1. Introduction
Cancer is one of the most common causes of death worldwide, and lung cancer is one of the most fatal types of cancer, irrespective of race or sex [
1]. The 2021 statistics on the causes of death in South Korea showed that cancer was the number one cause of death in both men and women aged 40 years or above, with lung cancer causing the highest level of mortality in both sexes. The death rate due to lung cancer was 54.0 deaths per 100,000 men and 18.8 deaths per 100,000 women, indicating a continuous increase in mortality compared to previous years [
2]. The highest mortality rate was observed in the population older than 60 years [
2].
A high percentage of cases of lung cancer are diagnosed when the disease has already progressed. The localized lung cancer diagnosis rate in patients diagnosed between 2012 and 2016 was only 21.0%, and the 5-year relative survival rate was 28.2%, which is relatively lower than that of other cancer types [
3]. Nevertheless, early detection of lung cancer increases the 5-year survival rate to 60–70% [
4]. Therefore, the diagnosis of asymptomatic lung cancer using an effective screening method is important for timely treatment and the extension of life.
Smoking is associated with all types of lung cancer (approximately 90%) and is the most significant risk factor. A large-scale comparative clinical study conducted in 2011 in the U.S. screened for lung cancer using low-dose chest computed tomography (CT) in individuals aged 55–74 years at high risk for lung cancer with a history of smoking of 30 pack-years. The study reported a 20% lower lung cancer mortality in the group that was screened for lung cancer as compared to the control group, and an overall decrease in mortality of 7% [
5]. Low-dose chest CT is a sensitive tool for the early detection of lung cancer [
6]. Thus, the U.S. Preventive Services Task Force and the South Korean government recommend chest CT for screening high-risk groups [
5,
7]. However, screening using low-dose chest CT is yet to be widely accepted worldwide, despite its advantages related to morbidity and mortality [
4].
Previous studies have reported the factors associated with a low rate of participation in lung cancer screening programs, including psychological and cognitive variables (social stigma, distrust, fatalism, anxiety, fear, and a low level of knowledge of lung cancer and lung cancer screening), health beliefs (perceived risk, perceived benefit, perceived barrier, and self-efficacy), medical experts’ recommendations, media exposure, and others [
8,
9]. The concept of health belief was first suggested by a social psychologist in the U.S. Public Health Service in the early 1950s to account for the low rate of participation in programs for disease prevention and health screening tests [
10]. Health belief is a critical predictor of various health behaviors, such as smoking, exercise, patient roles, and the use of healthcare services, and accounts for preventive health behaviors related to specific diseases [
11].
The expanded Health Belief Model (EHBM) is a commonly used model to describe participation in cancer screening, such as lung cancer [
9]. The EHBM includes the perceived risk, perceived benefits, perceived barriers, self-efficacy, and perceived severity [
9,
11]. The EHBM states that the probability of an individual participating in a lung cancer screening test increases as the levels of perceived benefit, perceived barriers, and self-efficacy increase, supporting the structure of the conceptual model describing the participation of high-risk groups in lung cancer screening [
4]. Hence, assessing and understanding personal beliefs regarding lung cancer screening are critical for improving the rate of screening for lung cancer in high-risk groups. Thus, the Lung Cancer Screening Health Belief Scale (LCSHBS) was developed in English to measure the beliefs of individuals regarding lung cancer screening [
12]. The LSCHBS includes health beliefs about lung cancer screening: (1) perceived risk of lung cancer; (2) perceived benefits of lung cancer screening; (3) perceived barriers to lung cancer screening; and (4) self-efficacy for lung cancer screening [
9]. Perceived severity, which was included in the EHBM, was excluded because it has been reported that it is not useful for cancer screening, which is already recognized as a serious disease [
9]. The validity and reliability of the LSCHBS have been tested and confirmed. However, applying the tool in South Korea requires the verification of the tool’s validity and reliability in high-risk patients in Korea to allow the collection of stronger evidence.
This study aimed to produce and validate a Korean version of the LCSHBS originally developed by Carter-Harris et al. [
12] by translating the tool according to the current statuses in South Korea among Korean adults at high risk for lung cancer.
4. Discussion
This study translated and produced a Korean version of the LCSHBS in South Korea and verified the suitability of the LCSHBS-K by testing its validity and reliability in Korean adults at high risk for lung cancer. The LCSHBS has verified validity and reliability in English-speaking countries, where it was originally developed, as well as in China, which shares cultural similarities with South Korea [
28]. In addition, the LCSHBS was translated into a Spanish version, and its validity and reliability were verified [
29].
