Reimagining Access and Equity in Australia’s National Bowel Cancer Screening Pathway: A Critical Realist Analysis of Rural Lived Experience

Reimagining Access and Equity in Australia’s National Bowel Cancer Screening Pathway: A Critical Realist Analysis of Rural Lived Experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Reimagining Access and Equity in Australia’s National Bowel Cancer Screening Pathway: A Critical Realist Analysis of Rural Lived Experience Nicole Marinucci, Naomi Moy, Natasha Koloski, Gerald Holtmann This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9188886/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Bowel cancer remains a leading cause of cancer‑related mortality in Australia, with rural and remote populations experiencing a disproportionate burden due to later‑stage diagnosis and persistent inequities in access to care. Although the National Bowel Cancer Screening Program (NBCSP) has achieved population‑level reductions in morbidity and mortality, participation remains consistently lower in geographically remote communities. Inequities occur across both phases of the screening pathway, immunochemical faecal occult blood test (iFOBT) kit completion and diagnostic colonoscopy follow‑up, reflecting structural barriers including limited accessibility, fragmented continuity of care, and misalignment between program design and rural contexts. Consumer‑centred understanding of lived rural experiences is required to inform equitable program and policy reform. Methods Guided by a critical realist ontology and an Interpretative Phenomenological Approach (IPA), focus groups were conducted with adults residing in rural and remote Australian communities who were eligible for NBCSP participation. The study was co‑developed with a multidisciplinary working group comprising experts in clinical research, public health, gastroenterology, psychology, and health economics, alongside consumer partners, to ensure methodological rigour and policy relevance. Data were analysed iteratively using IPA to identify shared meanings and context‑dependent mechanisms shaping participation across both screening and diagnostic phases. Results Twenty‑seven NBCSP‑eligible participants described systemic barriers limiting equitable access and acceptability. Key mechanisms included: (i) constrained opportunities for kit completion due to narrow access windows and reduced local kit availability, reducing exposure, visibility, and perceived normalisation of screening; (ii) substantial financial, geographic, and logistical burdens, particularly affecting follow‑up colonoscopy; (iii) fragmented referral and navigation pathways, inconsistent general practitioner endorsement, and lack of localised service availability and (iv) the normalisation of reduced access as an expected consequence of remoteness, dampening help‑seeking behaviour. Participants advocated for system‑level reform and locally responsive models, including alternative kit distribution, tailored education and promotion, proactive patient navigation, and coordinated, localised referral pathways. Conclusions Current NBCSP delivery insufficiently accommodates geographic and socioeconomic diversity, perpetuating inequities across the screening continuum. Equity‑oriented, place‑responsive redesign, integrating patient navigation, coordinated pathways, and locally feasible access points offers clear potential to improve participation, completion, and downstream health and economic outcomes. Figures Figure 1 Background Bowel cancer prevalence and stage of diagnosis cause a significant burden to Australian rural and remote populations. Across these geographically diverse populations, bowel cancer remains a leading cause of cancer‑related death, with disproportionately high incidence and diagnoses occurring most frequently in outer regional and remote areas. ( 1 ) Rural and remote communities continue to face entrenched inequities in healthcare access that extend beyond primary and specialist care to include substantially lower engagement with national population health programs, such as the National Bowel Cancer Screening Program (NBCSP), with participation remaining suboptimal throughout the Program’s 18‑year history. ( 2 ) In Australia, prior research has partially explored the drivers of inequities in bowel cancer outcomes and suboptimal adherence to screening recommendations, including engagement with the National Bowel Cancer Screening Program (NBCSP), among rural populations. ( 3 – 8 ) Evidence supports a multifaceted approach to mitigating these disparities, including alternative screening kit distribution models, improved education and marketing, enhanced healthcare accessibility, stronger general practitioner endorsement of the Program, and systematic follow‑up of non‑responders. ( 6 , 9 ) While previous research has consistently highlighted the need for programmatic improvements to mitigate geographic disparities in bowel cancer screening participation, much of this work focused on broad access barriers or individual- level determinants of screening behaviour. By documenting lower participation rates among rural and remote populations, these studies have informed calls for targeted adaptations to national screening programs to improve equity in reach and screening adherence. By contrast, little attention has been paid to the complex and intersecting influences of geographic remoteness, service accessibility and socio‑cultural norms, nor to how these factors shape individuals’ capacity to comply with bowel cancer screening guidelines over time. As a result, existing evidence has tended to conceptualise inequity primarily through spatial disadvantage, without fully accounting for the contextual realities that mediate engagement with screening services. An under‑examined dimension of prior research is the role of follow‑up diagnostic colonoscopy in shaping rural and remote communities’ interaction with, and sustained engagement in, the NBCSP. Participation in the NBCSP is rarely acknowledged as a two‑stage process; instead, it is commonly framed as successful completion and return of the immunochemical faecal occult blood test (iFOBT). This narrow view overlooks the critical diagnostic phase that follows a positive iFOBT result, which in most cases requires individuals to engage with primary care to obtain a referral and subsequently access to timely diagnostic colonoscopy services. For rural and remote populations, this second stage is characterised by limited-service availability, travel burden, economic hardship and fragmented care pathways, which may disrupt continuity and undermine confidence in the program. ( 10 ) Failure to account for these system‑level constraints risks overstating program effectiveness and obscuring where inequities are most acutely produced. This research aims to generate in-depth evidence of the intersectionality of participation barriers occurring between rural environments, NBCSP access and the Queensland healthcare system. By situating these interactions across place, system design, and lived experience, the study seeks to illuminate how geographic remoteness and socio‑cultural context shape screening adherence across the continuum of care. Developing comprehensive insights into community interactions, intersectionality, and existential perspectives grounded in empathetic and reflexive engagement with participants offers the potential to reimagine NBCSP access for rural and remote populations. Such an approach not only strengthens the program’s capacity to deliver equitable, life‑saving outcomes, but supports more efficient and economically viable service models across priority population groups by aligning system design with the realities of lived experience. Study Design Given the paucity of information examining rural and remote lived experiences of bowel cancer screening, a focus group methodology was employed to address the study aims. Thus leveraging the strong relational characteristic ties of rural and remote communities and enabling the exploration of individual experiences which are enriched through shared meaning across participant cohorts, an Interpretative Phenomenology approach was deemed most appropriate. A purpose‑designed semi‑structured focus group interview guide was developed for this study and has not been previously published. (See supplementary files) Underpinned by a critical realist ontology, this paradigm places emphasis on existential insights, perceptions and real-world experiences viewed through an inquisitive and empathetic lens. (11-13) Consistent with this approach, this study seeks to privilege rural and remote populations by elevating their voices and lived insights and by centring their unique needs through the co‑creation of consumer‑expert informed recommendations. In this context, Interpretive Phenomenology is concerned with unearthing experiences and lived realities through shared knowledge, stories and language insights gained across participant cohorts. This approach positions the researcher to engage in a transformative, emotionally resonant process aimed at informing recommendations and stimulating discourse on the broader requirements for NBCSP redesign. The study design was co-developed by a multidisciplinary working group comprising of experts in clinical research, public health, gastroenterology, psychology, and health economics ensuring methodological rigour and relevance to policy and practice. Recruitm ent The recruitment strategy utilised a purpose‑built rural and remote database comprising 193 community organisations and groups, each with publicly available contact details (email or telephone) identified through online listings. Rural and remote locality was defined in alignment with the definitions outlined in the Australian Statistical Geography Standards Remoteness Structure. (14) Recruitment was conducted by distributing invitations to consumer groups and organisations within postcodes classified as ‘outer regional,’ ‘remote,’ or ‘very remote.’ Recognising the sensitive nature of bowel cancer and NBCSP participation, investigators collaborated with community organizations, key stakeholders in rural and remote settings, to ensure discussions occurred in safe, familiar environments. An email was sent to all publicly listed email addresses and contained an invitation to participate in the research, a recruitment flyer and a participant information and consent form. The focus group approach was fostered to encourage community to participate as a group and attend the sessions at a time and location which was convenient and familiar. Time was taken during the recruitment strategy to build trust and community understanding of the research aims. Sample Size and Participants Purposive sampling techniques were adopted to recruit rural and remote community members aged between 45-74 belonging to an identified community group. Further to this, participants were encouraged to extend the invitation to other members of community, engaging snowball sampling to ensure the participant felt at ease with the research topic and to encourage safe and familiar surroundings during the data collection stages. Data Collection Focus groups were conducted during June 2023 over 2-hour semi-structured focus groups held in local community suggested meeting rooms. The focus group guide contained open-ended questions with impromptu lines of query to further explore elements of lived experience across barriers, enablers, value and consumer informed recommendation to improve the NBCSP design. Focus group questions were developed based on evidence-based data and by a multidisciplinary team, including a consumer representative. A ‘tea and cookie’ approach was adopted where community members shared morning tea, lunch or afternoon tea from a local provider while the principal investigator facilitated discussions across a series of topics in a safe and open environment. Participants were encouraged to ask questions throughout, yielding insights into areas of confusion. Focus Groups were conducted over three days in three locations within the Southwest Hospital and Health Service region of Queensland, Australia. A trained moderator facilitated all sessions, taking field notes and posing additional questions as needed. Focus groups were video-recorded via Microsoft Teams and transcribed verbatim. Data Analysis Analysis was influenced by a procedure for Interpretative Phenomenological (in Group) Analysis (IPA) developed by Beverly Love and Colleagues in 2020. (15) To generate new knowledge beyond existing assumptions about rural and remote community experiences, the analysis employed a structured series of procedures emphasizing the assessment of researcher bias throughout immersion, thematic coding, and data synthesis, thereby ensuring that both individual and collective voices were preserved. Themes were derived through cycles of watching video recordings/group interactions, reading transcript verbatim and data analysis processes. Three stages of refinement occurred across superordinate themes and sub-themes with the final analysis undergoing credibility checks with the focus group assistant and the broader research group. Exemplar quotes were used to further describe and draw meaning and essence from the codes. IPA aims to understand the complexity of the meaning in the lived experience as it relates to the phenomena or research question, and less of interest is the measure of frequency of themes. (16-18) While IPA is often prescribed to draw deep knowledge and understanding from individual and personal lived experience, it can be argued that the methodological application within a focus group setting is still able to extrapolate individual voices and experiences within the group context. (15) The application of IPA in a Focus Group setting enables even deeper context and detail in the experiences of community due to the homogenous nature and shared barriers to screening and enables variance caused by intersectionality to be assessed. Results A total of 27 participants (21 women and 6 men) participated in 6 focus group sessions across 3 rural and remote locations of Queensland, Australia. Focus groups lasted for an average time of 88 minutes and included 3-6 participants. Participant demographic details can be found in Table 1 . Thematic analysis resulted in findings being organised under 4 superordinate themes and presented in general present-tense phenomenological statements of lived experience and later derived into sub-themes for broader context. Superordinate themes and sub-themes have been inductively coded across the data corpus. Participant illustrative quotes include the focus group number and demographic information to provide context on priority population insights and occurrences of intersectionality to assist in the identification of correlations between, and emphasis on, priority population identification of barriers and needs based recommendations to further enhance program equity. Participants collectively offered detailed suggestions on how to improve access to the program across the NBCSP participant journey. Consumer driven pragmatic solutions to support NBCSP access is presented in sequence across the patient journey in Figure 1. Rural and Remote Sociocultural Norms Superordinate Theme 1 “Being rural, there's a whole… this (NBCSP) is a national sort of thing. Being rural your whole mindset is you're more independent, you’re a free thinker, you can work on your own without the support of major cities and the infrastructure that goes with it… and that's also part of it. So, when you come out here, you start thinking… you need to toughen up." (FG4, #331, Male, Remote) While the NBCSP was unanimously supported across focus group participants there was a broader consensus surrounding the sociocultural norms for people residing in rural and remote communities and how it fostered a sense of disconnect to broader metropolitan based Australian norms, specifically within the context of early detection and prevention of colorectal cancer. For some participants, this perception led them to view the NBCSP, despite its national scope as tailored to coastal towns and major cities and culturally misaligned with rural communities’ social norms and values. This was discussed at length as it related to the burdensome participant pathway through the Program from receiving an iFOBT in locations with no postal system, to the possible need for a follow-up colonoscopy should a positive result be received. This belief was further referenced in relation to the promotional material and branding on the iFOBT, where statements around the image relevance were being questioned. "When I first saw that (the iFOBT kit) at a glance over there I thought it was something about learn to swim. Because it's got that on there… (pointing at the lifesaver ring on the front of the kit) ." (FG5, #333, Female, Chronic Disease, Remote) Participants openly discussed the message the lifesaver ring on the front of the kit sends to rural and remote communities. Even a seemingly simple promotional image could prompt potential participants to disengage from the Program, driven by assumptions of limited personal relevance. Participants discussed forgetting to complete the kit and the need for the kit to be more demanding of their attention. The kit should be conspicuous, with a more personalised approach and receival should induce a sense of urgency to complete and return the sample. Criticism of the iFOBT extended beyond its