Awareness of colorectal cancer symptoms and risk factors: a cross-sectional study at the largest tertiary care centre in Sri Lanka

Abstract

Objectives

To assess awareness of colorectal cancer (CRC) symptoms and risk factors among adults attending Sri Lanka’s largest tertiary care hospital, and to identify sociodemographic predictors of awareness.

Design

Descriptive cross-sectional study.

Setting

Outpatient clinics at the National Hospital of Sri Lanka (NHSL), the country’s largest tertiary care centre.

Participants

A total of 506 adults (≥18 years) recruited via convenience sampling. Data were collected from May 2022 to May 2023 at the outpatient clinics of the NHSL, the country’s largest tertiary care centre. Eligible participants included clinic attendees as well as accompanying persons of attendees, provided they met inclusion criteria. Individuals with known gastrointestinal conditions or malignancies were excluded.

Primary and secondary outcome measures

Primary outcomes: awareness scores of CRC symptoms and risk factors using a culturally adapted Bowel Cancer Awareness Measure questionnaire.

Secondary outcomes: predictors of awareness based on sociodemographic variables.

Results

58.7% (n=297) of participants could not name any CRC symptoms unprompted; blood in stools (n=93, 18.4%) was the most identified symptom unprompted. Prompted awareness improved markedly, with 75.3% (n=381) identifying blood in stools when provided with a list. Similarly, 44.3% (n=224) could not identify any CRC risk factors unprompted; excessive alcohol intake (n=368, 72.7%) and low fibre intake (n=324, 64.0%) were the most commonly recognised risk factors when prompted. The mean symptom awareness score was 5.63 (SD=2.55), corresponding to ‘fair’ awareness, and the mean risk factor awareness score was 5.47 (SD=2.63), also indicating ‘fair’ awareness. Female gender (B=0.669, p=0.008; n=237) and older age (B=0.023, p=0.034) were significantly associated with higher symptom awareness. Awareness was significantly lower among participants with lower education (B = –0.104, p=0.018; n=219) and among the unemployed (B = –0.175, p=0.045; n=152).

Conclusions

Unprompted awareness of CRC symptoms and risk factors was suboptimal in this population, with marked gaps in spontaneous recall. Public health campaigns should prioritise men, younger adults and individuals with lower education to enhance CRC literacy and promote earlier detection.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• First Sri Lankan study to assess colorectal cancer awareness with a validated, culturally adapted tool.

• Use of both unprompted and prompted questions captured recall and recognition.

• Interviewer-administered surveys improved clarity and consistency.

• Single-centre, convenience sampling limits generalisability.

• Possible non-response bias, as those who declined may differ in awareness.

Introduction

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer-related mortality globally, with an estimated 1.9 million new cases and 935 000 deaths in 2020.¹ The global burden of CRC is projected to increase, reaching approximately 3.2 million cases and 1.6 million deaths by 2040.² In Sri Lanka, CRC is among the five most common cancers, with an age-standardised incidence rate of 10.2 per 100 000 reported in 2019.³ Recent data from the National Cancer Registry highlight an upward trend in incidence and mortality, emphasising the growing national burden.⁴ Despite this rising burden, public awareness about CRC remains limited, particularly in low- and middle-income countries where population-wide screening programmes are lacking.

Early detection and diagnosis of CRC are essential for improving survival outcomes. Symptoms such as rectal bleeding, altered bowel habits, unexplained weight loss and abdominal discomfort are common early indicators, but are often misattributed to benign gastrointestinal issues such as haemorrhoids or dietary changes.^{5 6} A lack of awareness and emotional barriers such as stigma, fear and embarrassment can delay help-seeking behaviour, leading to late-stage diagnoses and poorer prognoses.^{7 8}

Timely recognition of CRC symptoms is crucial for early diagnosis and improved prognosis. Public awareness of both CRC symptoms and risk factors is critical for enabling early diagnosis and effective prevention. Key modifiable risk factors include low dietary fibre, high consumption of red and processed meats, alcohol use, smoking, obesity and physical inactivity, while non-modifiable risks include age, sex and family history.9,11

Evidence indicates that greater awareness of CRC risk factors and symptoms increases timely care-seeking and participation in preventive screening.¹² Although CRC awareness has been extensively studied in high-income countries, research from Sri Lanka is scarce. A hospital-based study by Wijeratne et al³ reported gaps in treatment adherence and diagnosis timelines, indirectly suggesting low health literacy. While the Bowel Cancer Awareness Measure (BCAM) is widely applied internationally, only a few Sri Lankan studies have used such validated tools.

