Table 1.
Key characteristics, variables of interest and major findings of studies included in this review.
| Authors | Country | Sample size | Sample age range | Ethnic description of sample | Study design | Sampling strategy | HBM instrument(s) used | Exposure variable(s) | Outcome variable(s) | Major findings (directly associated with CRC screening) | Major findings (inversely associated with CRC screening) |
|---|---|---|---|---|---|---|---|---|---|---|---|
| (Almadi et al., 2015) | Saudi Arabia | 500 | 18–75 (Mean age 41 years) | 500 Saudi Arabians | Cross-sectional | One-stage cluster sampling of malls, convenience sampling within clusters | Questionnaire designed based on HBM, using a 5-point Likert scale | Sociodemographics Family history of CRC Knowledge of CRC symptoms, risk factors, screening HBM constructs (Perceived severity, perceived susceptibility, perceived barriers) |
Intention to screen for CRC | Knowledge of CRC risk factors (age, male gender as risk factors) were positively associated with intention to screen Perceived barrier (i.e. colonoscopy is harmful) positively associated with intention to screen |
Perceived barrier (i.e. not wanting to know about cancer) negatively associated with intention to screen |
| (Arnold et al., 2012) | USA | 975 | 50–89 (Median age 57 years) | 654 African Americans, 315 Whites, 3 Hispanics | Cross-sectional | Random sample from eight federally-qualified health centres (as part of RCT) Study comprised baseline measure for the RCT |
46-item questionnaire designed using HBM, validated in previous studies (Dolan et al., 2004 and Wolf et. al., 2005), using a 3-point scale | Sociodemographics Literacy Knowledge of CRC screening HBM constructs (Perceived susceptibility, perceived barriers, perceived benefits, cues to action, self-efficacy) |
Past CRC screening behaviour | Low literacy negatively associated with past CRC screening | |
| (Azaiza and Cohen, 2008) | Israel | 520 | 50–75 (Mean age 60 years) | 358 Jews, 162 Arabs | Cross-sectional | Random digit dialling of households from general population | 15-item questionnaire based on Becker's Health Belief Questionnaire (1980), using a 5-point scale | Sociodemographics Level of CRC worry HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits, cues to action) |
Past CRC screening behaviour | Demographics (age, educational attainment, first degree relative with CRC) positively associated with past CRC screening Cues to action (i.e. physician's recommendation), perceived susceptibility, perceived benefits positively associated with past CRC screening |
|
| (Bae et al., 2014) | South Korea | 237 | 50 and above (Mean age 60 years) | 237 South Koreans | Cross-sectional | Unspecified | A 36-item instrument was adapted from the Jacob's HBM scale for colon cancer screening (2002), using a 5-point Likert scale | Sociodemographics HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits, self-efficacy) Health motivation |
Adherence to CRC screening (i.e. annual FOBT completion between 2002 and 2011) | Perceived susceptibility positively associated with CRC screening adherence | Monthly household income negatively associated with CRC screening adherence Perceived barriers and severity negatively associated with CRC screening adherence |
| (Ben Natan et al., 2019) | Israel | 200 | 50–79 (Mean age 57 years) | 200 Israeli Arabs | Cross-sectional | Snowball sampling from general population | A 16-item questionnaire based on the questionnaire constructed by Azaiza and Cohen (Azaiza and Cohen, 2008), using a 5-point Likert scale | Sociodemographics HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits, cues to action) |
Past CRC screening behaviour (FOBT only) Intention to screen for CRC (FOBT only) |
Family history of CRC positively associated with intention to screen Perceived susceptibility, severity, benefits and cues to action positively associated with intention to screen |
Perceived barriers negatively associated with intention to screen |
| (Frank et al., 2004) | USA | 49 | 50 and above | 49 African American (Women) | Cross-sectional | Random sampling from four churches | 45-item Champion's HBM Scale (1999), using a 5-point scale | Sociodemographics HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits) Perceived confidence Health motivation |
Past CRC screening behaviour | Perceived susceptibility and benefits positively associated with past CRC screening Perceived confidence positively associated with past CRC screening |
