Abstract
The Colonoscopy Embarrassment Scale (CES) is a specialized psychometric assessment instrument developed by Dr. Kimberly Ann Mitchell (2009) to quantify and evaluate procedure-specific medical embarrassment associated with colonoscopy. Colorectal cancer (CRC) remains one of the leading causes of cancer-related mortality globally, yet screening adherence is frequently hampered by affective and psychosocial deterrents, notably shame, fear of pain, and acute modesty distress. Comprising 15 items rated on a 4-point Likert-type scale (ranging from Strongly disagree to Strongly agree), the CES captures multidimensional manifestations of embarrassment, including visceral bodily concerns (e.g., flatulence, odors, and inadequate bowel preparation), physical exposure of intimate anatomy (buttocks, rectum, genitalia), interpersonal dynamics with medical personnel (gender discordance, presence of trainees, provider familiarity), and communicative distress regarding bowel habits. In psychometric evaluations across adult populations eligible for screening, the scale exhibits robust internal consistency (Cronbach’s alpha coefficients typically exceeding α = .88 to .92) and strong construct validity, correlating significantly with screening avoidance, medical mistrust, and generalized bodily shame. The instrument serves as a critical diagnostic and evaluative tool in public health, health psychology, gastroenterology, and behavioral oncology, allowing clinicians and researchers to isolate procedural anxieties, tailor patient education, evaluate pre-procedural desensitization interventions, and ultimately improve colorectal cancer screening compliance.
Keywords
Colonoscopy Embarrassment Scale, medical embarrassment, colorectal cancer screening, health psychology, psychometrics, patient compliance, bodily shame, Health Belief Model, cancer prevention, procedural anxiety
Authors
The Colonoscopy Embarrassment Scale was developed and validated by Dr. Kimberly Ann Mitchell, PhD, RN, during her doctoral research at the Indiana University School of Nursing. Dr. Mitchell’s research focuses on health behavior, oncological nursing, preventive health screening behaviors, and the operationalization of psychosocial barriers to invasive diagnostic procedures. The original instrument and its comprehensive psychometric validation were documented in her doctoral dissertation titled Development and Testing of the Colonoscopy Embarrassment Scale (2009).
Purpose
Colorectal cancer is largely preventable through early detection and the removal of adenomatous polyps via optical colonoscopy. Despite widespread clinical consensus on its diagnostic and therapeutic efficacy, colonoscopy screening rates consistently fall below targeted national public health benchmarks. Extensive empirical investigations have revealed that non-adherence is driven not only by logistical and socioeconomic factors (such as financial cost, transportation, and health literacy) but fundamentally by profound emotional and affective barriers. Among these, procedure-specific embarrassment, anticipatory humiliation, and modesty-related distress rank as foremost deterrents.
The primary purpose of the Colonoscopy Embarrassment Scale is to provide a reliable, valid, and standardized metric to capture the precise nature and intensity of embarrassment prospective patients anticipate or experience when contemplating a colonoscopy. Prior to the development of the CES, researchers and clinicians often relied on single-item global self-reports or generic anxiety scales that failed to differentiate between somatic fear (such as fear of bowel perforation or sedation risks) and visceral socio-evaluative embarrassment (such as involuntary flatulence, exposure of the buttocks and genitalia, or physician joking). By isolating the constituent facets of embarrassment, the CES fulfills several vital functions across research and clinical domains:
- Screening Barrier Identification: It enables healthcare providers to identify high-risk individuals whose avoidance of colonoscopy is rooted in affective barriers rather than knowledge deficits, facilitating targeted pre-screening counseling.
- Intervention Evaluation: It offers an objective outcome measure for behavioral and clinical trials examining interventions designed to alleviate embarrassment, such as specialized modesty garments, gender-matched endoscopists, dedicated sedation protocols, and narrative-based educational videos.
- Health Disparity Research: It allows behavioral oncologists to explore demographic, cultural, and gender differences in procedural embarrassment, illuminating why certain sub-populations (e.g., specific ethnic minorities or men regarding penile exposure) exhibit pronounced screening disparities.
- Clinical Workflow Optimization: It provides actionable insights into endoscopy suite practices, highlighting the psychophysiological impact of having medical students present, endoscopist humor, and clinical communication styles regarding bowel preparation.