This study therefore assessed awareness of CRC symptoms and risk factors among adults at the country’s largest tertiary hospital and examined sociodemographic predictors to guide public health education and early detection strategies.

Methods

Study design and setting

A descriptive cross-sectional study was conducted from May 2022 to May 2023 at the National Hospital of Sri Lanka (NHSL), the country’s largest tertiary care institution. The study aimed to assess awareness of CRC symptoms and risk factors among adults attending outpatient clinics and their accompanying visitors.

Study population and sampling

Participants were selected using convenience sampling. Eligible participants were individuals aged 18 years and above who attended NHSL outpatient clinics for non-surgical or gastroenterological conditions, or accompanied patients (eg, family members or friends) during the study period. Individuals presenting with known or suspected gastrointestinal illnesses or malignancies were excluded to reduce bias from prior exposure to CRC-related information.

Sample size calculation

The sample size was calculated using Cochran’s formula for cross-sectional studies, assuming a 50% awareness level (to maximise sample size), a 5% margin of error and a 95% confidence level. This yielded a minimum required sample size of 384 participants.

To account for an anticipated 20% non-response rate, the final target sample size was increased to 600 participants. Of these, 506 completed the questionnaire, resulting in a response rate of 84.3%.

Study instrument

Data were collected using an interviewer-administered questionnaire based on the BCAM developed by Cancer Research UK and University College London, a validated tool designed to assess public awareness of CRC symptoms and risk factors.⁵ The tool included unprompted and prompted questions assessing symptom and risk factor awareness, as well as behavioural intent. It was adapted to the Sri Lankan context through expert consultation and pilot testing. It was translated into Sinhala and reviewed for face and content validity by a panel of oncologists, public health experts and individuals with a history of CRC to ensure cultural relevance and comprehension. The tool was pilot tested among a small sample (n=20) before full-scale data collection to assess clarity, acceptability and internal consistency.

Further details of the participant questionnaire are provided in online supplemental table S1.

Key changes included:

• Risk factor items: Added other risk factors including frequent consumption of deep-fried foods, having hypertension for over 10 years and having a close relative with breast, uterine or ovarian cancer.

• Screening questions: Removed items related to bowel cancer screening, which are not applicable to the Sri Lankan setting due to the absence of a national screening programme.

• Demographic form modifications: Ethnic group categories were expanded for analytical precision, and UK-specific questions (eg, postal code, years living in the UK) were removed. Employment, education and housing categories were localised. A new question on area of residence (urban/suburban/rural) and information sources (eg, TV, doctor, social media) was added.

The questionnaire comprised three sections:

1. Sociodemographic information—Age, sex, ethnicity, education level, employment status, living arrangement and usual mode of transport.

2. Awareness of CRC symptoms—Included one open-ended question to name symptoms without cues (unprompted) and nine closed-ended items to recognise a symptom after being presented with a structured list of options by the interviewer (prompted recognition). Each correct prompted response earned one point; incorrect answers and ‘don’t know’ responses scored zero. The total score ranged from 0 to 9 and negative scoring was not applied.

3. Awareness of CRC risk factors—Included one open-ended question and ten prompted statements. Each correct response (‘agree’ or ‘strongly agree’) earned one point; incorrect (‘disagree’ or ‘strongly disagree’) or ‘not sure’ responses scored zero. The total score ranged from 0 to 10 and negative scoring was not applied.

Awareness scores were categorised into three levels such as poor, fair and good based on thresholds commonly used in previous studies employing the BCAM and similar instruments. For symptom awareness (0–9), the categories were defined as poor (0–2), fair (3–5) and good (6–9). For risk factor awareness (0–10), the categories were poor (0–4), fair (5–8) and good (9–10). These thresholds were adapted from earlier studies conducted in Palestine¹³ and Lebanon,¹⁴ which used similar score-based groupings to classify awareness levels. This categorisation facilitates meaningful interpretation of public awareness and enables comparison with international literature, even though no universal BCAM scoring standard exists.

Data collection procedure

Data were collected by trained medical officers fluent in Sinhala and English. Interviewers received standardised training to ensure consistent administration of the questionnaire and minimise interviewer bias. All interviews were conducted in a private setting to ensure confidentiality and minimise social desirability bias. Participation was voluntary, and informed written consent was obtained from all participants before data collection.

