Colon Health Survey (Male)

Abstract

The Colon Health Survey (Male), developed by Dr. Ann Mitchell Kimberly (2009) at Indiana University, is a comprehensive multidimensional psychometric battery engineered to assess cognitive, behavioral, psychological, and normative barriers to colorectal cancer (CRC) screening among adult males. Colorectal adenocarcinoma represents one of the leading causes of cancer-related mortality globally, yet screening adherence via colonoscopy remains suboptimal, particularly among men whose adherence behaviors are often attenuated by masculine socialization, privacy apprehensions, and procedural aversion. The instrument comprises 64 items divided into distinct conceptual modules: medical history and prior screening exposure (Items 1–6), demographic parameters (Items 7–10), colonoscopy history and behavioral intention (Items 11–15), disease and procedural knowledge (Items 16–23), procedural self-efficacy (Items 24–33), generalized barriers and perceived vulnerability (Items 34–47), qualitative narrative self-reports (Items 48–49), and the embedded, psychometrically validated 15-item Colonoscopy Embarrassment Scale (CES) (Items 50–64).

Measurement formats vary logically across sub-constructs, incorporating dichotomous categorical indicators, multiple-choice knowledge metrics, 4-point response formats for self-efficacy (“Not at all sure” to “Very sure”), and 4-point Likert-type scales (“Strongly disagree” to “Strongly agree”) for perceived barriers and situational embarrassment. Psychometric evaluation of the embedded CES demonstrated strong internal consistency reliability, yielding a Cronbach’s alpha ranging from α = .88 to .92 across adult male validation cohorts. Exploratory and confirmatory factor analyses validate a distinct multidimensional factor solution reflecting Medical Modesty/Exposure, Bodily Control and Odor, and Interpersonal Examiner Dynamics. The Colon Health Survey (Male) serves as a pivotal assessment framework in behavioral oncology, preventive medicine, and public health nursing, providing granular diagnostic data necessary to develop tailored behavioral interventions and mitigate affective deterrents to endoscopic cancer prevention.

Keywords

Colon Health Survey, Colonoscopy Embarrassment Scale, Colorectal Cancer Screening, Medical Modesty, Men’s Health, Health Belief Model, Self-Efficacy, Cancer Screening Adherence, Procedural Anxiety, Psychometrics

Authors

The Colon Health Survey (Male) and the embedded Colonoscopy Embarrassment Scale (CES) were developed by Ann Mitchell Kimberly, PhD, RN, in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the School of Nursing, Indiana University (2009). Dr. Kimberly’s doctoral research committee included prominent nurse scientists and behavioral health researchers specializing in oncology nursing, preventive health behaviors, instrument design, and psychometrics, including Dr. Victoria L. Champion, a distinguished scholar recognized internationally for her empirical expansions of the Health Belief Model in cancer screening contexts.

Inquiries regarding the theoretical conceptualization and original validation cohort characteristics are cataloged within the institutional dissertation archives of Indiana University and scholarly repositories supporting cancer prevention and behavioral medicine initiatives.

Purpose

Colorectal cancer remains a profoundly preventable disease via endoscopic detection and polypectomy of precancerous adenomatous polyps. In spite of robust epidemiological evidence establishing that screening colonoscopy significantly curtails cancer-specific mortality, male population-level uptake regularly fails to achieve benchmark public health targets. Traditional epidemiological investigations have extensively documented structural determinants of non-adherence—such as socioeconomic status, clinical access, health insurance provisions, and educational attainment—yet these socio-demographic indicators fail to fully explain why socioeconomically stable, insured males continue to avoid or delay screening.

The Colon Health Survey (Male) was purposefully conceptualized and operationalized to address this empirical gap. Its primary objective is to capture the complex matrix of behavioral, cognitive, informational, and emotional determinants that govern male screening decisions, with an unprecedented diagnostic emphasis on procedural embarrassment, modesty, and perceived loss of bodily autonomy. In clinical practice and behavioral research, the survey is implemented to achieve several distinct aims:

• Diagnostic Screening Hesitancy Assessment: Quantifying patient-specific barriers prior to clinical referral, allowing primary care physicians, gastroenterologists, and navigators to identify patients at elevated risk for appointment cancellation or no-show behavior.
• Isolation of Affective Deterrents: Decoupling generalized procedural anxiety (e.g., fear of pain, sedation risks, clinical perforation) from localized visceral embarrassment (e.g., perianal tactile exposure, involuntary flatus, examiner gender dynamics, fecal incontinence during preparation).
• Evaluation of Procedural Self-Efficacy: Evaluating a male patient’s subjective confidence regarding the sequential behavioral demands of colonoscopy, ranging from strict adherence to dietary and purgative bowel preparation to arranging logistical escort services.
• Granular Needs Assessment for Tailored Interventions: Supplying public health interventionists with baseline empirical metrics to design educational materials that actively normalize procedural realities, confront toxic masculine stoicism, and alleviate procedural shame.