Perceived barriers and severity negatively associated with past CRC screening Health motivation negatively associated with past CRC screening |
| (Dashdebi et al., 2016) | Iran | 600 | 50 and above | 600 Iranians | Cross-sectional | One-stage cluster sampling of laboratories, convenience sampling within clusters | 52-item instrument based on Satia et. al., 2007, Shokar et. al., 2008 and Chen et. al., 2010 was used, using a 5-point Likert scale | Sociodemographics Knowledge of CRC HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits, self-efficacy) |
Past CRC screening behaviour (FOBT only) | Perceived benefits and self-efficacy positively associated with past CRC screening | Perceived barriers negatively associated with past CRC screening |
| (Gorin, 2005) | USA | 950 | 49 and above | 950 Hispanics | Cross-sectional (FOBT provided post-survey) | Convenience sampling of women from hospital-based national breast and cervical screening program | 2-item on barriers based on Manne et. al., 2002 using a 4-point Likert scale 5-item on supports based on Manne et. al., 2002 and Rakowski et. al., 1992, 1996, using a 4-point Likert scale 2-item on cues to action, based on Myers et. al., 1994, and Manne et. al., 2002, using a binary scale 1-item on susceptibility based on Lipkus et. al., 2000, using a 5-point scale 2-item on perceived severity based on Aiken et. al., 1994, using a 4-point Likert scale 7-item on fatalism based on Lerman et. al., 1991 and Powe, 1995. |
Sociodemographics Family and personal history of CRC Knowledge of CRC risk factors, symptoms, screening HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, cues to action) Cancer worry Fatalism |
Intention to screen for CRC (FOBT only) CRC screening uptake (completion of FOBT provided post-survey) |
Fatalism positively associated with CRC screening uptake | Perceived barriers negatively associated with CRC screening uptake Cancer worry negatively associated with CRC screening uptake |
| (Hay et al., 2003) | USA | 280 | 50–75 (mean age 62 years) | 44 African Americans, 213 Caucasians, 11 Latinos/Hispanics, 6 Asians, 6 Others | Cross-sectional | Convenience sampling of women from a large, urban breast cancer diagnostic facility | 1-item on perceived susceptibility based on Weinstein, 1980, 1987, using a 5-point scale 3-item on perceived severity using Aiken et. al., 1994, using a 5-point scale 3-item on self-efficacy, using a 5-point scale 27-item on perceived benefits and barriers based on Rakowski et. al., 1993, using a 5-point scale |
Sociodemographics Family history of CRC HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits, cues to action, self-efficacy) |
Past CRC screening behaviour | Perceived benefits, cues to action and self-efficacy positively associated with past CRC screening | Perceived barriers negatively associated with past CRC screening |
| (Hughes et al., 2015) | USA | 393 | 50–75 (Mean age 62 years) | 194 Rural Whites, 179 Urban Whites, 5 Rural Non-Whites, 12 Urban Non-Whites | Cross-sectional | Random sampling of patient population from two regional medical centres | 22-item instrument based on James et. al., 2002, Menon et. al., 2007, Ueland et. al., 2006 and Janz et. al., 2003, using a 5-point Likert scale | Sociodemographics Personal history of CRC HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits, cues to action, self-efficacy) |
Past CRC screening behaviour | Perceived benefits and susceptibility positively associated with past CRC screening | Perceived barriers negatively associated with past CRC screening |
| (James et al., 2002) | USA | 397 | 50 and above (Mean age 63 years) | 397 African Americans | Cross-sectional | Convenience sampling from a larger study involving 12 churches | Barrier and Benefit items were derived from focus groups conducted during the pilot studies, using a Likert-type scale | Sociodemographics HBM constructs (Perceived barriers, perceived benefits) |
Past CRC screening behaviour | Perceived benefits positively associated with past CRC screening (all screening modalities) | Perceived barriers negatively associated with past CRC screening (all screening modalities) |
