten- sive media coverage as a means to target hard-to-reach populations [82]. Unfortunately, the program has attracted some negative publicity since the incident with Page 12 of 21 faulty kits which has not helped the case for promoting CRC screening. 2.3 How does the NBCSP exclude Aboriginal and Torres Strait Islanders? Several features in the way the NBCSP operates, includ- ing downstream activities of follow-up and treatment, make access for Indigenous people particularly challen- ging. Many of these issues were highlighted in the 2005 evaluation report [91], yet to date no changes have been made to the program. Outlined below and summarised in Table 4 are specific elements of the program related to the way it is organised and disseminated that could contribute to unintentionally discouraging participation by Indigenous Australians. Particular socio-cultural bar- riers are also explored in relation to how they impact on program participation. i) Medicare enrolment requirement Enrolment with Australia’s universal health insurance program, Medi- care, determines who receives a screening kit, as this is the sampling frame from which participants are selected, based on their age [10]. Those who are not enrolled in Medicare are likely to be individuals from poorer socio- economic backgrounds, with lower English proficiency and living in remote locations, so that the program unintentionally excludes those from more disadvantaged backgrounds, exacerbating the already widening dispari- ties in health that exist. Indigenous people are less likely to be enrolled with Medicare than non-Indigenous peo- ple, with estimates from 1997 indicating enrolment rates in the range of 65-80% for Indigenous Australians [92]. It is believed that enrolments have improved over the past decade although recent estimates are not available. Moreover, if addresses recorded by Medicare are not updated - as may be the cases for many transient and mobile Indigenous people - it is likely many people will miss out on receiving a kit. ii) Postal route of FOBT screening kit distribution Delivery of the FOBT screening kit by post significantly impedes participation, for those who do not have a fixed address (or post box). This particularly affects mobile/ Table 4 Organisational and structural characteristics of the NBCSP that may exclude participation by Indigenous and disadvantaged populations 1. Medicare enrolment requirement 2. Postal route of FOBT screening kit distribution 3. Role of the General Practitioner 4. Target age group 5. Health information systems around recording Indigenous status 6. Other logistical issues- privacy, storage and test viability 7. Literacy requirement 8. Nature of the screening test 9. Barriers to compliance with follow-up and treatment