Constructing An Intervention Program For Peer Education In Stoma Patients With Stigma

BACKGROUNDIntestinal stoma refers to an artificial opening on the abdominal wall,and a section of the intestine is pulled out to the outside of the opening and flipped over the abdominal wall to form an artificial anus to excrete feces.There are two kinds of intestinal stoma:permanent stoma and preventive stoma(also known as temporary stoma).Patients with permanent stoma need to carry a stoma for life because they have had their anus removed.Patients with preventive stoma retain the anus.When the anastomosis is healed and bowel function is restored,the stoma will be closed according to individual conditions,and the normal defecation mode will be restored.It usually takes 3-6 months.The incidence rate of colorectal cancer in China is high,and low rectal cancer is the most common type.Abdominal perineal resection combined with rectal cancer(Miles surgery)as a radical surgery for the treatment of low rectal cancer has been used in clinical for many years.However,this kind of surgery has a large resection range and functional damage,and need to construct a permanent intestinal stoma on the abdominal wall of patients,which affects the postoperative quality of life of patients seriously.With the advancement of medical technology,the clinical treatment requirements for low rectal cancer have changed from simply pursuing the disease cure to combine disease cure with patients' quality of life.Therefore,with the premise of ensuring radical resection of tumor,total mesorectal excision is gradually becoming the gold standard for low rectal cancer treatment.This surgery preserves patients' anus and reduces the risk of postoperative anastomotic leakage by constructing a preventive stoma on patient's abdominal wall.As a result,the number of patients with preventive stoma is increasing.However,stoma has much negative impacts on patients' psychological and physical health.Stigma is a kind of inner shame experience that occurs when a patient is unfairly treated by others,and has negative emotions such as labeling,demeaning or discrimination.Stoma leads patients lost their ability to control bowel movements and changed their body image.Their social interactions and intimate relationships are hindered and challenged due to stoma.Compared with patients who do not have a stoma,patients with stoma have a worse quality of life,and they are more prone to have stigma,depression and suicidal tendencies.At present,domestic research on stigma of patients with stoma are mainly focused on patients with permanent stoma,while the status of stigma in patients with preventive ostomy is less reported.Patients with preventive ostomy need to bear the negative effects of ostomy on physical and psychological factors as same as the patients with permanent stoma.In addition,because knowing the stoma is temporary,patients with preventive ostomy will have self-imposed temporary isolated behavior,and a mentality of"avoiding others temporarily and returning to normal social life after stoma returned".At the same time,patients with preventive ostomy will have a'uncertainty,related to'I don't know if the stoma can be returned successfully'and'When will it return?',which makes patients feel that their future cannot be grasped.According to reports,only about 60%of patients with preventive ostomy can return the stoma successfully.Due to the injury of the anal sphincter by surgery and the laxation of the anal sphincter after changing the excretory passage,about 30%to 70%of patients with preventive ostomy will have complications such as fecal incontinence after the stoma retraction,which further aggravating patient's fear of the future.Therefore,patients with preventive ostomy have their own particularities comparedwith patients with permanent stoma,and the level and characteristics of their stigma are worth exploring.Peer education has been widely used to reduce the level of stigma of patients with mental illness and has achieved remarkable results at present.In the field of stoma,some scholars have applied peer education to improve the self-care ability and adaptation level of patients with permanent stoma.The results showed that patients'self-care ability and adaptation level were improved.Some studies have suggested that peer education can reduce the level of stigma in patients with stoma.However,no relevant research has been found yet.In addition,although peer education has been implemented in stoma patients' other aspects,the implementation standards for peer education are not clear,such as admission qualifications,training content and assessment criteria for peer educators,which hinders the development of peer education in the field of ostomy.OBJECTIVETo investigate the level and characteristics of stigma in patients with temporary ostomy and to analyze the relevant influencing factors.Using Systematic Reviews and Delphi methods to construct an intervention program for peer education to reduce the level of stigma in patients with intestinal stoma.METHODS(I)Stigma and associated factors in patients with preventive ostomyA convenient sampling method was used to select patients with temporary stoma in outpatients and wards of four hospitals in Guangzhou to conduct a questionnaire survey.The questionnaires included general information questionnaire?Social Impact Scale?Perceived Social Support Scale?Self-Concealment Scale and Medical Coping Modes Questionnaire.Descriptive analysis,correlation analysis,student's t-test and one-way ANOVA and multivariate analysis was used.(2)Construct an intervention program for peer education in stoma patients with stigmaUsing systematic reviews to search database and related websites according to retrieval strategy comprehensively.Finding the best evidence for peer education used in ostomy patients and refine the evidence to provide basis for construct the first round of Delphi expert opinion list.Inviting domestic experts in the field of stoma nursing and specialists in psychology to form an expert group to conduct two rounds of expert consultation.Each round of expert consultation questionnaires is distributed through paper questionnaire or an online electronic questionnaire.After each round of consultation,expert opinions were summarized and analyzed by the research group,and the intervention program was finally confirmed by the research group.Judging the scientificity and reliability of the research by using the expert positive coefficient,expert authority coefficient and expert opinion concentration and coordination degree.RESULTS(1)Findings of the stigma and associated factors in patients with preventive stomaThe mean total score of stigma in this study was 60.58(±7.35),item score was 2.52(±0.31),representing a moderate level of stigma.Each dimension entry scores from high to low:social isolation was 2.70(±0.44),internalized shame was 2.70(±0.48),financial insecurity was 2.69(±0.53),social rejection was 2.23(±0.29).The results of multiple regression analyses indicated that self-concealment,submission,social support,degree of influence of stoma on sexual life,whether have ostomy-related complications and living area into regression equation,which can explain 77%of the variation.(2)Results of construction an intervention program for peer education in stoma patients with stigmaAfter searching databases and related websites,9 interventional researches were included in our study.In the Delphi implementation phase,there are 23 experts in our study,including 21 ostomy nursing specialists and 2 psychologists.A total of two rounds of expert consultations were conducted,and the effective questionnaire recovery rates were 100%and 87.0%.The expert judgment coefficient was 0.939,expert familiarity coefficient was 0.835 and expert authority level was 0.887.In the two rounds of expert consultation,the Kendall coefficient significance test of the importance and feasibility of all indicators was P<0.05.The intervention program which includes 3 first-level indicators,15 second-level indicators and 68 third-level indicators was finally determined by two rounds of expert consultation and repeated discussions by the research team.CONCLUSIONS(1)Stigma score in patients with temporary stoma was in the middle level,and associated factors included patients' family location,stoma-associated complications,the impact extent of ostomy on sexual life,patients' self-concealment tendency,social support extent and coping style with disease.(2)The intervention program for peer education in stoma patients with stigma has certain scientific and reliability.It can be used by medical staff to conduct peer education intervetions for patients with ostomy to help patients reduce stigma.