Exploring the barriers and enablers of the self-management ability in colorectal cancer patients with enterostomy: a qualitative study based on social ecological model

doi:10.21203/rs.3.rs-3604154/v1

Download PDF

Research Article

Exploring the barriers and enablers of the self-management ability in colorectal cancer patients with enterostomy: a qualitative study based on social ecological model

https://doi.org/10.21203/rs.3.rs-3604154/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Background:Since enterostomy surgery changes the way a patient defecates, it is essential for the patient to be self-managing in order to adapt to this change.

Objective:We aimed to explore the barriers and enablers affecting the self-management ability of colorectal cancer patients with enterostomy from the perspectives of social ecological model, to provide insight for developing self-management intervention programs to better meet the needs of patients.

Methods:An exploratory qualitative study guided by social ecological model and followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines was conducted . A total of 11 colorectal cancer patients with enterostomy from in the gastrointestinal surgery ward and ostomy clinic of a Grade A tertiary hospital in Shandong Province from January 2023 to April 2023 were recruited, and semi-structured in-depth interviews were used to collect data. Colaizzi data analysis and Nvivo 11.0 software were used to analyze the interview data.

Results:Facilitators relating to self-management ability included perceived benefits of self-management, acquisition of enterostomy knowledge and skills, positive psychological adjustment, family responsibility drive, and improvement of the health care system. Barriers included lack of ostomy knowledge and skills, adverse experience of the disease, family barriers, social negative environmental influences, limited access to medical care, and barriers to information access.

Conclusion:This study indicated that factors from the aspects of microsystem(e.g.,lack of ostomy knowledge and skills, adverse experience of the disease), mesosystem(e.g.,family barriers, social negative environmental influences), macrosystem(e.g.,limited access to medical care, and barriers to information access) would potentially affect the self-management ability of the colorectal cancer patients with enterostomy, interventions taget n these aspects might improve patients' self-management ability.

Colorectal cancer

Enterostomy

Self-management

social ecological model

Qualitative study

Colorectal cancer (CRC) is one of the most common malignant tumors with approximately 1.9 million new cases and 940,000 deaths in the world in 2020, ranking the third and second in the incidence and mortality of malignant tumors, respectively [1]. Surgery is the main one at present [2]. However, while the enterostomy saves the patient's life, it also affects the quality of life for the rest of the patient's life to some extent, because it destroys the normal structure of the human body and might lead to a series complications, such as prolapse, bleeding, infection and stenosis of the stoma resulting serious burden to patients' physical and mental health, and affect their quality of life[3, 4].

Self-management ability is one of the important abilities of patients.Self-management of disease refers to a healthy behavior in which patients maintain and promote health through their own behaviors, monitor and manage the symptoms and signs of their own diseases, reduce the impact of diseases on physical, psychological, social functions and interpersonal relationships, and persistently manage and treat their own diseases [5]. Previous studies [6–9] have confirmed that improving patients' self-management ability is of great significance for their diseases treatment and long-term rehabilitation. Patients with high self-management skills had higher quality of life and survival, and were less likely to develop ostomy complications[10].

Previous qualitative studies of colorectal cancer patients with enterostomy mainly focused on the discussion of post-operative life experience, including topics such as experiencing traumatic events, living in a new reality, and striving to improve quality of life [11–14]. In addition, qualitative studies have been conducted on patients' ability to self-manage, including the process of receiving and managing an ostomy, physical limitations, psychological responses, social support, and the need for adequate ostomy preparation and education [15–16]. However, little is known about the barrier and facilitators related to the self-management of colorectal cancer patients with enterostomy.