| (Janz et al., 2003) | USA | 355 | 50–79 | 74 Black Male, 98 Black Female, 105 White Male, 98 White Female | Cross-sectional | Random sampling of household telephone numbers from general population | 18-item instrument on benefits and barriers based on Rawl et. al. 10-item instrument on perceived severity and susceptibility based on Myers et. al., |
Sociodemographics HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits) Salience and coherence of CRC screening |
Past CRC screening behaviour | Age positively associated with past CRC screening (FOBT and flexible sigmoidoscopy) Perceived susceptibility positively associated with past CRC screening (flexible sigmoidoscopy only) |
Perceived barriers negatively associated with past CRC screening (all screening modalities) |
| (Javadzade et al., 2012) | Iran | 196 | 50 and above | 196 Iranians | Cross-sectional | Random sampling of referral patients from four FOBT laboratories; one-stage cluster sampling from general population | 26-item instrument on perceived susceptibility, severity, benefits and barriers designed based on resources, books and papers, using a 5-point Likert scale 5-item instrument on self-efficiency designed based on resources, books and papers, using a 4-point Likert scale. |
Sociodemographics Knowledge of CRC screening Group assignment (referral or general population) HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits, cues to action, self-efficacy) |
Past CRC screening behaviour Intention to screen for CRC |
Referral group positively associated with past CRC screening | |
| (Khani Jeihooni et al., 2017) | Iran | 240 | 50 and above | 240 Iranians | Cross-sectional | Random sampling of referral patients from two FOBT laboratories; convenience sampling from general population | 26-item instrument on perceived susceptibility, severity, benefits and barriers designed based on Javadzade et. al., 2012, using a 5-point Likert scale 5-item instrument on self-efficiency designed based on Javadzade et. al., 2012, using a 4-point Likert scale. |
Sociodemographics Knowledge of CRC screening Group assignment (referral or general population) HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits, cues to action, self-efficacy) Perceived social support |
Past CRC screening behaviour (FOBT only) Intention to screen for CRC (FOBT only) |
Knowledge of CRC screening positively associated with past CRC screening Perceived severity, susceptibility, and benefits positively associated with past CRC screening Self-efficacy and perceived social support positively associated with past CRC screening |
Perceived barriers negatively associated with past CRC screening |
| (Koo et al., 2012) | Multinational | 2990 | 50 and above | 311 Australians, 161 Bruneians, 275 Chinese, 93 Filipinos, 289 Hong Kongers, 65 Indians, 203 Indonesians, 313 Japanese, 399 Koreans, 99 Malaysians, 93 Pakistanis, 436 Singaporeans, 90 Taiwanese, 163 Thais | Cross-sectional | Random sampling from outpatient clinics within each participating hospital | HBM Questionnaire based on Sung et. al., 2008 | Sociodemographics Knowledge of CRC symptoms, risk factors, and screening HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits, cues to action) Access to healthcare |
Past CRC screening behaviour Intention to screen for CRC |
Knowledge of CRC screening positively associated with past CRC screening Cues to action (physician's recommendation) positively associated with past CRC screening |
|
| (Lee et al., 2019) | USA | 121 | 50–75 (Mean age 61 years) | 121 Thais in USA | Cross-sectional | Convenience sampling from Thai community service agency and two temples | HBM subscale questionnaire based on Menon et. al., 2003, 2007, using a 5-point Likert scale | Sociodemographics Perceived health status HBM constructs (Perceived susceptibility, perceived barriers, perceived benefits, self-efficacy) Spousal support |
Past CRC screening behaviour | Age positively associated with past CRC screening Self-efficacy positively associated with past CRC screening |
|
| (Lee and Im, 2013) | USA | 281 | 50–88 (Mean age 67 years) | 281 Korean Americans | Cross-sectional | Convenience sampling from two Korean senior centres and two Korean churches | 33-item instrument adapted from Champion's original scale, using a 4-point Likert scale | Sociodemographics Family and personal history of CRC HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits, self-efficacy) Motivation to go for CRC screening Cultural factors (fatalism, modesty, family support, use of eatern medicine, helplessmess) |
