Access, Affordability, and Willingness to Undergo Screening Colonoscopy in a Low- and Middle-Income Country-A Cross-sectional Study From Sri Lanka

BACKGROUND: Colorectal cancer (CRC) incidence is rising rapidly across low- and middle-income countries (LMICs), yet most lack organised screening programmes. While colonoscopy is the diagnostic gold standard, its uptake depends not only on service availability but also on behavioural perceptions and health system design. Sri Lanka, an LMIC with a strong public health system but no national CRC screening programme, provides a relevant policy setting to examine these dynamics. METHODS: A cross-sectional survey of 500 adults at the National Hospital of Sri Lanka assessed willingness to undergo screening colonoscopy. Sociodemographics, CRC-related knowledge, perceptions of benefit/harm, and cost considerations were evaluated using non-parametric tests and multivariable logistic regression. RESULTS: Overall, 69.7% of participants were willing to undergo colonoscopy if recommended by a doctor; however, 42.7% would do so only if the procedure were free. Willingness was independently associated with belief that early detection improves outcomes (adjusted Odds Rate (aOR) 2.96, 95% confidence interval [CI] 1.94-4.53, p < 0.001) and fear of CRC (aOR 1.72, 95% CI 1.13-2.61, p = 0.012). Misconceptions about colonoscopy-related harm and fear of cancer diagnosis significantly reduced acceptance. Sociodemographic variables, education level, prior colonoscopy experience, and insurance status were not independently associated with willingness. Cost-related conditional willingness highlights substantial access barriers despite high stated acceptability. CONCLUSIONS: Among the variables examined, perceived benefit and affordability were important correlates of stated screening acceptability, while sociodemographic characteristics were not independently associated. Implementation requires strategies addressing affordability, capacity, and perceptions. A phased, publicly financed programme incorporating non-invasive testing and targeted communication may provide a feasible pathway for LMICs.