Cross-cultural modification strategies for instruments measuring health beliefs about cancer screening: Systematic review

Fang Lei, Eunice Lee

Research output: Contribution to journalReview articlepeer-review


Background: Modification is an important process by which to adapt an instrument to be used for another culture. However, it is not fully understood how best to modify an instrument to be used appropriately in another culture. Objective: This study aims to synthesize the modification strategies used in the cross-cultural adaptation process for instruments measuring health beliefs about cancer screening. Methods: A systematic review design was used for conducting this study. Keywords including constructs about instrument modification, health belief, and cancer screening were searched in the PubMed, Google Scholar, CINAHL, and PsycINFO databases. Bowling's checklist was used to evaluate methodological rigor of the included articles. Results were reported using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) approach with a narrative method. Results: A total of 1312 articles were initially identified in the databases. After removing duplications and assessing titles, abstracts, and texts of the articles, 18 studies met the inclusion criteria for the study. Based on Flaherty's cultural equivalence model, strategies used in the modification process included rephrasing items and response options to achieve semantic equivalence; changing subjects of items, changing wording of items, adding items, and deleting items to achieve content equivalence; adding subscales and items and deleting subscales and items to achieve criterion equivalence. Solutions used to resolve disagreements in the modification process included consultation with experts or literature search, following the majority, and consultation with the author who developed the scales. Conclusions: This study provides guidance for researchers who want to modify an instrument to be used in another culture. It can potentially give cross-cultural researchers insight into modification strategies and a better understanding of the modification process in cross-cultural instrument adaptation. More research could be done to help researchers better modify cross-cultural instruments to achieve cultural equivalence.

Original languageEnglish (US)
Article numbere28393
JournalJMIR Cancer
Issue number4
StatePublished - Oct 2021
Externally publishedYes

Bibliographical note

Publisher Copyright:
© JMIR Cancer 2021.


  • Cancer screening
  • Health beliefs
  • Instrument modification
  • Strategy
  • Systematic review


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