Exploration of health status, illness

perceptions, coping strategies, and

psychological morbidity in stoma patients
Simon R Knowles  1 , Davina Tribbick, William R Connell, David Castle, Michael
Salzberg, Michael A Kamm
Affiliations

 PMID: 25377108
 DOI: 10.1097/WON.0000000000000073

Abstract
Purpose: We employed the Common Sense Model (CSM) of illness perceptions to examine
the relative contribution of illness perceptions, stoma self-efficacy, and coping strategies in
explaining anxiety and depression symptoms in patients with a fecal ostomy. The CSM
suggests that the consequences of illness activity, such as psychological distress, are
influenced by an individual's illness perceptions as well as what coping strategies they engage
in.

Design: Descriptive, cross-sectional questionnaire-based study.

Subjects and setting: One hundred fifty adults with a stoma (54 males, and 96 females;
mean age 44 years) completed an online survey.

Methods: Several instruments were used to measure study outcomes, including the Health
Perceptions Questionnaire, Brief Illness Perceptions Questionnaire, Carver Brief Coping
Questionnaire, Stoma Self-Efficacy Scale, and the Hospital Anxiety and Depression Scale.
Participants were advised of the study through online forums containing a link to the survey.
Outcome measures used in the current study are valid and reliable and have been extensively
used in medically ill patients.

Results: Using structural equation modeling, the final model provided an excellent fit to the
data (χ23= 16.53, P = .22, χ/N = 1.27, SRMR < 0.03, RMSEA < 0.05, GFI > 0.97, CFI >
0.99). There was a direct pathway from health status to illness perceptions months since
surgery directly influenced health status, illness beliefs, and adaptive emotion-focused coping
(β= .81, P < .001). Several indirect (mediating) pathways were also identified. Illness
perceptions mediated the relationship between health status and stoma self-efficacy and
maladaptive and adaptive emotion-focused coping. Maladaptive coping mediated the
relationship between illness perceptions and depression and anxiety, and adaptive emotion-
focused coping mediated the relationship between illness perception and depression. The
final model provided support for the CSM, in that illness perceptions were directly related to
illness status, and that both illness perceptions and coping strategies directly influenced
anxiety and depression. More specifically, maladaptive coping style (eg, ignore problems)
exacerbated depression and anxiety symptoms, while self-efficacy and emotion-focused
coping style (eg, seek advice) ameliorate depression, but not anxiety. Months since surgery
was associated with improved health status, reduced poorer illness perceptions, and increased
emotional-focused coping.

Conclusions: Illness perceptions and coping were found to mediate anxiety and
depression. The results confirm that how individuals perceive their illness and what
coping strategies they engage in impacts their psychological well-being. Study findings
support the need for designing targeting psychological interventions based on individual
illness perceptions and self-efficacy rather than exclusively focusing on coping strategies
in patients with a stoma.
 Stress and other factors associated
with colorectal cancer outpatients
with temporary colostomies
Yi-Ling Tseng 1, Shu-Yuan Lin 2, Hui-Chen Tseng 2 3, Jaw-Yuan Wang 4, Jen-Li Chiu 5, Kai-
Ting Weng 6 7
Affiliations expand

 PMID: 30993754

 DOI: 10.1111/ecc.13054

Abstract
This study investigated stress and other factors associated with colorectal cancer
(CRC) outpatients with temporary colostomies in Taiwan. Temporary colostomies
have been incorporated as a defecation alternative to maintain physical function
and are accompanied by chemotherapy/radiotherapy in CRC patients. A cross-
sectional study was conducted, and a convenience sampling approach was
adopted to recruit 110 discharged CRC patients with temporary colostomies from
a medical centre in southern Taiwan. The mean score of the Stress of Colostomy
Patients Scale was 66.49 (out of 120). Demographic attributes were found to have
an impact on different stress types. Stress of changes in familial and social
interaction was affected by age, employment status, educational level and
colostomy assistant caregiver. The stress of colostomy care was impacted by the
factor of employment status, and the stress of changes of self-concept was
impacted by the factors of educational level and self-perception of disease. The
results provide post-operative information regarding stress and stress types
among CRC patients with temporary colostomies, serve as a reference for clinical
assessment, practice and care, and generate up-to-date knowledge and
comprehension of learning how to live with a temporary colostomy.

