Development and Validation of the Health Belief Model Scale

Introduction, Background and Research Context

Colorectal cancer (CRC) is a common fatal disease with no clear consensus on the cause (Siegel et al., 2020). According to Siegel et al., (2020) both men and women are susceptible to colon cancer. (CRC) is considered a primary disease which is gradually increasing in developed countries. This is due to the lifestyle and other modifiable risk factors, such as obesity, tobacco use, consumption of processed and red meat, and alcohol ingestion (Al-Zalabani, 2020). One third of the population in the United States die each year because of such risk factors (Yarbro et al, 2018). The correlation between diet and cancer has baffled researchers for decades. Scientist have investigated the positive impacts related to micronutrients (vitamins and minerals) and macronutrients (proteins, fats, carbohydrates) in (CRC). Results have shown these factors can help to reduce the incidence of (CRC) (Yarbro et al, 2018). A recent study conducted in Saudi Arabia showed the largest factor increasing the nrisk of (CRC) was an unhealthy diet consisting of processed and red meat (Al-Zalabani, 2020). Moreover, the risk decreases with consuming a sufficient healthy diet including fruits and vegetables (Al-Zalabani, 2020). A cross-sectional study was conducted in Madinah, Saudi Arabia, 385 participants were recruited to evaluate population knowledge pertaining to (CRC) disease and its risk factors. In an effort to improve awareness, a questionnaire was provided which included eight risk factors: eating red meat daily, sex, physical activities, smoking, eating fruits and vegetable regularly, and do you have history of inflammatory bowel disease and/or does any immediate family member have a history of (CRC)? (Almalki et al., 2020). The final result of the study showed 65% of them were males, 44.2% were 18–29 years old, and 54% an undergraduate. furthermore, Participant’s knowledge about CRC risk factors of eating red meat was 15.10%, which correlates with the incident that daily eating red meat consider one of the most common risk factors among Madinah population with 61.5%(n=237) (Almalki et al., 2020). lack of eating fruits and vegetables regularly was 49.3% (n=190) as a third factor (Almalki et al., 2020). Research has shown that a healthy diet can prevent the incidence of (CRC). As a result of this finding, it is recommended to educate Saudis pertaining to the importance of a healthy diet through educational programs. Such education programs would include topics that relate to a modifiable risk factor of unhealthy diets such as processed and red meat and low consumption of whole grains (Al-zalabani, 2020).

Health Beliefs and diet

There are many relevant studies conducted to limit the unpleasure outcome of dietary habits by predicting and changing health behaviours. One of them is to explore the population awareness by seeking and assessing their health behavior. There has been a relationship between healthy behavior performance and a variety of health outcomes for more than 40 years (Conner & Norman, 2015). For example, a qualitative study was conducted in French pregnant women. The researchers observed nutrition awareness raised by receiving nutrition-related information obtained from healthcare providers. The material was based on assessing and better understanding of the determinants of eating behavior by focusing on their concerns, attitudes and belief (Bianchi et al., 2016). Furthermore, theory of planned behavior was utilized to draw out Canadian adult population salient beliefs regarding milk and cheese consumption. This resulted in optimize approaches for promoting consumption of these foods among Canadian adults through understanding health beliefs. Based on these findings, a future social marketing campaign will be formed to contribute to improving the health of Canadians (Lacroix et al., 2016). A qualitative study in migrant African women with gestational diabetes living in Sweden was conducted related to developing beliefs for health, illness and healthcare. This study indicated the existence of low-risk awareness, limited knowledge and irrelevant worries about future health of Gestational diabetes (Hjelm et al., 2018). Moreover, it showed that health professionals beliefs related to the seriousness of Gestational diabetes is influenced patients’ beliefs and health-related behavior (Hjelm et al., 2018).

Saudi Arabia has a study investigating the implementation of dietary guidelines and the adoption healthy eating among Saudi adults (Hazam, 2018). Theory of Planned Behavior is a conceptual framework used to explain and understand important factors affecting healthy eating among Saudi adults: intention, attitude, Perceived Behavioral Control and subjective norms. in this study, 467 participants were selected as without-chronic illness, majority of them were young from (18-30), and 60.1% was female, The results helped design effective educational interventions to increase healthy eating intake among the Saudi population and recommended to Understanding the factors that influence healthy eating behavior (Hazam, 2018). Saudis’ health attitudes and behaviors examined in the context of health consciousness and it is illustrated Saudis’ health understanding is based on a broad range of cultural domains, their health behavior is influenced by personal, social, environmental, and economic factors. Saudis’ awareness not fully developed and that explains their tendency to uphold risky behaviours (Leenah Iskandarani, 2021). The author advised to conduct more qualitative studies on factors effecting Saudis population to adhere and compliance health behaviors, that would be helpful to fill in the knowledge gap in health eating (Leenah Iskandarani, 2021).

Health Belfies Model

The health beliefs model (HBM) has been widely used in Saudi Arabia. The model includes predicting barriers of Cervical Cancer Screening, knowledge, attitude, and practices towards diabetes mellitus in the Saudis population or predict breast self-examination among Saudi women (Alrashed et al., 2020). The studies recommended implementing a strong educational program based on effective measures taken (Alrashed et al., 2020). A national wide survey that utilized a health belief model was conducted in 2020 G Riyadh, Saudi Arabia to assess behavior and attitudes as well as the knowledge about and intent to undergo CRC screening (Almadi & Alghamdi, 2019). This was performed to fill the gap between knowledge and undergoing (CRC) screening (Almadi & Alghamdi, 2019). The study indicated the existence of a gap between accepting screening and proceed the procedure (Almadi & Alghamdi, 2019). Multiple factors other than knowledge, we believe that this represents an opportunity to borrow concepts from behavior, and beliefs (Almadi & Alghamdi, 2019). despite the importance and effectiveness of (HBM), there is a lack of validated Arabic scales that help the researchers to assess the HBM in colon cancer toward diet.

Health Beliefs, Diet and (CRC)

By searching and based on relation between diet awareness and colorectal cancer I found that Saudi Arabia has not performed a study for the Saudi population related to awareness of diet as a risk factor in increasing (CRC) incidences that measuring Saudis beliefs of such a correlation. For instance, in Western countries, the American Institution of Cancer Research recommends a reduction of (CRC) incidence by including behavioral changes (Schaberg et al., 2020). The researcher indicated a necessary awareness of colon cancer risk factors (Schaberg et al., 2020). They found adults are unwilling to adjust their dietary patterns and could not understand how the benefits of engaging in a health behavior can influence whether an individual will seek changes. As a result, the author utilizes (HBM) to assess attitudes and beliefs related to (CRC) risk and diet behavior in US adults. The findings of study indicated health beliefs toward (CRC) risk are influenced by an individual’s age and dietary habits (Schaberg et al., 2020).

So a fortiori, it is necessary to seek people’s awareness pertaining to diet as a (CRC) risk factor by measuring their perception. Additionally, in the Al Hassa region of Saudi Arabia, a cross-sectional study recommended that the Perceived barriers perception should be addressed prior to the implementation of (CRC) screening. (Galal et al., 2016).

Definition of Term

A.5.1. Health Belief Model: Is a psychological framework used for analyzing behavior change among different individuals by studying their reasoning characteristics in order to predict their health-related behaviors (Conner & Norman, 2015). In term of this study, health belief model refers to a person’s belief in a personal threat of a certain illness or disease accompanied with that person’s belief in the effectiveness of the recommended health behavior will predict the chance the person will adopt the behavior.

A.5.2. Colorectal Cancer: Combined in the term “colorectal cancer,” a series of mutations occurs in the epithelial cells of the colonic and rectal mucosa to the formation of an adenoma on the mucosal surface. The Stage is determined by the depth of penetration of the tumor into and through the intestinal wall, involvement of contiguous organs, the number of regional lymph nodes involved, and the presence or absence of distant metastases (Yarbro et al, 2018).

A.5.3. Saudis’ Belief: Pertains to religion and cultural traditions play a large role in the healthy and unhealthy beliefs of Saudis peoples and additionally some other factor can influence Saudis’ Belief in general not only related to their diet (L Iskandarani, 2021).

A.5.4. Saudi’s Dietary habits: Saudis’ diets do not follow the guidelines for healthy diets. Their study was conducted to describe the consumption of foods and beverages by Saudi adults. The National Nutrition Survey ranked Saudi Arabia as number 15 worldwide for its prevalence of obesity, with an overall obesity rate of 33.7% [7]. Obesity and unhealthy dietary pattern have been associated with an increased risk of various health problems (A. Jalloun & B. El Shikieri, 2021).