Statistical analysis

Data were analysed using IBM SPSS Statistics V.27. Descriptive statistics summarised participant characteristics and awareness levels. Categorical variables were reported as frequencies and percentages, and continuous variables as means with SD.

Symptom and risk factor awareness scores were treated as continuous outcomes. Their relationship was assessed with Pearson’s correlation. Predictors of awareness were examined using multivariable linear regression with age, gender, education, employment, living arrangement and transport mode entered a priori.

Backward stepwise elimination (p>0.05 for removal) was applied. Model fit was assessed by adjusted R², and results presented as unstandardised coefficients (B), t-values and p-values. Statistical significance was set at p<0.05. As analyses were explanatory, no prediction metrics (eg, calibration or validation) were applied.

Ethics approval

Ethical approval was obtained from the NHSL Ethics Review Committee (Ref: AAJ/ETH/COM/2021/JAN). Written informed consent was obtained from all participants, with administrative clearance from hospital authorities. All procedures adhered to the Declaration of Helsinki.

Patient and public involvement

Patients and members of the public were involved in the adaptation of the BCAM questionnaire to the Sri Lankan context. During the development phase, individuals with a history of CRC and community members provided feedback on the wording, cultural appropriateness and clarity of items in Sinhala. A pilot test with 20 participants from the target population further informed minor modifications to improve comprehension and acceptability. While patients and the public were not involved in the choice of research questions, outcome measures or recruitment, their input contributed to ensuring the tool was relevant and accessible to the study population.

Results

Participant characteristics

Of the 600 invited participants, 506 participants completed the interviewer-administered questionnaire (response rate: 84.3%). The sample comprised 269 males (53.2%). Most were Sinhalese (n=358, 70.8%), married (n=391, 77.3%) and residing in their own homes (n=416, 82.2%). Educational attainment was predominantly at the General Certificate of Education Ordinary Level (n=219, 43.2%) or Advanced Level (n=177, 35.0%). Employment status varied: 209 (41.3%) were employed full-time, 143 (28.3%) part-time or self-employed and 152 (30.0%) were unemployed (table 1).

Table 1. Sociodemographic characteristics of study population.

Characteristic	n	(%)
Gender
Female	237	−46.8
Male	269	−53.2
Ethnicity
Sinhalese	358	−70.8
Tamil	75	−14.8
Muslim	71	−14
Other	2	−0.4
Living arrangements
Own house	416	−82.2
Rented house	74	−14.6
With a relative	14	−2.8
Other	2	−0.4
Marital status
Unmarried	102	−20.2
Married	391	−77.3
Divorced or separated	7	−1.4
Widowed	6	−1.2
Highest level of education
Grade 8	29	−5.7
Ordinary Level (O/Ls)	219	−43.2
Advanced Level (A/Ls)	177	−35
Higher education	81	−16
Area of residence
Urban	290	−57.3
Suburban	159	−31.4
Residential	57	−11.3
Employment status
Full-time	209	−41.3
Part-time	19	−3.8
Self-employed	81	−16
Unemployed	152	−30
Retired	45	−8.9
Usual mode of transport
Own vehicle	224	−44.3
Work vehicle	4	−0.8
Hired	69	−13.6
Public transport	190	−37.5
Bicycle	18	−3.6
Walking	1	−0.2

Awareness of CRC symptoms

When asked to name symptoms without cues (unprompted), 297 participants (58.7%) could not name a single CRC symptom. The most commonly unprompted responses included blood in stools (n=93, 18.4%), abdominal pain (n=55, 10.9%) and constipation (n=49, 9.7%) (table 2).

Table 2. Responses to open-ended question regarding colorectal cancer (CRC) warning signs and symptoms.

Response	n	%
Didn’t recall any symptoms	297	58.7
Alteration of bowel habits	2	0.4
Constipation	49	9.7
Diarrhoea	12	2.4
Abdominal pain	55	10.9
Abdominal distension	8	1.6
Bleeding per rectum	93	18.4
Fever	1	0.2
Symptoms of anaemia	10	2
Loss of appetite	38	7.5
Loss of weight	10	2
Painful defecation	6	1.2
Lump at anus	13	2.6
Dysuria	2	0.4
Dyspepsia	10	2
Back pain	1	0.2
Gynaecological symptoms	2	0.4
Haemorrhoids	3	0.6

When prompted with symptom-related statements, 381 participants (75.3%) recognised blood in stools, and 365 (72.1%) identified bleeding from the back passage as signs of CRC. Other frequently recognised symptoms included unexplained weight loss (n=329, 65.0%) and pain in the back passage (n=311, 61.5%). Persistent abdominal pain had the lowest recognition rate (n=44, 8.7%) (table 3).