generic, government-issued appearance to include concerns about lengthy and, for some, confusing instructions for kit completion. Participants emphasized that the kit should be more conspicuous and personalized, with its delivery conveying a sense of urgency to complete and return the sample. "A lot of people and .. I don't mean to be rude… in our generation um a lot of people left school at 14 so they have... and it doesn't mean they aren't successful but they have low literacy levels and that (the brochure) is way too busy. They will say I can't do this." (FG1 #318, Female, CALD, Outer regional) Recommendations for kit design were suggested during discussions to address lengthy information brochures, literacy level of content, the government look and feel of the kit packaging and promotional images. A co-design process would ensure the kit was made more appealing and relevant to rural and remote communities. The low public profile of bowel cancer, limited awareness of its prevalence, and minimal media coverage of the NBCSP featured prominently in focus group discussions, reinforcing a perceived link between low perceived risk and screening avoidance. Participants consistently reported little exposure to bowel cancer education or NBCSP‑related advertising, frequently questioning whether this lack of information was specific to rural and remote areas. Many suggested that access to public health messaging about bowel cancer appeared to be disproportionately concentrated in metropolitan settings. Furthermore, reduced opportunities for exposure, arising from the narrow access window created by decreased kit availability within the ‘Hot Zone’, were identified as contributing to the persistence of taboo and the low public profile surrounding kit completion and its normalisation. Health messages perceived as important or urgent were described as highly visible, widely disseminated across multiple media platforms, and actively promoted within local communities, reinforcing their salience and relevance. In contrast, bowel cancer was rarely mentioned or visibly promoted, leading participants to infer that it was of lesser importance or concern. This absence of messaging contributed to assumptions that bowel cancer posed minimal risk for people living in geographically remote areas. This perception is compounded by the prevailing “bulletproof” mindset, the stoic nature of rural communities and the ‘tough’ mentality applied to daily life, thus reinforcing low-risk perceptions regarding colorectal cancer prevalence and susceptibility. “Yes I think because they think they’re bulletproof. Because they are taking such risk every day and um.. well, yes.” (FG2, #323, Female, Remote) Across all focus groups, participants highlighted the positive impact of health buses and mobile units in creating urgency and motivation to address health concerns primarily due to time-limited access and the effectiveness of a ‘whole-of-community’ approach in prompting action. This strategy was consistently recommended across all six focus groups. Participants further emphasised the value of community-driven initiatives, including distributing and completing kits collectively, as a means to increase participation, raise awareness, and reduce stigma and shame. “Bowel cancer is not something that is seen or that rural communities are exposed to. Where is the media? Where are the ads?” (FG 5, #335, Female, First Nations, Chronic Disease, Disability, Remote) The strong sociocultural norms, avoidance of prevention and the taboo of bowel cancer placed participation in screening as a low priority for many of the participants. This was further reinforced by the lack of capacity for rural healthcare providers to cover prevention and early detection alongside other clinical burdens for their commuities. Bowel cancer for many was still seen as an ‘icky’ topic and something that was avoided or not discussed in public. The call for an education program specifically targeting rural and remote communities was echoed across all 6 focus groups as a priority to raise the public profile of the importance of bowel cancer prevention and early detection. Participants spoke passionately about the need to influence younger generations, high school age and younger, to eradicate the taboo around bowel health and prevention. The asymptomatic nature of bowel cancer further diminished interest and reduced the perceived urgency or prioritization of participation in screening. In one larger focus group, a participant prompted laughter and extended discussion by suggesting that bowel cancer screening and participation in the NBCSP be featured in an episode of Bluey .* This idea was framed as a way to normalise screening as a routine, age‑based health check that “everyone” completes. Participants highlighted the value of the show’s colourful characters, multigenerational humour, and strong connection to Australian culture as mechanisms to engage families, foster shared understanding, and reduce discomfort around the topic. The discussion underscored humour and culturally resonant storytelling as potential tools to connect, normalise participation, and raise the profile of bowel cancer screening—an issue that remains taboo in many rural Australian communities. "If you isolate the very one factor that is sitting underneath this I think it is the yuck factor or the ick factor and I think that somehow if humour can get a hold of that. You know I said to you before the humour under Bluey, the Bluey show.. you know can't you just see the humour in it if one of the characters got a kit. The bluey humour is so smart, so smart." (FG1, #315, Female, Chronic Disease, Rural) Although there was support across all participants for broader program education that resonated with rural and remote communities, groups did not reach consensus over the use of humour or fear tactics to elevate messages around prioritising screening. While many adamantly believed humour would break down the barriers and taboo of bowel cancer, others believed a more serious approach was required. “ No not humour….for young people humour I think. For older people… honestly, when I hear something that is humorous I think… are they *fair dinkum? Why are they joking about it!” (FG3, #326, Female, First Nations, Disability, Chronic Disease, Outer Regional). *Bluey is an animated Australian preschool television series featuring Australian cattle dogs as the main characters. * Fair dinkum is an Australian slang meaning legitimate or true. Can be used as a question or a statement. "I think there needs to be some bushies stories." "We don't remember facts, we remember stories.” (FG5, #335, Female, First Nations, Chronic Disease, Disability, Rural) Participants expressively discussed the way of life, living and working on the land and emphasised the need for stories they could relate to. The power to grasp the viewers’ attention in a way that was relatable could only be found in the use of familiar/trusted ambassadors, add campaigns and stories from the land. This solution to mitigate the taboo/ick factor and to normalise bowel cancer screening as a routine part of looking after health and wellbeing was the key recommendation across focus groups to tackle the low profile and stigma around NBCSP participation. iFOBT Access and the Rural Post – a cause for concern. Theme 2 “It gives you one day of the week (the postal service). It's early in the week when you're sort of just getting into the week …and you know often then they are up the top paddock anyway… and um… not round the house at that time.” (FG2, #323, Female, Remote) Concerns about infrequent or absent postal services, which necessitate traveling long distances to send or receive mail, were identified as a fundamental barrier to NBCSP access for rural and remote populations. The participant pathway to the NBCSP relies heavily on the ability to access a frequent and reliable postal service, a detail that was not missed on the participant cohort. Each focus group included one or more participants who had no postal service deliveries to their property or infrequent (2 times a week) postal service access. This made receiving and completing the kit in a timely manner challenging and, in some cases, too great a burden to mitigate any risk or personal motivation to participate. "I think.. we just moved into town but we sort of lived 45ks out of town and when we received them (the iFOBT).. if you didn’t do it when you received them in the post and if you happened to know you weren't going into town then it was just that. Because you had to do it in two days and then get it in the mail and if you weren't going into town then you just forget.” (FG6 #337, Female, CALD, Chronic Disease, Rural) Hardships of daily life further compounded the challenges of travelling long distances to return completed kits. Participants who ran local businesses or worked the land described the difficulty of prioritising preventive health amid the competing demands of busy, labour‑intensive daily routines. Participants also highlighted the burden of the program design itself, including the requirement for two samples, complex instructions, and concerns about test accuracy, all of which made kit completion easier to delay or abandon. These challenges were exacerbated by difficulties returning kit samples within the required program timeframes, with several participants expressing frustration that NBCSP processes did not adequately account for the realities of rural and remote living, ultimately reinforcing disengagement from screening. “I know that they are temperature sensitive so the last time I did one we were in a heatwave and I knew where that test was going to sit if I sat it in my mailbox or the mail services. I knew how many days it would take before collected. The local post office is not airconned and I thought sitting in a red box in the sun.. so it was timing it. Not everyone wants the bother of that.” (FG1, #315, Female, Chronic Disease, Remote) “I sent one off and it came back irregular. They said it got there just too late and they weren't gonna do it. I left it in the fridge and then I sent it and they said it was too long.” (FG2, #320, Male, Outer Regional) “The business of a busy life. If you have done it before you know it takes two swipes (two samples). Right.. and you know if someone’s really busy thinking well one’s ok I can just get in and do it.. But two? You have to think about tomorrow.” ( FG 1, #315, Female Chronic Disease, Remote) Discussions highlighted tensions between privacy concerns and the strong sense of belonging within rural and remote communities. While participants valued close-knit support networks, they also expressed discomfort with others knowing or sharing personal health information. Privacy issues were particularly salient in small communities, where assumptions about health were common. One participant admitted delaying kit completion for years, explaining that returning the kit via the local post office would expose her and her husband’s personal business to others. “I think having to take them to the post office. We don't want everybody to know that we're doing tests and handing them into the post office.” (FG6, #336, Disability, Chronic Disease, Remote) The pivotal role of postal services prompted discussions on expanding kit availability across multiple community locations, a recommendation aimed at improving access for rural and remote populations, mitigating barriers linked to transient workforces, and elevating awareness of colorectal cancer prevention and early detection. Participants strongly advocated for a ‘whole-of-community’ approach, suggesting coordinated distribution of kits to all residents within the same week or month to normalise participation and reduce stigma. This strategy was framed as promoting community acceptance of NBCSP completion as part of routine health checks. Suggested kit distribution points included post offices, pharmacies, GP clinics, allied health practices, service stations, and supermarkets. Participants also emphasised the need for multiple drop-off sites, such as GP surgeries and pathology collection centres, to avoid reliance on postal boxes and reduce risks associated with heat exposure. “Well, I suppose one of the things is you don't have a backup kit. So, if you've done the first test and then a week later you've gone ahhh the pump on the thingy blew out and I had to race out the door at 2 o'clock in the morning or something like that and um..and deal with whatever the catastrophe was and well you've missed it. Oh well I'll throw it in the bin.” ( FG 1, #315, Female, Chronic Disease, Remote) The Role of the Rural GP Superordinate Theme 3 "Unless you've got a chronic health problem, most people aren't going to their doctor. I'll come across so many people .. not so much in my job because they are the vulnerable… who say I haven't been to the doctor since I had a baby." (FG4, #329, Female, Remote) Across all six focus groups, participants consistently emphasised the importance of access to primary healthcare and the ability to consult with, and establish continuity of care through, a single general practitioner. However, a recurrent theme was the inability to access a GP, which was identified as a critical barrier to care. This limitation not only undermines the development of therapeutic relationships but also contributes to fragmented service delivery and delays in diagnosis and treatment. GPs form an integral part of the patient pathway in the NBCSP yet no participants recalled any reminders or follow-up being received from the GP. Difficulties accessing GPs had participants recalling numerous accounts of feeling let down or unsupported through their care journeys. Hardships ranged from only accessing a GP if critical care was needed, to misdiagnoses, weekly to monthly delays in access and significant medical mistrust due to multiple occasions of denying follow-up specialist care, poor physician/patient communication of health outcomes and a general lack of support/trust. Some participants also viewed medical professionals as part of the larger government system, a system that required caution and care during interactions. “I think what (x participant’s name) is saying, it doesn’t matter what age you are, there is a general feeling that nobody really cares about our health.” (FG3, #324, Female, CALD, Chronic Disease, Outer Regional) Participants perceived health resourcing as a privilege largely reserved for metropolitan areas. They expressed that the design and accessibility of the NBCSP appeared to cater primarily to urban populations. In relation to their own health, access to support was often contingent upon the presence of illness rather than prevention. Sociocultural norms surrounding the low prioritisation of healthcare, coupled with a prevailing ‘tough rural’ mentality and limited access to primary healthcare services, were seen to contribute to delayed help-seeking behaviours. Consequently, rural populations frequently postpone seeking healthcare assistance until circumstances become critical. “In the city there are a hell of a lot more doctors for each area, each suburb, each community. Out here we've got 2 doctors and if you don't like that particular doctor …you avoid them unless you're dying. We don't get the diversity of medical practitioners where you can pick and choose who you want to see.” (FG 4, #331, Male, Rural) While many participants shared in the harrowing accounts of GP access and poor physician experiences, some participants could not speak highly enough of the GPs in their local areas and their commitment to providing an outstanding service to the community. “And they are good doctors. They just don't have time. He gets up at 6am in the morning seeing patients and their lifestyle is so different to city. They are not working daylight hours. They work weekends… they do things out of hours.” (FG3, #326, Female, First Nations, Chronic Disease, Disability, Outer Regional) Participants did not extend this sense of gratitude to the transient workforces and locum specialists with further accounts of inferior service delivery and lack of context and rigour. Regardless of the participants stance on the quality of care received in rural and remote locations, there was consensus on the difficulties in getting an appointment for medical care, leaving no space or consideration for prevention, early detection and support for NBCSP participation. “Yes, so if you're sick, bad luck! You go to the hospital emergency and then we stuff that up." (FG1, #316, Female, Outer Regional) "I think there is more mistrust out here for the medical profession as a whole, more than what you realise. You might think that your personal GP is a nice person as a person but as a profession there is a lot of mistrust and it's been made worse since the whole COVID situation." (FG4, #331, Male, Remote) Participants who experienced intersectionality, belonging to more than one priority population group, were more likely to share distressing accounts of medical mistrust and past negative encounters with the healthcare system some of which elicited disbelief among other participants. These narratives highlighted a profound disconnect between individuals, medical professionals as integrated members of society, and sociocultural beliefs surrounding government mistrust. Painful recollections of medical negligence, harrowing experiences, and feelings of powerlessness were recurrent themes. Discussions of medical mistrust