Background 

Colorectal cancer (CRC) incidence and mortality are increasing in many low- and middle-income countries (LMICs), driven by epidemiological transitions and growing exposure to modifiable risk factors such as unhealthy diets, physical inactivity, excess body weight, and chronic stress. In LMIC settings, preventive strategies are often constrained by fragmented health systems, social inequalities and limited access to clear, actionable health information. Health literacy plays a critical role in enabling individuals and communities to understand lifestyle-related cancer prevention messages and to engage with available preventive services. However, health literacy is rarely operationalised as a measurable quality dimension within CRC prevention strategies in LMICs, where communication barriers and contextual constraints may amplify preventable cancer risk. 

Objectives 

To explore how health literacy can be operationalised as a quality dimension within lifestyle-based colorectal cancer prevention in LMICs, and to propose context-sensitive indicators applicable to vulnerable settings. 

Methods 

This study draws on work developed within an international cancer prevention quality assurance scheme (QAS JRC ECICC) and applies it to LMIC contexts. A systematic review was conducted to identifyQI regarding stool sample collection. 

Building on this body of evidence, we will further explore how included studies conceptualise and report health literacy–related concepts, measures and practices relevant to colorectal cancer prevention in LMICs, with a particular focus on diet, nutrition, physical activity, body composition and other lifestyle-related exposures. 

A mapping approach will be applied using the Health Literacy Responsiveness (HLR) Framework across the CRC prevention pathway, adapted to reflect LMIC health system characteristics, including primary care–based prevention, community outreach and resource-constrained settings. Potential indicators will be selected and qualitatively assess by a multidisciplinary expert group for contextual relevance, feasibility and sensitivity to change in LMIC environments. 

Results 

Fifty-one studies were included from the systematic review. Evidence from the literature is currently being reviewed and mapped using the adapted HLR Framework. QIs assessments are ongoing. Preliminary findings will be available at the time of the conference. QIs proposal will consider existing but limited evidence suggesting potential benefits of health literacy–adapted lifestyle communication in LMIC settings. Given the scarcity of long-term outcome data, particularly on CRC incidence reduction, the adapted HLR Framework will be applied to structure and document assumptions related to community engagement, information accessibility, and system-level support. 

Implications for practice or policy
Health literacy remains an underutilised quality dimension in lifestyle-based colorectal cancer prevention in LMICs. Developing context-sensitive health literacy indicators can support more equitable and effective communication of modifiable risk factors, strengthen prevention efforts within primary care and community settings, and contribute to reducing the growing CRC burden in LMICs.