Keywords: colorectal cancer; colostomy; patient; stoma; stress.

 Stressors relating to patient
psychological health following
stoma surgery: an integrated
literature review
Seng Giap Marcus Ang 1, Hui-Chen Chen, Rosalind Jiat Chiew Siah, Hong-Gu He, Piyanee
Klainin-Yobas
Affiliations expand

 PMID: 24161637

 DOI: 10.1188/13.ONF.587-594

Abstract
Purpose/objectives: To summarize empirical evidence relating to stressors that
may affect patients' psychosocial health following colostomy or ileostomy surgery
during hospitalization and after discharge.

Data sources: An extensive search was performed on the CINAHL®, Cochrane

Library, PubMed, PsycINFO, Scopus, Science Direct, and Web of Science electronic
databases.

Data synthesis: Eight articles were included with three qualitative and five
quantitative research designs. Most studies were conducted in Western nations
with one other in Taiwan. Following colostomy or ileostomy surgery, common
stressors reported by patients during hospitalization included stoma formation,
diagnosis of cancer, and preparation for self-care. After discharge, stressors that
patients experienced encompassed adapting to body changes, altered sexuality,
and impact on social life and activities.

Conclusions: This review suggests that patients with stomas experience various

stressors during hospitalization and after discharge. Additional research is needed
for better understanding of patient postoperative experiences to facilitate the
provision of appropriate nursing interventions to the stressors.

Implications for nursing: To help patients deal with stressors following stoma
surgery, nurses may provide pre- and postoperative education regarding the
treatment and recovery process and encourage patient self-care. Following
discharge, nurses may provide long-term ongoing counseling and support, build
social networks among patients with stomas, and implement home visit
programs.

Knowledge translation: Stoma surgery negatively affects patients' physical,

psychological, social, and sexual health. Postoperative education programs
in clinical settings mostly focus on physical health and underemphasize
psychological issues. More pre- and postoperative education programs are
needed to help patients cope with stoma stressors.
 Overview of psychosocial problems
in individuals with stoma: A review
of literature
Sultan Ayaz-Alkaya 1
Affiliations expand

 PMID: 30392194

 DOI: 10.1111/iwj.13018

Abstract
This literature review was conducted to summarise empirical evidence relating to
psychosocial health following ostomy surgery during hospitalisation and after
discharge. Both qualitative and quantitative studies were searched from 2000 to
2017 using PubMed, CINAHL, Ebrary, Elsevier, Science Direct, and Scopus.
Twenty-seven articles were included that examined the patient's psychosocial
health following colostomy or ileostomy surgery. Among the 27 included studies,
11 adopted qualitative research methods and 16 used quantitative designs. Most
of the studies were conducted to determine psychosocial problems and emotions
of the individuals, their adaptation to the stoma, and their quality of life. Most of
the psychosocial problems identified in these studies were poor body image
perception and self-respect, depression, sexual problems, and lower psychosocial
adaptation. This literature review has illustrated the patient's psychosocial health
following stoma surgery. Further studies exploring the effect of psychosocial
interventions could be planned.

Keywords: psychosocial problems; qualitative; quantitative; research; stoma.

 Patient education has a positive
effect in patients with a stoma: a
systematic review
A K Danielsen 1, J Burcharth, J Rosenberg
Affiliations expand

 PMID: 23470040

 DOI: 10.1111/codi.12197

Abstract
Aim: A systematic review was performed to assess whether education of patients
having stoma formation improves quality of life and whether it is cost effective.

Method: A literature search was performed to identify studies on the structured

education of ostomates and outcome using the following databases: MEDLINE,
Cinahl, Embase, Cochrane and PsycInfo. Inclusion criteria were: clinical studies
reporting effects of educational interventions in relation to patients with a stoma.
Commentaries or studies not testing an intervention were excluded.