Literature Review

49 Quantitative and qualitative articles were obtained from the electronic databases PubMed, google scholar, Saudi digital library, PMC, and Web of Science. The obtained articles were published between 2015 and 2020. The following terms were used when we allocate the articles: “dietary habits or diet”, “CRC”, “health beliefs”, “HBM, health beliefs”, “perception, awareness” and Saudi Arabia, the Boolean operators “AND” to annex the search terms related to the search purpose of the study. Considering the research question and the aim of the study, we focus on the human studies as an inclusion criterion. Other criteria for the research include dietary habits, colorectal cancer and awareness. Moreover, these studies were written in English. As a result of these criteria, the retrieved numbers of articles were 28.

Existing Empirical Literature

The measurements are not limited to (HBM). As previously mentioned, there are many theoretical frameworks that can be used to assess Saudis perception toward diet as a risk factor of (CRC) incidence. Davis et al., (2015) suggested that behavioral theories are plentiful in fathoming perceptions owning to their focus on behavioral pattern related to issues such as bad dietary habits (Davis et al., 2015). These theories caused vigilant Saudis to act in certain way or produce healthy dietary habits to reduce the impact of colon cancer issues. The health behaviour theories were used to predict of the performance of health behaviors include: Protection motivation theory (PMT). (PMT) describes adaptive and maladaptive responses to a health threat (Conner & Norman, 2015). The theory of planned behavior (TPB). The Intentions represent a person’s motivation in their conscious decision to perform that behavior(Conner & Norman, 2015). Social cognitive theory; the individual’s motivation is based upon three types of expectancies which are “situation outcome, action outcome and perceived self-efficacy”(Conner & Norman, 2015). Health locus of control (HLC) theory is used to predict behavior occurring in a given situation is related to the individual’s expectancy that the behavior will lead to a particular reinforcement. The theory of health beliefs model which will guide our study (Conner & Norman, 2015).

The (HBM) has been considered as a useful theoretical framework for investigators to determinant a wide range more than 30 years in behaviors patterns from health enhancing behavior such as healthy eating and exercise participation to avoidness of health-harm behaviour such as smoking (Abraham & Sheeran, 2014).The model has inspired researchers to develop interventions found as to be effective in changing health behavior However, there was no validated scale that is written in Arabic to assess Saudis perception toward diet as a risk factor of CRC(Conner & Norman, 2015). Therefore, filling this gap in literature will be the purpose of our research. The aim of study is to translate, modify and validate a scale that is specific to the Saudis culture. Thus, Arabic Construction of a validated scale that is translated into Arabic will help researchers investigate the concerns relating diet as a risk factor of (CRC) through use of the Health Belief Model (HBM). Furthermore, health belief constructs have been shown to be effective in many recent studies related to reducing the incidence of cancer. Some examples are applying health promotions such as cervical cancer screening behaviors among American Indian women regarding the relative benefits to the barriers of receiving preventive health services (Lee et al., 2020), colonoscopy screening behavior in China which resulted in the suggestion to examine cultural beliefs in future studies (Bai et al., 2020), and using predictive effects of health beliefs toward prostate cancer screening among Nigerian immigrant men in U.S. (Ekeh, 2020).

In 2018, a study was conducted to map validity of health belief model variables in predicting behavioral change. All results showed that (HBM) variables are consistently related to health behavior (Sulat et al., 2018). Moreover, a scoping review showed empirical evidence supporting the use of the Health Beliefs Model constructs in contributing to predict individuals’ health behaviors (Sulat et al., 2018). A randomized controlled trial initiated for postpartum Japan women indicates beneficial effects of individual dietary intervention based on HBM (Shiraishi et al., 2021).

A recent study about theoretically designed interventions in Thran region, Shahid Beheshti University, for colorectal cancer prevention showed an effectiveness regarding implementation of educational intervention based on health belief model for personnel. Additionally, it was shown to enhance the preventative health behaviors related to colorectal cancer (Rakhshanderou et al., 2020).

(HBM) is a composite of psychological models provided to illustrate individual characteristics related to health behavior patterns. These patterns help to identify health prevention behaviors (Abraham & Sheeran, 2014)The (HBM) consisted of perceived susceptibility (possibility of getting ill and involving awareness that a health threat exists); perceived severity (involving both the medical severity of a disease and the associated psychosocial severity); perceived benefit (comprises both medical and psychosocial benefits of engaging in health-promoting behaviors); perceived barrier(comprises practical barriers to performing the behavior); and cues to action (included a diverse range of triggers) (Abraham & Sheeran, 2014)The (HBM) is one of the psychological frameworks used for analyzing behavior change among different individuals by studying their reasoning characteristics in order to predict their health-related behaviors.

Accordingly, this model could be applied in studying Saudis’ perception of the risk of unhealthy diet since its constructs foster a clear comprehension of the psychological tendencies of different individuals that influences their behavior in response to various stimuli. The theoretical constructs of the (HBM) theory that can be applied in this case include self-efficacy, perceived benefits, perceived barriers, perceived susceptibility, perceived severity, modifying variables, cues to action, and general security orientation as described below.

Perceived Barriers

Perceived barriers also comprise another concept of the (HBM) model. It informs people’s health related behaviors. Perceived barriers entail a person’s assessment of the various hindrances that deter them from changing their health behaviors. According to the (HBM) model, certain barriers such as emotional disturbance or pain may hinder a person from engaging in a health-promoting behavior that is perceived to be of significance resulting in positive health outcomes (Djatsa, 2019). It may be influential in predicting Saudis perception of the risk relating to an unhealthy diet as a risk factor of (CRC). Consequently, these perceived barriers of unhealthy diet negatively impact on Saudi’ perceptions on the risk of it.

Perceived Susceptibility

The HBM’s concept of perceived susceptibility can be used in studying and predicting Saudis’ perception of the risk of unhealthy diet among themselves. Perceived susceptibility implies one’s assessment of their subjective risk of suffering a health issue. In this case, people who perceive themselves to be highly susceptible to certain health conditions are highly likely to modify their behaviors and embrace health-promoting ones with a view to mitigate their susceptibility to suffering from the health issue (Osta et al., 2018; Sulat et al., 2018). On the other hand, individuals who believe that they are less susceptible to suffering from various health conditions are highly likely to adopt risky or unhealthy health behaviors. In accordance with this concept, Saudis’ perception regarding the risk of healthy diet is pegged on their assessment of the susceptibility of their health to experiencing health issues. Individuals who perceive their health to be highly susceptible to colon cancer are likely to embrace change their diet. Therefore, individuals’ perceived susceptibility to the risk of unhealthy diet is positively related to their regulation of their diet habits.

Perceived Severity

The (HBM) model is also based on the concept of perceived severity that informs individual health-related behaviors and can be used to study Saudis’ perception of the risk of their unhealthy diet. An individual who perceives a health condition to be severe may readily embrace health-promoting behaviors. Similarly, an individual who perceives the risks an unhealthy diet has severe consequences on their colons will be motivated to embrace healthy diet measures as opposed to one who perceives the risk to be low. Hence, HBM’s concept of perceived diet is positively related to Saudis behavior (Osta et al., 2018; Sulat et al., 2018).

Cues to Action

Cues to action is another HBM’s concept that can be used to evaluate Saudis’ perception regarding unhealthy diet. Schaffer and Debb (2019) maintain that stimuli are imperative to promoting a person’s decision to engage in health-promoting behaviors. External triggers often influence health-related behaviors in diverse dimensions. For example, a person’s experience with an individual suffering from a particular ailment may motivate them to adopt health-promoting behaviors that would prevent them from similar suffering (Hanus et al., 2015).

In the case of Saudis’ perception regarding the risk of unhealthy diet as a risk factor of (CRC), external triggers such as diet awareness campaigns may influence their perceptions p. Particularly, an individual who is aware of the health risks that are associated with unhealthy diet may be prompted to embrace diet measures to protect his or health against (CRC). On the contrary, an individual who is less aware of risks surrounding un healthy diet is less likely to adopt new healthy eating habit behaviors. Therefore, cues to action positively relates to Saudis’ perception of the risk of unhealthy diet.