frequently extended to broader government mistrust, which, when combined with privacy concerns in small communities, rendered healthcare engagement and completion of the iFOBT through the NBCSP a highly challenging and deeply private matter. "But anyway… mistrust mate...It's just one thing after the other.. that mistrust!" (FG3, #326, Female, First Nations, Chronic Disease, Disability, Outer Regional) Participants described an inability to speak up or self-advocate for their healthcare needs, which was reinforced by a deep-seated fear of antagonising healthcare providers. The absence of options for a second opinion compounded this concern. Several participants believed that challenging clinical recommendations or expressing dissatisfaction could result in punitive consequences, such as being denied future care, leaving them with no accessible medical support. “If I knew I could swap GPs, I'd certainly speak up.” (FG3, #326, Female, First Nations, Chronic Disease, Disability, Outer Regional) Despite the broad theme of distrust for the medical world, support was unanimously given for the need for a larger prevention focus in general practice and more allied health support, however there was a sense of defeat and resolve surrounding the feasibility of the recommendation. A seemingly accepted fate for rural and remote communities was to have inferior, challenging and delayed access healthcare. “Unless you are going to give your local GP more money, no they will not do it because they are absolutely on the bones of their bums. Because the Medicare rebate they get for each person they see is about this much (demonstrating a small amount with two fingers).” (FG2, #322, Female, Remote) Discussions to improve poor access to GPs to enhance reminders, follow-up referrals and support from general practice through the NBCSP pathway included the need for remuneration and broader external support. Suggestions focused largely on the need for Telehealth support to navigate people through the participant pathway and GP incentivisation, with broader support from allied health professionals. Follow-up support for non-responders was discussed at length with GPs often being the first suggestion put forward during conversations. Resolve was always met with the incapacity of rural general practice to provide NBCSP support with lengthy discussions around the need for NBCSP or local government support to prompt and remind people to participate. Colonoscopies and the Economic Implications Superordinate Theme 4 "People that are 50 years and over they've been taught to think and behave in a very specific way. So those people even if they've got slightly off health, they don’t want to know. They won't want to know that they might be sick. They've got responsibilities in the paddock. They wanna work until they drop dead. " (FG4, #331, Male, Remote) The burden and economic implications of undergoing a diagnostic colonoscopy following a positive iFOBT were unanimously identified as significant barriers for rural and remote populations. Participants highlighted the absence of localised endoscopy services, disruptions to work and business operations, and the considerable financial and logistical challenges associated with multi-day travel. These factors collectively impose substantial constraints on timely access to diagnostic care for busy rural and remote communities. "When we look at the way ah.. we live our lives, we're very...we tend to be very busy. A lot of the guys are on the land, they don't.. It's like what I feel and this is just my own personal ahh sort of thoughts around it is that the land, the business, that all comes first and they come afterwards.” (FG5, #334, Female, Chronic Disease, Rural) Participants recounted the pressing demands and responsibilities of daily life, noting that concepts of prevention and follow-up care were frequently deprioritised in favour of other tasks perceived as more urgent—most commonly heavy work-related obligations. This tendency reflects the competing priorities faced by rural populations, where immediate economic and labour demands often overshadow long-term health considerations. "If you take a sick day, you don't get paid. You don't do this you don't get any of that. And once again it's an inconvenience. “( FG4 #328, Male, Remote) Participants highlighted additional complexity arising from the absence of local colonoscopy services, the need for long‑distance travel, and the burden of completing complex travel and accommodation subsidy forms. These structural barriers generated discussion about the inadequacy of current service arrangements for rural populations and reinforced calls for more localised diagnostic service provision. Participants also emphasised the need for clearer and more streamlined care pathways, improved support to navigate subsidy processes, and more equitable financial allowances for travel and accommodation associated with follow‑up care. "They've got to stop fighting us for the travel allowance and the motel allowance!" (FG3, #326, Female, First Nations, Chronic Disease, Disability, Outer Regional) The participant discussed the stress of having an illness or needing a test and the harrowing process of applying for subsidy allowance, the immense stress of the application process as well as the effort of changing or adjusting the initial request should a change in care be required. "I haven't used it for years because it was so hard to access. You've got to know all this before you go down there which I didn’t the first time. I didn’t know it was available because the doctor hadn't told me and they're supposed to tell you before you go away. Um.. and so I was going to do mine retrospectively and I had to get a special appointment to go to the doctor and get the referral and I had already had the procedure... it was just not worth the effort." (FG4 #321, Female, Remote) Participants demonstrated an awareness of the broader community’s needs and expressed gratitude for their own ability to access colonoscopy services and travel subsidies. However, they acknowledged that for some individuals within their communities, the absence of a companion to assist with accessing, understanding, or completing subsidy forms rendered these supports unattainable. Additionally, each focus group noted a lack of local service knowledge by health professionals in the health system, which often resulted in participants travelling greater distances to access services that may have been available closer to home. “We don’t know what services are here and when we have VMOs (visiting medical officers) come out, they don’t know what services are here. So they automatically refer them away.” (FG5, #334, Female, Chronic Disease, Rural) Participants expressed a deep sense of discrimination when discussing confusing subsidy forms, a lack of support, and significant financial gaps not covered by existing allowances, an injustice they felt would be unacceptable in metropolitan or major city contexts. Recommendations included increasing GP awareness and involvement in providing information and guidance on form completion, establishing helplines, and expanding Telehealth support to assist patients through the process of accessing colonoscopy. Patient navigation emerged as a key theme, with participants emphasising the need for dedicated support to overcome the multiple barriers and hardships faced by rural communities when seeking to participate in the NBCSP. These challenges are further compounded by the requirement to access colonoscopy services away from home, which adds considerable logistical, emotional, and financial burden to an already complex and demanding situation. "I drove meself over, I wasn't sposed to, you're sposed to have someone to drive you and pick you up. Yeah, I drove myself home too. I didn’t have anyone I could ask to come with me, so I just did it." (FG5, #335, Female, First Nations, Chronic Disease, Disability, Remote) Participants widely acknowledged the need to travel for diagnostic colonoscopy; however, this acceptance often came at the cost of engagement with follow‑up care. For many, the requirement for colonoscopy rendered both diagnostic follow‑up and in some cases participation in the initial iFOBT stage of the NBCSP untenable, as they were unwilling to proceed to colonoscopy if required. The economic implications of colonoscopy were profound for rural and remote communities. Out-of-pocket travel expenses, loss of income due to lack of sick leave, and the cost of hiring someone to manage farms or businesses were identified as significant barriers. Participants emphasised that these challenges could only be mitigated through a more localised approach to care. Unanimously, they expressed that their homes and hearts remained in the country, and the need to travel for care represented yet another injustice, resulting not in equivalent care to metropolitan patients, but in inferior healthcare access. Consequently, participants strongly recommended increasing local access to colonoscopy services to minimise economic burden and reduce the excessive hardships associated with obtaining essential diagnostic care. Discussion This study provides novel existential insight into how rural and remote populations perceive and navigate participation in colorectal cancer screening, revealing that engagement with the NBCSP can be influenced by systemic inequities and historically embedded patterns of low healthcare utilisation. Analysis and interpretation highlight that participants’ interactions with the program cannot be disentangled from broader experiences of limited healthcare access, geographic isolation, and socio‑cultural norms that have normalised reduced reliance on health services. Shared beliefs and collective experiences around health‑seeking behaviours strongly influenced how participants perceived the relevance, feasibility, and value of engaging with the NBCSP. Barriers to accessing general practice were a dominant theme across all focus groups, including prolonged waiting times, lack of continuity of care, limited preventive focus, and a prevailing tendency to seek care only when acutely unwell. Participants commonly described travelling long distances for care and expecting waits of three to six weeks for GP appointments. These access constraints have reinforced a culture of low dependency on the healthcare system, directly shaping engagement with preventive initiatives such as the NBCSP. Within this context, the rural GP out of necessity was perceived as primarily oriented toward acute and chronic illness management, rather than as a facilitator of preventive screening. While strategies to increase GP involvement were initially discussed and theoretically supported, ongoing dialogue revealed a shared recognition of workforce strain and limited capacity within rural general practice, ultimately questioning the feasibility of GP‑led solutions. These experiential accounts align with national data demonstrating substantial geographic disparities in primary healthcare utilisation and workforce distribution. Rural populations experience disproportionately lower rates of GP attendance compared with metropolitan counterparts, alongside markedly reduced access to healthcare professionals relative to population size, particularly in small rural towns. ( 19 ) ( 20 ) The rate of increase in potentially avoidable deaths (potentially preventable through primary or hospital care) is directly related to increasing remoteness, this includes cancers that could have been diagnosed through cancer screening programs such as the NBCSP. While participants shared stories of strength surrounding the dedication and commitment of healthcare workers to operate under high pressure and dire circumstances, there was an evident undertone of mistrust expressed in relation to the lack of genuine care for the health outcomes of rural and remote communities. Mistrust, perceptions of withheld information, and an inability to self-advocate were themes disproportionately expressed by participants experiencing intersectionality, particularly those identifying as First Nations or living with disability. Shared and sometimes conflicting narratives highlighted how diverse demographic characteristics shaped the interplay between NBCSP access and lived experience. Participants consistently conceptualised solutions in terms of GP endorsement, telehealth, allied‑health‑led patient navigation, and reminder or recall systems such as SMS messaging. However, as discussions progressed, there was growing consensus that the capacity constraints of rural general practice limit the viability of GP‑centred interventions. Participants instead proposed freeing clinical time through metropolitan outreach and external navigation support to guide individuals through the pathway to diagnostic colonoscopy, thereby reducing burden on local services. Beyond improving onsite, localised resourcing, metropolitan outreach models that relieve time pressures within rural practice and support patients in navigating the pathway to colonoscopy were viewed as advantageous. Findings from this study highlight reliance on the postal system as a significant and under‑recognised structural barrier to participation in the NBCSP for rural and remote populations. Infrequent or absent mail delivery, long distances to postal outlets, and limited opportunities to post kits within required timeframes complicated receipt, completion, and return of iFOBT kits. Participants described how these logistical constraints intersected with the demands of daily rural life, including farm work, business responsibilities, and unpredictable schedules, making timely completion difficult to prioritise. Program design features such as the requirement for two samples, temperature sensitivity, and strict return windows further compounded these challenges, particularly in hot climates and areas with limited mail infrastructure. Collectively, these barriers contributed to frustration and disengagement, reinforcing the perception that the NBCSP is insufficiently responsive to the lived realities of rural and remote communities. These findings underscore the need to reconsider distribution, return, and timing mechanisms within population‑based screening programs to ensure equitable access irrespective of geography A critical and frequently overlooked component of the NBCSP is the requirement for follow‑up diagnostic colonoscopy after a positive iFOBT. Profound geographic inequities exist in endoscopy service distribution, with endoscopist density dramatically lower in rural compared with metropolitan Local Government Areas. ( 19 ) Participants described the need to travel long distances, often over multiple days, to access diagnostic care, requiring time away from work, loss of income, and in many cases the absence of paid leave or replacement labour. These challenges were amplified among small business owners, who are disproportionately represented in regional areas of Queensland and Tasmania compared with capital cities. ( 20 ) Economic burden associated with livelihood and business ownership emerged as a system‑level barrier to equitable access, particularly during the diagnostic phase of screening. Although travel subsidy schemes exist, participants identified substantial shortcomings, including requirements for upfront payment, partial reimbursement, administrative complexity, and limited awareness or support in navigating subsidy processes (21). The subsidy system was frequently described as unjust and inaccessible, particularly for individuals with low literacy, disability, or limited administrative support. Consistent with international evidence, participants strongly endorsed patient navigation models external to general practice as a mechanism to address persistent rural barriers, including assistance with subsidy applications and coordination of care (22). Low visibility of bowel cancer within rural and remote communities was also widely discussed. Participants cited limited exposure to education, promotion, GP endorsement, and community‑level dialogue, contributing to low perceived risk, stigma, shame, and avoidance behaviours. The need to normalise bowel cancer screening and raise its public profile was echoed across all groups, particularly to counter taboo and disengagement. While past media campaigns have demonstrated effectiveness in increasing kit returns among targeted populations (23), participants questioned whether state‑based campaigns adequately reach rural and remote communities. Many reported no exposure to NBCSP advertising, suggesting gaps in outreach and communication. Participants raised concerns regarding the NBCSP “Hot Zone Policy,” which restricts annual screening windows in postcodes where average monthly temperatures exceed 30°C to comply with sample stability requirements (24). Rural and remote populations are disproportionately affected by this policy, yet its impact on participation, cancer detection, and community normalisation of screening remains poorly understood. Reduced access windows may further diminish program visibility and continuity in already underserved regions. To address these challenges, participants recommended more engaging, locally tailored approaches to communication and outreach, including personalised and repeated reminders, trusted and verifiable messaging sources, and digital engagement strategies such as social media presence. Print media was commonly perceived as outdated, while digital platforms were viewed as more