The social ecosystem theory proposed by Charles Zastrow closely combines system theory, sociology and ecology, and emphasizes the interaction between individual development and the surrounding environment to form a complete ecosystem, including microsystem, mesosystem and macrosystem [17]. This theory has been widely used in studies on social work intervention, chronic disease management and health promotion [18–20], playing an important guiding role to explore the factors related to a certain disease. At present, there are few qualitative studies on the self-management ability of colorectal cancer enterostomy patients at home and abroad[15–16], and there is a lack of discussion and summary of factors affecting self-management, especially based on the theoretical framework of social ecology, and no relevant research reports.Therefore, we aimed to conducte a qualitative study to explore the barriers and enablers affecting the self-management ability of colorectal cancer patients with enterostomy under the guidance of social ecological model, thereafter to provide reference for the development of targeted self-management intervention programs for colorectal cancer enterostomy patients.

Design

A qualitative study with semi-structured in-depth interviews were conducted with colorectal cancer patients with enterostomy. And, this study was reported followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (See Supporting Information).

Theoretical framework

Social ecological model emphasizes the interaction between system and individual and influences individual development, and divides human social ecosystem into three basic types: microsystem, mesosystem and macrosystem. Microsystem is the personal system, including the physiological, psychological, behavioral and other subsystems that affect the individual. The mesosystem refers to small groups associated with individuals, including families, occupational groups, and other social groups. Macrosystem refer to larger groups, including organizations, communities, and social cultures[17].Based on the social ecological model, this study analyzed the obstacles and facilitators of self-management ability in colorectal cancer patients with enterostomy, so as to help them improve their self-management level and quality of life.

Setting and participants

The purpose sampling method was adopted in this study, WWT recruited colorectal cancer enterostomy patients in the gastrointestinal surgery ward and stomostomy clinic of a Grade-A hospital in Shandong Province from January 2023 to April 2023.Inclusion criteria were:(1) Patients diagnosed with colorectal cancer by pathological examination and had receiving enterostomy; (2) Age ≥ 18 years old; (3) ≥ 30 days after enterostomy(4) clear mind, normal thinking, able to communicate in language; (5) Patients who voluntarily accepted and cooperated in the investigation. Exclusion criteria were: (1) patients who are participating in other studies; (2) Patients with unstable or rapidly deteriorating conditions; (3) Severe mental illness or cognitive impairment. Recruitment ceased when data saturation was met (i.e. when no new information was being generated). A total of 11 patients were interviewed in this study with 5.5 hours, and the general information of the interviewees is shown in Table 1.

Table 1

Demographic characteristics of 11 patients with enterostomy
Sample Code Number	Gender	Age	Educational Level	Profession	Stoma type	Years Living with Colostomy
1	male	72	Junior high school	retire	Permanent enterostomy	6 months
2	male	67	Primary school	Peasant	Permanent enterostomy	4 months
3	female	56	Junior high school	worker	Temporary enterostomy	3 months
4	male	46	Junior high school	Peasant	Permanent enterostomy	3 months
5	female	62	Senior high school	retire	Permanent enterostomy	6 months
6	male	65	Technical secondary school	retire	Temporary enterostomy	2 months
7	male	74	Primary school	Peasant	Permanent enterostomy	12 months
8	male	64	Primary school	Peasant	Temporary enterostomy	2 months
9	male	67	Senior high school	retire	Permanent enterostomy	12 months
10	male	45	Undergraduate course	worker	Permanent enterostomy	5 months
11	male	62	Technical secondary school	retire	Permanent enterostomy	9 months

Data collection

The investigators WWT used semi-structured in-depth interviews to collect data. A pilot interview was conducted on two patients to improve the interview outline and avoid the completeness and accuracy of data collection affected by omissions.

When the subjects' health and time allowed, the researchers chose to conduct face-to-face interviews in a quiet, uninterrupted, separate office with no third person present.Before the formal interview, the researcher first introduced himself to the study subjects, fully explained the research purpose, recording needs, research confidentiality principles and precautions, and obtained the consent and recording permission of the patients. In the interview process, the researchers should give the participants the opportunity and time to fully express themselves, so as to collect rich data. In addition, the researchers carefully observed facial expressions of the interviewees. The interview time of each subject was about 20 to 30 minutes. Semi-structured interviews do not design very specific interview questions, leaving room for interviewees to speak freely.