Significance of the Study

Validating translated instruments of (HBM) in Arabic is very important. First, from a practitioner standpoint, is very well known that prevention is better than cure. Using the prevention approach will help to reduce (CRC) incidence in Saudi Arabia. Therefore, this research will contribute to literature about the factors that influence Saudis perceptions toward diet as a risk factor of (CRC) incidence. Accordingly, future researchers will be able to utilize the translated validated instruments of (HBM) to better gain insight of what factors practitioners need to focus on when running campaigns that targeting the initiative toward health diet in Saudi Arabia.

Research Questions

Answer the following research questions:

1. Is the translated health belief model scale valid in Saudi population?
2. Is demographic variable show a difference in their health beliefs in this pilot study?

Summary

The (HBM) is a sufficient theoretical framework for investigators of the cognitive determinants of numerous behaviors such as unhealthy habits. Health belief model includes common-sense constructs that are easy for non-psychologists to operationalize in self-report questionnaires. It provided scientists’ attention on modifiable psychological determinants of behavior. Therefore, the model is a good fit to the problem of diet. Moreover, it can consider an educational opportunity to teach Saudis about the predeterminants of cancer.

Methods

The central methodological approach underlying this study was a pilot study designed to test the feasibility of using a translated survey questionnaire to identify patterns of interest among the sample. In particular, since the research question was an attempt to determine the Saudis perception regarding the relationship of dietary habits to colorectal cancer risk, the survey method was an integral part of the current study. However, as noted in the literature review, a gap was identified among the sources in the availability of a valid questionnaire scale to determine the patterns of interest. For this reason, it was necessary to develop our own scale or modify an existing scale in order to determine its validity, relevance, and relevance to the stated topic. The reason for not creating a proprietary scale was to save resources and time spent on this study. Thus, I decided to use an off-the-shelf questionnaire modified for the specifics of the current study.

A thorough search among academic sources for the given criteria led to an article by Smith et al. (2019), which evaluated the relationship between respondents’ eating habits and expected health outcomes. More specifically, the outcome of this study was to prove the validity of the (DHCCBS) questionnaire to produce results on assessing the relationship between variables. Since the (DHCCBS) questionnaire did show reliability and validity for measuring precisely the patterns that its developers intended, so decided to use this material for a pilot test for a sample of Saudis. It is emphasized that the use of the specific questionnaire in the current study was implemented only with the full consent of the authors of the original article. Smith et al. were fully informed of the goals of the current study and the methodological steps that will be used to modify the original scale.

Several key assumptions were made to ensure that this extrapolation would be valid. In particular, it is assumed that if the (DHCCBS) questionnaire were effective for measuring among U.S. respondents, it would also prove useful for a study aimed at measuring (HBM) patterns for Saudi population. In addition, it is assumed that translating this article into Arabic does not change the contextual meaning of the questions, thus preserving the validity of the survey questionnaire. It is also assumed that the sample for the current study is thoroughly familiar with the terms used in the questionnaire and has no difficulty interpreting them semantically. Finally, the primary assumption was that if the pilot study being initiated shows the expected results, then extrapolation to a larger sample, constructed according to the principles of representativeness of the Saudi Arabian general population, would retain validity.

Pilot Study

The design of this research project is based on the principle of a pilot test that will be able to confirm or refute the prospects of using the modified (DHCCBS) questionnaire for Saudi population. The pilot test was necessary because the potentially broad results of the study itself are of profound importance to the public health industry, and thus the academic responsibility for the published material is critically high. In addition, as stated, Saudi Arabia does not yet have a survey scale of its own, which means that the use of foreign material must be not only motivated but also scientifically sound. Thus, pilot testing on a small sample was a necessary step that would qualitatively improve the reliability of the (DHCCBS) extrapolation. In addition, because the use of the scale is a first for Saudi patients, pilot testing was a necessary step to verify the validity, especially in the public health industry, whose findings are critical to society (Gause et al., 2018).

It is essential to clarify that the pilot test cannot be conducted to test the stated hypotheses and find answers to research questions since this is not the intended mission of this approach. Nevertheless, the pilot test will identify fundamental limitations and errors that should be neutralized in the further stages of the research development. Subsequently, these assumptions and corrections will improve the quality of the scale used for a broader study, first for a Saudi population and then, if necessary, for a broader sample, such as the Gulf regions (Joseph et al., 2016).

Research Design

The methodological basis for this study is based on a mixed-methods approach, using both qualitative and quantitative techniques to elicit responses. If the pilot test shows high validity using the (DHCCBS), subsequent phases should focus on evaluating research hypotheses and seeking answers to the research questions posed. Thus, post-pilot studies are expected to seek both qualitative and quantitative answers. From a qualitative perspective, the answers will shed light on the potential relationship between perceptions of dietary habits and patterns associated with the development of colorectal cancer. From a quantitative methodology, DHCCBS will assess numerical trends relevant to the Saudi population: the dynamics of responses, the correlation between them, and the chi-squared distribution of shares. The use of a quantitative approach is driven by the mechanics of the survey, in which the questions are structured along the lines of a psychometric Likert scale. Specifically, this (DHCCBS) design included thirteen questions assessing different aspects of (HBM) in sequence. Among other things, this would provide conclusions for cohort testing, in which perceptions of the association between proper diet and colorectal cancer risk are tested separately by gender, age, and occupational criteria. Taken together, both qualitative and quantitative trial approaches will provide an overall picture that reflects the research question’s agenda. Meanwhile, the experiment design is based on a cross-sectional measurement of trends, which means specific patterns were measured for audiences in the same time period (Cherry, 2019).

Study Participants and Sample

The translated and cross-culture adaption of Dietary Habits and Colon Cancer Beliefs Survey (DHCCBS) study will be carried out in all districts in the Kingdom of Saudi Arabia.

Inclusion: The target population was male and female adult who will meet the eligibility criteria and consent to participate in the study.

1. Saudi Adult person aged 18 years or more of both genders.
2. Being able to speak and read the Arabic language.
3. Whether they have colorectal cancer or not.
4. living in Saudi Arabia and willing to participate.

Exclusion:

1. People under 18 years of both genders.
2. Saudi participant who are don’t live in Saudi Arabia.
3. People who answer the survey randomly

Data Collection Procedure

There are important limiting criteria for a pilot test that do not allow the project to be scaled up. In a general sense, the pilot test should not be large-scale because the goal is not to use a representative sample to produce results on a research question. Therefore, with limited budget and needs, it is recommended to use a sample of no more than thirty participants. The motivation for this number is justified by the minimum sample size requirements in psychometric and social tests: a vice of thirty respondents is precisely the minimum required (Gause, 2018). A pilot test will be conducted for thirty respondents, the purpose of which is to test whether the translated (DHCCBS) can be used for the purposes of broader research in subsequent phases.

Sampling among Saudi residents will be based on the use of social media contacts and personal acquaintances. This method significantly simplifies the technical part of the study and saves resources (Joseph et al., 2016). Nevertheless, this approach must ensure that systematic sampling error is minimized, even though it is used as the respondent group for the pilot test. More specifically, participants from all regions of Saudi Arabia are invited for the pilot phase, as if it were the sample for the present study. This strategy helps to cover the needs for minimal representativeness of the pilot sample and the detection of potentially hidden problems that may be identified by regional residents but not detected by respondents from other city.

Pilot sample participants are collected through the text an invitation link to participate. The researcher’s tasks at this stage include critical monitoring of the demographic and geographic metrics of the invited individuals to cover the goals of the stated minimum representativeness. Along with the link to the survey document located on the Google Drive cloud storage, participants receive informed consent, which introduces them to the goals of the testing being conducted, discloses sensitivities, Once the participants agree to fill out the questionnaire, they are considered as informed consent.

Participants will complete the questionnaire via WhatsApp, which is less resource-intensive and saves time.

Results Processing

The question of the validity of using the modified (DHCCBS) is answered by using quantitative methods to evaluate the results obtained. Specifically, this includes determining the mean, SD, and IQR to judge trends common among the pilot sample. In addition, content analysis is proposed to determine the most frequent verbal constructions reflecting the responses of the sample. Additionally, the use of Cronbach’s Alpha consistency criterion, Pearson’s coefficient to test the reliability of repeated trials and to determine the validity period of the questionnaire is suggested (Tsang et al., 2017). All of the tools used together allow us to not only assess the questionnaire’s applicability to broader studies but also to simulate results that may be obtained in future questionnaires on larger samples.

