Diet and Colorectal cancer
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 that is gradually increasing in developed countries. This gradual rise is due to lifestyle alongside various flexible risk factors, such as obesity, tobacco consumption, red and processed meat consumption, and alcohol ingestion (Al-Zalabani, 2020). These risk factors contribute to one-third of the mortalities in the United States annually (Yarbro et al., 2018). Diet is considered impactful on the etiology of colorectal cancer, especially in combined high-calorie intake, poor diet, weight gain, physical inactivity, and unhealthy habits such as high alcohol intake and smoking (Ryan-Harshman & Aldoori, 2007).
Scientists have investigated the effects of micronutrients (vitamins and minerals) and macronutrients (proteins, fats, carbohydrates) in the etiology and prevention of CRC. Results indicate that these factors provide optimism to researchers on eradicating CRC (Yarbro et al., 2018). A study conducted in Saudi Arabia showed that poor dietary behaviors such as processed and red meat consumption are the top risk factors for colorectal cancer (Al-Zalabani, 2020). The risks, however, reduce with the adoption of healthy dietary habits, such as the intake of fresh fruits and vegetables (Al-Zalabani, 2020).
A cross-sectional study conducted in Madinah, Saudi Arabia, involving 385 participants recruited to evaluate population knowledge on CRC and its risk factors. Questionnaires helped gather information about eight risk factors related to colorectal cancer: sex, smoking, physical activities, red meat consumption, regular consumption of fruits and vegetables, histories of inflammatory bowel disease, and history of colorectal cancer (Almaki et al., 2020). The participants constituted 65% males with 18 – 29-year-olds contributing to 44.2%, and graduates comprising 54% of the study subjects. Furthermore, the participants’ knowledge about CRC risk factors of eating red meat was 15.10%, which correlates with the thesis that is daily eating red meat consider one of the most common risk factors among the Madinah population, with 61.5% (n=237) linked to acquiring colorectal cancer due to unhealthy diet. Lack of regular fruits and vegetables was 49.3% (n=190) as a third factor. The study’s recommendations were to create and facilitate awareness programs among the Saudis on the importance of practicing healthy dietary activities using educational programs. Such education programs would include topics related 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
Many relevant studies limit the unpleasant outcome of dietary habits by predicting and changing health behaviors. There has been a relationship between healthy behavior performance and various health outcomes for more than 40 years (Conner & Norman, 2015). For instance, a qualitative study conducted on pregnant French women observed that nutrition awareness among the women rose upon receiving nutrition-based information obtained from the healthcare practitioners. The study assessed, evaluated, and enhanced the understanding of determinant factors on eating behaviors by focusing on their concerns, beliefs, and attitudes (Bianchi et al., 2016).
On the other hand, the theory of planned behavior aided in identifying the Canadian adult population’s prominent beliefs on the consumption of cheese and milk. The study determined optimized methodologies for promoting the consumption of the foods within the Canadian adult population through understanding health beliefs. Based on these findings, a recommendation for forming social marketing campaigns is necessary for enhancing Canadian’s dietary health habits (Lacroix et al., 2016).
Saudi Arabia has a study investigating the implementation of dietary guidelines alongside the population’s healthy eating habits (Hazam, 2018). Alongside other Gulf Cooperation Council (GCC) nations, Saudi Arabia experiences nutrition transitions leading to elevated burdens of chronic diseases such as cancers, obesity, diabetes, and cardiovascular diseases. The Planned Behavior Theory is a framework conceptualized to analyze and integrate crucial factors determining healthy eating behaviors among Saudi adults: intention, attitude, Perceived Behavioral Control, and subjective norms. For instance, the Saudi Arabian Health Interview Survey determined that poor dietary behaviors such as high fats, sugar, and meat consumption and decreased intake of vegetables and fruits lead to the country’s increased prevalence of chronic diseases (Otaibi, 2018). The study’s results helped develop operative educational interventions to enhance healthy eating tendencies among the Saudi population and recommended internalizing factors influencing healthy eating behavior.
The Saudi Ministry of Health drafted eight easy-to-understand dietary guidelines to enhance healthy eating. Furthermore, the publications recommended daily food serving guidelines based on age groups to enhance healthy dietary habits among the citizens (Otaibi, 2018). Saudis’ health-based behaviors and attitudes are examinable in a health consciousness context, illustrating that Saudis’ understanding of health depends on widely ranging cultural domains. Their health behavior is a consequence of environmental, social, economic, and personal factors. Saudis’ awareness is underdeveloped, thus illustrating their nature of upholding health-risk behaviors (Iskandarani, 2021). The author advised conducting more qualitative studies on factors affecting the Saudis population to adhere to and comply with the necessary health behaviors to narrow the knowledge gap of proper dietary habits.