Table 3. Responses to the prompted items of colorectal cancer (CRC) warning signs and symptoms.

Prompted item	Yes	(%)	Don’t know	(%)	No	(%)
	n		n		n
Is bleeding from back passage a feature of large bowel cancer?	365	72.1	102	20.2	39	7.7
Is persistent pain in the abdomen a feature of large bowel cancer?	44	8.7	102	20.2	44	8.7
Is a change of bowel habits (diarrhoea, constipation) over weeks a feature of large bowel cancer?	291	57.5	143	28.3	72	14.2
Is feeling bowel is not completely empty a feature of large bowel cancer?	246	48.6	202	39.9	58	11.5
Is blood in your stools a feature of large bowel cancer?	381	75.3	95	18.8	30	5.9
Is pain in your back passage a feature of large bowel cancer?	311	61.5	139	27.5	56	11.5
Is lump in your abdomen a feature of large bowel cancer?	298	58.9	132	26.1	76	15
Is tiredness/anaemia a feature of large bowel cancer?	299	59.1	155	30.6	52	10.3
Is unexplained weight loss a feature of large bowel cancer?	329	65	136	26.9	41	8.1

Figure 1 compares the number of participants who identified symptoms without prompting versus those who correctly recognised them when prompted.

Figure 1. Responses to each symptom in the open-ended question versus the prompted part. This figure shows the number of participants who could recall colorectal cancer (CRC) symptoms spontaneously compared with those who recognised them when prompted.

The mean symptom awareness score was 5.63 (SD=2.55), corresponding to ‘fair’ awareness. Based on score categories, 56.5% (n=286) of participants were classified as having ‘good’ awareness (score 6–9), 31.0% as ‘fair’ (score 3–5) and 12.5% as ‘poor’ (score 0–2).

Awareness of CRC risk factors

Unprompted, 224 participants (44.3%) were unable to name any CRC risk factor. The most frequently recalled unprompted factors included low dietary fibre intake (n=79, 15.6%), alcohol consumption (n = 71, 14.0%) and smoking (n=59, 11.7%) (table 4).

Table 4. Responses to open-ended question regarding colorectal cancer (CRC) risk factors.

Response	n	(%)
Didn’t recall any CRC risk factors	224	44.3
Excessive alcohol	71	14.0
Smoking	59	11.7
Low fruit intake	3	0.6
Excessive deep-fried food	30	5.9
Excessive red meat consumption	10	2.0
Low fibre intake	79	15.6
Being overweight	3	0.6
Older age	2	0.4
Family history	31	6.1

When provided with statements about risk factors, 368 participants (72.8%) agreed that alcohol consumption increases CRC risk, 379 (74.9%) identified frequent consumption of deep-fried foods and 324 (64.0%) recognised low fibre intake as a risk factor. Increasing age was recognised by 208 participants (41.1%). Diabetes was not included in the prompted list. Detailed frequencies for all prompted items are presented in online supplemental table S2.

Figure 2 compares the number of participants who identified risk factors without prompting versus those who correctly recognised them when prompted.

Figure 2. Responses to each risk factor in the open-ended question versus the prompted part. This figure illustrates the contrast between participants’ unprompted recall of colorectal cancer (CRC) risk factors and their recognition after prompting.

The mean risk factor awareness score was 5.47 (SD=2.63), corresponding to ‘fair’ awareness. Based on this score, 178 participants (35.2%) were categorised as having ‘good’ awareness (score 9–10), 208 (41.1%) as ‘fair’ (score 5–8) and 116 (22.9%) as ‘poor’ (score 0–4).

Predictors of awareness

Predictors of symptom awareness

Multivariable linear regression analysis revealed that female gender (B=0.669, p=0.008) and increasing age (B=0.023, p=0.034) were positively associated with higher symptom awareness scores. Conversely, lower educational attainment (B = –0.104, p=0.018) and unemployment (B = –0.175, p=0.045) were significantly associated with lower awareness. Marital status, living arrangement and mode of transport were not significant predictors (table 5).

Table 5. Multivariable linear regression analysis of predictors of colorectal cancer symptom awareness score.