Translation Process of the Outcome Measures

In research study based on the use of foreign materials, it is crucial to achieve reliability in which the results of this linguistic combination are valid and reproducible. Translating materials from English into Arabic requires special attention, thus, since negligence or ignoring contextual semantics poses threats to the quality of the entire study. At best, the loss of nuance can lead to ignoring minor details or increasing the time to complete the questionnaires because of the need for additional awareness of the logic of the questions. On the contrary, the worst-case scenario poses the danger of wholly misinterpreted questions and, as a consequence, poor-quality conclusions, which is particularly sensitive for clinical trials on promising cancer issues. Thus, situations in which a large-scale study using an inaccurately translated questionnaire would show that (for example) Saudis are unaware of the association of a proper diet with the development of colorectal cancer, although this is not true, should be excluded. This is why enough attention should be given to the procedure of translating the questionnaire material from English into Arabic to ensure that the copy is semantically identical. The methodological framework used for the correct translation procedure was selected from the research paper by Tsang et al. (2017) on the correctness of using translated questionnaires for clinical trials: the general process is demonstrated step-by-step in Figure 1 below.

As can be seen from Figure 1, the survey translation procedure, once approved for use, should be conducted using a double translation technique. In this case, the source material in English is first translated into Arabic, and then the reverse translation is done. The need for back-translation is motivated by the need to verify consistency and preserve the contextual details of all questions (Shakhnovich, 2018). In the use of translation, as reported by Tsang et al. (2017), it is not enough to only translate survey material into Arabic even while preserving the complete contextual accuracy of the questions. Instead, the mechanics of the questionnaire need to be adapted to the specific objectives of the current study. In particular, since the questionnaire is designed to reveal — not in the pilot study, but in the following stages — Saudis’ awareness of the relationship between good nutrition and the development of colorectal cancer, it is highly likely that respondents will tend to misrepresent their answers in order to demonstrate their professionalism, even if this is not the absolute truth. Consequently, the format of the translated survey questionnaire should consider the potential for these distortions and try to minimize them.

Culture adaption

It is mean alter previously validated survey in another language. And it’s vital for the whole improvement of theories in environmental studies seeing that no person lifestyle consists of all environmental situations which can have an effect on human behavior (O. Abdullah & Bamaga, 2017). The intention of translation is to attain equivalence among the original model and the translated model of the scale. The first hassle is what is supposed ‘equivalence’. Mean? (Streiner et al., 2021). across culture adaption process contain a route of translation stages and assessment of psychometric properties there is a different type of equivalencies that have been agree by most of authors, there are five key ones:

1. Conceptual equivalence; that is, do humans withinside the two cultures see the idea within side the equal way? Conceptual equivalence may be determined via an evaluation of the ethnographic and anthropological literature about the target group, interviews and focus groups, and consultations with a huge variety of experts (Streiner et al., 2021).
2. Item equivalence. This determines whether or not the specific items are acceptable in the target population. and it is established in equal manner as conceptual equivalence (Autoridad Nacional del Servicio Civil, 2021).
3. Semantic Equivalence: Do the ward imply the same thing? Are their more than one meaning to a given item? Are there grammatical problems withinside the translation? (Streiner et al., 2021). It is can determined through the following process: First by pre-testing method, that intend to discover any mistakes discrepancies in translation process, and pre-testing method can be done in two ways: either probe technique where we can distribute the questionnaire belong to target population, or submitter questionnaire to bilingual lay individual (Guillemin et al., 1993). The goal of pilot-testing is not to change the wording of the actual item but to express the ward clarity in the language of translation. structured interview should be directed for the version item separately to determine whether the wording used made any difficult to answer, understanding Confusing, Upsetting or would have asked the question in a different way (O. Abdullah & Bamaga, 2017). See Appendix (2). Second, the translation process (forward and back-translation) will uncover discrepancies in interpretation between the two versions (O. Abdullah & Bamaga, 2017).
4. Operational equivalence is going beyond the items themselves and appears at whether the same format of the survey, the instructions, and the way of distribution can be used in the target population (Streiner et al., 2021).
5. Measurement equivalence investigates: we cannot assume that the psychometric properties of the test are the same in both versions until the test has been translated. we can establish the psychometric properties of the translated scale by determining its reliability and doing some validity studies. An extra thorough testing trying out could additionally see if the norms and once it has been determined that the scale can be translated (i.e., if conceptual equivalence exists, and items that may present problems for item and semantic equivalence can be changed), it is time to begin the translation process itself (Streiner et al., 2021).

Psychometric properties

Validity: The validity of a questionnaire is determined by analyzing whether the questionnaire measures what it is intended to measure. In other words, are the inferences and conclusions made based on the results of the questionnaire (Martin-Delgado et al., 202). There is a various form of validity test (theoretical construct which contain face and content validity) and (empirical construct which contain criterion related validity and construct validity) (O. Abdullah & Bamaga, 2017).

Reliability: The reliability of a questionnaire is a consistency of the survey results. As measurement error is present in content sampling, changes in respondents, and differences across raters, the consistency of a questionnaire can be evaluated using its internal consistency, test‑retest reliability, and inter‑rater reliability, respectively (Martin-Delgado et al., 202).

Cross-culture translation and adoption process

The direct translation procedure from English to Arabic must be carried out by at least two independent linguists whose proficiency in both languages is either native or close to the native speaker level. This strategy ensures diversity of opinion and reduces the likelihood of systematic error, while the requirement for independence of the translators responds to the threat of interaction between them, which would introduce an element of bias into the study (Tsang et al., 2017). In addition, an additional requirement for this pilot test is the need for professional qualifications of an experienced physician, preferably in the oncology field. This requirement is related to the use of specific medical terms that may not be understood by the interpreter, which would affect the quality of the survey material being broadcast. (Martin-Delgado et al., 202). Thus, two bilinguals were chosen for the present test, including a medical oncologist and an information technology student. The motivation for selecting this faculty student stems from the assumption that information analysis skills would be useful in translating the survey material. Additionally, according to Tsang et al. (2017), one of the independent translators had to be unfamiliar with the concepts of the target survey to allow for more accurate control of subtle differences (Tsang et al., 2017).

Therefore, each translator received a survey document in the original English language and was asked to translate this material into their native Arabic, using the most accurate constructions possible, preserving the semantic identity of the texts. Based on the results of the direct translation, the researcher had two independent surveys for which a synthesis had to be found. For this purpose, a third, unbiased Assistant’s professor bilingual translator who had Ph.D. (Oncology Nursing), MSc Nursing, was invited to collaborate with the author of the study to form a single questionnaire document based on the two created translations, which would meet the criteria of semantic accuracy, contextual closeness, grammatical accuracy and logical presentation of the questions as much as possible.

Back Translation

A back-translation consider a method to maintain equivalence between the original and translated versions. back-translation procedure for a newly created survey material from Arabic to English would allow any hidden inaccuracies to be detected and the translation to be further edited if necessary (Tsang et al., 2022). Ensuring maximum independence to achieve translation validity was realized through the use of additional one translator who had English as their first language. For this purpose, it was decided to turn to local expats from the United States who were excellent not only in English but also in Arabic, and therefore could assist in this study. Interestingly, Saudi Arabia is an excellent environment for an expatriate approach, as the Vision 2030 programs and government reforms of Crown Prince Mohammed bin Salman Al Saud have been reasons for the increased investment popularity, including through foreign labor, of Saudi Arabia in the global capital market (Lazell, 2021). Moreover, the choice of expats as independent translators was further motivated by the fact that his expertise did not include knowledge of oncological disciplines, and therefore the questionnaire created in Arabic could be translated into English with a minimum of bias. Thus, the one-translated (DHCCBS) questionnaire would be compared with the original material. Any deviations, differences, and inaccuracies relevant to differences in semantic perception will be corrected if necessary. this procedure has been done by one independent translator, English speaker who is proficient in the Arabic language and understand the cultural context.

Expert Commission

The translation of the survey material, back-translation, and corrections, if needed, should be qualitatively checked with the help of an expert committee. (Tsang et al., 2017). This strategy allowed for the creation of a pre-final questionnaire file that accurately reflects the desired context and meets the stated criteria to achieve validity. The expert panel which included two academic Assistant’s professor, both of them had Ph.D. (Oncology Nursing), MSc Nursing,). a qualitative comparison of the resulting material and the original (DHCCBS) had been done and reviewed the Arabic translated questionnaire for semantic, idiomatic, experiential, conceptual equivalence and structured technique to clear up inconsistency.

