Christou et al. BMC Public Health 2010, 10:373 http://www.biomedcentral.com/1471-2458/10/373 Page 8 of 21 Table 1: Participation in the NBCSP according to Indigenous status, gender, SES, geographic location and language spoken (Continued) Preferrred language Disability status/activity limitation# Geographic location Indigenous status# Preferred language SES English 96.7* Severe or profound 90.6* Other 91.7 * None 96.5* Indigenous 46.4 English 43.6* Lowest SES 43.9* Non- Indigenous 43.7 Other language 40.0* Highest SES 40.4* Total 96.2 Total 96.2 Total 43.2 Very Remote Remote Outer Inner Major Total regional regional cities 96.0 97.4* 96.8* Primary Practitioner visits after a positive test 96.9* 95.8* 96.2 Significantly lower number of correctly completed tests among those whose preferred language is not English Significantly lower number of correctly completed tests in those with activity limitation No significant difference Those with a preferred language other than English were significantly less likely to visit a GP after a positive test result. Those in the most disadvantaged quintile were significantly more likely to see a GP following a positive test result Percentages are the number of people participating as a proportion of the total number of the eligible population who were sent invitation to screen 2008 - 2008 Monitoring report reports performance of NBCSP from 30 June 2006-7 August 2008. Included 55 and 65 year olds 2009 - 2009 Monitoring report reports performance of NBCSP from January 2008- 31 December 2008. Included 50, 55 and 65 year olds *significant difference exists #Disability status and Indigenous status were self reported measures Stage 1- the most treatable stage, compared to 14% among individuals who presented with symptoms to their doctor [57]. Critical Review and Interpretation 1.1 Factors contributing to poor uptake of bowel cancer screening in Indigenous populations An individual’s decision to engage in CRC screening is complex and influenced by socio-cultural, historical, sys- tem and organizational factors, and individual beha- vioural factors - all of which impact on screening uptake at a population level [8,58]. Unfortunately, the design of screening programs often does not reflect the diversity of social and cultural values of a nation’s population, creat- ing significant barriers to participation in CRC screening. Bowel cancer screening using the FOBT differs quite considerably from other screening programs in its com- plexity, and is unique in many ways which makes it a difficult program to promote. A self-administered test requires that one complete it at home and return it, hence relying on individuals to take initiative and follow instructions. Moreover, people may find it an unpleasant test to complete, and the first faecal sample must be stored appropriately until the other is taken. CRC screening targets both males and females, which not only increases the size of the target population, but men’s lack of previous involvement in screening pro- grams poses additional challenges for recruitment. There is also some confusion surrounding the age groups for screening with inadequate understanding by and explanation to participants as to why only certain people are chosen. As with most screening tests the FOBT is not diagnostic and only identifies those at high risk, so further investigation is necessary for a definitive diagnosis to be made, making the process longer and more stressful for the client. Thus, participation must be addressed along the entire screening pathway - at the screening stage, if further investigation with colonoscopy is required, then again when treatment is required. Where ongoing screening is incorporated into the pro- gram, difficulties arise getting people to return for sub- sequent two-yearly screens.