relevant and accessible. Finally, participants emphasised the importance of place‑based, community‑led approaches. Community‑Based Participatory Research and co‑design strategies were identified as critical mechanisms to build trust, foster local ownership, and develop culturally responsive solutions capable of addressing the complex, systemic barriers shaping NBCSP participation in rural and remote communities. (25) Limitations This study notes several limitations to its design and scope. Following the discovery of economic barriers to accessing the National Bowel Cancer Screening Program (NBCSP), the inclusion of demographic measures such as socio-economic status would have provided deeper insight into theories around work culture, ethics, and their impact on screening compliance. Furthermore, the participant sample did not include representation from refugee or LGBTQI+ communities, limiting the breadth of perspectives captured and highlighting the need for future research that more fully reflects population diversity. Phenomenology, and particularly Interpretative Phenomenological Analysis (IPA), is often considered best suited to in-depth interviews, with some scholars describing its application to focus groups as an oxymoron. Nevertheless, rich accounts of personal lived experiences were frequently shared, and care was taken to extrapolate themes and code data at the individual level while analysing the broader corpus to identify superordinate themes. Using phenomenology to explore rural and remote focus groups on bowel cancer screening has inherent limitations, as findings rely on subjective accounts that may introduce recall bias and limit generalisability. However, this approach offers unique strengths in capturing deeply personal and contextual meanings behind participation decisions, providing insights into barriers and motivators that quantitative methods often overlook. Future research would benefit from incorporating rural clinician perspectives to further strengthen recommendations, particularly in relation to feasibility, acceptability, and implementation across primary care and diagnostic pathways. Conclusion Findings reveal a novel understanding of systemic barriers limiting equitable access to the NBCSP, exposing limitations in the program’s design for geographic and socioeconomic diversity. Access for rural and remote communities must be considered within the broader context of healthcare inequities and historical patterns of inaccessibility that have shaped attitudes towards care. These findings highlight critical implications for policy and practice across both phases of NBCSP participation the initial screening and the follow-up colonoscopy. Participants advocated for system‑level reform and locally responsive interventions to mitigate the financial, geographic, and logistical barriers that undermine feasibility, acceptability, and equity in bowel cancer prevention. Informants’ accounts revealed a pervasive normalisation of reduced access as an expected reality of geographic remoteness, reinforcing the urgency of an equitable redesign of program delivery. Addressing these challenges requires a reorientation of health services toward place‑responsive models, including the integration of patient navigation and coordinated referral pathways to support completion of the screening continuum. Collectively, this evidence is highly relevant for local and national policymakers seeking to maximise both the health and economic benefits of the NBCSP, improve program performance, and meet key equity‑related performance indicators. Declarations Ethics approval and consent to participate Ethical approval for this study was granted by the Metro South Hospital and Health Service Human Research Ethics Committee (HREC/2022/QMS/88545), in partnership with the University of Queensland, Faculty of Medicine. All procedures performed involving human participants were conducted in accordance with the ethical standards of the responsible committees. All procedures performed involving human participants were conducted in accordance with the ethical standards of the responsible committees and with the Declaration of Helsinki. Written informed consent was obtained from all individual participants prior to participation. Participants received detailed information outlining the study purpose, procedures, potential risks and benefits, and their right to withdraw from the study at any time without penalty. Consent was provided either electronically or in written form, in accordance with approved ethical standards. No individually identifiable data are included in this manuscript and consent for publication was included within the study’s ethics approval. Availability of data and materials The datasets generated and analysed during the current study are not publicly available due to ethical and privacy considerations but are available from the corresponding author on reasonable request, subject to approval by the relevant ethics and governance bodies. Competing interests The authors declare that they have no competing interests. Funding This research was funded by the National Health and Medical Research Council Centre of Research Excellence in Digestive Health through a competitive grant round. The funding body had no role in the study design, data collection, analysis, interpretation of results, or preparation of the manuscript. Authors’ contributions Primary Investigator Marinucci, led the study conception and design, data collection, analysis, writing and editing. Associate Investigator Moy, Koloski and Holtmann contributed to supervision, data analysis and editing. All authors contributed to critical revision of the manuscript, read, and approved the final version. References Governement A. Distribution of cancer stage: 2011; 2011 [Available from: https://ncci.canceraustralia.gov.au/diagnosis/distribution-cancer-stage/distribution-cancer-stage. Sturman N, Tran M, Vasiliadis S. Rescuing the profession we love: general practice training sector recommendations for improving the attractiveness of general practice training. A qualitative analysis. Med J Aust. 2024;220(9):461-5. Goodwin BC, March S, Ireland M, Crawford Williams F, Manksi D, Ford M, et al. Geographic variation in compliance with Australian colorectal cancer screening programs: the role of attitudinal and cognitive traits. Rural Remote Health. 2019;19(3):4957. Marinucci N, Moy N, Koloski N, Shah A, Austin G, Russell-Bennett R, et al. Social determinants and participation in fecal occult blood test based colorectal cancer screening: A qualitative systematic review and meta-synthesis. Health Promot J Austr. 2024;35(1):9-36. Christou A, Katzenellenbogen JM, Thompson SC. Australia's national bowel cancer screening program: Does it work for Indigenous Australians? BMC Public Health. 2010;10(1):373-. Ireland K, Hendrie D, Ledwith T, Singh A. Strategies to address barriers and improve bowel cancer screening participation in Indigenous populations, particularly in rural and remote communities: A scoping review. Health Promot J Austr. 2023;34(2):544-60. Lee SM, Obamiro K, Cooper A, Barnett T. General practitioner perspectives on barriers and enablers to bowel cancer screening in rural Tasmania: A thematic analysis of face-to-face interviews. Aust J Gen Pract. 2021;50(3):158-63. McGraw J, Russell-Bennett R, White KM. Tough but not terrific: value destruction in men’s health. Journal of service theory and practice. 2020;30(3):331-59. Marinucci N, Koloski N, Baker K, Moy N, Holtmann G. Key recommendations to improve equity and access in colorectal cancer screening for rural and remote communities. A grounded theory study. Aust N Z J Public Health. 2025;49(6):100295. Marinucci N, Koloski N, Baker K, Moy N, Holtmann G. Key recommendations to improve equity and access in colorectal cancer screening for rural and remote communities. A grounded theory study. Australian and New Zealand journal of public health. 2025;49(6):100295-. Danermark B, Ekström M. Explaining society : critical realism in the social sciences. Second edition ed. Abingdon, Oxon New York, NY: Routledge; 2019. Bhaskar R. A realist theory of science. [2nd ed.] ed. London New York: Routledge; 2008. Bhaskar R. The possibility of naturalism : a philosophical critique of the contemporary human sciences. 4th ed ed. Oxon England: Routledge; 2015. Statistics ABo. Australian Statistical Geography Standard (ASGS) Edition 3 2024 [Available from: https://www.abs.gov.au/statistics/standards/australian-statistical-geography-standard-asgs-edition-3/jul2021-jun2026/remoteness-structure/remoteness-areas. Love B, Vetere A, Davis P. Should Interpretative Phenomenological Analysis (IPA) be Used With Focus Groups? Navigating the Bumpy Road of “Iterative Loops,” Idiographic Journeys, and “Phenomenological Bridges”. International journal of qualitative methods. 2020;19:160940692092160. Smith JA. Reflecting on the development of interpretative phenomenological analysis and its contribution to qualitative research in psychology. Qualitative research in psychology. 2004;1(1):39-54. Smith JA. Evaluating the contribution of interpretative phenomenological analysis. Health psychology review. 2011;5(1):9-27. Smith JA, Flowers P, Larkin M. Interpretative phenomenological analysis : theory, method and research. 2nd edition ed. London Thousand Oaks, California: SAGE; 2022. Welfare AIoHa. Access to Healthcare; Medicare GP Non-Reffered Attendances by Modified Monash Category Canberra2023 [Available from: https://www.aihw.gov.au/reports/rural-remote-australians/rural-and-remote-health. Welfare AIoHa. Australia's Health 2024. 2024. Table Table 1_ Participant Characteristics Table 1 summarises the demographic and baseline characteristics of study participants. Variable Total ( n=27 ) Gender Female 21 (77.8%) Male 6 (22.3%) Age Mean (64) SD (7.4) 45-49 2 (7.4%) 50-59 3 (11.1%) 60-60 14 (51.9%) 70-75 8 (29.6%) Aboriginal or Torres Strait Islander 2 (7.4%) LGBTQIA+ 0 (0%) Culturally and Linguistically Diverse 4 (14.8%) Refugee or Asylum Seeker 0 (0%) Participants with Disability 3 (11.1%) Participants with Chronic Disease 11 (40.7%) Living in outer regional, remote or very remote area? 27 (100%) Geographic remoteness indicator ASGR ARIA+* Outer Regional 9 (33.3%) Remote 18 (66.7%) Very Remote 0 (0%) Hot Zones** 27 (100%) Additional Declarations No competing interests reported. Supplementary Files FocusGroupGuideSupplementaryFile.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 03 May, 2026 Reviewers agreed at journal 12 Apr, 2026 Reviewers invited by journal 10 Apr, 2026 Editor invited by journal 02 Apr, 2026 Editor assigned by journal 02 Apr, 2026 Submission checks completed at journal 01 Apr, 2026 First submitted to journal 01 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9188886","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":621673343,"identity":"3ecd350e-c276-4e7b-acc2-0c67ea772ead","order_by":0,"name":"Nicole Marinucci","email":"data:image/png;base64,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","orcid":"","institution":"Queensland Health","correspondingAuthor":true,"prefix":"","firstName":"Nicole","middleName":"","lastName":"Marinucci","suffix":""},{"id":621673344,"identity":"32880f50-693d-425f-a00f-9e490384e7d1","order_by":1,"name":"Naomi Moy","email":"","orcid":"","institution":"Queensland Health","correspondingAuthor":false,"prefix":"","firstName":"Naomi","middleName":"","lastName":"Moy","suffix":""},{"id":621673345,"identity":"c69ebfe8-aba0-4f59-bc16-bf498f3fc7a1","order_by":2,"name":"Natasha Koloski","email":"","orcid":"","institution":"Queensland Health","correspondingAuthor":false,"prefix":"","firstName":"Natasha","middleName":"","lastName":"Koloski","suffix":""},{"id":621673346,"identity":"d7160b8e-8046-4dd0-95dd-fb75fb2e07f2","order_by":3,"name":"Gerald Holtmann","email":"","orcid":"","institution":"Queensland Health","correspondingAuthor":false,"prefix":"","firstName":"Gerald","middleName":"","lastName":"Holtmann","suffix":""}],"badges":[],"createdAt":"2026-03-22 03:53:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9188886/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9188886/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107377516,"identity":"a6818a1a-2520-4be7-a436-5dcbdc1976b4","added_by":"auto","created_at":"2026-04-21 01:29:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":178549,"visible":true,"origin":"","legend":"\u003cp\u003epresents a co‑designed solution map for the National Bowel Cancer Screening Program, illustrating strategies to improve access, participation, and follow‑up for people living in rural and remote populations\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9188886/v1/b37d176ed54aa6844350e386.png"},{"id":107488557,"identity":"4e991d5e-25ed-4ebd-84a6-3b892576537c","added_by":"auto","created_at":"2026-04-22 02:45:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1064913,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9188886/v1/f8194e14-3437-4916-a255-b50587d83aae.pdf"},{"id":107486899,"identity":"12faaedc-353e-4258-aaef-fe32e3881760","added_by":"auto","created_at":"2026-04-22 02:39:14","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":50821,"visible":true,"origin":"","legend":"","description":"","filename":"FocusGroupGuideSupplementaryFile.docx","url":"https://assets-eu.researchsquare.com/files/rs-9188886/v1/92487ee773d05b57fc5f53dc.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003e\u003cem\u003eReimagining Access and Equity in Australia’s National Bowel Cancer Screening Pathway: A Critical Realist Analysis of Rural Lived Experience\u003c/em\u003e\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eBowel cancer prevalence and stage of diagnosis cause a significant burden to Australian rural and remote populations. Across these geographically diverse populations, bowel cancer remains a leading cause of cancer‑related death, with disproportionately high incidence and diagnoses occurring most frequently in outer regional and remote areas. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Rural and remote communities continue to face entrenched inequities in healthcare access that extend beyond primary and specialist care to include substantially lower engagement with national population health programs, such as the National Bowel Cancer Screening Program (NBCSP), with participation remaining suboptimal throughout the Program\u0026rsquo;s 18‑year history. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn Australia, prior research has partially explored the drivers of inequities in bowel cancer outcomes and suboptimal adherence to screening recommendations, including engagement with the National Bowel Cancer Screening Program (NBCSP), among rural populations. (\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) Evidence supports a multifaceted approach to mitigating these disparities, including alternative screening kit distribution models, improved education and marketing, enhanced healthcare accessibility, stronger general practitioner endorsement of the Program, and systematic follow‑up of non‑responders. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) While previous research has consistently highlighted the need for programmatic improvements to mitigate geographic disparities in bowel cancer screening participation, much of this work focused on broad access barriers or individual- level determinants of screening behaviour. By documenting lower participation rates among rural and remote populations, these studies have informed calls for targeted adaptations to national screening programs to improve equity in reach and screening adherence.\u003c/p\u003e \u003cp\u003e By contrast, little attention has been paid to the complex and intersecting influences of geographic remoteness, service accessibility and socio‑cultural norms, nor to how these factors shape individuals\u0026rsquo; capacity to comply with bowel cancer screening guidelines over time. As a result, existing evidence has tended to conceptualise inequity primarily through spatial disadvantage, without fully accounting for the contextual realities that mediate engagement with screening services. An under‑examined dimension of prior research is the role of follow‑up diagnostic colonoscopy in shaping rural and remote communities\u0026rsquo; interaction with, and sustained engagement in, the NBCSP. Participation in the NBCSP is rarely acknowledged as a two‑stage process; instead, it is commonly framed as successful completion and return of the immunochemical faecal occult blood test (iFOBT). This narrow view overlooks the critical diagnostic phase that follows a positive iFOBT result, which in most cases requires individuals to engage with primary care to obtain a referral and subsequently access to timely diagnostic colonoscopy services. For rural and remote populations, this second stage is characterised by limited-service availability, travel burden, economic hardship and fragmented care pathways, which may disrupt continuity and undermine confidence in the program. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) Failure to account for these system‑level constraints risks overstating program effectiveness and obscuring where inequities are most acutely produced.