Results: Seven articles met the inclusion criteria of having rigorously evaluated an

educational programme related to living with a stoma. The programmes were
organized in different ways and had explored various interventions. The results
showed an increase in health-related quality of life, as measured using a stoma
quality of life instrument (P = 0.00001) and with the Short Form 36 (SF-36) (P =
0.000-0.006), an increase in proficiency in management of the stoma (P = 0.0005),
two studies pointed to a reduction in postoperative hospital stay (8 days vs 10
days, P = 0.029; and 8 days vs 14 days, P = 0.17), a significant reduction in cost in
the intervention group ($US 8570.54) compared with the control group ($US
7396.90) as well as higher effectiveness scores in the intervention group (166.89)
compared with the control group (110.98), a significant rise in stoma-related
knowledge (P = 0.0000) and an increase in psychosocial adjustment (P = 0.000).

Conclusion: Structured patient education aimed at patients' psychosocial needs

seems to have a positive effect on quality of life as well as on cost. The
interventions may be performed before, during or after hospital stay. However,
the available data come from few studies with differences in interventions and in
study design, and further studies are therefore needed before a final conclusion
can be drawn.

Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and

Ireland.
 Life after stoma creation
Anne Kjærgaard Danielsen 1
Affiliations expand

 PMID: 24083536

Free article

Abstract
Background: Stoma creation is a surgical operation where the surgeon makes an
artificial opening on the abdomen from where the bowel is taken out. It is a
radical treatment with permanent physical signs of bodily change. In general, it
leads to loss of a central and personal physical function, as well as an alteration in
the bodily design. Research in the field may provide additional information about
central elements when adapting to life with a stoma. There are currently no
studies that adequately focus on the relationship between health-related quality
of life and stoma construction in a Danish context, neither for temporary or
permanent construction, nor in relation to the importance of stoma handling.

Purpose: The overall objective of the study was to investigate health-related

quality of life related to stoma creation and patient education. Methodologically,
the project was implemented as a mixed methods study in which qualitative
interview studies and two systematic literature reviews identified interventions,
which were subsequently tested in a clinical case/control study. Finally the
case/control study was made subject to an economic analysis. The project is
based on 6 papers reporting the results. ARTICLE 1: Impact of a temporary stoma
on patients everyday-lives: feelings of uncertainty while waiting for closure of the
stoma. The study included 7 participants who were interviewed in focus groups.
The results indicated that patients experienced a high degree of uncertainty in
connection with the stoma being temporary. At the same time, participants had a
strong need to control both their physical appearance and their changed bodily
functions. Participants opted for education programs involving teachers with a
stoma. ARTICLE 2: Learning to live with a Permanent Intestinal Ostomy: Impact on
everyday life and Educational Needs. The study included 15 participants who were
interviewed in groups related to whether they were treated for cancer or non-
cancer. The results showed that participants often experienced the stoma as a
taboo, and emotions related to stigma were identified. In addition, participants
were influenced by the stoma in various ways, and the stoma imposed some
restrictions on the participants. Participants pointed at group-based education, as
well as the involvement of teachers who had a stoma. ARTICLE 3: Spouses of
patients with a stoma lack information and support and are restricted in their
social and sexual life: a systematic review. The study included 6 articles based on
quantitative and qualitative data showing that spouses were affected in several
ways by the construction of the stoma. The results pointed at spouses not being
informed and supported sufficiently by neither enterostoma therapists or
surgeons. ARTICLE 4: Patient education has a positive effect in patients with a
stoma - a systematic review The study included 7 studies, all with quantitative
results. They showed that patient education had a positive impact in several areas
including shorter hospital stay, less time until proficiency in stoma management is
reached, an increase in quality of life, increased knowledge about the stoma, and
increased self-efficacy. ARTICLE 5: Health-related quality of life increases when
patients with a stoma attend patient education - a case/control study. The study
included 50 participants shortly after stoma creation. The results showed that the
disease-specific quality of life was significantly increased in the intervention
group, while generic health-related quality of life was positively affected in
different dimensions in both groups. ARTICLE 6: Decreased costs with patient
education after stoma creation. The study was an economic analysis based on
participants in Article 5. The results indicated that there were fewer unplanned re-
admissions related to the stoma, and that patients in the intervention group did
not visit the general practitioner as much as patients in the control group.
Furthermore, we found that the average cost per patient did not increase when
establishing a patient education program.