Past CRC screening behaviour (colonoscopy and flexible sigmoidoscopy) | Perceived severity positively associated with past CRC screening (females only) Motivation positively associated with past CRC screening (females only) Self-efficacy positively associated with past CRC screening (both males and females) |
Fatalism negatively associated with past CRC screening (males only) |
| (Leung et al., 2016) | Hong Kong SAR | 240 | 60 and above (Mean age 75 years) | 240 Chinese | Cross-sectional | Convenience sampling from three non-governmental organisations' elderly centres | 35-item CRC Perception and Screening instrument was based on Green and Kelly, 2004, Leung et. al., 2014, using a 5-point Likert scale 4-item on self-efficacy based on von Wagner et. al., 2009, using a 5-point scoring scale 3-item on cue to action based on Sung et. al., 2008, using a binary yes/no format |
Sociodemographics Knowledge of CRC symptoms, risk factors, and screening HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits, cues to action, self-efficacy) Fear of CRC |
Past CRC screening behaviour | Cues to action positively associated with past CRC screening | Perceived severity and barriers negatively associated with past CRC screening |
| (Lin et al., 2019) | Taiwan | 391 | 50–75 | 391 Taiwanese | Cross-sectional | Unspecified | HBM subscale questionnaire based on Wu et. al., 2013, Wong et. al., 2013, using a 5-point Likert scale | Sociodemographics Family and personal history of CRC HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits, cues to action, self-efficacy) |
Intention to screen for CRC (FOBT only) | Perceived severity, benefits and self-efficacy positively associated with intention to screen | Perceived barriers negatively associated with intention to screen |
| (Macrae et al., 1984) | Australia | 581 | 40–75 | 523 Australians, 58 undefined | Cross-sectional (FOBT provided post-survey) | Convenience sampling from 14 clinical outpatient practices | 11-item instrument constructed using specifications based on Rosenstock, 1975, using a 5-point scale | Sociodemographics Family and personal history of CRC HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits) Health motivation Efficacy of treatment |
CRC screening uptake (completion of FOBT provided post-survey) | Perceived susceptibility positively associated with CRC screening uptake | Perceived barriers negatively associated with CRC screening uptake |
| (Menon et al., 2007) | USA | 206 | 50 and above (Mean age 61 years) | 167 White, 39 Nonwhite | Cross-sectional | Convenience sampling from large health maintenance organisation | 55-item instrument validated previously by author, using Likert scales | Sociodemographics Knowledge of CRC risk factors and screening HBM constructs (Perceived susceptibility, perceived barriers, perceived benefits, self-efficacy) |
Transtheoretical Model constructs (Precontemplation, contemplation, action) (FOBT and sigmoidoscopy) Note: Participants in “action” phase counted as ever having completed CRC screening |
Perceived susceptibility and benefits positively associated with past CRC screening (FOBT only) Perceived susceptibility and self-efficacy positively associated with past CRC screening (sigmoidoscopy only) |
Perceived barriers negatively associated with past CRC screening (FOBT and sigmoidoscopy) |
| (Ng et al., 2007) | Singapore | 514 | 50 and above | 514 Singaporean-Chinese | Cross-sectional | Random sampling from general population | 22-item instrument adapted from Green and Kelly, 2004, which was based on Stretcher and Rosenstock's HBM, 1997, using a 5-point likert scale | Sociodemographics Knowledge of CRC and screening HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits, cues to action) |
Past CRC screening behaviour | Knowledge of CRC and screening positively associated with past CRC screening Perceived benefits and cues to action positively associated with past CRC screening |
Perceived severity and barriers negatively associated with past CRC screening |
| (Palmer et al., 2011) | USA | 504 | 50–75 | 504 African Americans | Cross-sectional | Random digit dialling of households from general population | 3-item on perceived susceptibility based on Lipkus, using a 4-point Likert scale 3-item on self-efficacy based on Rakowski et. al., 2004 4-item on perceived barriers and benefits based on Vernon et.al., 1997 and Jacobs, 2002, using a 5-point Likert scale |