Each expert panel member will conduct the content validity ratio (CVR), by given a list of the items along with the content dimension they belong. They will evaluate each item on a 4-point scale (4 = Highly Relevant; 3 = Quite Relevant; 2 = Somewhat Relevant; and 1 = Not Relevant). Then the CVR is calculated using a specific formula.

Preliminary pilot test

as a process to assess semantic Equivalence we will conduct probe technique by administer the translated questionnaire to 10-15 respondents from the same target population, and conducting structured interviews with each patient individually to eliminate any mistake or discrepancies. based on feedback from the pretest, the questionnaire should be edited, and the identified problems corrected. After each significant revision of the questionnaire, another pretest should be conducted, using a different sample of respondents (Cull et al., 2002).

The structured interview:

1. it will direct to every item separately to decide whether or not the wording used made any of the translated items:
2. Difficult to answer;
3. Confusing;
4. Difficult to understand;
5. Upsetting
6. Whether the respondent would have asked the question in a different way (Tsang et al., 2017).

Initial validation

after the translated questionnaire will through pass initial pilot testing and subsequent revisions, it will be the time to conduct a pilot study among the intended respondents for empirical validity.

Reliability

Reliability The reliability of a questionnaire may be taken into consideration as the consistency of the survey results. As size mistakes is found in content material sampling, adjustments in respondents, and variations throughout raters, the consistency of a questionnaire may be evaluated the use of its inner consistency, test‑retest reliability, and inter‑rater reliability, respectively.

Outcome Measures (Scales/Instruments)

The instruments are based on the original theoretical model. However, they will be adjusted slightly to fit our study. The two instruments to be utilized for this study are:

1. Background (Modifying factors which may affect an individual’s perceptions and thus indirectly influence health–related behaviors).
2. The questionnaire was modified according to the most important variables which could influence a person’s belief as follows; Age, gender, marital status, level of education, monthly household income, family history of CRC, and number of family members affected by CRC.
3. The (HBM) scale was obtained from a standard questionnaire used in recent studies (Schaberg et al., 2020), This included 13 HBM Likert scale questions assessing the five domains of health behavior; one susceptibility question, two severity questions, two barrier questions, three benefits questions, and four cues-to-action questions.

Ethical Consideration

The study will adhere to the ethical principles by the Research Ethical Committee from Fakeeh college of medical sciences.

Information sheet and consent forms are developed (See Appendix: M).

Informed consent

Informed consent is a vital principle to protect the rights of participants while conducting a study. Obtaining consent from the study participants is the basic step prior to beginning to conducting field research, and the researcher must ensure that consent is voluntary and informed. For this study, all study participants should provide their informed consent before the study. On online survey there is always informed consent option. In addition, participants will be given a study information package explaining their responsibilities and the likely risks and benefits incurred by their participation. The nature of the data needed for study purposes will be explained to participants and they have the right to enrol in this study without coercion and to withdraw from the study at any point.

Data Analysis

A fundamental research interest of the present dissertation was to run a pilot test on a small sample (more than thirty participants) to assess the possibility of using questionnaires as a tool to assess Saudis’ perception of dietary habits as predictors of colorectal cancer development. In other words, the relationships — and the possibility of exploring them through questionnaires — between dietary habits and the diagnosis of colorectal adenocarcinoma were explored. In fact, dietary habits are an essential component of patients’ lifestyles, and many studies have focused on their impact on cancer (Smith et al., 2019). However, in the region of Saudi Arabia, the number of reliable case studies establishing a relationship between the two variables appears to be low. It is for this reason that this dissertation benefited from a pilot test on a small sample to assess the feasibility of a survey questionnaire before scaling up.

The data used for the analysis were the results of an online questionnaire administered using the Google Forms platform. The questions were preliminarily derived from a benchmark survey, as specified in the Methodology. The link to participate in the survey was distributed among familiar respondents — convenience sample — via WhatsApp; each participant was invited to answer twenty questions formally divided into three blocks. The first block assessed the respondent’s willingness to participate in the survey, so it was a dichotomous yes/no level value. Notably, this question was not strictly necessary and was actually a digital signature signifying willingness to participate in the survey. Looking ahead, only one of the subjects responded negatively to this question and then gave no responses to the others. Given the mandatory nature of the answers, it is likely that the individual closed the web tab and did not return to the test; his or her answers were not taken into account in processing, and thus he or she was excluded from the analysis.

The second block was represented by the sociodemographic characteristics of the respondents. This included age, gender, social status, level of education and current occupational orientation, and average monthly income. In addition, this section included the respondent’s body mass index (BMI) as a characteristic of his or her belonging to specific weight categories. The following twelve questions in the third block were based on the Likert scale, in which the respondent is invited to measure their agreement or disagreement with specific statements. Thus, the variables in each of the twenty questions were based on a nominal scale unrelated to numerical attributes; each value represented a categorical label, which had to be taken into account in the statistical analyses.

The results of all nominal variables were processed in two ways. First, it was descriptive statistics, which summarized the results and showed significant trends that were true for each of the variables. Second, it was a deeper level of statistical analysis, based on the use of correlation and regression analysis. In this section, the key issues were attempts to identify implicit relationships between variables and detect some variables’ potential influences on others. One needs to keep in mind, however, that all variable fields in SPSS were collected in a nominal form, which meant that additional transformations had to be performed for deeper statistical analyses.

Psychometric Properties of Testing

The questionnaire administered is a translated version of the English-language document, which has already been demonstrated to be academically correct and reliable for sampling. However, translating the document into Arabic to administer the questionnaire to a Saudi audience is a threat to the validity of the results. A double-translation mechanism involving several unrelated independent bilinguals, including people with a medical background, was used to preserve the material’s validity and ensure that the questionnaire actually measured the expected results. Using this approach was expected to minimize the risks of maintaining the questionnaire’s validity.

However, it is important to take into account the common Hawthorne effect, whereby increased attention distorts the results of the experiment. Inviting respondents from a list of people known to the author to participate in the survey questionnaire may have skewed the actual results for the general population, as each respondent may have felt responsible and pressured to participate. The Hawthorne effect postulates that participants in such academic interventions tend to produce more encouraged outcomes when they feel increased interest from clinicians. Regarding the material used, respondents may have skewed the results toward plant foods and red meat in ways that are “socially encouraged.” Unfortunately, there was no additional assessment of the participants’ responses at this point, which means there is no way to measure the validity of the test this time qualitatively.

Construct Reliability

Peter (1979) defined reliability as “the degree to which measures are free from error and therefore yield consistent results.” There are many ways to test the reliability of constructs for example, a researcher may use one of the common reliability test such as Cronbach’s alpha, and composite reliability. For this research, I am utilizing Cronbach’s alpha as measure for the construct’s reliability of my research. Many resources suggested that of Cronbach’s alpha value should be greater than.60 (Hair, 2006).

According to our analysis, Cronbach’s alpha for our constructs ranges from.68 to.35. Internal consistencies were achieved for all of the constructs except for perceived barrier (α <.60).

Internal consistency: Cronbachs Alpha

Results

Since the first question determined individuals’ willingness to participate in the survey and all subsequent questions were required to be answered, a hundred percent result for the first question was expected and corresponded to the final number of respondents. As mentioned above, however, one individual declined to participate, and his results were not used for the entire analysis. Thus, the total number of individuals who participated in the pilot test was thirty-two (n = 32). There were no responses from the next two blocks in which respondents chose to ignore the question, so each of the questions in the entire questionnaire had a one hundred percent response rate.

In terms of socioeconomic and demographic characteristics, the sample collected was predominantly female, with the average age of participants ranging from 18 to 30 years old. From the more detailed statistics of Figure 1, it is clear that the central core of the sample was represented by young women under the age of 30; in other words, the respondents were young, primarily female Saudis concerned about their health in light of colorectal cancer.