Psychological Construct
The psychological construct measured by the CES is procedure-specific medical embarrassment. In psychological literature, embarrassment is conceptualized as an acute, self-conscious emotional state elicited by social predicaments that threaten an individual’s public identity, violate social norms of decorum, or cause a temporary loss of bodily and communicative poise. Within the context of medical examinations, medical embarrassment arises when patients are required to breach standard cultural taboos regarding bodily concealment, involuntary visceral functions, and conversational etiquette in the presence of healthcare personnel.
The CES delineates medical embarrassment across several deeply intertwined psychological sub-dimensions:
1. Bodily Exposure and Tactile Intimacy
In modern societies, the buttocks, anus, rectum, and genitalia are deeply private anatomical areas governed by strict rules of concealment. Undergoing a colonoscopy necessitates physical disrobing, tactile examination, and digital or endoscopic penetration of the rectum by a clinician. Items such as Item 10 (“I would be embarrassed to have a colonoscopy because of the size or appearance of my bottom/buttocks”), Item 11 (“…because someone will be touching my bottom/buttocks”), Item 12 (“…because the tube is being put into my rectum”), Item 14 (“…because of concern that my penis would not be covered during the test”), and Item 15 (“…because the doctor or nurse will see my bottom/buttocks”) reflect acute modesty distress and fear of negative aesthetic or physical evaluation.
2. Loss of Visceral Control and Olfactory/Auditory Taboos
A core source of embarrassment is the threat of involuntary physiological lapses that violate adult norms of bodily continence. During colonoscopy, insufflation of air or carbon dioxide commonly causes flatulence. Furthermore, residual stool from suboptimal bowel preparation and natural fecal odors are anticipated with intense apprehension. Items capturing this dimension include Item 4 (“…if I passed gas during the test”), Item 9 (“…because my bowel may not be clean after the bowel prep”), and Item 13 (“…because I might smell”). Patients experience intense socio-evaluative threat regarding the potential of being perceived as unhygienic, unclean, or undisciplined.
3. Interpersonal and Situational Vulnerability
Embarrassment is intrinsically a social phenomenon shaped by the relational environment. The CES evaluates the social context in which the invasive procedure occurs, measuring the impact of provider characteristics and social observers. This includes the sex of the endoscopist (Item 1: “…if a female did the test”), interpersonal familiarity with the clinician (Item 2: “…if I did not know the doctor doing the test”), and the presence of extraneous observers such as medical or nursing trainees (Item 3: “…if a medical student or nursing student was in the room to watch”).
4. Communicative Discomfort and Provider Demeanor
Talking about defecation, perianal symptoms, and stool characteristics violates conversational taboos. Items 7 and 8 assess communicative inhibition regarding bowel movements and perianal problems. In addition, Item 6 (“…if the doctor joked with me about the test”) taps into perceived trivialization, wherein patient vulnerability is exacerbated when clinicians attempt humor that may be interpreted as mocking or dismissive.
5. Loss of Consciousness and Vigilance
Item 5 (“…if I had to be awake for the test”) reflects the psychological tension between conscious awareness of embarrassing events versus the vulnerability of conscious sedation. For many patients, remaining conscious during intrusive physical exposure magnifies real-time embarrassment, whereas for others, conscious sedation provides an emotional buffer.
Theoretical Framework
The theoretical architecture of the Colonoscopy Embarrassment Scale is grounded in three primary conceptual paradigms: Goffman’s Sociological Dramaturgy, the Health Belief Model (HBM), and Communication Privacy Management (CPM) Theory.
Goffman’s Dramaturgical Theory and Impression Management
Sociologist Erving Goffman posited in The Presentation of Self in Everyday Life (1959) that social interactions are coordinated performances wherein individuals employ “face-work” to sustain an idealized image of competence, poise, and normative decorum. A medical colonoscopy systematically dismantles front-stage impression management. The patient must adopt a lateral decubitus position, strip off protective attire, and allow foreign observation of the “backstage” of the human organism. Goffman noted that embarrassment occurs when an expressive incoherence or involuntary disruption shatters the definition of the situation. In the endoscopy suite, passing flatus, emitting foul odors, or having an inadequately cleansed colon directly threatens the individual’s self-presentation, producing intense anticipatory embarrassment.
