This is the first published study to examine awareness, knowledge, attitudes and behavioural intention in regard to bowel cancer screening in the Indigenous Australian population. Given significantly lower levels of CRC screening participation by this population group, it is critical to elucidate reasons behind lower uptake to ensure good evidence informs program policy makers in the design of ongoing and future health interventions.
This study indicates that among the population we sampled, general awareness of CRC and CRC screening was low. Most had heard about bowel cancer but were not able describe any particular detail of what it was or what polyps were, and the vast majority had not heard of bowel cancer screening or the FOBT test. The evaluation of Australia’s NBCS pilot program also showed that inadequate understanding and awareness of bowel cancer were major impediments to the participation of Aboriginal people in bowel cancer screening
Having seen media advertising on bowel cancer screening was significantly associated with greater awareness and higher overall bowel cancer knowledge scores, consistent with findings reported by Schroy et al. examining the effect of media on awareness
. Despite this, media exposure was not an independent predictor of screening intention among our respondents, suggesting that although it has a critical role to play, it is insufficient on its own. Exposure to media promotions prior to receiving a screening kit was found to be an important trigger for participation for Indigenous people in the final evaluation of the NBCSP pilot program in 2002. This suggests a pivotal role of mass media for public education and raising the profile of bowel cancer
 and confirms the recommendations of its use to raise awareness and ultimately facilitate screening participation in minority groups
Bowel cancer knowledge
Knowledge of specific bowel cancer risk factors was reasonable, with about two thirds or more of participants identifying the main risk factors. However, that over half of participants did not know bowel cancer can be asymptomatic, suggests this is an important concept to be emphasised in education and awareness campaigns.
Factors significantly associated with bowel cancer knowledge included having participated in cancer screening in the past, seeing a doctor more often, having a family or personal experience with cancer, having been exposed to media advertising about bowel cancer screening, greater levels of perceived self-efficacy and perceived susceptibility. Most of these factors are related to exposure to experiences that facilitate greater cancer awareness and knowledge, implying that knowledge can be gained and is not necessarily determined by education, income or age.
Perceived susceptibility to bowel cancer
Perceived susceptibility to CRC was generally quite low, with only a third of our sample believing they were at risk despite the majority being aged over 45 years, and is in line with findings elsewhere in the literature
. Greater perceived risk to a disease can in some cases be associated with more positive preventive behaviour
 and our study also showed that those with a greater perceived risk were significantly more likely to consider FOBT participation. However, perceived risk was not an independent predictor of screening intention, supporting the theory that despite being important in influencing CRC screening behaviour, it requires other mediating factors to have an effect
Intention to screen using FOBT
Intention to screen for bowel cancer was relatively high among our respondents with almost two-thirds reporting they would undertake FOBT screening in the future if they received a kit. This is much higher than the 17% participation rate observed from the most recent report of Australia’s NBCSP
, but equivalent to that found in a study of rural Australians and low-income, ethnically diverse groups in the US
[31, 40]. An even greater proportion of respondents said they would do the FOBT test if their doctor recommended it - a response which supports research that shows endorsement of screening by a primary care practitioner can facilitate participation
[32, 41, 42]. These results suggest that doctors and possibly other trusted health providers have an important role to play in encouraging screening adherence. It also supports findings from the NBCSP evaluation which demonstrated that Indigenous people needed extra support and encouragement to participate in CRC screening
Bivariate analyses indicated that intention to take up FOBT screening was significantly higher among those who were married or in de-facto relationships, employed, had at least eight years of education, higher income, and a history of undergoing cancer screening or a colonoscopy. Existing research also shows that lower CRC screening uptake is consistently observed among those who are less educated and from lower income groups, and those from non-English speaking backgrounds
[20, 43–45]. In contrast with the literature, English reading ability was not related to screening intention in our study
, however, this measure was self-reported. Moreover, respondents with greater overall knowledge and awareness of bowel cancer and the screening test, greater perceived self-efficacy and perceived susceptibility to the disease were also more likely to consider screening, as were those who personally knew someone with cancer.
On multivariate analysis, significant predictors of screening intention were, being aged 45 years or more, having greater levels of perceived self-efficacy or confidence in carrying out the FOBT, and past participation in cancer screening. Past screening participation was also demonstrated to be an independent correlate of CRC screening uptake in several studies
[29, 47], and although our research does not directly measure participation, intention to participate can provide some indication of behaviour.