In terms of the other traits of the sample collected, as Figure 2 shows, 62.5% of respondents identified themselves as married individuals, with 75% having an academic degree or higher from a university. Notably, about one in six participants identified themselves as unemployed, which generally satisfies two features of the Saudi Arabian general population at once. For example, many women do not have access to work because of local Sharia law, and while this practice is changing rapidly, it takes time to implement changes. In addition, about 66 percent of the sample are young people who probably have not yet found stable employment and therefore tend to describe themselves as unemployed. The average monthly income among respondents was almost evenly distributed across both borders from the 5,000 SAR mark, indicating the heterogeneity of the sample collected in the context of economic descriptions. Finally, respondents were unevenly distributed across the four groups in terms of BMI. Recall that BMI is understood as an indicator that allows us to examine the degree of correspondence between a patient’s height and body weight: the lower or higher this characteristic, the more likely an individual is to belong to the risk groups. In this sense, the sample expected prevails in the average interval from 18.5 to 24.9 kgm^-2, which is considered normal.

The results of the third block of data reflect general trends among respondents’ perceptions of specific statements. Examining this data helps to assess how widespread a particular opinion is in the sample of 32 participants. Summary data for all twelve questions in this block are shown in Table 2. It can clearly be seen that respondents’ answers were not homogeneous, and while positive answers prevailed for some questions, respondents tended to disagree with the statement for others. Notably, only on question 14 did the majority of participants not give a specific answer, indicating that the question was difficult to formulate or ambiguous in its interpretation. When assessing the possibility of getting colorectal cancer, one in two individuals (50.1%) expressed concern about it. Expected results were also obtained for questions 10 and 11, in which most individuals (75.1% and 59.4%, respectively) agreed that cancer could negatively affect the quality of life and reduce life expectancy. It was also found that clinical providers did not advise patients to give up red meat but advised them to eat plant foods in large quantities. However, the situation changes with recommendations from friends and family: incompetent individuals tended to advise against red meat, with two out of three respondents stating that family or friends advised them to eat more plant foods. Thus, it is helpful to emphasize that plant-based foods are perceived by most as a good diet that balances the diet, whereas such beliefs are contradictory with regard to red meat.

Table 2. Frequencies and relative frequencies for Likert scale measures of agreement

Finally, an interesting pattern was evident among the entire sample with respect to perceptions of red meat and plant-based food tastes. Figure 3 shows that the overwhelming majority of participants disagree that they do not like the taste of red meat; therefore, this product tastes good to them. The situation remains the same for plant foods, which means that both vegetables and red meat are shared among the diet of this sample. However, in terms of the questioning audience, about four times as many respondents could not say they disliked and liked the taste of red meat compared to plant-based foods. In other words, red meat is more controversial to the sample than vegetables.

For deeper, non-descriptive statistical tests, it was taken into account that each of the variables used is nominal, which means that classical regression and correlation analysis procedures prove ineffective for nonnumerical variables. The nominal scale of variables means that the data in a category cannot be sorted in ascending or descending order because they contain only information about the object belonging to a particular category. SPSS built-in procedures allow us to bypass these limitations by using polynomial regression models. This method can be used to measure how independent parameters are related to the dependent variable under study. For example, Table 3 shows well that BMI as an independent variable was statistically independent of respondents’ age, gender, and even more so income because the corresponding p-value values were significantly higher than the critical level of 0.05. Consequently, a change in any of these variables does not result in a pattern change in respondents’ BMI.

Table 3. The output of polynomial regression for BMI as the dependent variable 

A similar polynomial regression procedure was performed for each question in the third block as a separate dependent variable, with demographic parameters as independent factors. Thus, it was interesting to determine whether age, gender, income, social status, level of education received and position held, as well as BMI, influenced respondents’ responses to the Likert scale questions. Table 4 illustrates these results: any p-value below the critical level corresponded to the presence of an effect for this pair, although the strength and extent of this influence could not be measured at this stage. It is well seen that gender and BMI were predictors of the response to the question that colorectal cancer reduces the quality of life. If one examines the statistics of the answer to this question in detail, one finds that women were five times more likely to agree with this statement than men. A significant effect was also shown for the relationship with BMI, with an additional finding that people with average BMI values (18.5-24.9) were more likely to agree with this statement: they accounted for 50% of all responses among respondents. In addition, social status and level of education were positive predictors for agreement with the statement that colorectal cancer causes death; respondents with higher education were shown to be more likely to agree with this statement. Meanwhile, unmarried people were 1.7 times more likely than married people to agree.

For the twelfth question, postulating an association between red meat consumption and reduced risk of a cancer diagnosis, it was shown that gender and social status were the only statistically significant predictors. Specifically, 37.5% of respondents who agreed with this statement were unmarried women. In response to the seventeenth question, stating a recommendation by the clinical provider to consume less red meat, the patterns of association with age and BMI were noticeable. In this sense, people in the middle age range (18 to 30) and average BMI were more likely to disagree, as one-third of individuals in this cluster answered negatively, and one-third answered affirmatively. The eighteenth question postulated a similar statement, only in this case the advice had to come from family or friends. Interestingly, this question no longer revealed the same patterns as the previous question. More often than not, women with monthly incomes below SAR 5,000 received such recommendations from their significant others; no such pattern was found for men.

Table 4. Testing the effects of independent contributions to the polynomial regression for each of the questions in the third block, with a critical level of 0.05 

Notably, relationships with independent sociodemographic factors were not found for all questions in this block. In particular, questions 13 through 16, as well as the last two statements, showed no relationship patterns. It may follow from this that patients responded evenly to all of these statements, and thus no significant trends can be detected. At the same time, the individual’s work alone as an independent factor showed no effect on either question. From this, it can be concluded that work is not a statistically significant factor influencing the perception of food habits of Saudis.

The nonparametric Pearson chi-square test was an important data processing task. In general, this method is commonly used to compare two or more categorical data, but in the context of the current study, it was interesting to determine how evenly the data were distributed for each question in the third block. Table 5 below shows the p-value for each nonparametric test: a value below 0.05 answered the need to reject the null hypothesis. In other words, for these relationships, the distribution of responses within a category was different from uniform (0.50/0.50). This table clearly shows that only social status, position held, and monthly income occurred with equal (or close to equal) probability among the sociodemographic variables. Only questions #16 and #20 had the same property among the third block categories. This implies that an equal number of respondents in the sample were equally likely to be unable and unable to imagine their lives without red meat; the exact distribution is noticeable for recommendations to consume more plant foods.

Table 6. Outcomes of a nonparametric chi-test to determine the uniformity of the distribution of values within categories, with a critical level of 0.05 

It is worth emphasizing that the initially stated correlation test proved impossible to perform within the current array because none of the variables had a numerical scale. Instead, it was possible to test the relationship between factors by cross-tabulation using the chi-squared technique: this helps to assess the effect of one variable on another (Udayton, n.d.). However, it is impossible to conduct multiple cross-tabulations simultaneously, so patterns must be evaluated in pairs. The results of a summary table of such a pairwise comparison are shown in Table 7.

Table 7. P-value values for pairwise cross-tabulations to determine common effects, at a critical level of 0.05 

It is clearly evident that only four of the eighty-four pairs were found to have statistically significant (p<0.05) patterns. Thus, people with higher education were more likely to agree with the statement that colorectal cancer reduces patients’ quality of life (Figure 4A). At the same time, employed respondents were more loyal to the opinion that cancer causes death, whereas non-employed respondents showed more doubts (Figure 4B).

Also noteworthy is the fact that people with a university education were more likely than others to disagree with the statement that they “Do not like the taste of other protein-rich foods” (Figure 5A). In other words, an intermediate conclusion can be drawn that more educated people often like the taste of protein-rich foods, although this statement requires careful verification. Also related to education is the pattern that university-educated respondents were more likely than others to receive recommendations from friends and family to consume more vegetables (Figure 5B). The overall conclusion is then that education is an essential predictor of individuals’ perceptions of dietary habits.

Summary of Main Results

The present study aimed to critically evaluate the feasibility of using the translated English to Arabic questionnaire framework (HBM) for a pilot sample from Saudi Arabia. This study was of high academic significance because it addressed the critical public health problem of the lack of adequate colorectal cancer prevention activities. This disease is known to be on the list of some of the most common threats to health and quality of life, being also highly fatal (Almalki et al., 2020). As a consequence, improving the preventive management of this diagnosis qualitatively improves the level of national health care and the well-being of the population. Meanwhile, it is well known that there is a direct link between an individual’s daily diet and the risk of acquiring colorectal cancer. In other words, the use of specific foods in the diet may positively or negatively affect the likelihood of developing cancer. Based on these beliefs, expert diagnosis of the problem of perceptions of dietary habits in light of cancer risk is a crucial question, the answer to which has excellent potential for constructive change in the health agenda in Saudi Arabia.