Variable	Unstandardised coefficients (B)	Standardised coefficients (β)	t	Sig.
Age	0.023	0.121	2.122	0.034
Gender (female)	0.669	0.129	2.673	0.008
Ethnic group	0.072	0.020	0.446	0.656
Living arrangement	−0.101	−0.019	−0.430	0.668
Marital status	0.312	0.058	1.091	0.276
Highest level of education	−0.104	−0.110	−2.379	0.018

Predictors of risk factor awareness

Older age (B=0.029, p=0.007), female gender (B=0.559, p=0.028) and living in one’s own home (B=0.569, p=0.021) were positively associated with higher risk factor awareness scores. Marital status, education level, employment status and mode of transport were not significantly associated (table 6).

Table 6. Multivariable linear regression analysis of predictors of colorectal cancer risk factor awareness score.

Variable	Unstandardised coefficients (B)	Standardised coefficients (β)	t	Sig.
Age	0.029	0.156	2.686	0.007
Gender	0.559	0.107	2.199	0.028
Ethnic group	−0.056	−0.016	−0.342	0.732
Living arrangement	0.569	0.106	2.315	0.021
Marital status	0.064	0.012	0.218	0.828
Highest level of education	0.016	0.017	0.363	0.717
Employment status	−0.143	−0.081	−1.627	0.104
Usual mode of transport	−0.133	−0.078	−1.688	0.092

Discussion

This study evaluated public awareness of CRC symptoms and risk factors in a Sri Lankan tertiary care setting and found substantial gaps with important public health implications. Awareness was defined as the ability to recognise CRC symptoms and risk factors either spontaneously (unprompted) or when prompted with a list, rather than deeper medical knowledge or familiarity with screening. This distinction is important to frame results within the survey’s scope.

Unprompted recognition of CRC warning signs was poor: 59% could not name any symptom, and only 18% identified rectal bleeding, though recognition rose to 75% when prompted. This pattern shows low spontaneous recall but higher recognition with cues, resembling findings in other low- and middle-income settings. In rural Malaysia, over 70% of adults failed to recall any symptom unaided, and only 40% recognised ‘blood in stool’.¹⁵ In India, a community study in South Kerala found that the median number of unprompted CRC symptoms or risk factors recalled was only 1.¹⁶ Our findings mirror regional trends of inadequate cancer symptom awareness. As in prior studies, participants recognised overt or widely publicised symptoms (rectal bleeding, altered bowel habits) more readily than subtle ones. Fatigue, unexplained weight loss and anaemia, early signs of CRC, were least recognised. Similarly low awareness of these ‘quiet’ symptoms has been reported elsewhere; for example, fewer than one-third of rural Malaysians recognised weight loss or anaemia even after prompting.¹⁵ Such gaps may delay help-seeking, as individuals often wait for obvious signs like pain or bleeding. Delayed presentation is a well-documented driver of late-stage CRC diagnoses.^{7 8} Public campaigns must therefore highlight all warning signs, not only dramatic ones, to enable earlier detection.

Knowledge of risk factors was also limited, particularly for modifiable behaviours. Nearly half of respondents could not name a single risk factor unprompted. Even when prompted, awareness was uneven: while most recognised excessive alcohol use and low dietary fibre, fewer identified inactivity, obesity or red meat intake as risks. Comparable deficits have been observed in Lebanon (83% unaware of CRC risk factors)¹⁴ and a Palestinian,¹³ underscoring the global nature of this problem. In contrast, non-modifiable factors (age, family history) were more widely recognised. This pattern suggests cancer is often perceived as genetic or ‘fate-driven’, with less appreciation of lifestyle influences. Similar misconceptions have been described elsewhere, even among high-risk groups.¹² Misperceptions may reduce motivation for preventive lifestyle changes. A limitation of our tool was including ‘long-term hypertension’ as a risk factor, which some respondents incorrectly endorsed, reflecting a tendency to link chronic illness broadly with cancer. This underscores the need for clearer public education on true CRC risks to dispel myths.

Certain demographic groups showed lower awareness, highlighting socioeconomic and educational disparities. In regression analyses, men, those with less education and the unemployed had lower scores. Similar trends are reported globally, with awareness higher among educated and economically advantaged groups.^{13 14} A rural Malaysian study found post-secondary education strongly predicted awareness,¹⁵ while a Palestinian survey noted men had lower odds of good symptom awareness.¹³ However, gender patterns vary; an Indian study reported the opposite, possibly due to cultural or access differences. In Sri Lanka, women may gain incidental exposure through family health services or breast/cervical cancer programmes. Unexpectedly, younger adults had lower awareness than older participants, unlike some international studies.¹⁵ This may reflect sample context: older attendees had more illness exposure or healthcare contact, while younger visitors may have been healthier companions with less personal interest. These findings suggest campaigns should target men, young adults and socioeconomically disadvantaged groups.

