Table 6 Recommendations for alterations to Australia's NBCSP to improve access and participation for Indigenous Australians

Recommendations

1) Alternative means of distribution of FOBT test kits

Provide an alternative mechanism of delivery and return of kit (to target those who may not have a post box or Medicare enrolment). This could entail supplying hospitals and AMSs with kits to distribute to increase opportunistic screening.

2) Dedicated health personnel for follow-up and support

Ensure there is a dedicated health worker knowledgeable about the program to follow-up individuals receiving a kit and to provide personalised advice, education and assistance with completing the test. Intensive support of Aboriginal people will be necessary for increasing screening uptake.

3) Integration of screening into primary care/general chronic disease management

GPs have an important role in actively encouraging participation in screening [96], however many GPs are neither supportive of or knowledgeable enough about the program nor do they have time to discuss screening with patients [138, 139]. Their key role in the program means that whether a patient has a regular GP or not can affect participation and attendance to follow up procedures. (If an individual receives a positive test but has not nominated a GP, then is it is up to the individual to follow up their test result)

The key role of the GP in activating post screening diagnostic and follow up requires reconsideration of alternative approaches using either dedicated health professionals or centralised screening centres to support a greater number of people having access to the screening kit and opportunities for referral. Opportunistic screening through file tagging is also another potential way in which to improve participation [140].

Completion of forms by GPs and colonoscopists should be mandatory as should identification of Indigenous status in order to attain greater quality data that will give an indication of the burden of bowel cancer and how the program impacts on incidence and mortality, and levels of follow-up and treatment. This is also important for the general population. Perhaps greater incentives for health professionals may be needed for this as presently GPs receive $7.70 for each form submitted [95].

The administrative role of GPs in the program is poorly defined and needs attention with accountability and responsibilities clarified, and appropriate interventions implemented to increase GP's awareness of their roles and responsibilities [95].

4) Improve health promotion and availability of culturally relevant educational materials

Greater coverage of bowel cancer screening in health promotion campaigns and the media is needed to increase general knowledge and awareness in the population. This will also help to remove the shame and stigma associated with discussing bowel cancer. Promotional activities should occur prior to individuals receiving the kit so that there is some awareness and expectation of the test.

Increase the availability of culturally appropriate, Indigenous-specific educational resources, if possible in local languages and including local terms for main parts of the body. Translated materials were available in 13 languages for CALD groups during the pilot therefore it should be possible to make information and brochures available in Indigenous languages.

To overcome the literacy barrier, greater emphasis on pictorial methods of education including videos and diagrams should be included with the screening kit.

5) More community-based participatory research into Indigenous understandings and perceptions of bowel cancer

Further research into Aboriginal understandings and perceptions of CRC and CRC screening, including knowledge, beliefs and attitudes is necessary to inform appropriate approaches for intervention and resources. This includes a greater emphasis on participatory methods of health promotion.

6) Implement ongoing annual or biennial screening for CRC

Currently the NBCSP is offering only once of testing to the Australian population and only to those in the specified age brackets. Provision of funding for ongoing rounds of screening are necessary for not only targeting a greater number of people and enhancing opportunities for screening uptake, but allowing time for familiarization with the program[141].

7) Ensure Indigenous Australians have access to FOBT kits from the age of 45 years

Given the younger age at which CRC is occurring among Indigenous people, consideration should be given to ensuring screening kits are available to Indigenous Australians from the age of 40-45 years.