Several interesting patterns emerged from the key findings of this dissertation study conducted for a Saudi pilot sample. First, the composite reliability test for the critical questions in block three, which measure the core of the research question, showed an acceptable level: according to Cronbach’s Alpha, it was 0.656, whereas, for McDonald’s Omega, it was 0.579. Both values are statistically significant and reflect that the Arab questionnaire is methodologically suitable for producing consistent, consistent, and reproducible data (Rajput, 2015; Ursachi et al., 2015). Second, it was shown that Saudis were less likely to receive recommendations to reduce red meat consumption from doctors than from family or friends. This result may indicate a stigmatized, contradictory view in the community of local clinicians. Third, it has been found and statistically proven that individual sociodemographic and economic factors influence perceptions of dietary habits. Fourth, using Pearson’s chi-square, it was shown that current data could be used — and thus, when scaled, this effect should persist — to determine the equal probability distribution of responses in the sample. In more detail, only three of the seven sociodemographic variables (social, occupational status, and monthly income) had a statistically significant equal probability of distribution in the sample; in other words, the sample was not wholly heterogeneous, and imbalances in age, gender, education, and BMI were found. Fifth, a nonparametric test showed that respondents’ employment and academic status were the only statistically significant predictors of the perception of certain aspects of colorectal cancer.

Interpretation of the Study Results

The results obtained from a small sample pilot survey show an intriguing picture. One of the very first conclusions that can be drawn from the available data is that the pilot sample has a high awareness of the threat of susceptibility to colorectal cancer. Specifically, approximately 50% of respondents said they might be susceptible to this diagnosis. This statistic does not reflect a real public health agenda, as only 4.3% for men and 4.0% for women actually have a lifetime risk of developing colorectal cancer, according to ACS (2022). However, the apparent hyperbolization of perceptions of commitment to this health threat, contrary to the real numbers, may be evidence of high levels of anxiety in the population. On the other hand, individuals can adequately assess their health and attend timely diagnostic examinations that can detect the risk of developing a disease early on, since a high percentage of the perception of being exposed to a diagnosis need not necessarily be equal to the real risk. This statement is perfectly supported by the results of the following two survey questions, in which the majority of respondents said they agreed that colorectal cancer could negatively affect their quality of life or lead to death altogether. However, the above statement is not reconciled with the results of a study showing that Saudi students lack knowledge about the issue and consequently neglect screening (Althobaiti & Jradi, 2019). In this context, the observed contradiction between the results obtained and those available is created. Several reasons may explain these discrepancies. First, Althobaiti & Jradi’s study involved students, which means that the mean age of the sample was significantly lower. Based on this reason, age may have the potential to influence colorectal cancer awareness, but this assumption is not tested in this paper. Second, the comparative study assessed qualitative, reliable medical knowledge, whereas information about cancer threats can spread through word of mouth. In this case, relatives, family members, and friends may be sources of information about colorectal cancer, but the reliability of the knowledge conveyed may be questionable.

The results of the survey suggest that the perception of the real threat of colorectal cancer is shared among the pilot sample. Among other things, there was a good correlation between dietary habits and increased cancer risk, as most respondents systematically endorsed more consumption of green foods. This may be reflected in the published results, which indicated that “dietary intervention based on the health belief model improved nutrition… although the impact was limited” (Shiraishi et al., 2021, p. 1). Although Saudis are perfectly aware of the threat of colorectal cancer and can adequately perceive the danger, Iskandarani (2021) reports an observed dichotomy between knowledge and practice. In particular, the local population is not ready for real action to improve their diet or change their lifestyle habits, which poses a tangible threat to any preventive action by the national health system.

Meanwhile, exciting patterns were found for perceptions of threats and benefits to the consumption of red meat and plant foods. The results reflect that only about one in five members of the experimental group experienced a recommendation from a clinical provider to reduce red meat intake; with 46.9% stating that they could not live without red meat. This creates an environment in which the diet of the pilot sample is, for the most part, dependent on red meat. Red meat is considered by the nutritionist and scientific community to be the primary type of carcinogen that can cause, among other things, colorectal cancer (CC, n.d.; Smith et al., 2019). This becomes particularly interesting to examine in light of data from Al Otaibi’s (2018) article, in which it was shown that only a tiny fraction of the local population in Saudi Arabia tends to follow minimal recommendations for good nutrition.

At the same time, 78.1% of participants stated that their physician recommended that they consume more plant-based foods. This begs the conclusion that plant-based foods tend to be perceived by clinical staff as beneficial for minimizing colorectal cancer risks, whereas red meat, by contrast, is more questionable. This pattern is well supported in part by scientific research: in particular, Madigan and Karhu (2018) acknowledge that “whole foods plant-based diets have been shown to significantly protect against cancer” (p. 1). Interestingly, respondents’ family members and friends seem to understand the potential risks of red meat as well as local clinical providers. Thus, one in two respondents stated that they had received appropriate advice from loved ones to reduce red meat consumption: in other words, such advice came from family and friends with the same frequency as from competent physicians.

A significant result for the present dissertation was to determine the patterned relationship between the sociodemographic descriptions of the sample and existing beliefs about dietary habits in light of colorectal cancer. For this purpose, Pearson’s pseudo-correlation chi-squared method for nominal variables was used. Among the entire matrix of pairwise comparisons (Table 7), only four statistically significant relationships between factors were found, three of which depended on education. Thus, the test showed that education was a significant predictor for respondents’ beliefs that colorectal cancer affects individuals’ quality of life, perceptions of the taste of protein foods, and the frequency of recommendations to increase plant-based food consumption by loved ones. More specifically, it was demonstrated that the higher the level of education individuals received, the more seriously they perceived the threats of colorectal cancer to quality of life. Meanwhile, a higher level of education also responded to respondents’ love of red meat, although these same participants stated that they received more dietary advice from loved ones to enrich their diets with vegetables. From this, one can conclude that education level is a statistically significant variable for influencing the perception of colorectal cancer associated with dietary habits.

In addition, it was also shown that the employment status of participants in the pilot sample was associated with perceptions of risk of death from CRC. Unemployed individuals tended to have more inconsistent perceptions of this link, whereas working group participants, by contrast, showed more unequivocal agreement with the threat of cancer leading to patient death. Interestingly, the resulting set of findings — concerning work status and educational attainment — is inconsistent with those of the original study that proposed the use of the DHCCBS. Specifically, Schaberg et al. (2020), in a sample for the American population, showed that the perception of colorectal cancer threats depended only on the age and some dietary habits of participants. However, the results of the present dissertation for the Saudi sample showed that age was not a statistically significant variable for any level of perception. One can say that the pilot survey expanded the range of essential criteria by showing the statistical significance of education and work status for preventive threat management. The results seem reasonable (though absent from the original articles) in terms of applicability to the Saudi population. As the Madinah case study showed, “the higher the education level and income, the higher was the knowledge regarding CRC among the study subjects” (Almalki et al., 2020, p. 352). It is excellent to see that education level as a predictor of perception of the problem is confirmed by local clinicians, which means that the apparent discrepancy with the original work may be due to ethnic differences in the samples used. Meanwhile, for the pilot sample, there was no confirmed association between colorectal cancer risk perception and overweight, which was one of the findings of the Al-Zalabani (2020) study. In that paper, the authors demonstrated that being overweight was positively associated with the risks of developing CRC, but the current survey showed that BMI was not statistically associated with any level of threat perception.

The pilot test thus conducted shows good consistency with publicly available scientific evidence; however, there are evident contradictions and gaps. Among the strengths of the work is the novelty of using the DHCCBS within (HBM) for a Saudi Arabian audience. The validity and reliability tests of the translated questionnaire in Arabic show an acceptable level, which confirms the advantages of the double-translation method used. Moreover, the thesis was able to detect patterns in the influence of individuals’ work and work status on the perception of dietary habits in light of the threat. The listed strengths are enough to recognize the current dissertation work as unique and relevant to a critical applied public health problem. Nevertheless, the pilot test is not without its shortcomings, among which it should be highlighted the comparatively small sample size and the non-probability of its formation mechanism. This results from the heterogeneity of the formed group of participants in terms of age, gender, BMI, and education: not all clusters of the general population could be represented in this sample. The listed weak points have the potential to affect the validity of pilot testing, and hence there is a need to improve sample formation procedures when scaled to larger audiences.