Sociodemographics Personal history of CRC Sources of health information Knowledge of CRC HBM constructs (Perceived susceptibility, perceived barriers, perceived benefits) |
Past CRC screening behaviour Intention to screen for CRC |
Perceived susceptibility and cues to action positively associated with past CRC screening | |
| (Sammut et al., 2019) | Malta | 245 | 57–61 | 245 Maltese | Cross-sectional | Random sampling from national screening database | Instrument based on Dome Le et. al., 2013 and Champion et. al., 2014 | Sociodemographics HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits) Fear of CRC |
Past CRC screening behaviour | Perceived barriers negatively associated with past CRC screening | |
| (Sohler et al., 2015) | USA | 1101 | 50–75 (Mean age 57 years) | 112 Hispanic, 67 Black, 60 Non-hispanic White, 11 Other | Cross-sectional | Convenience sampling from primary care clinics in four states; study comprised baseline measure for CRC screening RCT | 13-item Instrument based on EHBM | Sociodemographics Knowledge of CRC risk factors and screening HBM constructs (Perceived barriers, cues to action, self-efficacy) |
CRC screening uptake (at 12-month follow-up in RCT) | Cues to action and self-efficacy positively associated with CRC screening uptake (colonoscopy only) | |
| (Taheri-Kharameh et al., 2016) | Iran | 200 | 50 and above (Mean age 62 years) | 200 Iranians | Cross-sectional | Convenience sampling from outpatient clinics in three teaching hospitals | 36-item Champion's Health Belief Model Scale using a 5-point Likert scale | Sociodemographics Family history of CRC Knowledge of CRC and screening HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits) Health motivation |
Past CRC screening behaviour | Knowledge of CRC and screening positively associated with past CRC screening | Perceived barriers negatively associated with past CRC screening |
| (Taş et al., 2019) | Turkey | 235 | 50–70 (Mean age 59 years) | 235 Turks | Cross-sectional | Convenience sampling from one family health center | 33-item instrument based on Health Belief Model Scale for Protection from Colorectal Cancer, evaluated in Tureky by Ozsoy et. al., 2007, using a 5-point Likert scale | Sociodemographics Family and personal history of CRC Knowledge of CRC risk factors, symptoms, screening HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits) Health motivation |
Past CRC screening behaviour | Knowledge of CRC screening positively associated with past CRC screening | |
| (Tastan et al., 2013) | Turkey | 160 | 50 and above (Mean age 61 years) | 160 Turks | Cross-sectional | Convenience sampling from one family medicine clinic | 33-item instrument derived from Champion's Health Belief Model Scale | Sociodemographics Personal history of CRC Knowledge of CRC risk factors and screening HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits) Health motivation |
Past CRC screening behaviour | Perceived benefits positively associated with past CRC screening | |
| (Wong et al., 2013) | Singapore | 1763 | 50 and above (Mean age 61 years) | 1410 Chinese, 157 Indians, 136 Malays, 40 Others | Cross-sectional | Stratified random sampling of residential households from general population | 24-item instrument designed based on HBM, piloted on 10 subjects | Sociodemographics Family and personal history of CRC Knowledge of CRC, symptoms and screening HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits, cues to action) |
Past CRC screening behaviour | Perceived susceptibility and cues to action positively associated with past CRC screening (males and females) Family history of CRC positively associated with past CRC screening (females) |
Perceived barriers negatively associated with past CRC screening (males and females) |
| (Yoo et al., 2013) | USA | 5586 | 50 and above (Mean age 63 years) | 2769 Caucasians, 718 Non-Caucasians | Cross-sectional | Random digit dialling from general population | 18-item instrument based on HBM constructs was used | Family and personal history of CRC Perceived health status HBM constructs (Perceived severity, perceived susceptibility, perceived barriers, perceived benefits) |
Past CRC screening behaviour (FOBT only) | Perceived threat (composite of severity and susceptibility) positively associated with past CRC screening Positive expectations (composite of benefits minus barriers) positively associated with past CRC screening |