Awareness and uptake of colorectal cancer screening after Healthier-SG launch: A questionnaire survey

Dear Editor,

Colorectal cancer (CRC) is one of the most common malignancies in high-income countries.¹ Despite Singapore’s well-established cancer screening infrastructure, uptake remains below target. Early detection through screening is crucial for improving outcomes, yet many eligible individuals remain unscreened.² In July 2023, the Ministry of Health launched Healthier-SG, a national preventive health initiative encouraging residents aged 40 years and above to take charge of their health. CRC screening using the faecal immunochemical test (FIT) was emphasised for adults aged 50 years and above, with free FIT kits distributed through primary care clinics, community pharmacies and the Singapore Cancer Society.

To assess the impact of this initiative, we conducted a community-based, cross-sectional questionnaire survey in March 2024 among residents aged 50 to 85 years at a public multipurpose complex in Bedok, Singapore. The site was selected due to its high footfall of 280,000 to 300,000 per month and accessibility to residents from diverse socioeconomic backgrounds.³ Using a case-encounter sampling approach, participants were invited to complete an anonymised electronic survey in English. Demographics, awareness of CRC and its screening, history of CRC screening and reasons for participation or non-participation were collected.

A total of 350 participants were recruited. Table 1 below shows most participants were female (60.3%), of Chinese ethnicity (92.0%) and residents of public housing (76.9%). The majority (89.4%) were aware of CRC, and 84.6% were aware of available CRC screening. Overall, 65.1% reported having undergone screening, most commonly through FIT kits (47.4%) or colonoscopy (38.2%). Among those screened, key motivators included routine health checks (41.7%) and recommendations by healthcare professionals (25.0%). Among non-screeners, the primary reason cited was absence of symptoms (47.5%), followed by a lack of awareness about the test (19.7%).

Table 1. Participant characteristics.

Further analysis using Poisson regression revealed that participants who were aware of CRC screening were over 8 times more likely to have been screened than those who were unaware (adjusted prevalence ratio: 8.489, 95% confidence interval 3.085–23.363, P<0.001).⁴ In contrast, demographic variables, such as sex, education level, income proxy or medical subsidy status, were not significantly associated with screening uptake.

These findings suggest a notable increase in CRC screening compared to national statistics prior to Healthier-SG. According to the National Population Health Survey 2022, only 38.1% of residents aged 50 to 74 years had undergone CRC screening at recommended intervals.⁵ The observed rise to 65.1% in our study likely reflects a combination of enhanced public awareness, stronger engagement by healthcare providers and increased accessibility to free FIT kits. Nevertheless, this level remains below the 70% target commonly cited for effective population-level cancer screening.

Importantly, the gap between awareness and action highlights unresolved misconceptions and behavioural barriers. Many participants who had not undergone screening believed it was unnecessary in the absence of symptoms.⁶ This misunderstanding of the merits of screening undermines the concept of preventive care. CRC screening aims to detect early-stage disease or pre-cancerous lesions before symptoms appear, improving treatment success and reducing mortality. Patient education efforts must therefore address this misconception by reinforcing the value of asymptomatic screening.

Healthcare professionals, particularly family doctors and polyclinic physicians, have a vital role in closing this awareness–action gap. Our findings reinforce evidence from prior local and regional studies showing that primary care physician’s recommendation is a powerful motivator for screening.^7,8 Under the national Healthier-SG programme, primary care professionals, including general practitioners, polyclinic physicians and community nurses, are now tasked with building long-term, preventive-focused relationships with patients. They are at the frontline to routinely initiate conversations about CRC screening, clarify doubts and align test options with individual preferences.

To support these efforts, decision aids and digital tools are under development. A locally designed patient decision aid tailored to Singapore’s diverse population has shown promise in raising awareness and facilitating informed choices.⁹ However, its current print-only format limits scalability. Efforts are underway to develop artificial intelligence agents or mobile applications with interactive features and built-in reminders in smart phones to encourage regular annual screening. Such digital health interventions could be particularly useful to complement personal approaches by primary care professionals to nudge at-risk adults to screen for CRC.

Aside from personal interventions, logistical challenges persist. Only 19.7% of those screened obtained FIT kits from community pharmacies, suggesting the underutilisation of this distribution channel. Innovative delivery methods, such as self-serve kiosks at community hubs or direct-to-home mailing of FIT kits, may help address this gap. Pilot testing of a kiosk has begun, and further research will be needed to assess their effectiveness, feasibility and user experience.

This study has several limitations. The case-encounter sampling method may introduce selection bias, and the participant pool overrepresented Chinese residents (92.0%) relative to the national population aged 50 to 85 years. Additionally, data were self-reported and not independently verified, raising the possibility of recall bias or social desirability bias. Nevertheless, the study provides timely community-level insights into CRC screening behaviour in the early months of the Healthier-SG rollout.

In conclusion, CRC screening awareness and uptake have improved substantially following the launch of Healthier-SG, indicating that national preventive strategies may be making an impact. However, gaps remain, particularly among asymptomatic individuals who remain unconvinced of the need for screening. To increase the CRC screening uptake beyond 70% for the successful implementation of a nationwide preventive health programme, future efforts should prioritise patient education, reinforce the role of trusted healthcare professionals, and expand access for the convenient collection of FIT kits. With coordinated action across primary care, public health and community platforms, Singapore can move closer to its goal of effective CRC prevention for its adult population.

Acknowledgements

The study team would like to acknowledge Singapore Cancer Society for funding the study; SingHealth Polyclinics Centre Grant by the National Medical Research Council for supporting the publication; Jessica Koh and Vincent Chia for their kind support and approval to use a location within Heartbeat@Bedok to implement the study; Patricia T Kin, Caris Tan, Usha Sankari and other administrators in the SingHealth Polyclinics Research department for supporting the logistics, procurement, ethics approval and data management; and Satyakala D/O Raj Kapoor and Janice Cheng Shu Hui for contributing to the manuscript.

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