Christou et al. BMC Public Health 2010, 10:373 http://www.biomedcentral.com/1471-2458/10/373 an impact on cancer incidence and mortality [26]. Not knowing how many Indigenous people are completing the test and being followed up, impedes assessing how well the screening program is targeting Indigenous peo- ple, and hence the development and modification of the program. Thus, adequate identification is crucial for improving the delivery of screening services to the Indi- genous population. The inadequate information systems are reflected in the high loss to follow-up (45%) observed in the NBCSP, both concerning and ethically unacceptable as many people with a positive test could miss out on colonoscopy and potentially lifesaving treat- ment [25]. Although not a direct barrier, recording of Indigenous status is important in evaluating participa- tion, and targeting younger Indigenous people for a screening kit. vi) Other logistical issues- privacy, storage and test viability Other logistical barriers relate to an indivi- dual’s access to privacy needed to do the test and an appropriate place to store samples until a second sample is taken. The way the test is designed at present assumes access to conventional housing with a private toilet. Although the test does not need to be kept refrigerated it is recommended that the sample is kept in a dark and cool place. Many Indigenous people live in substandard housing, sadly, many without functioning facilities. Sev- eral families often live within one house, which may compromise the privacy required for test completion. High temperatures and delays in completing the test are known to affect the sensitivity of the immunochem- ical FOBT test [99]. This problem has been noted in several European countries and is likely to arise in Aus- tralia where many regions experience extremely hot conditions. In remote areas where postal collections are infrequent, many completed kits could remain in post boxes for several days before being collected and deliv- ered to the laboratory. vii) Literacy requirement Literacy is essentially a pre- requisite for participation and completion of screening tests distributed by post. The initial contact with poten- tial participants is through a written letter and the infor- mation material and the screening kit is with limited and limited graphical instructions. An investigation into the impact of health literacy on participation in CRC screening revealed that lower literacy was associated with reduced confidence and perceived self-efficacy in carrying out the test and lower likelihood of completion [100]. Being able to read the instructions is imperative to completing the test correctly; the task and instruc- tions are complicated, relying on a wordy instruction sheet. While the kit provides instructions in a number of languages, Indigenous languages are not included. Potential participants may feel unable or unsure about whether they would be completing it correctly. Although Page 14 of 21 doing the test at home might appear be more appealing and less shameful, correct execution remains a chal- lenge. The requirement to fill identification details on small labels to be stuck on the sample sticks presents another potential obstacle. These literacy-related issues are a major drawback of the postal distribution of test kits where language and poor literacy is a critical, often unaddressed, factor influencing cancer screening behaviour. The qualitative evaluation report of the NBCSP noted that language and literacy issues were a major barrier for Indigenous Australians with many unable to under- stand or read the instructions and putting the kit aside after opening it. Furthermore, it was noted that Indigen- ous people were unlikely to seek assistance if they experienced difficulties. An analysis of those who did not complete the screening test revealed that they were less confident about their ability to take the test and the accuracy of the results. They also had lower levels of English competency, felt overwhelmed with the contents of the kit and confused regarding what had to be sent back. Community health workers were an important source of information and support for Indigenous peo- ple compared to GPs and helped to encourage participa- tion. In some cases Indigenous people did not respond until they were contacted by a health worker and many were more interested in undertaking the test once they had spoken to a health worker about it [82]. With test kits mailed to home, an individual’s decision about com- pleting the test (or not) is made without discussion with a health practitioner over the benefits and harms of par- ticipation. Encouragement and assistance from health personnel is important for facilitating participation. It is well known that Indigenous people respond to information more effectively through oral and pictorial, rather than written methods of communication [101]; this should be taken into consideration in the future design of the NBCSP. An educational bowel cancer screening flipchart for Indigenous Australians has been developed using pictures to demonstrate how to do the test. Animated video is currently being used in the USA to encourage screening uptake among American Indians [102]. Similar methods could be used in Australia in contexts where such technology is accessible. viii) Nature of the screening test This issue is underex- plored in regard to CRC screening. Although discomfort and uneasiness with handling faecal material could be experienced by almost all participants, little is known about any taboos in Indigenous culture in regard to this. The qualitative evaluation of the pilot did not find any significant issues with this, although it was noted that those selected to participate in interviews were those who were comfortable to discuss the topic [82]. This potentially significant barrier to participation needs