Data analysis

The researcher WWT used personal in-depth interview method to collect data from patients with colorectal cancer stoma through semi-structured interview outline, and managed with the help of Nvivo 11 analysis software.

Within 24 hours after the interview, the interview data shall be transcribed in time, and the two persons shall communicate and check, and the interview results shall be returned to the interviewees for confirmation. The interview materials shall be marked, saved and backed up in detail. The researcher codes the interviewees, uses the Colaizzi data analysis method, and organizes and analyzes the data in combination with notes, which is mainly divided into seven stages:

①Record and read all interview materials in detail;

②Extract intentional statements consistent with the phenomena studied;

③Summarize and extract meaning from meaningful statements;

④Find common concepts or characteristics of numbers to form themes, theme groups and categories;

⑤Connect the theme with the research phenomenon and make a complete description;

⑥ State the essential structure of the phenomenon;

⑦Return the obtained results to the interviewees to verify the authenticity of the content. This can improve the validity of the essential structure through the research participants. During the verification process, if there is new data, integrate them into a detailed description.

Ethical considerations

Study protocol was approved by the Biomedical Ethics Committee of Shandong First Medical University (Shandong Academy of Medical Sciences) on November 14, 2022, with ethical approval number (R202211140138). This survey is entirely voluntary, anonymous, and confidential. All participants are requested to obtain informed consent prior to the interview.

Rigour

To ensure the rigor of the data collection process, all interviews were conducted using semi-structured interview guidelines, see Table 2 for details. All interviews were conducted by the same interviewer (WWT), the researcher contacted the patient as a clinical intern, directly participated in the clinical care work of the patient, got to know the patient and established a good relationship with the patient, and ensured its authenticity through long-term participation. And ensure data saturation.

At the same time, researcher need to constantly clarify and reflect on themselves, and keep a reflection diary when collecting and analyzing data, focusing on recording their feelings, reflections and interactions with data during the study [21–22]. The investigator regularly communicated with the supervisor, nursing specialist and members of the research team and discussed the interview outline.

Two authors (WWT and XMY) were involved in all steps of the data analysis, independently re-reading interviews, discussing the results and performing code validation and category refinement. In the process of continuous analysis and coding, experienced researcher (WJH) checked and verified the coding and reviewed the analysis process, and then returned the analysis results to the original interview data for continuous comparison and modification. The research results are presented in strict accordance with the original statements of the interviewees, so as to ensure the authenticity of the research results.

Table 2

Interview schedule designed based on the Social Ecological Model
Domains	Questions
Microsystem	Could you talk about your feelings after the operation?
	How do you manage your stoma?
	What do you think of the effect of ostomy management?
	Are there specific experiences that have made you more confident in your ability to manage your enterostomy?
	Have you had any problems with ostomy management? How did you handle it?
	Has your lifestyle and behavior changed since before? What motivated you to change?
	Have emotional problems associated with an enterostomy (such as anxiety, impaired self-esteem, etc.) ever bothered you? How did you handle it?
Mesosystem	Did your family member help you with the bag replacement and related care?
	What support did your family or friends provide in your self-management process?
Macrosystem	How did the doctor and nurse guide you to self-management after the enterostomy? How does it work?
	How do you get information about enterostomy management?
	Have you participated in relevant health activities to share your experience with other enterostomy patients?
	What support do you currently receive from the government, the community, and the hospital?
	What else would you like your medical staff to help you with? Any suggestions or expectations?

The two broad themes are Facilitators and Barriers.There are 5 subthemes for facilitators and 6 subthemes for Barriers.(See Fig. 1 for details)

Facilitators

Subtheme 1: Perceive the benefits of self-management

When patients with enterostomy perceive the benefits of self-managed behavior change or perceive the negative consequences of non-self-managed behavior change, they would have a stronger belief in self-managed behavior change and will invest more energy in healthy behaviors.