Conclusion: The thesis concludes that patient education has a positive impact on

patients' quality of life, and that costs are reduced. At the same time, it is
concluded that living with a stoma is a complex situation, which also involves
spouses and close relatives, and that patient education must be based on
multiple interventions that are not all explored in this project.
 Learning to live with a permanent
intestinal ostomy: impact on
everyday life and educational needs
Anne Kjaergaard Danielsen 1, Erik Elgaard Soerensen, Kirsten Burcharth, Jacob Rosenberg
Affiliations expand

 PMID: 23820473

 DOI: 10.1097/WON.0b013e3182987e0e

Abstract
Purpose: The aim of the study was to explore the impact of a permanent stoma
on patients' everyday lives and to gain further insight into their need for ostomy-
related education.

Subjects and setting: The sample population comprised 15 persons with

permanent ostomies. Stomas were created to manage colorectal cancer or
inflammatory bowel disease. The research setting was the surgical department at
a hospital in the Capitol Region of Denmark associated with the University of
Copenhagen.

Methods: Focus group interviews were conducted using a phenomenological

hermeneutic approach. Data were collected and analyzed using qualitative
content analysis.

Results: Stoma creation led to feelings of stigma, worries about disclosure, a

need for control and self-imposed limits. Furthermore, patients experienced
difficulties identifying their new lives with their lives before surgery. Participants
stated they need to be seen as a whole person, to have close contact with health
care professionals, and receive trustworthy information about life with an ostomy.
Respondents proposed group sessions conducted after hospital discharge. They
further recommended that sessions be delivered by lay teachers who had a stoma
themselves.

Conclusions: Self-imposed isolation was often selected as a strategy for avoiding

disclosing the presence of a stoma. Patient education, using health promotional
methods, should take the settings into account and patients' possibility of
effective knowledge transfer. Respondents recommend involvement of lay
teachers, who have a stoma, and group-based learning processes are proposed,
when planning and conducting patient education.

Fear
 Physical activity and exercise after
stoma surgery: overcoming the
barriers
Sarah Russell 1
Affiliations expand

 PMID: 28328269

 DOI: 10.12968/bjon.2017.26.5.S20

Abstract
This article presents the results from a large nationwide survey completed in 2016
that investigated the physical health and wellbeing of people living with stomas
in the UK. In particular, the survey looked at physical activity and exercise, general
attitudes and opinions about exercise, whether or not advice about physical
activity had been received and other general questions about parastomal hernia
and quality of life. There were 2631 respondents making it one of the largest
known surveys to date. The findings were concerning yet unsurprising,
highlighting a trend toward inactivity after stoma surgery and a fear of exercise in
general. People also seem to have poor knowledge about appropriate activities,
with many suggesting that the fear of developing a parastomal hernia is a major
barrier to activity. Unsurprisingly, those who have a stoma owing to cancer seem
to fare worse, reporting even lower levels of physical activity and worse quality of
life compared to those with other conditions. This indicates that people who have
a combination of a cancer diagnosis and also a stoma may need more specific or
additional support in the longer term. The most concerning finding, however, was
that the majority of patients could not recall being given any advice about
exercise or physical activity by their nurse or surgeon. While this survey presents
some initial findings, it raises questions for further research and work. It also
highlights a significantly neglected area in both research and support for stoma
patients and the health professionals caring for them.

Keywords: Exercise; Hernia; Quality of life; Stoma.

 [Psychological and psychiatric
problems in cancer patients:
relationship to the localization of
the disease]
[Article in Modern Greek (1453-)]
G I Moussas 1, A G Papadopoulou, A G Christodoulaki, A P Karkanias
Affiliations expand