Health Beliefs Model
The Health Belief Model (HBM), assumed in the 1950s, is a model theorized to guide health promotion and disease prevention activities alongside explaining and predicting individual changes towards healthy habits. The health beliefs model is popular in Saudi Arabia. The model includes predicting barriers of Cervical Cancer Screening, knowledge, attitude, and practices towards diabetes mellitus in the Saudis population, or predicting breast self-examination among Saudi women (Alrashed et al., 2020, Abdullah et al., 2020). The studies recommended implementing a solid educational program based on effective measures taken (Alrashed et al., 2020, Abdullah et al., 2020, Abolfotouh et al., 2015). The critical components of HBM entail focusing on personal beliefs on health conditions that influence an individual’s health-related habits.
Additionally, the model highlights significant factors that determine health as an individual’s perceived susceptibility to disease, perceived benefits, cues to actions, and self-efficacy. Utilizing the Health Belief Model, a 2020 nationwide survey carried out in Riyadh, Saudi Arabia, assesses behavior, attitudes, knowledge, and intent of pursuing colorectal cancer screening (Almadi & Alghamdi, 2019). The study intended to fill the gap between knowledge and undergoing CRC screening besides determining and analyzing the gap between an individual’s acceptance of screening and proceeding to the procedures (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
Saudi Arabia has conducted few studies regarding the relationship between diet awareness and how it affects the prevalence of colorectal cancer in the population. However, Western nations, particularly the United States, through the American Institution of Cancer Research, recommend a reduction of CRC incidences by including behavioral changes as a result of extensive studies carried out in their health institutes (Schaberg et al., 2020). The findings of the studies highlight an individual’s dietary habits and age as the key influencers of health beliefs towards colorectal cancers. In essence, the studies determined a high case of unwillingness among American adults towards adjusting their dietary patterns to help curb colorectal cancer since most of them do not understand the impacts of practicing healthy behaviors on an individual’s will to seek transformations.
Furthermore, the studies use HBM to assess and evaluate the attitudes and beliefs regarding risks of CRC and diet behavior in the adult American population. The study’s findings indicate that age and dietary habits are critical factors determining an individual’s susceptibility to CRC (Schaberg et al., 2020). Consequently, the population’s awareness about diet as a colorectal cancer risk factor can be determined by evaluating their perceptions of the topics. Similarly, a cross-sectional study done in the Al Hassa region of the kingdom of Saudi Arabia, a cross-sectional study recommended that the perceived barriers perception be addressed prior to implementing CRC screening (Galal et al., 2016).
Definition of Terms
Health Belief Model
This is a psychological framework used for analyzing behavior change among individuals by studying their reasoning characteristics to predict health-related behaviors (Conner & Norman, 2015). In terms of this study, the HBM refers to an individual’s belief in a personal threat towards certain illnesses or diseases and their belief in the efficacy of the suggested health behavior, thus predicting the individual’s chances of adopting the foresaid behavior.
Colorectal Cancer
Colorectal cancer entails a series of mutations occurring in the colonic and rectal mucosa epithelial cells, leading to the formation of an adenoma on the mucosal surface. The cancer stage is determinable by the extent of penetration of the tumor within the intestinal walls, involvement of critical organs, the depth of regional lymph nodes involved, and the viability of distant metastases (Yarbro et al., 2018).
Health Beliefs
Health beliefs are what an individual believes regarding their health, what an individual considers as a constituent of their health, what they believe causes their illnesses, and means of overcoming the illnesses. The beliefs are determined by culture and congregate to produce a more comprehensive system of health beliefs (Misra & Kaster, 2015). Cultures have varying perceptions of the components of health and causes of illness. For instance, the health beliefs of the Saudi population play an essential role in the unhealthy and healthy living patterns of the Saudis. However, other factors other than diet can also influence the health habits of the population (Iskandarani, 2021).
Dietary Habits
Dietary Habits entail the habitual decisions made by an individual regarding food preferences based on food type. Healthy dietary choices include the consumption of carbohydrates, vitamins, fats, proteins, and minerals (Preedy & Watson, 2010). Dietary habits and decisions are critical influencers of human health. Most Saudi diets do not follow the healthy diet guidelines provided by the health ministry. Studies highlight Saudis as heavy consumers of unhealthy foods and beverages whereby it is ranked 15th globally based on its obesity prevalence, whereby 33.7% of the population is obese (Jalloun & El Shikieri, 2021). The high risk of health-related conditions is a consequence of poor dietary habits and obesity.
Literature Review
Existing Empirical Literature
The measurements are not limited to Health Belief Model since many theoretical frameworks can assess Saudis’ perception of diet as a risk factor of CRC incidence. Davis et al. (2015) suggest that behavioral theories are plentiful in fathoming perceptions due to their focus on behavioral patterns related to bad dietary habits. These theories caused vigilant Saudis to act in specific manners or adopt healthy dietary habits to minimize their chances of acquiring colon cancer. The health behavior theories used to predict the performance of health behaviors include Protection Motivation Theory (PMT), Theory of Planned Behaviour (TPB), Social Cognitive Theory, and Health Locus of Control (HLC) theory.
PMT illustrates the adaptive and maladaptive reactions to a health threat (Conner & Norman, 2015). The Theory of Planned Behaviour (TPB) highlights intentions as a representative of an individual’s motivation through their conscious decisions towards implementing the perceived behavior (Conner &Norman, 2015). In the Social Cognitive Theory, an individual’s motivation relies on three possibilities: “situation outcome,” “action-outcome,” and “perceived self-efficacy” (Conner & Norman, 2015). Health Locus of Control (HLC) theory predicts behavior occurring as per situation and is associated with the individual’s expectation that the behavior act as reinforcement (Conner & Norman, 2015).