① The quality of life was improved after enterostomy. Self-management is a skill that patients with enterostomy need to learn and an important means to improve their quality of life. S9: "After learning to manage the enterostomy properly on my own, including changing bags, keeping clean, etc., I feel I have become more confident and independent. If my ostomy bag breaks in public, I can handle it myself, I don't feel scared, and I can plan my life more freely." S4: "Although she had an enterostomy, she is still continuing chemotherapy in the hope that she can control the cancer through chemotherapy."

② Effectively avoid complications. After enterostomy, there are some complications, such as intestinal obstruction and stomy infection, which patients perceive can be effectively avoided through self-management. S8: "Once eating ribs did not eat slowly, intestinal obstruction, went to the hospital to solve, got our disease, we have to eat carefully in the future, can not eat quickly" S3 "My stoma is temporary, the doctor told me that if you do not pay attention to management, if there are complications, it is easy to not recover, I do not want to carry the stoma bag for a lifetime." S1: "For those of us who are older, if we don't pay attention, it's easy not to treat an infection in case it happens."

Subtheme 2: Acquire enterostomy knowledge and skills

Patients with colorectal cancer enterostomy acquired self-management knowledge after surgery through the guidance of doctors and nurses, other people's experience, professional books, the Internet and other ways, actively learn how to manage ostomy, master ostomy nursing skills, and explore self-management methods that are suitable for themselves and combined with their own health conditions

① Doctor and nurse guidance. S3: "The doctors and nurses said I could walk, jog, tai chi, and that these activities would not put undue pressure on the enterostomy. I'm just going downstairs for a walk, a stroll, a break when I'm tired and then go. The doctor told me to gradually increase the amount of exercise, I still don't feel too strong in my legs, and I will jog when I recover."

② The experience of others. S10 "At the beginning of changing the ostomy bag, I spread a lot of ostomy protection powder, thinking that the more the better, the ostomy chassis and the skin were not tight, and after communicating with people who also have ostomy, I realized that I should not spread so much ostomy powder. After reducing the use of ostomy powder, I found that the ostomy chassis is more solid."

③ Network learning. S11: "In the patient group, nurses posted videos about stoma management, such as diet management, how to clean and care for stoma, stoma nursing skills, etc., I opened them when I was free, which was easier to understand than plain text."

④ Professional books. S3. "After my enterostomy, my daughter bought me a book called 'Mind of the Gut', which explains which foods are easily digested by the gut and which foods should be avoided. It helps me choose which foods to eat. Interestingly, the book also mentions the relationship between mood and gut health, which has made me more focus on emotion management and keeping a happy mood."

Subtheme 3: Positive mental adjustment

① The power of religious belief. patients with an enterostomy may experience physical and emotional difficulties, and religious beliefs can help them cope with these challenges. S4: "When I was ill, I started to believe in Buddhism, which freed me from pain and desire."

② Positive emotional regulation. Positive emotion regulation is to face difficulties and challenges with a positive view, thinking and attitude to help oneself gradually come out of the negative state and obtain a positive psychological impact. S2: "In the early days after the operation, the stoma did cause me a lot of trouble, with the help of my family for each care, but considering that the enterostomy saved my life, this difficulty is nothing compared with that." S3: "The doctor told me that I can have this operation when the wound (anastomosis) grows well and the anal function is normal. Now I actively cooperate with the treatment, regular review, and try to return the surgery as soon as possible."

Subtheme 4: Family responsibility driven

The family is the inner motivation source of the patient's self-management, and the patient takes the initiative to adopt healthy behaviors in order to be responsible for the family. It is reflected in the following four aspects.

① Reduce the burden of family care. The disease recurrence of patients will increase the burden of family care, and the burden of only-child families is heavier. The sense of family responsibility enhance patients' awareness of active management. S11: "I only have one child and she's usually busy with work.I don't want to bother her again and put too much pressure on her."

② Reduce the financial burden on families. After enterostomy, patients need to buy special medical equipment (such as enterostomy bags, stomostomy protection powder, etc.) and nursing supplies (such as gauze, medical gloves, etc.), and also need to undergo regular medical examinations and rehabilitation, which brings a heavy burden to the family. S2 "I took good care of myself, learned to change my ostomy bag correctly, didn't waste it, didn't have to run to the hospital, and spent less money."