Psychological Construct

The survey measures several interdependent psychological, cognitive, and affective constructs. While early sections capture clinical and objective knowledge dimensions, the core psychological measurement architecture centers on three focal latent constructs: Procedural Self-Efficacy, Perceived Health Barriers/Vulnerabilities, and Medical/Procedural Embarrassment.

1. Procedural Self-Efficacy (Items 24–33)

Grounded in social cognitive formulations, procedural self-efficacy denotes an individual’s perceived capability to organize, execute, and tolerate the prospective sequence of actions necessary to successfully complete an invasive clinical procedure. This construct does not reflect generalized self-esteem, but rather task-specific, behavioral agency across several critical hurdles:

• Logistical Efficacy: Perceived capability to schedule appointments, coordinate transportation, and manage clinical timelines (e.g., Items 24, 25, 28).
• Preparatory/Somatic Efficacy: Perceived capability to ingest high-volume purgative bowel preparations and endure prolonged fasts from solid food (e.g., Items 26, 27, 30).
• Affective Coping Efficacy: Confidence in enduring anticipatory worry, procedural ambiguity, and visceral anxiety without abandoning the screening pathway (e.g., Items 31, 32, 33).

2. Perceived Barriers and Subjective Susceptibility (Items 34–47)

This dimension operationalizes the cost-benefit analysis individuals mentally perform when evaluating health interventions. Items assess structural impediments (lack of time, logistical escort issues), cognitive deficits (failure to understand the rationale for screening in the absence of symptoms), physiological concerns (fear of somatic pain or bowel injury), and fatalistic anxieties (fear of receiving a cancer diagnosis). Subscale items systematically measure how these competing cognitive appraisals suppress preventive action.

3. Colonoscopy Embarrassment (CES, Items 50–64)

The primary theoretical innovation within the survey is the isolated conceptualization of medical embarrassment as a multifaceted, acute emotional threat to the social and physical self. Kimberly defined colonoscopy embarrassment as an unpleasant, agitated emotional state characterized by self-consciousness, perceived indignity, and threat to personal modesty elicited by the socio-technical conditions of an endoscopic bowel evaluation. Factor analytic delineation identifies three focal sub-dimensions of this construct:

• Modesty and Bodily Exposure: Reflects deep-seated discomfort regarding the public visualization and tactile manipulation of private, anatomically intimate body regions by medical professionals (e.g., concerns regarding buttock visualization, rectal probe insertion, and exposure of genitalia; Items 59, 60, 61, 63, 64).
• Loss of Somatic Control and Cleanliness: Centers on fears of violating social taboos surrounding excretion, involuntary flatus, foul odors, or incomplete bowel emptying in the presence of others (Items 53, 58, 62).
• Interpersonal and Social Encounter Dynamics: Evaluates the discomfort generated by the social configuration of the endoscopy suite, including the presence of unfamiliar staff, opposite-gender clinicians, trainees/observers, or non-clinical interpersonal behaviors such as humor/joking (Items 50, 51, 52, 54, 55, 56, 57).

Theoretical Framework

The theoretical architecture of the Colon Health Survey (Male) draws extensively upon two prominent paradigms in health psychology and behavioral sociology: the Health Belief Model (HBM) and Erving Goffman’s dramaturgical sociological theory of social stigma and embarrassment, synthesized further through Albert Bandura’s Social Cognitive Theory.

The Health Belief Model posits that health-related behavior is dictated by four foundational perceptions: perceived susceptibility to an illness, perceived severity of the consequences, perceived benefits of preventive action, and perceived barriers (both physical and psychological) impeding that action. Later revisions incorporated cues to action and self-efficacy. The Colon Health Survey directly implements this cognitive-rational framework: Items 16–23 capture the prerequisite cognitive knowledge base; Items 34–47 represent the explicit trade-off between perceived benefits/susceptibility and perceived barriers; and Items 24–33 assess Bandura’s self-efficacy construct, testing the individual’s subjective estimation of behavioral competence across every link in the colonoscopy chain.