Summary

To summarize the discussion section, the use of a survey questionnaire for pilot testing on a Saudi sample was able to address the stated research questions. First of all, the validity and reliability of the survey were statistically valid, which means that the results obtained can be expected to be consistent and consistent, even when scaled up. On the other hand, patterns of association in perceived colorectal risk and association with dietary habits were found for the pilot sample. More specifically, education and work status were the only statistically reliable predictors for this association. The study also demonstrated a seeming inconsistency in the perceived benefits and harms of red meat by the Saudi medical community, as respondents stated that clinical providers advised eating less red meat as a potential carcinogen only half of the time.

The next chapter discusses the general conclusions drawn from the entire paper. This includes the results of the literature review and own conclusions based on the statistical models used. The findings and conclusions have great potential for use in preventive colorectal cancer control tactics. However, the pilot test was not intended to generate data for this but rather to measure the ability to use the translated Arabic questionnaire and the ability to detect patterns. Since both capabilities have been confirmed, an expansion of the sample and modification of the weaknesses is needed to create a more robust, valid research design. For this reason, a discussion of the long-range implications of this pilot study is also an essential part of the discussion in the next chapter. This may require not only changing the sampling logic and increasing the number of participants but also adding new parameters for measurement. Ultimately, this will provide potentially valuable data with the ability to improve Saudi national health policy. However, there is no need to limit the data to just one region, as obtaining reliable data for Saudi Arabia will potentially allow for scaling up to other Gulf states. These issues are discussed in the next chapter, including recommendations for scaling up the work.

Implications, Recommendations, and Conclusions

The findings of this dissertation work have great potential to be useful for more in-depth research into the prospective threat of national health care in Saudi Arabia. The findings, consisting of the proven and statistically valid possibility of using the translated DHCCBS survey material for the Arab patient environment and finding and statistically validating key sociodemographic patterns, allow for the expansion of further research. In particular, as was shown for the literature review, there are not many qualitative scientific sources evaluating the relationship between Saudis’ dietary habits and perceptions of colorectal cancer threat. From this perspective, the results of this dissertation study showed the possibility of academic continuity for foreign research materials in the Arab regional context. As a consequence, this creates a positive agenda for future research, as the need to develop and validate effective survey protocols turns out to be solved by the possibility of using already ready-made research schemes. This is particularly useful in the context of intensified globalization processes, when relations between states, including those that lie on the research plane, are considerably densified. This consequence, however, also affects the clinical environment, where the speed of decisions taken, combined with the need for their analytically proven accuracy, are key predictors of outcomes for national health care.

Meanwhile, the discovered links between individuals’ employment and educational status in pattern with perceptions of colorectal cancer threat extend the available knowledge. Previous research sources, including those in which the DHCCBS was used as original material, have not demonstrated this relationship; consequently, the results of this dissertation show that patterns may be influenced by geographic and ethnographic features of the population. The fact that a study of similar thematic problems by Arab authors demonstrated the influence of work status on feelings of threat from colorectal cancer confirms the value of the available data and creates positive opportunities for scaling it up.

Recommendations

Given the generality of the findings, several specific recommendations should be emphasized. The suggestions listed below would not only broaden the academic scope of research in future work but also implement some of the clinical practices now. First, more attention should be paid to sample formation for non-pilot testing since the probabilistic nature of its creation should increase cluster representation. Second, it is recommended that new parameters be introduced to broaden the field of research interest. In this study, only seven sociodemographic patterns were examined, with only two having statistically significant relationships to the issues under study. Thus, in future studies, it would be logical to add some new independent factors and create categories for existing ones. For example, it would be appropriate not to use the dichotomous division of respondents’ labor status but to measure more levels in this variable. Similar recommendations are similar for the geographic and religious division of the Saudi sample since Shariah law is expected to affect the dietary habits of the population.

In addition, attention should be drawn to some of the recommendations that can already be used by clinicians. Although it should be emphasized that the current thesis was a pilot study for a small sample, it showed that perceptions of the threat of colorectal cancer might be broader than previously thought. The patterns found for the American population may not be applicable to Arab residents. Therefore, clinicians should be more careful in adapting foreign clinical practices. The association of colorectal cancer threat perception with the educational status of the individual shown in the paper can be used because the pilot testing showed a lack of awareness among people without higher education. This creates a positive signal for decision-makers to develop educational programs and disseminate quality knowledge to the population.

Conclusions

Thus, the general conclusion for the entire dissertation work is that it is possible to use foreign materials — in particular, the DHCCBS — adapted to local characteristics for research work. In this dissertation, a pilot testing technique was used to assess the validity of the translated questionnaire and to search for possible patterns initially. The borrowed survey technique showed acceptable composite reliability and even found statistically significant relationship results between variables. From the data, it was concluded that there is a real need for a qualitative modernization of Saudi health care practices because the perception of colorectal cancer threat is differential across demographic groups. As the literature review showed, specific calls to action as health campaigns can qualitatively raise awareness of the current problem. The stated research questions were fully addressed by this dissertation, which illustrated the positive opportunities for expanding academic opportunities for local researchers. The problem of lack of resources and time in research can be solved by ethically borrowing foreign experiences adapted to the context. Meanwhile, the educational and employment status of respondents was claimed to be the only significant demographic predictors influencing the perception of colorectal cancer. At the same time, it was found that plant-based foods were perceived by those involved as healthier and healthier for minimizing risks, whereas red meat consumption generated controversy. All of the above, in turn, should raise the level of knowledge about good nutrition, which is expected to improve national health in the long run.

Appendices

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Appendix (1): Questionnaire

Appendix (1): Informed Consent

Purpose of the Research: The purpose of this replication study is to understand how Saudi’s’ perceptions of unhealthy diet as a cause of colon cancer.

What You Will Be Asked to Do in the Research: You are being asked to complete a survey online and submit it through Qualtrics. The survey will take approximately ten minutes of your time to complete. Participants must click yes showing that they agree to take part in the study. The study participants can skip questions within the survey. This study will investigate employees’ perceptions of injustice and computer abuse intentions.

Risks and Discomforts: We do not foresee any risks or discomfort from your participation in the research. You have the right to not answer any questions.

Benefits of the Research and Benefits to You: Although there are no direct benefits to you, the possible benefits of your participation in this research study would help to identify potentially significant perceptions of diets’ as cause of cancer.

Voluntary Participation: This form explains the nature, demands, benefits and any risk of the project. Remember, your participation is voluntary. You may choose not to participate or to withdraw your consent and discontinue participation at any time without penalty or loss of benefit. By taking this survey, you are not waiving any legal claims, rights, or remedies.

Withdrawal from the Study: You can stop participating in the study at any time, for any reason, if you so decide. Your decision to stop participating, or to refuse to answer particular questions, will not affect your relationship with the researchers or any other group associated with this project. In the event you withdraw from the study, all associated data collected will be immediately destroyed wherever possible.

Confidentiality: All information that will be obtained in this study is strictly anonymous. The results of this research study may be used in reports, presentations, and publications, but the researchers will not identify you. The responses to the questionnaire will remain completely anonymous. Unless you choose otherwise, all information you supply during the research will be held in confidence and unless you specifically indicate your consent, your name will not appear in any report or publication of the research. Your data will be safely stored in a password protected computer and only research staff will have access to this information. The data will be permanently destroyed after 3 years. Confidentiality will be provided to the fullest extent possible by law.

Questions About the Research? If you have questions about the research in general or about your role in the study, please feel free to contact 0536305025 or by e-mail ([email protected]). This research has been reviewed and approved by the Research Committee and conforms to the standards of the Research Ethics guidelines.

Appendix (1): Original form of (DHCCBS)

Appendix (2): Arabic Translation version 1

Appendix (3): Arabic Translation version 2

Appendix (4): Thesis Questionnaire

Part 1: Demographic Profile

Part 2: the final translation questionnaire(T1+T2)

Appendix (5): back translation questionnaire

Appendix (6): Pilot-testing: Sample of a participant response sheet completed by interviewer

Question number —— —–

Comments:

1. Difficulty? Yes ❐ ——————————-
2. Confusing? Yes ❐ ——————————-
3. Difficult words? Yes ❐ ——————————
4. Upsetting? Yes ——————————-
5. How would you ask this question? ——————————–

Appendix (7): Content Validation Form for the health beliefs model to assessing Saudis’ perception toward dietary habits as a risk of colorectal cancer