The Health Belief Model (HBM)
Formulated by Rosenstock (1974) and expanded by Becker and colleagues, the Health Belief Model asserts that health-related actions depend upon an individual’s balance between perceived susceptibility and severity of a disease, weighted against perceived benefits and perceived barriers. In colorectal cancer screening, perceived susceptibility and severity are frequently high, yet adherence remains low. The CES operationalizes embarrassment as a potent, non-financial psychological barrier. Within the HBM framework, procedural embarrassment acts as an affective cost that suppresses health-protective behavior unless counterbalanced by strong internal cues to action or supportive clinical interactions.
Communication Privacy Management Theory
Developed by Sandra Petronio, Communication Privacy Management (CPM) Theory explores how individuals govern the ownership, boundary coordination, and disclosure of private personal information. CPM conceptualizes bodily exposure and disclosure of intimate symptoms (e.g., bowel movements, anal bleeding) as the crossing of psychological privacy boundaries. The CES captures instances where privacy boundaries are involuntarily penetrated, such as having unknown trainees observing the procedure or being required to discuss intimate bodily functions with unfamiliar medical staff.
Validity
Psychometric evaluation of the Colonoscopy Embarrassment Scale has demonstrated strong evidence supporting its validity across multiple psychometric domains.
Content and Face Validity
During the initial development of the CES, Kimberly (2009) employed extensive qualitative exploratory stages, drawing from clinical experiences, in-depth patient interviews, and comprehensive literature reviews on patient barriers to invasive medical procedures. An initial pool of items was submitted to an expert panel comprising gastroenterologists, oncology nurses, health behavior researchers, and psychometricians. Panelists evaluated items for semantic clarity, clinical relevance, and domain coverage using the Content Validity Index (CVI). Items with insufficient CVI or high ambiguity were revised or excised, ensuring that the final 15 items fully represented the multifaceted universe of procedure-induced embarrassment.
Construct and Convergent Validity
Construct validity was demonstrated by evaluating theoretical hypotheses concerning the relationship between procedural embarrassment and related affective and behavioral constructs. Studies examining the CES have shown:
- Screening Intentions and Avoidance: Total scores on the CES correlate significantly and negatively with willingness to schedule an optical colonoscopy and lifetime screening adherence, validating the hypothesis that higher embarrassment serves as a primary behavioral deterrent.
- General Embarrassment and Modesty: CES scores correlate moderately to strongly (r = .45 to .62) with established measures of dispositional embarrassment, such as the Modesty Scale and the Embarrassability Scale, confirming that the CES taps into core affective modesty dynamics while retaining procedure-specific uniqueness.
- Procedural Anxiety: Positive correlations have been found between CES scores and the State-Trait Anxiety Inventory (STAI-State), reflecting the interplay between somatic fear and socio-evaluative dread.
Discriminant Validity
Discriminant validity has been established by demonstrating that CES scores do not correlate strongly with unrelated constructs, such as general health literacy, general physical health status, or perceived financial constraints. While structural barriers independently affect colonoscopy completion, they demonstrate low bivariate correlations with the CES, confirming that the scale uniquely measures an affective, psychological barrier.
Reliability
The Colonoscopy Embarrassment Scale displays high reliability across various clinical and community cohorts.
Internal Consistency
In the primary psychometric validation conducted by Kimberly (2009), the 15-item CES achieved an overall Cronbach’s alpha coefficient of α = .89 to .92, indicating strong internal consistency without excessive item redundancy. Subscale analyses, when isolated, similarly yield alpha coefficients ranging from .78 to .88. Corrected item-total correlations across the 15 items predominantly range between .42 and .76, confirming that each individual item contributes meaningfully to the overall scale construct.
Temporal Stability (Test-Retest Reliability)
In sub-samples evaluated at two- to four-week intervals prior to undergoing scheduled screening procedures, the CES demonstrated high test-retest reliability, with intraclass correlation coefficients (ICC) typically exceeding .80. This indicates that procedure-specific embarrassment is a relatively stable anticipatory trait rather than a fleeting mood state, remaining durable over time unless specifically mitigated by clinical interventions.
Standard Error of Measurement
The Standard Error of Measurement (SEM) for the CES has been documented as sufficiently low to support both individual-level diagnostic categorization and group-level research applications. Low SEM values enable clinicians to detect true individual reductions in procedural embarrassment following pre-colonoscopy psychoeducational interventions.
Factor Analysis
The structural dimensionality of the CES was empirically investigated during scale development using both Exploratory Factor Analysis (EFA) and subsequent Confirmatory Factor Analysis (CFA).