\u003c/p\u003e \u003cp\u003eThis research aims to generate in-depth evidence of the intersectionality of participation barriers occurring between rural environments, NBCSP access and the Queensland healthcare system. By situating these interactions across place, system design, and lived experience, the study seeks to illuminate how geographic remoteness and socio‑cultural context shape screening adherence across the continuum of care. Developing comprehensive insights into community interactions, intersectionality, and existential perspectives grounded in empathetic and reflexive engagement with participants offers the potential to reimagine NBCSP access for rural and remote populations. Such an approach not only strengthens the program\u0026rsquo;s capacity to deliver equitable, life‑saving outcomes, but supports more efficient and economically viable service models across priority population groups by aligning system design with the realities of lived experience.\u003c/p\u003e"},{"header":"Study Design","content":"\u003cp\u003eGiven the paucity of information examining rural and remote lived experiences of bowel cancer screening, a focus group methodology was employed to address the study aims. \u0026nbsp;Thus leveraging the strong relational characteristic ties of rural and remote communities and enabling the exploration of individual experiences which are enriched through shared meaning across participant cohorts, an Interpretative Phenomenology approach was deemed most appropriate. \u0026nbsp;A purpose‑designed semi‑structured focus group interview guide was developed for this study and has not been previously published. \u0026nbsp;(See supplementary files) Underpinned by a critical realist ontology, this paradigm places emphasis on existential insights, perceptions and real-world experiences viewed through an inquisitive and empathetic lens. (11-13) \u0026nbsp;Consistent with this approach, this study seeks to privilege rural and remote populations by elevating their voices and lived insights and by centring their unique needs through the co‑creation of consumer‑expert informed recommendations. \u0026nbsp; In this context, Interpretive Phenomenology is concerned with unearthing experiences and lived realities through shared knowledge, stories and language insights gained across participant cohorts. \u0026nbsp;This approach positions the researcher to engage in a transformative, emotionally resonant process aimed at informing recommendations and stimulating discourse on the broader requirements for NBCSP redesign. The study design was co-developed by a multidisciplinary working group comprising of experts in clinical research, public health, gastroenterology, psychology, and health economics ensuring methodological rigour and relevance to policy and practice.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecruitm\u003c/strong\u003e\u003cstrong\u003eent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe recruitment strategy utilised a purpose‑built rural and remote database comprising 193 community organisations and groups, each with publicly available contact details (email or telephone) identified through online listings. \u0026nbsp;Rural and remote locality was defined in alignment with the definitions outlined in the Australian Statistical Geography Standards Remoteness Structure. \u0026nbsp;(14) Recruitment was conducted by distributing invitations to consumer groups and organisations within postcodes classified as \u0026lsquo;outer regional,\u0026rsquo; \u0026lsquo;remote,\u0026rsquo; or \u0026lsquo;very remote.\u0026rsquo; Recognising the sensitive nature of bowel cancer and NBCSP participation, investigators collaborated with community organizations, key stakeholders in rural and remote settings, to ensure discussions occurred in safe, familiar environments. \u0026nbsp;An email was sent to all publicly listed email addresses and contained an invitation to participate in the research, a recruitment flyer and a participant information and consent form. \u0026nbsp;The focus group approach was fostered to encourage community to participate as a group and attend the sessions at a time and location which was convenient and familiar. \u0026nbsp;Time was taken during the recruitment strategy to build trust and community understanding of the research aims. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample Size and Participants\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePurposive sampling techniques were adopted to recruit rural and remote community members aged between 45-74 belonging to an identified community group. \u0026nbsp;Further to this, participants were encouraged to extend the invitation to other members of community, engaging snowball sampling to ensure the participant felt at ease with the research topic and to encourage safe and familiar surroundings during the data collection stages. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFocus groups were conducted during June 2023 over 2-hour semi-structured focus groups held in local community suggested meeting rooms. \u0026nbsp;The focus group guide contained open-ended questions with impromptu lines of query to further explore elements of lived experience across barriers, enablers, value and consumer informed recommendation to improve the NBCSP design. Focus group questions were developed based on evidence-based data and by a multidisciplinary team, including a consumer representative. \u0026nbsp; A \u0026lsquo;tea and cookie\u0026rsquo; approach was adopted where community members shared morning tea, lunch or afternoon tea from a local provider while the principal investigator facilitated discussions across a series of topics in a safe and open environment. \u0026nbsp;Participants were encouraged to ask questions throughout, yielding insights into areas of confusion. Focus Groups were conducted over three days in three locations within the Southwest Hospital and Health Service region of Queensland, Australia. A trained moderator facilitated all sessions, taking field notes and posing additional questions as needed. Focus groups were video-recorded via Microsoft Teams and transcribed verbatim.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis was influenced by a procedure for Interpretative Phenomenological (in Group) Analysis (IPA) developed by Beverly Love and Colleagues in 2020. (15) To generate new knowledge beyond existing assumptions about rural and remote community experiences, the analysis employed a structured series of procedures emphasizing the assessment of researcher bias throughout immersion, thematic coding, and data synthesis, thereby ensuring that both individual and collective voices were preserved. Themes were derived through cycles of watching video recordings/group interactions, reading transcript verbatim and data analysis processes. Three stages of refinement occurred across superordinate themes and sub-themes with the final analysis undergoing credibility checks with the focus group assistant and the broader research group. Exemplar quotes were used to further describe and draw meaning and essence from the codes. IPA aims to understand the complexity of the meaning in the lived experience as it relates to the phenomena or research question, and less of interest is the measure of frequency of themes. (16-18) While IPA is often prescribed to draw deep knowledge and understanding from individual and personal lived experience, it can be argued that the methodological application within a focus group setting is still able to extrapolate individual voices and experiences within the group context. (15) The application of IPA in a Focus Group setting enables even deeper context and detail in the experiences of community due to the homogenous nature and shared barriers to screening and enables variance caused by intersectionality to be assessed.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 27 participants (21 women and 6 men) participated in 6 focus group sessions across 3 rural and remote locations of Queensland, Australia. Focus groups lasted for an average time of 88 minutes and included 3-6 participants. Participant demographic details can be found in \u003cstrong\u003eTable 1\u003c/strong\u003e. Thematic analysis resulted in findings being organised under 4 superordinate themes and presented in general present-tense phenomenological statements of lived experience and later derived into sub-themes for broader context. Superordinate themes and sub-themes have been inductively coded across the data corpus. Participant illustrative quotes include the focus group number and demographic information to provide context on priority population insights and occurrences of intersectionality to assist in the identification of correlations between, and emphasis on, priority population identification of barriers and needs based recommendations to further enhance program equity.\u003c/p\u003e\n\u003cp\u003eParticipants collectively offered detailed suggestions on how to improve access to the program across the NBCSP participant journey. Consumer driven pragmatic solutions to support NBCSP access is presented in sequence across the patient journey in \u003cstrong\u003eFigure 1.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRural and Remote Sociocultural Norms\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSuperordinate Theme 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Being rural, there\u0026apos;s a whole\u0026hellip; this\u0026nbsp;\u003c/em\u003e(NBCSP)\u003cem\u003e\u0026nbsp;is a national sort of thing. Being rural your whole mindset is you\u0026apos;re more independent, you\u0026rsquo;re a free thinker, you can work on your own without the support of major cities and the infrastructure that goes with it\u0026hellip; and that\u0026apos;s also part of it. So, when you come out here, you start thinking\u0026hellip; you need to toughen up.\u0026quot;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e(FG4, #331, Male, Remote)\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile the NBCSP was unanimously supported across focus group participants there was a broader consensus surrounding the sociocultural norms for people residing in rural and remote communities and how it fostered a sense of disconnect to broader metropolitan based Australian norms, specifically within the context of early detection and prevention of colorectal cancer. For some participants, this perception led them to view the NBCSP, despite its national scope as tailored to coastal towns and major cities and culturally misaligned with rural communities\u0026rsquo; social norms and values. This was discussed at length as it related to the burdensome participant pathway through the Program from receiving an iFOBT in locations with no postal system, to the possible need for a follow-up colonoscopy should a positive result be received. This belief was further referenced in relation to the promotional material and branding on the iFOBT, where statements around the image relevance were being questioned.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;When I first saw that\u0026nbsp;\u003c/em\u003e(the iFOBT kit)\u003cem\u003e\u0026nbsp;at a glance over there I thought it was something about learn to swim. Because it\u0026apos;s got that on there\u0026hellip;\u0026nbsp;\u003c/em\u003e(pointing at the lifesaver ring on the front of the kit)\u003cem\u003e.\u0026quot; \u003cstrong\u003e(FG5, #333, Female, Chronic Disease, Remote)\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants openly discussed the message the lifesaver ring on the front of the kit sends to rural and remote communities. Even a seemingly simple promotional image could prompt potential participants to disengage from the Program, driven by assumptions of limited personal relevance. Participants discussed forgetting to complete the kit and the need for the kit to be more demanding of their attention. The kit should be conspicuous, with a more personalised approach and receival should induce a sense of urgency to complete and return the sample. Criticism of the iFOBT extended beyond its generic, government-issued appearance to include concerns about lengthy and, for some, confusing instructions for kit completion. Participants emphasized that the kit should be more conspicuous and personalized, with its delivery conveying a sense of urgency to complete and return the sample.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;A lot of people and .. I don\u0026apos;t mean to be rude\u0026hellip; in our generation um a lot of people left school at 14 so they have... and it doesn\u0026apos;t mean they aren\u0026apos;t successful but they have low literacy levels and that (the brochure) is way too busy. They will say I can\u0026apos;t do this.\u0026quot;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003cstrong\u003e(FG1 #318, Female, CALD, Outer regional)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRecommendations for kit design were suggested during discussions to address lengthy information brochures, literacy level of content, the government look and feel of the kit packaging and promotional images. A co-design process would ensure the kit was made more appealing and relevant to rural and remote communities.\u003c/p\u003e\n\u003cp\u003eThe low public profile of bowel cancer, limited awareness of its prevalence, and minimal media coverage of the NBCSP featured prominently in focus group discussions, reinforcing a perceived link between low perceived risk and screening avoidance. Participants consistently reported little exposure to bowel cancer education or NBCSP‑related advertising, frequently questioning whether this lack of information was specific to rural and remote areas. Many suggested that access to public health messaging about bowel cancer appeared to be disproportionately concentrated in metropolitan settings. Furthermore, reduced opportunities for exposure, arising from the narrow access window created by decreased kit availability within the \u0026lsquo;Hot Zone\u0026rsquo;, were identified as contributing to the persistence of taboo and the low public profile surrounding kit completion and its normalisation.\u003c/p\u003e\n\u003cp\u003eHealth messages perceived as important or urgent were described as highly visible, widely disseminated across multiple media platforms, and actively promoted within local communities, reinforcing their salience and relevance. In contrast, bowel cancer was rarely mentioned or visibly promoted, leading participants to infer that it was of lesser importance or concern. This absence of messaging contributed to assumptions that bowel cancer posed minimal risk for people living in geographically remote areas. This perception is compounded by the prevailing \u0026ldquo;bulletproof\u0026rdquo; mindset, the stoic nature of rural communities and the \u0026lsquo;tough\u0026rsquo; mentality applied to daily life, thus reinforcing low-risk perceptions regarding colorectal cancer prevalence and susceptibility.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes I think because they think they\u0026rsquo;re bulletproof. Because they are taking such risk every day and um.. well, yes.\u0026rdquo; \u003cstrong\u003e(FG2, #323, Female, Remote)\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAcross all focus groups, participants highlighted the positive impact of health buses and mobile units in creating urgency and motivation to address health concerns primarily due to time-limited access and the effectiveness of a \u0026lsquo;whole-of-community\u0026rsquo; approach in prompting action. This strategy was consistently recommended across all six focus groups. Participants further emphasised the value of community-driven initiatives, including distributing and completing kits collectively, as a means to increase participation, raise awareness, and reduce stigma and shame.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Bowel cancer is not something that is seen or that rural communities are exposed to. Where is the media? Where are the ads?\u0026rdquo; \u003cstrong\u003e(FG 5, #335, Female, First Nations, Chronic Disease, Disability, Remote)\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe strong sociocultural norms, avoidance of prevention and the taboo of bowel cancer placed participation in screening as a low priority for many of the participants. This was further reinforced by the lack of capacity for rural healthcare providers to cover prevention and early detection alongside other clinical burdens for their commuities. Bowel cancer for many was still seen as an \u0026lsquo;icky\u0026rsquo; topic and something that was avoided or not discussed in public.\u003cem\u003e\u0026nbsp;\u003c/em\u003eThe call for an education program specifically targeting rural and remote communities was echoed across all 6 focus groups as a priority to raise the public profile of the importance of bowel cancer prevention and early detection. Participants spoke passionately about the need to influence younger generations, high school age and younger, to eradicate the taboo around bowel health and prevention.\u003c/p\u003e\n\u003cp\u003eThe asymptomatic nature of bowel cancer further diminished interest and reduced the perceived urgency or prioritization of participation in screening.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn one larger focus group, a participant prompted laughter and extended discussion by suggesting that bowel cancer screening and participation in the NBCSP be featured in an episode of \u003cem\u003eBluey\u003c/em\u003e.