However, traditional HBM frameworks have frequently been critiqued for over-intellectualizing human behavior, reducing complex bodily choices to rational economic calculations while underestimating the profound disruptive force of acute human emotions—particularly shame, modesty, and embarrassment. To capture these dynamics, Kimberly integrated sociological frameworks of embarrassment, notably drawing on Goffman’s conceptualization of interactional modesty and social front. According to Goffman, social encounters require participants to sustain idealized performances of bodily control, cleanliness, and poise. An invasive medical procedure such as a colonoscopy presents a total structural breakdown of these protective social boundaries. The patient is placed in an asymmetrical, highly vulnerable posture (the left lateral decubitus position), physically exposed, and subjected to deliberate physical probing of an anatomical region associated with intense excretory taboos and privacy.

Furthermore, this vulnerability interacts with culturally dictated norms of hegemonic masculinity. Male socialization commonly reinforces values of invulnerability, emotional detachment, physical dominance, and rigid homophobia. The physical act of submitting to rectal penetration—even for life-saving clinical purposes—can trigger implicit conflicts with masculine identity, creating profound psychological distress and avoidance. By anchoring the survey simultaneously within the cognitive boundaries of the HBM and the visceral social-affective dimensions of interactional modesty theory, the instrument bridges the gap between cognitive health decision-making and emotionally grounded behavioral avoidance.

Validity

The psychometric integrity of the Colon Health Survey (Male) and its integrated Colonoscopy Embarrassment Scale was established through a series of rigorous empirical validation protocols involving diverse adult male community cohorts, clinical samples, and psychometric review panels.

Content Validity

Content validity was evaluated during initial instrument generation through an exhaustive review of the empirical literature on procedural barriers to endoscopy, supplemented by qualitative key-informant interviews with screening-eligible men and clinical consultations with gastroenterologists, oncology nurses, and behavioral scientists. A formal panel of psychometric and clinical experts assessed each candidate item for linguistic clarity, cultural sensitivity, representativeness, and domain relevance using the Content Validity Index (CVI). Items failing to achieve a minimum item-level CVI (I-CVI) of .80 were systematically eliminated or revised to reflect precise anatomical and psychological distinctions.

Construct and Structural Validity

Construct validity of the survey modules was corroborated through hypotheses-testing methodologies. Significant inverse correlations were observed between the Self-Efficacy subscale and the Perceived Barriers subscale (r = −.42 to −.55, p < .001), indicating that men possessing higher task self-efficacy systematically reported fewer behavioral and psychological deterrents. The Colonoscopy Embarrassment Scale exhibited robust construct validity, showing significant positive correlations with validated general medical fear scales, situational procedural anxiety metrics, and generalized body shame inventories.

Convergent and Discriminant Validity

Convergent validity of the CES was confirmed by its strong positive correlation with generalized medical avoidance measures (r = .48 to .62, p < .001) and explicit state anxiety scores immediately prior to clinical appointments. Discriminant validity was substantiated by demonstrating that the CES shared low, statistically non-significant correlations with unrelated personality attributes, such as generalized intellectual curiosity or unrelated somatic awareness. Additionally, the CES demonstrated divergent validity against objective CRC screening knowledge scores, confirming that affective embarrassment operates as an independent psychological construct distinct from mere health literacy or factual ignorance regarding colon cancer epidemiology.

Predictive and Known-Groups Validity

Known-groups validity testing confirmed that the instrument clearly differentiates between adherence-ready and non-adherent populations. Men who had never completed a colonoscopy scored significantly higher on the CES (t-test comparisons, p < .001) and exhibited significantly lower procedural self-efficacy compared to men with a documented history of routine endoscopic screening. Logistic regression models confirmed that high scores on the CES independently predicted reduced intention to schedule a colonoscopy within the subsequent 6 months (Odds Ratio [OR] < 0.65, p < .01), controlling for socioeconomic factors, physician recommendations, and baseline knowledge.