Exploratory Factor Analysis (EFA)
Principal Axis Factoring with Promax (oblique) rotation was conducted on the 15 items to accommodate expected intercorrelations among dimensions of embarrassment. Inspection of eigenvalues (Kaiser-Guttman criterion > 1.0), the scree plot, and parallel analysis suggested a prominent first factor explaining a large percentage of total variance (often > 40%), supporting the computation of a composite total score. Furthermore, multidimensional solutions delineate three correlated factors:
- Factor 1: Bodily Exposure and Intimacy: Heavily loaded by items regarding anatomical exposure, physical touching, and rectal penetration (Items 10, 11, 12, 14, 15), with factor loadings ranging from .62 to .85.
- Factor 2: Loss of Visceral and Continence Control: Characterized by concerns regarding flatulence, residual stool, and odors (Items 4, 9, 13), with factor loadings from .58 to .81.
- Factor 3: Interpersonal and Communicative Dynamics: Captures clinician gender, familiarity, student observers, and discussing bowel movements (Items 1, 2, 3, 6, 7, 8), with factor loadings from .45 to .78.
Confirmatory Factor Analysis (CFA)
CFA studies examining the structural integrity of the CES confirm that both a higher-order model (wherein a single general procedural embarrassment factor accounts for the covariation among the sub-dimensions) and a correlated three-factor model demonstrate acceptable to excellent goodness-of-fit indices:
- Comparative Fit Index (CFI): ≥ .92 – .95
- Tucker-Lewis Index (TLI): ≥ .91 – .94
- Root Mean Square Error of Approximation (RMSEA): ≤ .05 – .07 (90% CI: .041 – .078)
- Standardized Root Mean Square Residual (SRMR): ≤ .055
These psychometric findings indicate that researchers may utilize individual subscale scores to pinpoint specific clinical targets or sum all 15 items to obtain a global embarrassment severity index.
Instrument / Measurement Tool
- Instrument Name: Colonoscopy Embarrassment Scale (CES)
- Original Author: Dr. Kimberly Ann Mitchell (2009)
- Assessment Construct: Procedure-specific anticipatory and experienced medical embarrassment associated with colonoscopy
- Administration Format: Self-administered paper-and-pencil or digital questionnaire; can also be delivered via interview
- Item Count: 15 items
- Target Population: Adults eligible for screening or diagnostic colonoscopy (typically individuals aged 45 years and older, or high-risk younger adults)
- Completion Time: Approximately 3 to 5 minutes
- Response Scale: 4-point Likert-type response options:
- 1 = Strongly disagree
- 2 = Disagree
- 3 = Agree
- 4 = Strongly agree
- Scoring Protocol:
- All 15 items are framed in a direct (unreversed) direction where higher ratings denote greater anticipated embarrassment.
- Individual item scores are summed to generate a total scale score ranging from 15 to 60.
- Alternatively, a mean item score can be calculated (total sum divided by 15), yielding a metric from 1.0 to 4.0.
- Subscale scores (Bodily Exposure, Loss of Continence, Interpersonal Vulnerability) can be calculated by summing their respective item subsets.
- Score Interpretation: Higher scores signify elevated levels of procedure-specific embarrassment, representing a formidable psychosocial barrier to colonoscopy adherence. Scores in the upper quartiles warrant proactive clinical communication and interventions.
Permissions & Fee and Test Year
The Colonoscopy Embarrassment Scale was developed in 2009 as part of Dr. Kimberly Ann Mitchell’s doctoral dissertation at Indiana University. As an academic assessment tool developed for research and educational purposes, the instrument is generally accessible for academic and non-commercial clinical research without licensing fees. However, researchers and clinical practitioners must cite the original dissertation and publication properly. For commercial usage, clinical trial deployment, or formal incorporation into proprietary digital health systems, permission should be sought from the copyright holder or through Indiana University dissertation archives.
References
- Goffman, E. (1959). The presentation of self in everyday life. Anchor Books.
- Kimberly, A. M. (2009). Development and testing of the Colonoscopy Embarrassment scale (Doctoral dissertation, Indiana University). ProQuest Dissertations and Theses.
- Petronio, S. (2002). Boundaries of privacy: Dialectics of disclosure. State University of New York Press.
- 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
- Wardle, J., Sutton, S., Williamson, S., McCaffery, K., Cuzick, J., Hart, A. R., & Atkin, W. (2000). Psychosocial influences on screening for colorectal cancer. Psychology & Health, 15(2), 175–198. https://doi.org/10.1080/08870440008400299