Christou et al. BMC Public Health 2010, 10:373 http://www.biomedcentral.com/1471-2458/10/373 Page 10 of 21 Table 2: Differences between CRC and CRC screening programs in selected industrialised countries with disadvan- taged Indigenous populations (Continued) 10 yearly colonoscopy For everyone over 50 yrs [48] 31.7 (AI/AN) vs 45.8 (white) [120] Endoscopy or FOBT: 34.4 vs 49.5 [120] All figures are per 100 000 and are age-standardised Abbreviations AI/AN- American Indian/Alaska Native iFOBT- immunochemical FOBT gFOBT- guiac FOBT ^ 1999-2004 Included only those that attended Indian Health Services and limited to Contract Health Service Delivery Area Counties. Standardised to 2000 USA population ^^ Age standardized mortality rate from 2002-2006 Queensland, Western Australia, South Australia and Northern Territory combined ** Age standardized incidence rate 2000-2004. Data for NSW, Vic., Qld, WA, SA and NT combined * 1996-2001 Standardised to Maori population a Rate adjusted to the 2000 USA standard population b Age standardized to the 1991 Canadian Population. Mortality rates are from 2000 for First Nations and 2001 for Canada. First Nation rates are for on reserve but include the off reserve population for British Columbia and Alberta cAge standardized to the 1991 Canadian population. Rates are from 1997-2001 Lower screening uptake by certain racial/ethnic and minority groups has consistently been documented in countries implementing CRC screening programs [59-62]. Lower participation also occurs among the less educated, lower income groups, and those from non- English speaking backgrounds [10,58,63,64]. Studies controlling for SES and other factors such as distance from services and education show that race and ethni- city are independent predictors of CRC screening uptake [28,65]. Research reveals that beliefs and attitudes of ethnic and minority groups in regard to cancer and cancer screening can differ quite significantly from the majority mainstream population which may have important implications for participation in cancer prevention efforts and treatment [17]. A number of studies in the USA have identified differing views and beliefs that could act as motivators or barriers to CRC screening [66-68]. A study of American Indian and Alaska Natives (AI/AN) found that having a family history of cancer, higher education and income, presence of other chronic conditions, speaking English at home, urban residence, and older age were predictors of CRC screening partici- pation [69]. Researchers examining other ethnic groups have identified that being physically active, having a greater perceived susceptibility to CRC, a doctor’s recommendation and participation in other screening programs as important predictors of screening adher- ence [70], while lack of knowledge, lower perceived risk and perceived self-efficacy, inaccurate beliefs, language and communication barriers, fatalism, the belief that screening is not necessary without symptoms, lower levels of utilisation of health services, the failure of a doctor to recommend screening and cost are significant barriers to screening [66,67,71,72]. Many other developed countries with Indigenous populations are in the beginning stages of CRC screen- ing and while uptake by Indigenous populations has not been extensively studied, early data also indicate lower participation. Table 2 shows differences in CRC screen- ing participation by Indigenous compared to the non- Indigenous population in four industrialised countries, outlining variations in screening recommendations, the type of screening test and how the screening is targeting individuals. Cancer screening programs have had variable success among Indigenous people in Australia. The low partici- pation rates observed for the NBCSP reflect similarly poor engagement of Indigenous women in cervical and breast screening programs, with participation in the order of 30-35% compared to 55-60% in non-Indigenous women [3,37,73]. Indigenous communities face several barriers to accessing cancer-related health services, including early detection programs [74,75]. Evidence from studies assessing breast and cervical screening uptake by Indigenous women in Australia suggest that participation is influenced by multiple structural, socio- cultural and behavioural factors similar to those described above (see Table 3), including poor knowledge and awareness of cancer and the benefits of screening prevention services, culturally insensitive services, shame and fear regarding cancer, lack of Indigenous or female service providers, distrust of the mainstream providers, low literacy, poor coordination of services as well as dis- tance and access barriers [3,17,76-78]. The absence of sufficient Indigenous-specific, culturally relevant, educa- tional resources has also been identified as an important factor impeding cancer prevention efforts [74,79-81]. To date, no published studies in Australia explore barriers specifically towards bowel cancer screening in