Reliability

Empirical analyses validate the Colon Health Survey (Male) as a psychometrically robust, internally reliable measurement tool. Statistical analyses conducted during the initial development and subsequent validation studies produced the following reliability metrics:

• Colonoscopy Embarrassment Scale (CES, Items 50–64): The 15-item embarrassment inventory demonstrated excellent internal consistency, with an overall Cronbach’s alpha of α = .91 in the primary validation cohort (with sub-dimensions ranging between .82 and .89). Corrected item-total correlations across all 15 items consistently exceeded the psychometric threshold of .40 (ranging from .45 to .78), confirming strong item homogeneity.
• Procedural Self-Efficacy Subscale (Items 24–33): This 10-item scale demonstrated high internal reliability, yielding a Cronbach’s alpha of α = .87 to .89. Deletion of any single item did not produce an increase in the composite coefficient, affirming that all items contribute meaningfully to the overarching self-efficacy construct.
• Perceived Barriers Subscale (Items 34–47): The 14-item generalized barriers metric exhibited acceptable to strong reliability, reporting a Cronbach’s alpha of α = .81 to .84.
• Test-Retest Stability: Stability evaluations across a 2- to 4-week test-retest administration interval in stable, non-intervened male cohorts yielded intraclass correlation coefficients (ICC) ranging from .78 to .85 for the CES, indicating that individual levels of procedural modesty and embarrassment remain temporally stable in the absence of targeted cognitive-behavioral exposure or clinical desensitization.

Factor Analysis

The structural dimensionality of the items comprising the psychological sections of the survey—specifically the Colonoscopy Embarrassment Scale (CES)—underwent thorough examination using both Exploratory Factor Analysis (EFA) and subsequent Confirmatory Factor Analysis (CFA).

Exploratory Factor Analysis (EFA)

Principal Axis Factoring (PAF) accompanied by oblique (Promax) rotation was conducted on the 15 items of the CES to accommodate theoretical intercorrelations among affective dimensions. Prior to extraction, the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy yielded a value of .90, and Bartlett’s Test of Sphericity was highly significant (χ² = 1842.36, p < .0001), confirming matrix factorability.

Scree plot inspection, Kaiser’s eigenvalue-greater-than-one criterion, and parallel analysis converged on a robust three-factor solution accounting for approximately 61.4% of the total variance:

• Factor 1: Bodily Exposure and Tactile Modesty (Items 59, 60, 61, 63, 64): Accounted for the largest proportion of variance (approx. 41.2%, eigenvalue > 6.1). Primary item factor loadings ranged from .62 to .86. Items reflect visceral distress regarding buttock presentation, rectal penetration, and physical exposure of genitalia.
• Factor 2: Loss of Visceral Control and Cleanliness (Items 53, 58, 62): Accounted for approximately 11.5% of the variance (eigenvalue > 1.7). Item loadings ranged from .58 to .79. This factor captures fears of physiological failure, such as passing flatus, emitting foul odors, or having residual stool present during the exam.
• Factor 3: Interpersonal and Examiner Characteristics (Items 50, 51, 52, 54, 55, 56, 57): Accounted for approximately 8.7% of the variance (eigenvalue > 1.3). Item loadings ranged from .48 to .74. This dimension encapsulates distress elicited by female examiners, observer students, unfamiliar personnel, flippant humor, and verbal discussions regarding bowel functioning.

Confirmatory Factor Analysis (CFA)

Subsequent CFA testing confirmed the superiority of the correlated three-factor model over a unidimensional model. Goodness-of-fit indices demonstrated acceptable to excellent model fit:

• Comparative Fit Index (CFI) = .948
• Tucker-Lewis Index (TLI) = .936
• Root Mean Square Error of Approximation (RMSEA) = .058 (90% CI [.046, .070])
• Standardized Root Mean Square Residual (SRMR) = .051

All standardized factor loadings were statistically significant (p < .001), confirming the multi-faceted nature of procedural embarrassment.

Instrument / Measurement Tool

The Colon Health Survey (Male) is a modular, multi-item self-report questionnaire. It can be administered via paper-and-pencil, secure digital web portals, or integrated clinical health application platforms.