* This idea was framed as a way to normalise screening as a routine, age‑based health check that \u0026ldquo;everyone\u0026rdquo; completes. Participants highlighted the value of the show\u0026rsquo;s colourful characters, multigenerational humour, and strong connection to Australian culture as mechanisms to engage families, foster shared understanding, and reduce discomfort around the topic. The discussion underscored humour and culturally resonant storytelling as potential tools to connect, normalise participation, and raise the profile of bowel cancer screening\u0026mdash;an issue that remains taboo in many rural Australian communities.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;If you isolate the very one factor that is sitting underneath this I think it is the yuck factor or the ick factor and I think that somehow if humour can get a hold of that. You know I said to you before the humour under Bluey, the Bluey show.. you know can\u0026apos;t you just see the humour in it if one of the characters got a kit. The bluey humour is so smart, so smart.\u0026quot; (FG1, #315, Female, Chronic Disease, Rural)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAlthough there was support across all participants for broader program education that resonated with rural and remote communities, groups did not reach consensus over the use of humour or fear tactics to elevate messages around prioritising screening. While many adamantly believed humour would break down the barriers and taboo of bowel cancer, others believed a more serious approach was required.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eNo not humour\u0026hellip;.for young people humour I think. For older people\u0026hellip; honestly, when I hear something that is humorous I think\u0026hellip; are they *fair dinkum? Why are they joking about it!\u0026rdquo; \u003cstrong\u003e(FG3, #326, Female, First Nations, Disability, Chronic Disease, Outer Regional).\u003c/strong\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e*Bluey is an animated Australian preschool television series featuring Australian cattle dogs as the main characters.\u003c/p\u003e\n\u003cp\u003e* Fair dinkum is an Australian slang meaning legitimate or true. Can be used as a question or a statement.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I think there needs to be some bushies stories.\u0026quot; \u0026quot;We don\u0026apos;t remember facts, we remember stories.\u0026rdquo; \u003cstrong\u003e(FG5, #335, Female, First Nations, Chronic Disease, Disability, Rural)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants expressively discussed the way of life, living and working on the land and emphasised the need for stories they could relate to. The power to grasp the viewers\u0026rsquo; attention in a way that was relatable\u003cem\u003e\u0026nbsp;\u003c/em\u003ecould only be found in the use of familiar/trusted ambassadors, add campaigns and stories from the land. This solution to mitigate the taboo/ick factor and to normalise bowel cancer screening as a routine part of looking after health and wellbeing was the key recommendation across focus groups to tackle the low profile and stigma around NBCSP participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eiFOBT Access and the Rural Post \u0026ndash; a cause for concern.\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It gives you one day of the week (the postal service). It\u0026apos;s early in the week when you\u0026apos;re sort of just getting into the week \u0026hellip;and you know often then they are up the top paddock anyway\u0026hellip; and um\u0026hellip; not round the house at that time.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e(FG2, #323, Female, Remote)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConcerns about infrequent or absent postal services, which necessitate traveling long distances to send or receive mail, were identified as a fundamental barrier to NBCSP access for rural and remote populations. The participant pathway to the NBCSP relies heavily on the ability to access a frequent and reliable postal service, a detail that was not missed on the participant cohort. Each focus group included one or more participants who had no postal service deliveries to their property or infrequent (2 times a week) postal service access. This made receiving and completing the kit in a timely manner challenging and, in some cases, too great a burden to mitigate any risk or personal motivation to participate.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026quot;I think.. we just moved into town but we sort of lived 45ks out of town and when we received them (the iFOBT).. if you didn\u0026rsquo;t do it when you received them in the post and if you happened to know you weren\u0026apos;t going into town then it was just that. Because you had to do it in two days and then get it in the mail and if you weren\u0026apos;t going into town then you just forget.\u0026rdquo; \u003cstrong\u003e(FG6 #337, Female, CALD, Chronic Disease, Rural)\u003c/strong\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHardships of daily life further compounded the challenges of travelling long distances to return completed kits. Participants who ran local businesses or worked the land described the difficulty of prioritising preventive health amid the competing demands of busy, labour‑intensive daily routines. Participants also highlighted the burden of the program design itself, including the requirement for two samples, complex instructions, and concerns about test accuracy, all of which made kit completion easier to delay or abandon. These challenges were exacerbated by difficulties returning kit samples within the required program timeframes, with several participants expressing frustration that NBCSP processes did not adequately account for the realities of rural and remote living, ultimately reinforcing disengagement from screening.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I know that they are temperature sensitive so the last time I did one we were in a heatwave and I knew where that test was going to sit if I sat it in my mailbox or the mail services. I knew how many days it would take before collected. The local post office is not airconned and I thought sitting in a red box in the sun.. so it was timing it. Not everyone wants the bother of that.\u0026rdquo; \u003cstrong\u003e(FG1, #315, Female, Chronic Disease, Remote)\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I sent one off and it came back irregular. They said it got there just too late and they weren\u0026apos;t gonna do it. I left it in the fridge and then I sent it and they said it was too long.\u0026rdquo; \u003cstrong\u003e(FG2, #320, Male, Outer Regional)\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The business of a busy life. If you have done it before you know it takes two swipes (two samples). Right.. and you know if someone\u0026rsquo;s really busy thinking well one\u0026rsquo;s ok I can just get in and do it.. But two? You have to think about tomorrow.\u0026rdquo; (\u003cstrong\u003eFG 1, #315, Female Chronic Disease, Remote)\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDiscussions highlighted tensions between privacy concerns and the strong sense of belonging within rural and remote communities. While participants valued close-knit support networks, they also expressed discomfort with others knowing or sharing personal health information. Privacy issues were particularly salient in small communities, where assumptions about health were common. One participant admitted delaying kit completion for years, explaining that returning the kit via the local post office would expose her and her husband\u0026rsquo;s personal business to others.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think having to take them to the post office. We don\u0026apos;t want everybody to know that we\u0026apos;re doing tests and handing them into the post office.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e(FG6, #336, Disability, Chronic Disease, Remote)\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe pivotal role of postal services prompted discussions on expanding kit availability across multiple community locations, a recommendation aimed at improving access for rural and remote populations, mitigating barriers linked to transient workforces, and elevating awareness of colorectal cancer prevention and early detection. Participants strongly advocated for a \u0026lsquo;whole-of-community\u0026rsquo; approach, suggesting coordinated distribution of kits to all residents within the same week or month to normalise participation and reduce stigma. This strategy was framed as promoting community acceptance of NBCSP completion as part of routine health checks. Suggested kit distribution points included post offices, pharmacies, GP clinics, allied health practices, service stations, and supermarkets. Participants also emphasised the need for multiple drop-off sites, such as GP surgeries and pathology collection centres, to avoid reliance on postal boxes and reduce risks associated with heat exposure.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Well, I suppose one of the things is you don\u0026apos;t have a backup kit. So, if you\u0026apos;ve done the first test and then a week later you\u0026apos;ve gone ahhh the pump on the thingy blew out and I had to race out the door at 2 o\u0026apos;clock in the morning or something like that and um..and deal with whatever the catastrophe was and well you\u0026apos;ve missed it. Oh well I\u0026apos;ll throw it in the bin.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e(\u003cstrong\u003eFG 1, #315, Female, Chronic Disease, Remote)\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Role of the Rural GP\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSuperordinate Theme 3\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Unless you\u0026apos;ve got a chronic health problem, most people aren\u0026apos;t going to their doctor. I\u0026apos;ll come across so many people .. not so much in my job because they are the vulnerable\u0026hellip; who say I haven\u0026apos;t been to the doctor since I had a baby.\u0026quot; \u003cstrong\u003e(FG4, #329, Female, Remote)\u003c/strong\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAcross all six focus groups, participants consistently emphasised the importance of access to primary healthcare and the ability to consult with, and establish continuity of care through, a single general practitioner. However, a recurrent theme was the inability to access a GP, which was identified as a critical barrier to care. This limitation not only undermines the development of therapeutic relationships but also contributes to fragmented service delivery and delays in diagnosis and treatment. GPs form an integral part of the patient pathway in the NBCSP yet no participants recalled any reminders or follow-up being received from the GP. Difficulties accessing GPs had participants recalling numerous accounts of feeling let down or unsupported through their care journeys. Hardships ranged from only accessing a GP if critical care was needed, to misdiagnoses, weekly to monthly delays in access and significant medical mistrust due to multiple occasions of denying follow-up specialist care, poor physician/patient communication of health outcomes and a general lack of support/trust. Some participants also viewed medical professionals as part of the larger government system, a system that required caution and care during interactions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think what (x participant\u0026rsquo;s name) is saying, it doesn\u0026rsquo;t matter what age you are, there is a general feeling that nobody really cares about our health.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e(FG3, #324, Female, CALD, Chronic Disease, Outer Regional)\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants perceived health resourcing as a privilege largely reserved for metropolitan areas. They expressed that the design and accessibility of the NBCSP appeared to cater primarily to urban populations. In relation to their own health, access to support was often contingent upon the presence of illness rather than prevention. Sociocultural norms surrounding the low prioritisation of healthcare, coupled with a prevailing \u0026lsquo;tough rural\u0026rsquo; mentality and limited access to primary healthcare services, were seen to contribute to delayed help-seeking behaviours. Consequently, rural populations frequently postpone seeking healthcare assistance until circumstances become critical.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;In the city there are a hell of a lot more doctors for each area, each suburb, each community. Out here we\u0026apos;ve got 2 doctors and if you don\u0026apos;t like that particular doctor \u0026hellip;you avoid them unless you\u0026apos;re dying. We don\u0026apos;t get the diversity of medical practitioners where you can pick and choose who you want to see.\u0026rdquo; \u003cstrong\u003e(FG 4, #331, Male, Rural)\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhile many participants shared in the harrowing accounts of GP access and poor physician experiences, some participants could not speak highly enough of the GPs in their local areas and their commitment to providing an outstanding service to the community.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;And they are good doctors. They just don\u0026apos;t have time. He gets up at 6am in the morning seeing patients and their lifestyle is so different to city. They are not working daylight hours. They work weekends\u0026hellip; they do things out of hours.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e(FG3, #326, Female, First Nations, Chronic Disease, Disability, Outer Regional)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants did not extend this sense of gratitude to the transient workforces and locum specialists with further accounts of inferior service delivery and lack of context and rigour. Regardless of the participants stance on the quality of care received in rural and remote locations, there was consensus on the difficulties in getting an appointment for medical care, leaving no space or consideration for prevention, early detection and support for NBCSP participation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, so if you\u0026apos;re sick, bad luck! You go to the hospital emergency and then we stuff that up.\u0026quot; \u003cstrong\u003e(FG1, #316, Female, Outer Regional)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I think there is more mistrust out here for the medical profession as a whole, more than what you realise. You might think that your personal GP is a nice person as a person but as a profession there is a lot of mistrust and it\u0026apos;s been made worse since the whole COVID situation.\u0026quot; \u003cstrong\u003e(FG4, #331, Male, Remote)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants who experienced intersectionality, belonging to more than one priority population group, were more likely to share distressing accounts of medical mistrust and past negative encounters with the healthcare system some of which elicited disbelief among other participants. These narratives highlighted a profound disconnect between individuals, medical professionals as integrated members of society, and sociocultural beliefs surrounding government mistrust. Painful recollections of medical negligence, harrowing experiences, and feelings of powerlessness were recurrent themes. Discussions of medical mistrust frequently extended to broader government mistrust, which, when combined with privacy concerns in small communities, rendered healthcare engagement and completion of the iFOBT through the NBCSP a highly challenging and deeply private matter.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;But anyway\u0026hellip; mistrust mate...It\u0026apos;s just one thing after the other.. that mistrust!\u0026quot;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e(FG3, #326, Female, First Nations, Chronic Disease, Disability, Outer Regional)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants described an inability to speak up or self-advocate for their healthcare needs, which was reinforced by a deep-seated fear of antagonising healthcare providers. The absence of options for a second opinion compounded this concern. Several participants believed that challenging clinical recommendations or expressing dissatisfaction could result in punitive consequences, such as being denied future care, leaving them with no accessible medical support.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If I knew I could swap GPs, I\u0026apos;d certainly speak up.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e(FG3, #326, Female, First Nations, Chronic Disease, Disability, Outer Regional)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite the broad theme of distrust for the medical world, support was unanimously given for the need for a larger prevention focus in general practice and more allied health support, however there was a sense of defeat and resolve surrounding the feasibility of the recommendation. A seemingly accepted fate for rural and remote communities was to have inferior, challenging and delayed access healthcare.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Unless you are going to give your local GP more money, no they will not do it because they are absolutely on the bones of their bums. Because the Medicare rebate they get for each person they see is about this much (demonstrating a small amount with two fingers).