 PMID: 22549040

Abstract
Cancer may be localized in a variety of areas in the human body. This localization is
associated with significant issues concerning not only therapy and prognosis but also
psychological and psychiatric problems that the patient may be confronted with. The
psychic impact on the patient is determined to a significant degree by the symbolism
the affected organ carries. The symbolic significance of a sick body area triggers
emotions and sets in motion self-defence mechanisms. In this way, patients deal with
the new psychic reality that cancer creates. Therapeutic choices may include
interventions, involving mutilation, which cause disfigurement and major
consequences in the body image which result in narcissistic injuries. The
phenomenology of anxiety and depressive disorders is connected to the affected
body area. The appearance of cancer not only in sexual organs but also in other body
areas, may disturb sexual function and therefore lead to sexual disorders. Especially,
head and neck are connected with vital functions. This area of the body has had a
major impact on psychic reality since early life. Complicated psychic functions have
developed in relation to organs of the head and neck. Therefore, localization of
cancer in this area leads to individual psychological and psychiatric problems, since
eating and breathing are harmed, verbal communication becomes difficult and body
image alters. Also, increased incidence of alcohol and nicotine abuse in these
patients reflects special aspects of psychic structure and personality. Because of
severe somatic symptoms and poor prognosis, lung cancer patients feel
hopelessness and helplessness. Patients with gynaecological cancer are confronted
with a disease that affects organs like breast and internal female sexual organs
associated with femininity, attractiveness and fertility. Dietary habits are often a
source of guilt for patients who suffer from cancer of the gastrointestinal tract.
Additionally, stomas, as colostomy, affect body image and cause feelings of
embarrassment with severe consequences on the patient's sense of wellbeing, his or
her daily activities, interpersonal relationships or sexuality. Depressive symptoms
often occur in prodromal stages of pancreatic cancer. Depression is a common
diagnosis in patients with prostate cancer. Prostatectomy negatively affects patient's
self-esteem, because it might be experienced as a threat to his sexual life.
Disfigurement is related to skin cancer because of both cancer and surgical
procedures. Therefore, it is a challenge for modern psycho-oncology to identify
those patients who are vulnerable in developing psychiatric symptoms, to early
diagnose anxiety and depression and to use psychotherapeutic interventions
targeting individual psychological and psychiatric problems in relation to the
localization of disease in the human body.
 Psychiatric disorders in patients
undergoing intestinal
transplantation
C Pither 1, J Green 1, A Butler 2, B Chukaulim 2, S West 1, R Gao 1, S Gabe 3, S J Middleton 4

Affiliations expand

 PMID: 25131124

 DOI: 10.1016/j.transproceed.2014.06.033

Abstract
Background: Psychiatric disorders are common in chronic disease states;
intestinal transplantation recipients may therefore be at high risk for psychiatric
disorder (PD). We sought to investigate the frequency and type of PD in our
cohort of patients undergoing transplantation between 2007 and 2012.

Results: The notes of 25 patients who had undergone transplantations since 2007

were available for analysis. Five of 25 patients had died at the time of data
collection. Pretransplantation, 14 of 25 patients had a history of a single
psychiatric disorder (SPD) (depression). Two of 25 had double psychiatric
diagnoses (DPD; depression with anxiety), and 1 had three PDs. Three of 25
patients suffered from chronic pain syndrome and 1 patient had this as an
isolated diagnosis without any other PD. Post-transplantation, 10 of 14 patients
still had an SPD; however, 3 of 14 had acquired a second diagnosis (DPD; anxiety
with depression) with suicidal ideation in 2 cases. Those with DPD preoperatively
did not improve. Depression resolved in 1 of 14 after transplantation. One patient
without a history of psychiatric issues developed DPD during the postoperative
course. Only 3 of 25 surviving patients are free of any psychological diagnosis
post-transplantation. The presence of other problems in the cohort such as
chronic pain syndrome in 4 of 25, medical noncompliance in 3 of 25, cyclizine
dependency in 2 of 25, and recreational drug use suspected in 1 were also
identified. Problems with body image relating to the stoma were experienced by
2 of 25 patients.