③ Avoid family worry. Most patients expressed willingness to take the initiative to self-manage and reduce the psychological burden on their families. S4 "I usually pay close attention to the change of the ostomy bag, and check the condition of the ostomy myself. If there is any abnormality, I will tell the child in time, so as not to let them worry."

④ Dedication to family. The patient expects to resume a family role after an enterostomy, caring for and taking care of other family members and sharing family responsibilities, within the limits of their abilities. S4: "I am now actively adjusting to life after having an stoma and I want to look after their baby."

Subtheme 5: The medical security system has been improved

By providing comprehensive medical security, professional medical team support and reimbursement system, the self-management ability of enterostomy patients is effectively improved.

① Adequate medical resources. Patients after enterostomy surgery can get more comprehensive medical resources, including regular outpatient review, professional nursing guidance, timely complication management and health education. S5: "The ostomy clinic goes to work every day, and it is very convenient to take the ostomy bag and repeat the ostomy situation." S10: "Now I often participate in the health lectures organized by the hospital, we sit together and exchange the experience of ostomy care and how to care well."

② Medical expenses protection. In recent years, starting from the reform of workers' medical insurance, China has comprehensively integrated the two systems of urban residents' medical insurance and the new rural cooperative medical care system, unified the urban and rural residents' medical insurance system, effectively improved fairness and inclusiveness, and effectively protected the people's demand for "medical care for sick people". S2: "I always pour three times a day, and change the bag every two or three days. We are urban residents' medical insurance, and the reimbursement costs about 700 yuan per month, which our family can accept, but if we don't have medical insurance, we have to spend more than 2,000 yuan, which is quite a big cost, thank the state for such a good policy."

Barriers

Subtheme 1: Lack of ostomy knowledge and skills

For patients with enterostomy, knowledge about stoma is the basis for self-management, and the lack of knowledge and skills includes the following points.

①Improper postoperative care. Improper use of medical devices, not understanding the correct use of ostomy products and replacement frequency. S2: "I sometimes get itchy around my stoma. I asked the doctors and nurses, and they said it was dermatitis and asked me to change my stoma bag frequently. I didn't know how many days I had to change my stoma bag. S6 "Before, I cut the stomostomy chassis too big, I thought it would not get stuck to the intestines if it was too big. Later, I began to itch and redness around the stomostomy. When I came to the stomostomy clinic for a return visit, I realized that it was because the understomy was cut too big and the skin was stimulated by the stool " S1 "When my family first changed me, they did not dare to put too much ostomy protective powder, for fear of irritating the ostoma and failing to stick to the chassis of the ostoma."

② Not familiar with the management of complications: do not know the possible complications and management methods after ostomy. S6 "There was a slight bleeding around the stoma, and I didn't know why, which scared me to go to the stoma clinic."

Subtheme 2: Adverse experience of disease

Patients with enterostomy do not adapt to the changes brought about by the disease, resulting in adverse experiences and negative emotions, which brings challenges to self-management.

① The quality of life is declined. Patients with enterostomy face dietary restrictions and weight restrictions, which are easy to cause depression, anxiety, self-esteem damage, etc., affecting their enthusiasm for self-management of stoma. S6: "It is very annoying, after the operation, the medicine can not be broken, eating is controlled, dare not exercise too much, and all aspects are restricted."

② Feeling of uncertainty about the disease. Patients lack knowledge about the disease and are not sure whether various postoperative symptoms are related to enterostomy, resulting in psychological anxiety. S2: "I always feel bloated after the operation. I don't know if it is because of the ostomy and I am afraid of the tumor spreading."

③ Changes in body image. Enterostomy may cause changes in the patient's body image, and this change may trigger self-esteem and confidence challenges in some patients, resulting in patients unwilling to face the problem of stomy. S9: "I feel like it is a very embarrassing thing to have this disease and to have a stoma, and I don't want my stool to get out of control and come out of my abdomen."