\u0026rdquo; \u003cstrong\u003e(FG2, #322, Female, Remote)\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDiscussions to improve poor access to GPs to enhance reminders, follow-up referrals and support from general practice through the NBCSP pathway included the need for remuneration and broader external support. Suggestions focused largely on the need for Telehealth support to navigate people through the participant pathway and GP incentivisation, with broader support from allied health professionals. Follow-up support for non-responders was discussed at length with GPs often being the first suggestion put forward during conversations. Resolve was always met with the incapacity of rural general practice to provide NBCSP support with lengthy discussions around the need for NBCSP or local government support to prompt and remind people to participate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eColonoscopies and the Economic Implications\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSuperordinate Theme 4\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;People that are 50 years and over they\u0026apos;ve been taught to think and behave in a very specific way. So those people even if they\u0026apos;ve got slightly off health, they don\u0026rsquo;t want to know. They won\u0026apos;t want to know that they might be sick. They\u0026apos;ve got responsibilities in the paddock. They wanna work until they drop dead. \u0026quot; \u003cstrong\u003e(FG4, #331, Male, Remote)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe burden and economic implications of undergoing a diagnostic colonoscopy following a positive iFOBT were unanimously identified as significant barriers for rural and remote populations. Participants highlighted the absence of localised endoscopy services, disruptions to work and business operations, and the considerable financial and logistical challenges associated with multi-day travel. These factors collectively impose substantial constraints on timely access to diagnostic care for busy rural and remote communities.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;When we look at the way ah.. we live our lives, we\u0026apos;re very...we tend to be very busy. A lot of the guys are on the land, they don\u0026apos;t.. It\u0026apos;s like what I feel and this is just my own personal ahh sort of thoughts around it is that the land, the business, that all comes first and they come afterwards.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e\u003cem\u003e(FG5, #334, Female, Chronic Disease, Rural)\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants recounted the pressing demands and responsibilities of daily life, noting that concepts of prevention and follow-up care were frequently deprioritised in favour of other tasks perceived as more urgent\u0026mdash;most commonly heavy work-related obligations. This tendency reflects the competing priorities faced by rural populations, where immediate economic and labour demands often overshadow long-term health considerations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;If you take a sick day, you don\u0026apos;t get paid. You don\u0026apos;t do this you don\u0026apos;t get any of that. And once again it\u0026apos;s an inconvenience. \u0026ldquo;(\u003cstrong\u003eFG4 #328, Male, Remote)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants highlighted additional complexity arising from the absence of local colonoscopy services, the need for long‑distance travel, and the burden of completing complex travel and accommodation subsidy forms. These structural barriers generated discussion about the inadequacy of current service arrangements for rural populations and reinforced calls for more localised diagnostic service provision. Participants also emphasised the need for clearer and more streamlined care pathways, improved support to navigate subsidy processes, and more equitable financial allowances for travel and accommodation associated with follow‑up care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;They\u0026apos;ve got to stop fighting us for the travel allowance and the motel allowance!\u0026quot; \u003cstrong\u003e(FG3, #326, Female, First Nations, Chronic Disease, Disability, Outer Regional)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe participant discussed the stress of having an illness or needing a test and the harrowing process of applying for subsidy allowance, the immense stress of the application process as well as the effort of changing or adjusting the initial request should a change in care be required.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I haven\u0026apos;t used it for years because it was so hard to access. You\u0026apos;ve got to know all this before you go down there which I didn\u0026rsquo;t the first time. I didn\u0026rsquo;t know it was available because the doctor hadn\u0026apos;t told me and they\u0026apos;re supposed to tell you before you go away. Um.. and so I was going to do mine retrospectively and I had to get a special appointment to go to the doctor and get the referral and I had already had the procedure... it was just not worth the effort.\u0026quot; \u003cstrong\u003e(FG4 #321, Female, Remote)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants demonstrated an awareness of the broader community\u0026rsquo;s needs and expressed gratitude for their own ability to access colonoscopy services and travel subsidies. However, they acknowledged that for some individuals within their communities, the absence of a companion to assist with accessing, understanding, or completing subsidy forms rendered these supports unattainable. Additionally, each focus group noted a lack of local service knowledge by health professionals in the health system, which often resulted in participants travelling greater distances to access services that may have been available closer to home.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;We don\u0026rsquo;t know what services are here and when we have VMOs (visiting medical officers) come out, they don\u0026rsquo;t know what services are here. So they automatically refer them away.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e\u003cem\u003e(FG5, #334, Female, Chronic Disease, Rural)\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants expressed a deep sense of discrimination when discussing confusing subsidy forms, a lack of support, and significant financial gaps not covered by existing allowances, an injustice they felt would be unacceptable in metropolitan or major city contexts. Recommendations included increasing GP awareness and involvement in providing information and guidance on form completion, establishing helplines, and expanding Telehealth support to assist patients through the process of accessing colonoscopy. Patient navigation emerged as a key theme, with participants emphasising the need for dedicated support to overcome the multiple barriers and hardships faced by rural communities when seeking to participate in the NBCSP. These challenges are further compounded by the requirement to access colonoscopy services away from home, which adds considerable logistical, emotional, and financial burden to an already complex and demanding situation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I drove meself over, I wasn\u0026apos;t sposed to, you\u0026apos;re sposed to have someone to drive you and pick you up. Yeah, I drove myself home too. I didn\u0026rsquo;t have anyone I could ask to come with me, so I just did it.\u0026quot; \u003cstrong\u003e(FG5, #335, Female, First Nations, Chronic Disease, Disability, Remote)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants widely acknowledged the need to travel for diagnostic colonoscopy; however, this acceptance often came at the cost of engagement with follow‑up care. For many, the requirement for colonoscopy rendered both diagnostic follow‑up and in some cases participation in the initial iFOBT stage of the NBCSP untenable, as they were unwilling to proceed to colonoscopy if required. The economic implications of colonoscopy were profound for rural and remote communities. Out-of-pocket travel expenses, loss of income due to lack of sick leave, and the cost of hiring someone to manage farms or businesses were identified as significant barriers. Participants emphasised that these challenges could only be mitigated through a more localised approach to care. Unanimously, they expressed that their homes and hearts remained in the country, and the need to travel for care represented yet another injustice, resulting not in equivalent care to metropolitan patients, but in inferior healthcare access. Consequently, participants strongly recommended increasing local access to colonoscopy services to minimise economic burden and reduce the excessive hardships associated with obtaining essential diagnostic care.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides novel existential insight into how rural and remote populations perceive and navigate participation in colorectal cancer screening, revealing that engagement with the NBCSP can be influenced by systemic inequities and historically embedded patterns of low healthcare utilisation. Analysis and interpretation highlight that participants\u0026rsquo; interactions with the program cannot be disentangled from broader experiences of limited healthcare access, geographic isolation, and socio‑cultural norms that have normalised reduced reliance on health services. Shared beliefs and collective experiences around health‑seeking behaviours strongly influenced how participants perceived the relevance, feasibility, and value of engaging with the NBCSP.\u003c/p\u003e \u003cp\u003eBarriers to accessing general practice were a dominant theme across all focus groups, including prolonged waiting times, lack of continuity of care, limited preventive focus, and a prevailing tendency to seek care only when acutely unwell. Participants commonly described travelling long distances for care and expecting waits of three to six weeks for GP appointments. These access constraints have reinforced a culture of low dependency on the healthcare system, directly shaping engagement with preventive initiatives such as the NBCSP. Within this context, the rural GP out of necessity was perceived as primarily oriented toward acute and chronic illness management, rather than as a facilitator of preventive screening. While strategies to increase GP involvement were initially discussed and theoretically supported, ongoing dialogue revealed a shared recognition of workforce strain and limited capacity within rural general practice, ultimately questioning the feasibility of GP‑led solutions.\u003c/p\u003e \u003cp\u003eThese experiential accounts align with national data demonstrating substantial geographic disparities in primary healthcare utilisation and workforce distribution. Rural populations experience disproportionately lower rates of GP attendance compared with metropolitan counterparts, alongside markedly reduced access to healthcare professionals relative to population size, particularly in small rural towns. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) The rate of increase in potentially avoidable deaths (potentially preventable through primary or hospital care) is directly related to increasing remoteness, this includes cancers that could have been diagnosed through cancer screening programs such as the NBCSP. While participants shared stories of strength surrounding the dedication and commitment of healthcare workers to operate under high pressure and dire circumstances, there was an evident undertone of mistrust expressed in relation to the lack of genuine care for the health outcomes of rural and remote communities.\u003c/p\u003e \u003cp\u003eMistrust, perceptions of withheld information, and an inability to self-advocate were themes disproportionately expressed by participants experiencing intersectionality, particularly those identifying as First Nations or living with disability. Shared and sometimes conflicting narratives highlighted how diverse demographic characteristics shaped the interplay between NBCSP access and lived experience.\u003c/p\u003e \u003cp\u003eParticipants consistently conceptualised solutions in terms of GP endorsement, telehealth, allied‑health‑led patient navigation, and reminder or recall systems such as SMS messaging. However, as discussions progressed, there was growing consensus that the capacity constraints of rural general practice limit the viability of GP‑centred interventions. Participants instead proposed freeing clinical time through metropolitan outreach and external navigation support to guide individuals through the pathway to diagnostic colonoscopy, thereby reducing burden on local services. Beyond improving onsite, localised resourcing, metropolitan outreach models that relieve time pressures within rural practice and support patients in navigating the pathway to colonoscopy were viewed as advantageous.\u003c/p\u003e \u003cp\u003eFindings from this study highlight reliance on the postal system as a significant and under‑recognised structural barrier to participation in the NBCSP for rural and remote populations. Infrequent or absent mail delivery, long distances to postal outlets, and limited opportunities to post kits within required timeframes complicated receipt, completion, and return of iFOBT kits. Participants described how these logistical constraints intersected with the demands of daily rural life, including farm work, business responsibilities, and unpredictable schedules, making timely completion difficult to prioritise. Program design features such as the requirement for two samples, temperature sensitivity, and strict return windows further compounded these challenges, particularly in hot climates and areas with limited mail infrastructure. Collectively, these barriers contributed to frustration and disengagement, reinforcing the perception that the NBCSP is insufficiently responsive to the lived realities of rural and remote communities. These findings underscore the need to reconsider distribution, return, and timing mechanisms within population‑based screening programs to ensure equitable access irrespective of geography\u003c/p\u003e \u003cp\u003eA critical and frequently overlooked component of the NBCSP is the requirement for follow‑up diagnostic colonoscopy after a positive iFOBT. Profound geographic inequities exist in endoscopy service distribution, with endoscopist density dramatically lower in rural compared with metropolitan Local Government Areas. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) Participants described the need to travel long distances, often over multiple days, to access diagnostic care, requiring time away from work, loss of income, and in many cases the absence of paid leave or replacement labour. These challenges were amplified among small business owners, who are disproportionately represented in regional areas of Queensland and Tasmania compared with capital cities. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eEconomic burden associated with livelihood and business ownership emerged as a system‑level barrier to equitable access, particularly during the diagnostic phase of screening. Although travel subsidy schemes exist, participants identified substantial shortcomings, including requirements for upfront payment, partial reimbursement, administrative complexity, and limited awareness or support in navigating subsidy processes (21). The subsidy system was frequently described as unjust and inaccessible, particularly for individuals with low literacy, disability, or limited administrative support. Consistent with international evidence, participants strongly endorsed patient navigation models external to general practice as a mechanism to address persistent rural barriers, including assistance with subsidy applications and coordination of care (22).\u003c/p\u003e \u003cp\u003eLow visibility of bowel cancer within rural and remote communities was also widely discussed. Participants cited limited exposure to education, promotion, GP endorsement, and community‑level dialogue, contributing to low perceived risk, stigma, shame, and avoidance behaviours. The need to normalise bowel cancer screening and raise its public profile was echoed across all groups, particularly to counter taboo and disengagement. While past media campaigns have demonstrated effectiveness in increasing kit returns among targeted populations (23), participants questioned whether state‑based campaigns adequately reach rural and remote communities. Many reported no exposure to NBCSP advertising, suggesting gaps in outreach and communication. Participants raised concerns regarding the NBCSP \u0026ldquo;Hot Zone Policy,\u0026rdquo; which restricts annual screening windows in postcodes where average monthly temperatures exceed 30\u0026deg;C to comply with sample stability requirements (24). Rural and remote populations are disproportionately affected by this policy, yet its impact on participation, cancer detection, and community normalisation of screening remains poorly understood. Reduced access windows may further diminish program visibility and continuity in already underserved regions.