Conclusion: The incidence of psychiatric disorder in patients embarking on

transplantation is high and relates to their history of chronic illness. The
additional stress of the transplantation operation and the long in-hospital
rehabilitation period takes its toll on patients' emotional health and many acquire
further psychiatric diagnoses. Managing the psychiatric health of patients is
important for successful rehabilitation and their long-term health and wellbeing.
 The recognition of psychiatric
morbidity on a medical oncology
ward
A Hardman 1, P Maguire, D Crowther
Affiliations expand

 PMID: 2724199

 DOI: 10.1016/0022-3999(89)90051-2

Abstract
The Generalised Health Questionnaire and Standardised Psychiatric Interview
were used to determine psychiatric morbidity among 126 patients consecutively
admitted to a medical oncology unit. Senior house officers and nurses also rated
anxiety and depression. 36 (29%) patients were psychiatrically ill and affective
disorders (29, 23%) predominated. Psychiatric morbidity was associated with
feeling moderately or severely physically ill, and previous psychiatric illness, but
not with awareness of having cancer or lack of a confiding tie. The General Health
Questionnaire identified 79% of affective disorders at the cost of a 34% false
positive rate. Doctors and nurses recognised only 49% of the depressed group;
more of those with morbid anxiety (79%) were identified but only because they
assumed most patients were anxious. Training in interviewing skills could
substantially improve the identification and referral rates of patients with
psychiatric morbidity.
 Psychiatric co-morbidity in primary
care and hospital referrals, Saudi
Arabia
N A Qureshi 1, T A al-Habeeb, Y S al-Ghamdy, M E Magzoub, H T van der Molen
Affiliations expand

 PMID: 12690771

Free article

Abstract
Psychiatric and physical morbidities among patients referred from primary health
care (PHC) centres and general hospitals (GH) in Al-Qassim region were
compared. Thus, 540 psychiatric referrals (GH = 138; PHC = 402) were selected
randomly. Fifteen GH patients but no PHC patients were referred for admission.
Psychiatrists made more diagnoses of dementia, affective and anxiety disorders,
mixed anxiety-depression and somatoform disorders than clinicians and general
practitioners (GPs). Clinicians made significantly more diagnoses of acute
psychoses and somatoform disorders than GPs. Physical morbidity was noted in
38.4% and 17.2% of GH and PHC referrals respectively.
 Psychological factors in
postoperative adjustment to stoma
surgery
C A White 1, J C Hunt
Affiliations expand

 PMID: 9038488

 PMCID: PMC2502633

Free PMC article

Abstract
Around one-quarter of stoma patients experience clinically significant
psychological symptoms post-operatively. Psychological disorders are often not
detected by those involved with the care of stoma patients. Past psychiatric
history, dissatisfaction with preoperative preparation for surgery, postoperative
physical symptomatology and the presence of negative stoma-related
thoughts/beliefs have all been shown to be significantly associated with
psychological morbidity after surgery. These findings suggest that healthcare
professionals (especially surgeons involved with this patient population) should
ask all patients about these factors before and after surgery. Questionnaires could
be used to screen for difficulties and/or staff could undertake training aimed at
improving the detection of psychological morbidity and endeavour to strengthen
links with liaison mental health services. Future research in this area should be
prospective, using psychometrically valid measures and be focused on the
prediction, prevention, detection and treatment of poor psychological adjustment
after stoma surgery.
 Evaluation of psychiatric illness in
Iranian stoma patients
Bahar Mahjoubi 1, Homa Mohammadsadeghi, Mastoureh Mohammadipour, Rezvan
Mirzaei, Reyhaneh Moini
Affiliations expand

 PMID: 19232238

 DOI: 10.1016/j.jpsychores.2008.10.015

Abstract
Introduction: The objective of this study was to assess the nonpsychotic
psychiatric disorders of stoma patients in Iran.

Method: In this cross-sectional study, patients referred to the Iranian Ostomy

Association from 2005 to 2006 filled the 28-item General Health Questionnaire
(GHQ) in Farsi as a screening instrument to identify cases of nonpsychotic
psychiatric morbidity.

Results: A total of 155 patients participated in the study, of whom 79 (51%) were
female and 76 (49%) were male. Fifty-five percent of the patients (n=86) had
psychiatric problems. The females' mean GHQ score was significantly higher than
that of males (P=.001). Psychiatric disorder was significantly more frequent
among patients with the following specifications: educational level of high school
or lower (P=.001), mucosal hemorrhage of the ostomy (P=.03), stomal stenosis
(P=.012), and history of psychiatric drug consumption (P=.000). GHQ score
decreased as stoma age increased (P=.032; r=-.177).

Discussion: Similar to other complications, psychiatric problems are prevalent in

Iranian stoma patients. Our findings highlight the need for special support.