One of the strongest associations and independent predictors of screening intention in our sample was perceived self-efficacy. This is highly pertinent to the Australian program as bowel cancer screening is entirely based upon a self-screening kit delivered by post, which in urban areas is to participant’s homes, although mail is not delivered to homes in some rural and remote areas. Self-efficacy has not been explored extensively in the literature as countries such as the US and UK promote alternative methods for CRC screening such as colonoscopy or sigmoidoscopy alongside FOBT. Feufel et al
 have shown that improved instructions accompanying self-screening FOBT tests can help facilitate appropriate of test completion. This is particularly relevant for Indigenous Australians who had a higher proportion of incorrectly completed FOBT tests compared to the general population
In the second logistic regression model, bowel cancer knowledge and marital status remained independent predictors of intention to screen. Knowledge and awareness can be important determinants of screening behaviour, as a greater understanding of a disease, its risk factors and methods of prevention affects an individual’s decision to participate in screening. Lower knowledge levels are associated with a lower perceived risk and poorer CRC screening adherence rates in studies with ethnic minorities
. An Australian study also found that those born overseas had poorer bowel cancer knowledge scores compared to those born in Australia, with knowledge a predictor of screening intent
. Our research finds a strong relationship between bowel cancer knowledge score and intention to screen for CRC, with screening intention increasing with each increase in knowledge tertile. This relationship was retained in multivariable analyses and is line with other research demonstrating knowledge to be a significant predictor of bowel cancer screening uptake
[29, 47, 49]. Enhancing knowledge can also lead to more positive attitudes towards the disease and reduce negative perceptions, which could in turn impact positively on screening uptake
. Health education and promotion should therefore focus on improving overall knowledge related to bowel cancer and screening as a means to facilitate screening compliance.
Screening intent and fatalistic attitudes
Previous studies have reported associations between screening intent and fatalistic attitude towards bowel cancer
[50, 51], but this was not evident in our study despite the large proportion of respondents possessing a fatalistic attitude. Shame was strongly associated with intention to screen in bivariate analyses but was not an independent predictor of screening intent. Concerns about shame and embarrassment differed from those observed in studies of Latinos
, yet corroborated findings from other ethnic minority groups
[52–54]. This shows the need for culturally targeted education and screening promotion campaigns to address the differing beliefs and views towards bowel cancer screening that exist between different cultural groups in order to deliver appropriate messages that are effective.
Perceived benefits to screening
Most participants agreed with the benefits of CRC screening, although this did not appear to influence screening intent among our sample, and is unlikely to be a successful focal point in prevention or education campaigns. Similar findings have been observed in a study of African Americans
. Why this is the case needs to be explored in greater depth, but it may be related to not understanding personal risk or that perceived barriers have a larger impact on screening decisions.
Barriers to FOBT screening
Fear of finding out something is wrong or finding out they had cancer were major barriers to FOBT screening for over a third of our sample. This is similar to research undertaken with Italian migrants in Australia that found fear of cancer and finding out they have cancer were major barriers to screening
. In the present study, additional barriers related to the design of the screening program and test method including the postal distribution, storage of samples, and lack of privacy in which to do the test. The absence of symptoms and not having a family history of bowel cancer were also reasons that respondents felt discouraged them from screening. Again, the concept of self-efficacy arose with ‘not knowing what to do’ being reported by over a third of respondents as a major reason they would not complete the screening test. These barriers cannot be ignored and most are heavily impacted by the way the screening program is designed and delivered to the Australian population. Research into test preferences for Indigenous people is an area that is under-investigated and is warranted if screening rates for bowel cancer are to be increased
Several limitations to this study must be noted. As our sampling strategy was non-random, the results of this study cannot be considered representative of all Indigenous Australians. Participants were recruited primarily through respected community members working in health settings and are therefore likely to be more health connected, proactive in their health behaviour, better informed about health issues and have greater exposure to prevention messages. Furthermore, participants lived in urban and regional centres so results may not reflect the views of those living in very remote regions and living traditional/nomadic lifestyles.
The over-representation of females limited our ability to find differences in knowledge or intention to screen across gender. The nature of gender relations in Aboriginal culture may have influenced our ability to recruit male participants as well as the fact that all researchers involved in data collection and recruitment were female. The higher proportion of females and persons unemployed or not working in this study occurred because these groups are more likely to have the time to take part.
Our main outcome measure was largely hypothetical, asking participants on their future ‘intention’ to take up CRC screening. Such questions may not translate or predict real life behaviours, so results need to be interpreted with caution. Nevertheless, considering undertaking a preventive behaviour is a first step towards behaviour modification and therefore remains important.
Additionally, knowledge items from the survey were based on recognition rather than recall, limiting how far this information can be extrapolated. We felt that this approach would elicit greater responses than recall on its own, and it is more commonly used in studies with ethnic and minority groups
Finally, our small sample size was a major limitation on the extent of analysis that could be conducted, and is partially responsible for the wide confidence intervals observed particularly in the multivariate analysis. Despite these limitations, our results have generated important information on Aboriginal views of bowel cancer and bowel cancer screening in an otherwise unexplored area of Indigenous health.