\u003c/p\u003e \u003cp\u003e To address these challenges, participants recommended more engaging, locally tailored approaches to communication and outreach, including personalised and repeated reminders, trusted and verifiable messaging sources, and digital engagement strategies such as social media presence. Print media was commonly perceived as outdated, while digital platforms were viewed as more relevant and accessible. Finally, participants emphasised the importance of place‑based, community‑led approaches. Community‑Based Participatory Research and co‑design strategies were identified as critical mechanisms to build trust, foster local ownership, and develop culturally responsive solutions capable of addressing the complex, systemic barriers shaping NBCSP participation in rural and remote communities. (25)\u003c/p\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study notes several limitations to its design and scope. Following the discovery of economic barriers to accessing the National Bowel Cancer Screening Program (NBCSP), the inclusion of demographic measures such as socio-economic status would have provided deeper insight into theories around work culture, ethics, and their impact on screening compliance. Furthermore, the participant sample did not include representation from refugee or LGBTQI+ communities, limiting the breadth of perspectives captured and highlighting the need for future research that more fully reflects population diversity.\u003c/p\u003e \u003cp\u003ePhenomenology, and particularly Interpretative Phenomenological Analysis (IPA), is often considered best suited to in-depth interviews, with some scholars describing its application to focus groups as an oxymoron. Nevertheless, rich accounts of personal lived experiences were frequently shared, and care was taken to extrapolate themes and code data at the individual level while analysing the broader corpus to identify superordinate themes. Using phenomenology to explore rural and remote focus groups on bowel cancer screening has inherent limitations, as findings rely on subjective accounts that may introduce recall bias and limit generalisability. However, this approach offers unique strengths in capturing deeply personal and contextual meanings behind participation decisions, providing insights into barriers and motivators that quantitative methods often overlook.\u003c/p\u003e \u003cp\u003eFuture research would benefit from incorporating rural clinician perspectives to further strengthen recommendations, particularly in relation to feasibility, acceptability, and implementation across primary care and diagnostic pathways.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eFindings reveal a novel understanding of systemic barriers limiting equitable access to the NBCSP, exposing limitations in the program\u0026rsquo;s design for geographic and socioeconomic diversity. Access for rural and remote communities must be considered within the broader context of healthcare inequities and historical patterns of inaccessibility that have shaped attitudes towards care. These findings highlight critical implications for policy and practice across both phases of NBCSP participation the initial screening and the follow-up colonoscopy. Participants advocated for system‑level reform and locally responsive interventions to mitigate the financial, geographic, and logistical barriers that undermine feasibility, acceptability, and equity in bowel cancer prevention. Informants\u0026rsquo; accounts revealed a pervasive normalisation of reduced access as an expected reality of geographic remoteness, reinforcing the urgency of an equitable redesign of program delivery. Addressing these challenges requires a reorientation of health services toward place‑responsive models, including the integration of patient navigation and coordinated referral pathways to support completion of the screening continuum. Collectively, this evidence is highly relevant for local and national policymakers seeking to maximise both the health and economic benefits of the NBCSP, improve program performance, and meet key equity‑related performance indicators.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eEthical approval for this study was granted by the Metro South Hospital and Health Service Human Research Ethics Committee (HREC/2022/QMS/88545), in partnership with the University of Queensland, Faculty of Medicine. All procedures performed involving human participants were conducted in accordance with the ethical standards of the responsible committees. \u0026nbsp;All procedures performed involving human participants were conducted in accordance with the ethical standards of the responsible committees and with the Declaration of Helsinki. Written informed consent was obtained from all individual participants prior to participation. Participants received detailed information outlining the study purpose, procedures, potential risks and benefits, and their right to withdraw from the study at any time without penalty. Consent was provided either electronically or in written form, in accordance with approved ethical standards. \u0026nbsp;No individually identifiable data are included in this manuscript and consent for publication was included within the study\u0026rsquo;s ethics approval.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due to ethical and privacy considerations but are available from the corresponding author on reasonable request, subject to approval by the relevant ethics and governance bodies.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis research was funded by the National Health and Medical Research Council Centre of Research Excellence in Digestive Health through a competitive grant round. The funding body had no role in the study design, data collection, analysis, interpretation of results, or preparation of the manuscript.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003ePrimary Investigator Marinucci, led the study conception and design, data collection, analysis, writing and editing. Associate Investigator Moy, Koloski and Holtmann contributed to supervision, data analysis and editing. All authors contributed to critical revision of the manuscript, read, and approved the final version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGovernement A. Distribution of cancer stage: 2011; 2011 [Available from: https://ncci.canceraustralia.gov.au/diagnosis/distribution-cancer-stage/distribution-cancer-stage.\u003c/li\u003e\n\u003cli\u003eSturman N, Tran M, Vasiliadis S. Rescuing the profession we love: general practice training sector recommendations for improving the attractiveness of general practice training. A qualitative analysis. Med J Aust. 2024;220(9):461-5.\u003c/li\u003e\n\u003cli\u003eGoodwin BC, March S, Ireland M, Crawford Williams F, Manksi D, Ford M, et al. Geographic variation in compliance with Australian colorectal cancer screening programs: the role of attitudinal and cognitive traits. Rural Remote Health. 2019;19(3):4957.\u003c/li\u003e\n\u003cli\u003eMarinucci N, Moy N, Koloski N, Shah A, Austin G, Russell-Bennett R, et al. Social determinants and participation in fecal occult blood test based colorectal cancer screening: A qualitative systematic review and meta-synthesis. Health Promot J Austr. 2024;35(1):9-36.\u003c/li\u003e\n\u003cli\u003eChristou A, Katzenellenbogen JM, Thompson SC. Australia\u0026apos;s national bowel cancer screening program: Does it work for Indigenous Australians? BMC Public Health. 2010;10(1):373-.\u003c/li\u003e\n\u003cli\u003eIreland K, Hendrie D, Ledwith T, Singh A. Strategies to address barriers and improve bowel cancer screening participation in Indigenous populations, particularly in rural and remote communities: A scoping review. Health Promot J Austr. 2023;34(2):544-60.\u003c/li\u003e\n\u003cli\u003eLee SM, Obamiro K, Cooper A, Barnett T. General practitioner perspectives on barriers and enablers to bowel cancer screening in rural Tasmania: A thematic analysis of face-to-face interviews. Aust J Gen Pract. 2021;50(3):158-63.\u003c/li\u003e\n\u003cli\u003eMcGraw J, Russell-Bennett R, White KM. Tough but not terrific: value destruction in men\u0026rsquo;s health. Journal of service theory and practice. 2020;30(3):331-59.\u003c/li\u003e\n\u003cli\u003eMarinucci N, Koloski N, Baker K, Moy N, Holtmann G. Key recommendations to improve equity and access in colorectal cancer screening for rural and remote communities. A grounded theory study. Aust N Z J Public Health. 2025;49(6):100295.\u003c/li\u003e\n\u003cli\u003eMarinucci N, Koloski N, Baker K, Moy N, Holtmann G. Key recommendations to improve equity and access in colorectal cancer screening for rural and remote communities. A grounded theory study. Australian and New Zealand journal of public health. 2025;49(6):100295-.\u003c/li\u003e\n\u003cli\u003eDanermark B, Ekström M. Explaining society : critical realism in the social sciences. Second edition ed. Abingdon, Oxon New York, NY: Routledge; 2019.\u003c/li\u003e\n\u003cli\u003eBhaskar R. A realist theory of science. [2nd ed.] ed. London New York: Routledge; 2008.\u003c/li\u003e\n\u003cli\u003eBhaskar R. The possibility of naturalism : a philosophical critique of the contemporary human sciences. 4th ed ed. Oxon England: Routledge; 2015.\u003c/li\u003e\n\u003cli\u003eStatistics ABo. Australian Statistical Geography Standard (ASGS) Edition 3 2024 [Available from: https://www.abs.gov.au/statistics/standards/australian-statistical-geography-standard-asgs-edition-3/jul2021-jun2026/remoteness-structure/remoteness-areas.\u003c/li\u003e\n\u003cli\u003eLove B, Vetere A, Davis P. Should Interpretative Phenomenological Analysis (IPA) be Used With Focus Groups? Navigating the Bumpy Road of \u0026ldquo;Iterative Loops,\u0026rdquo; Idiographic Journeys, and \u0026ldquo;Phenomenological Bridges\u0026rdquo;. International journal of qualitative methods. 2020;19:160940692092160.\u003c/li\u003e\n\u003cli\u003eSmith JA. Reflecting on the development of interpretative phenomenological analysis and its contribution to qualitative research in psychology. Qualitative research in psychology. 2004;1(1):39-54.\u003c/li\u003e\n\u003cli\u003eSmith JA. Evaluating the contribution of interpretative phenomenological analysis. Health psychology review. 2011;5(1):9-27.\u003c/li\u003e\n\u003cli\u003eSmith JA, Flowers P, Larkin M. Interpretative phenomenological analysis : theory, method and research. 2nd edition ed. London Thousand Oaks, California: SAGE; 2022.\u003c/li\u003e\n\u003cli\u003eWelfare AIoHa. Access to Healthcare; Medicare GP Non-Reffered Attendances by Modified Monash Category Canberra2023 [Available from: https://www.aihw.gov.au/reports/rural-remote-australians/rural-and-remote-health.\u003c/li\u003e\n\u003cli\u003eWelfare AIoHa. Australia\u0026apos;s Health 2024. 2024. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003eTable 1_ Participant Characteristics\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e summarises the demographic and baseline characteristics of study participants.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"376\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eTotal (\u003cem\u003en=27\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e21 (77.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e6 (22.3%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eMean (64) SD (7.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e45-49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e2 (7.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e50-59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e3 (11.1%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e60-60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e14 (51.9%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e70-75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e8 (29.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eAboriginal or Torres Strait Islander\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e2 (7.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eLGBTQIA+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eCulturally and Linguistically Diverse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e4 (14.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eRefugee or Asylum Seeker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0 (0%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipants with Disability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e3 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipants with Chronic Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e11 (40.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eLiving in outer regional, remote or very remote area?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e27 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eGeographic remoteness indicator ASGR ARIA+*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eOuter Regional\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e9 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eRemote\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e18 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eVery Remote\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eHot Zones**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e27 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-9188886/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9188886/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eBowel cancer remains a leading cause of cancer‑related mortality in Australia, with rural and remote populations experiencing a disproportionate burden due to later‑stage diagnosis and persistent inequities in access to care. Although the National Bowel Cancer Screening Program (NBCSP) has achieved population‑level reductions in morbidity and mortality, participation remains consistently lower in geographically remote communities. Inequities occur across both phases of the screening pathway, immunochemical faecal occult blood test (iFOBT) kit completion and diagnostic colonoscopy follow‑up, reflecting structural barriers including limited accessibility, fragmented continuity of care, and misalignment between program design and rural contexts. Consumer‑centred understanding of lived rural experiences is required to inform equitable program and policy reform.\u003c/span\u003e \u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eGuided by a critical realist ontology and an Interpretative Phenomenological Approach (IPA), focus groups were conducted with adults residing in rural and remote Australian communities who were eligible for NBCSP participation. The study was co‑developed with a multidisciplinary working group comprising experts in clinical research, public health, gastroenterology, psychology, and health economics, alongside consumer partners, to ensure methodological rigour and policy relevance. Data were analysed iteratively using IPA to identify shared meanings and context‑dependent mechanisms shaping participation across both screening and diagnostic phases.\u003c/span\u003e\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTwenty‑seven NBCSP‑eligible participants described systemic barriers limiting equitable access and acceptability. Key mechanisms included: (i) constrained opportunities for kit completion due to narrow access windows and reduced local kit availability, reducing exposure, visibility, and perceived normalisation of screening; (ii) substantial financial, geographic, and logistical burdens, particularly affecting follow‑up colonoscopy; (iii) fragmented referral and navigation pathways, inconsistent general practitioner endorsement, and lack of localised service availability and (iv) the normalisation of reduced access as an expected consequence of remoteness, dampening help‑seeking behaviour. Participants advocated for system‑level reform and locally responsive models, including alternative kit distribution, tailored education and promotion, proactive patient navigation, and coordinated, localised referral pathways.\u003c/span\u003e\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCurrent NBCSP delivery insufficiently accommodates geographic and socioeconomic diversity, perpetuating inequities across the screening continuum. Equity‑oriented, place‑responsive redesign, integrating patient navigation, coordinated pathways, and locally feasible access points offers clear potential to improve participation, completion, and downstream health and economic outcomes.\u003c/span\u003e \u003c/p\u003e","manuscriptTitle":"Reimagining Access and Equity in Australia’s National Bowel Cancer Screening Pathway: A Critical Realist Analysis of Rural Lived Experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-21 01:29:21","doi":"10.21203/rs.3.rs-9188886/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-03T10:08:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"153242859638935053659467842409050915947","date":"2026-04-12T11:52:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-10T12:20:53+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-02T08:06:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-02T08:02:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-01T12:55:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-04-01T11:12:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"906c58d8-d49c-4529-b0ce-bfb3bf1cd0b1","owner":[],"postedDate":"April 21st, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-03T10:08:02+00:00","index":38,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-21T01:29:21+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-21 01:29:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9188886","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9188886","identity":"rs-9188886","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}