Subscale Modular Breakdown

• Medical and Screening History (Items 1–6): Six dichotomous items (Yes / No) assessing personal history of fecal occult blood testing, flexible sigmoidoscopy, barium enema, colectomy, inflammatory bowel disease (Crohn’s/colitis), and colorectal malignancy.
• Demographic Profile (Items 7–10): Four categorical socio-demographic indicators capturing educational attainment, marital status, racial identity, and gross annual household income.
• Colonoscopy-Specific History & Behavioral Intentions (Items 11–15): Five categorical and dichotomous items measuring lifetime colonoscopy experience, time elapsed since last examination, six-month scheduling intent, active appointment booking, and physician recommendation receipt.
• Colorectal Cancer and Colonoscopy Knowledge (Items 16–23): Eight objective multiple-choice items testing knowledge regarding screening intervals, prevention mechanisms, biological age-related risk, familial genetic risk, gender parity, and procedural mechanics.
• Procedural Self-Efficacy Scale (Items 24–33): Ten items assessing subjective confidence in executing colonoscopy preparation and completion. Scored on a 4-point response scale: Not at all sure (1), Not so sure (2), Somewhat sure (3), Very sure (4). Total score range: 10 to 40, with higher scores reflecting greater procedural self-efficacy.
• Generalized Perceived Barriers and Beliefs (Items 34–47): Fourteen items measuring health beliefs, psychological impediments, and logistical resistance. Scored on a 4-point Likert scale: Strongly disagree (1), Disagree (2), Agree (3), Strongly agree (4). Total score range: 14 to 56, with higher scores reflecting greater perceived barriers.
• Qualitative Narrative Prompts (Items 48–49): Two open-ended sentence completion items soliciting unstructured patient narratives regarding the single most embarrassing aspect of colonoscopy and potential institutional modifications that would mitigate embarrassment.
• Colonoscopy Embarrassment Scale (CES) (Items 50–64): Fifteen items assessing fine-grained situational modesty, interpersonal anxiety, and somatic vulnerability. Scored on a 4-point Likert scale: Strongly disagree (1), Disagree (2), Agree (3), Strongly agree (4). Total score range: 15 to 60. Composite scores can be computed as a continuous summation or averaged to maintain the original 1–4 metric, where higher scores represent severe procedural embarrassment.

Administration Guidelines

• Target Respondent: Adult males aged 45 years and older (or younger males presenting with clinical indications, elevated familial risk, or hereditary colorectal cancer syndromes).
• Completion Time: Approximately 15 to 25 minutes for the entire 64-item battery. The embedded 15-item CES requires approximately 4 to 6 minutes when deployed independently.
• Setting: Outpatient primary care waiting rooms, gastroenterology intake clinics, behavioral oncology trials, or community-based public health interventions.

Permissions & Fee and Test Year

The Colon Health Survey (Male) and the Colonoscopy Embarrassment Scale (CES) were developed and validated in 2009 by Dr. Ann Mitchell Kimberly as part of her doctoral dissertation at the Indiana University School of Nursing. The instrument is cataloged within public academic repositories and doctoral dissertation registries.

The scale was developed for academic and clinical research purposes. In keeping with typical academic dissemination standards, the instrument may be utilized for non-commercial research, academic inquiry, institutional quality improvement, and clinical evaluation, provided appropriate formal scholarly citation is credited to Dr. Kimberly and Indiana University. Modifying the scale, integrating it into commercial digital health software platforms, or translating it into alternative languages generally necessitates formal written consent from the author or the Indiana University copyright administration. Researchers are encouraged to reference the original doctoral dissertation (Kimberly, 2009) in all derived peer-reviewed publications.

References

• Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman.
• Champion, V. L., & Skinner, C. S. (2008). The health belief model. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health behavior and health education: Theory, research, and practice (4th ed., pp. 45–65). Jossey-Bass.
• Goffman, E. (1956). Embarrassment and social organization. American Journal of Sociology, 62(3), 264–271. https://doi.org/10.1086/222003
• Kimberly, A. M. (2009). Development and testing of the Colonoscopy Embarrassment Scale (Publication No. 3380065) [Doctoral dissertation, Indiana University]. ProQuest Dissertations and Theses Global. https://scholarworks.iupui.edu/
• Kimberly, A. M., & Champion, V. L. (2008). Development and preliminary testing of the Colonoscopy Embarrassment Scale. Oncology Nursing Forum, 35(3), 517–518.
• Rosenstock, I. M. (1974). Historical origins of the health belief model. Health Education Monographs, 2(4), 328–335. https://doi.org/10.1177/109019817400200403
• Vernon, S. W. (1997). Participation in colorectal cancer screening: A review. Journal of the National Cancer Institute, 89(19), 1406–1422. https://doi.org/10.1093/jnci/89.19.1406

Items of the Scale