Sri Lanka lacks universal CRC screening, and cancers are often diagnosed symptomatically. Low public awareness risks delayed presentation and poorer survival (90% in localised vs <15% in metastatic disease).¹⁷ In Malaysia, 65% present at Stage III–IV, partly due to poor awareness.¹⁵ Without action, Sri Lanka may face similar patterns. Yet awareness is modifiable: Malaysia’s ‘Be Cancer Alert’ campaign significantly improved symptom recognition.¹⁸ While it did not immediately increase screening uptake, it demonstrated that education is feasible at scale. Sri Lanka could adapt similar culturally tailored, multiplatform campaigns using simple Sinhala/Tamil materials, pictorial aids and trusted community messengers. Efforts should especially engage men and younger adults, for example, through workplaces, sports or social networks.

This study has several strengths, including the use of a validated and culturally adapted questionnaire (the BCAM) to systematically measure CRC awareness to the authors’ knowledge, the first such study in the Sri Lankan context and a relatively large sample size for a survey of this nature (>500 participants). The combination of open-ended and prompted questions provided a nuanced assessment of both spontaneous recall and recognition ability. However, we also acknowledge important limitations. The sample was drawn from outpatient clinics of a single large hospital using convenience sampling, which introduces potential selection bias. Attendees at a tertiary hospital (and their accompanying family members) might be more health-conscious or have greater exposure to health information than the general population. For instance, simply being in a hospital environment or visiting an ailing relative could increase one’s awareness of health issues. This means our results could overestimate the true population awareness of CRC; rural and less-connected communities might have even lower awareness than what we observed. Additionally, those who declined to participate (approximately 16% of approached individuals) might systematically differ from participants; if non-responders were less interested in health topics, their exclusion could also inflate the measured awareness levels. In short, our findings may represent a ‘best-case scenario’ for Sri Lankan public awareness, and the reality in the broader population is likely worse. Another limitation is that causality cannot be inferred due to the cross-sectional design. For example, while we found associations between education and awareness, we cannot prove that improving education alone would raise CRC awareness, even though it’s a reasonable assumption. Finally, our study did not encompass an evaluation of behavioural outcomes; we do not know if those who were aware of symptoms actually sought care earlier. Future research could build on this by linking awareness levels to stages at diagnosis or uptake of any screening when available.

Despite these caveats, our study provides timely and policy-relevant insights. With CRC incidence rising in Sri Lanka, there is an urgent need to integrate cancer awareness into national non-communicable disease control strategies. We recommend that Sri Lanka’s healthcare planners develop targeted interventions (possibly a national CRC awareness campaign similar to those for breast and cervical cancers) to improve public understanding of CRC. Such efforts should involve patients and survivors as partners in spreading awareness, leveraging personal stories to make the risks and symptoms more relatable. In the absence of universal screening, educating the public is our main tool to promote early detection. In parallel, it would be prudent for Sri Lanka to explore the feasibility of introducing opportunistic screening, for example, faecal occult blood testing in primary care for older adults; public awareness campaigns now could also improve the acceptance and uptake of any screening programme should one be launched. In conclusion, addressing the gaps identified in this study is critical. Raising awareness of CRC symptoms and risk factors can empower the population to seek timely medical advice, potentially shift diagnoses to earlier stages, and ultimately improve CRC outcomes in Sri Lanka.

Conclusion

As the first Sri Lankan study to apply a validated, internationally benchmarked CRC awareness tool (BCAM), this work demonstrates critically low levels of unprompted awareness of CRC symptoms and risk factors among adults at the country’s largest tertiary hospital, reflecting wider community health literacy gaps. Although prompted awareness was higher, many individuals may not recognise early warning signs without cues, risking delays in help-seeking and diagnosis. Disparities by age, gender and education emphasise the need for targeted communication strategies.

In the absence of a universal CRC screening programme in Sri Lanka, public awareness serves as a form of primary prevention, enabling earlier recognition and care-seeking. Integrating CRC literacy into national Non-Communicable Disorders (NCD) programmes and community health promotion offers a low-cost, high-yield strategy to encourage earlier detection and reduce disease burden. Future policies should prioritise awareness-building as a cornerstone of cancer control in resource-limited settings like Sri Lanka.

Data availability statement

Data are available upon reasonable request.