Verification of the validity of a tool is essential. The American Educational Research Association stated that the evidence for validity cannot be supported using a single approach [
30]. Hence, the present study aimed to test the validity of the LCSHBS-K using various methods.
The present study complied with the guidelines for tool development to translate the LCSHBS based on the current status in South Korea. First, to ensure the cultural equivalence between the country where the original tool was developed and South Korea, where the tool is to be applied, the Brislin method was used to produce the Korean version of the tool. For this purpose, bilingual experts familiar with both cultures and a panel of experts, including lung cancer and nursing specialists, were recruited to ensure the content validity of the tool. Items that satisfied the item-content validity by the panel of experts were selected.
To ensure the construct validity of the LCSHBS-K, a revised version of the initial model was adopted, as it satisfied the CMIN, SRMR, RMSEA, and CFI criteria. The factor structures of the English and Korean versions of the LCSHBS were similar.
To ensure the concurrent validity of the LCSHBS-K, the correlation coefficients for the LCSHBS-K and the health belief scale for adults developed by Moon [
17] were obtained and showed a significant correlation for the overall scale. However, the correlation coefficient for the perceived barrier was 0.08, indicating a lack of correlation, in contrast to all the other dimensions, which showed significant correlations. This is similar to a study of high-risk Chinese-American smokers who were interviewed about their beliefs regarding lung cancer screening using low-dose CT [
31]. The responses of the participants on perceived severity, perceived benefits, and perceived susceptibility were similar, but the responses to the perceived barriers varied across the participants [
31]. Lei et al. reported that the obstacles reported by participants regarding lung cancer screening included emotional factors, inadequate knowledge of lung cancer screening, economic factors, physical barriers, ill-advised beliefs regarding health maintenance, language barriers, and social stigma regarding screening tests, which varied widely across the participants [
31]. Hence, the barriers preventing target behaviors in participants could be similar or vary widely. Similarly, in the LCSHBS, the perceived barrier also includes a higher number and variety of questions than in the other dimensions; therefore, the total score, as well as the content, should be examined for this particular dimension when using the LCSHBS. On the other hand, when health beliefs were compared between individuals who received lung cancer screening and those who did not, statistical differences were found only in the perceived barriers. The Spanish version of LCSHBS also showed no differences in all dimensions [
29]. However, the difference in scores between the two groups in both the Korean and Spanish versions was consistent with the theoretical direction of the EHBM [
29].
All the convergent and discriminant validity criteria for the LCSHBS-K were satisfied. For all the factors, the AVE and CR were ≥0.90 and ≥0.98, respectively. The r across the factors was −0.51 to 0.38, which satisfied r2 < AVE.
The internal consistency of the LCSHBS-K in this study showed a Cronbach’s α of 0.80. The reliability of dimensions was relatively high, ranging between 0.78 and 0.93, and was similar in the reliabilities of the English and Chinese versions. These results confirmed the internal consistency of the tool [
12,
28].
The results of this study demonstrate that the LCSHBS-K is a valid and reliable tool for assessing health beliefs regarding lung cancer screening. The LCSHBS-K will contribute to a more accurate assessment and in-depth understanding of the levels and types of health beliefs regarding lung cancer screening in Korean patients at high risk for lung cancer. This accurate understanding may lead to a positive change in these health beliefs, which would ultimately promote decision-making regarding lung cancer screening for positive health outcomes [
9]. Therefore, the LCSHBS-K is anticipated to enable personalized interventions to develop various policies and programs aimed at increasing lung cancer screening in the Korean population, especially for those at high risk of lung cancer. Although the LCSHBS-K is available for measuring Korean speakers’ health beliefs regarding lung cancer screening, this study has several limitations. First, the characteristics of the participants recruited via online platforms may have influenced the results. Since subjects who did not use smartphones or PCs frequently or who did not know how to use them were excluded, the participants might have differences in age or knowledge level compared to those excluded from the study. Therefore, future study is required to include a variety of participants, including those excluded from this study. Second, since the Korean HBS compared to check concurrent validity—even though it has been used several times in Korea—was not a scale for lung cancer or other cancer screening, but a scale for measuring health beliefs for overall health promotion behaviors to prevent chronic disease, careful interpretation is required. Third, it was necessary to include in the model several correlations between the perceived barriers scale items to obtain a satisfactory model fit for a tool. These correlated residuals suggest that those items share some variance beyond the generic perceived barrier theme, indicating that this is a heterogeneous dimension that may comprise several subdimensions. Future research should explore putative subdimensions for perceived barriers in lung cancer screening.