The HBM is a crucial theoretical framework used by investigators to determine an extended range of more than 30 years in behavior patterns from pro-health behaviors such as healthy eating and exercising to avoiding health-harm behaviors such as smoking (Abraham & Sheeran, 2014). However, no validated scale is written in Arabic to assess Saudi’s perception toward diet as a risk factor of CRC (Conner & Norman, 2015). Therefore, this research intends to narrow the literature gap in Health Belief Model, dietary habits, and colorectal cancer. Additionally, this research aims to translate, modify and validate a scale specific to Saudi’s culture and dietary habits.
A recent study about theoretically designed interventions in the Thran region, Shahid Beheshti University, for colorectal cancer prevention showed effectiveness in implementing an educational intervention that uses the health belief model for personnel. Additionally, it enhances the preventative health practices linked to colorectal cancer (Rakhshanderou et al., 2020).
HBM is a composite of psychological models that illustrate individual characteristics related to health behavior patterns. These patterns help identify health prevention behaviors (Abraham & Sheeran, 2014). The HBM consists of perceived susceptibility (possibility of getting ill and involving awareness that a health threat exists), perceived severity, perceived benefit, perceived barrier, and cues to action (Abraham & Sheeran, 2014). The HBM is one psychological framework used to analyze behavior change among individuals by studying their reasoning characteristics to predict health-related behaviors.
Additionally, this model is applicable in studying Saudis’ perception of the risk of an unhealthy diet since its constructs foster a clear comprehension of different individuals’ psychological tendencies that influence their behavior in response to various stimuli. The theoretical constructs of the HBM theory that is usable 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 include additional concepts 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 into productive ones. According to the HBM model, specific barriers such as emotional disturbance or pain may hinder a person from engaging in a health-promoting behavior that is perceived to be significant, 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 to an unhealthy diet negatively impact Saudi perceptions of its risk.
Perceived Susceptibility
The HBM’s concept of perceived susceptibility can aid in studying and predicting Saudis’ perception of the risk of unhealthy diet among themselves. In this case, people who perceive themselves to be highly susceptible to specific health conditions are highly likely to modify their behaviors and embrace health-promoting ones to mitigate their susceptibility to the disease (Osta et al., 2018; Sulat et al., 2018). On the other hand, individuals who believe they are less susceptible to various health conditions are highly likely to adopt risky or unhealthy health behaviors. Individuals who perceive their health to be highly susceptible to colon cancer are likely to embrace changes in their diet. Therefore, individuals’ perceived susceptibility to the risk of an unhealthy diet is positively related to regulating their diet habits.
Perceived Severity
The HBM model also applies the concept of perceived severity that informs individual health-related behaviors and can study Saudis’ perception of the risk of their unhealthy diet. Individuals who perceive a health condition as 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 instead of one who perceives the risk below. Hence, HBM’s concept of the perceived diet is positively related to Saudis behavior (Osta et al., 2018; Sulat et al., 2018).
Cues to Action
Cues to action are other HBM concepts that can evaluate Saudis’ perception of an unhealthy diet. Schaffer and Debb (2019) maintain that stimuli are imperative to promoting a person’s decision to engage in health-promoting behaviors. In the case of Saudis’ perception regarding the risk of an unhealthy diet as a risk factor of (CRC), external triggers such as diet awareness campaigns may influence their perceptions. Notably, an individual aware of the risks associated with an unhealthy diet tends to embrace diet measures to protect his or her health against CRC. Contrarily, an individual who is less aware of risks surrounding a healthy diet is less likely to adopt new healthy eating habits. Therefore, cues to action positively relate to Saudis’ perception of the risk of an unhealthy diet.
Significance of the Study
Validating translated instruments of HBM in Arabic is crucial to several health practices. First, from a practitioner standpoint, it is very well known that prevention is better than cure. Using the prevention approach will help reduce CRC incidences in Saudi Arabia. Therefore, this research will contribute to literature about influencing Saudis’ perceptions of diet as a risk factor of CRC incidences. Furthermore, future researchers will utilize the translated validated instruments of HBM to gain better insight into what factors practitioners need to focus on when running campaigns that target the initiative toward a healthy diet in Saudi Arabia.
Research Questions
This research determines the validity of the translated health belief model within the Saudi population. Additionally, it attempts to analyze the ability of the demographic variables to show differences in the health beliefs of the subjects – Saudi residents.
Summary
The HBM is a sufficient theoretical framework for investigators of the cognitive determinants of numerous behaviors such as unhealthy habits. The health belief model includes common-sense constructs that non-psychologists can quickly operationalize in self-report questionnaires. It provided scientists’ attention to modifiable psychological determinants of behavior. Therefore, the model is a good fit for the problem of diet. Moreover, it can consider an educational opportunity to teach Saudis about the predeterminants of cancer.
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