④ There is a sense of drop. Enterostomy surgery can have a certain impact on the patient's body image and daily life, resulting in a sense of drop in the patient. S5: "My original patient friend, his stoma has been restored, but mine can not, I have to carry the stoma belt all the time, I envy him."

Subtheme 3: Social negative environmental impact

Enterostomy patients not only have to deal with physical challenges, but also are affected by the social environment.

①Social alienation and exclusion: Patients with an enterostomy may be considered unfit to participate in activities or may cause physical discomfort and thus be excluded from social activities. S10: "I used to go out to eat and travel with my poker friends, but since I got this disease, people also know that I am inconvenient and don't call me anymore, and gradually I have no friends."

② Embarrassment and shame: Some patients may feel embarrassed or ashamed because of their enterostomies and are afraid to talk openly about their condition. S6: "I used to go for a walk and play chess with my friends, but now I don't go. I always feel that they are staring at my abdomen. I am afraid that they will ask me about my enterostomy, which will become the topic of their conversation.

③ Excessive fear of enterostomy. Excessive fear due to the external environment may make it difficult for patient to carry out normal care of the enterostomy. S2: "A relative died because of this disease, just one year after the operation, I am also very afraid, dare not look at the enterostomy, do not know when the life will suddenly end, dare not think."

④ The traditional culture is deeply rooted. In traditional Chinese culture, some patients may consider having an enterostomy to be a shame. S10 "Body hair and skin by the parents, there is a abdomen on the stomach, very ugly."

⑤Fewer job opportunities. An enterostomy may result in some physical limitations, such as the need for special care and regular replacement of the ostomy bag. These restrictions may prevent the patient from engaging in certain social activities or jobs. S6: "I used to do decoration, after having an ostomy, I can't do heavy work, and the decoration company doesn't want me, I feel bad about this."

Subtheme 4: Family barrier

Family is an important support force for self-management of enterostomy patients, but when family members lack health management knowledge or support for patients' life, it will affect the self-management ability of enterostomy patients.

① Family members lack knowledge. Family members do not agree or understand the patient's lifestyle, dietary preferences, exercise habits, etc., and are unable to provide effective guidance and advice. S1: "Now retired at home, my wife does not let me do anything, afraid of ostomy out" S9: "My wife let me eat more meat, and make me take nutritional supplements for fear that I'll be weak, and once constipation is very serious, I'll have to drink lactulose to relieve it."

② Family responsibility pressure. Some patients focus on taking care of other family members and family affairs, ignoring the management of their own diseases, and the pressure of family responsibilities makes their self-management face challenges. S8: "Now I am guarding the gate for others, do not pay attention to my meals, go to the canteen, and have no time to exercise." S3: "I have not done my duty as a mother. I can't help my child in many things because of this illness. I feel very guilty."

③ The family atmosphere is tense. As a result of the disease, family members may need to spend more time and energy to care for the patient, and their life status will be significantly changed, and family relationships and family atmosphere will also be affected. S4:I'm also uneducated, I was supposed to deliver to other people's supermarket, I can't do hard work since I got this disease, my partner sometimes complains about me and says I'm useless, I can not lift my head at home."

Subtheme 5: Limited access

① The level of community nurses is limited. Community nurses play a key role in the residents' health management and rehabilitation process, and can help residents cope with ostomy problems. However, at present, the number of ostomy nurses in the community is relatively insufficient, and most community nurses, as the main component of community health institutions, do not have the professional level of continuity care, which can not meet the growing demand. S2: "It took my family four hours to drive to the hospital that had an ostomy clinic. The ostomy was infected and the community hospital couldn't do it and they didn't dare." S11: "I hope the community nurse can also answer the knowledge about stoma, and some community nurses can conduct home visits."
② The hospital level is limited. S1 "Our county hospital can not do enterostomy surgery, can only go to the big hospital, do not know which specialist, before and after a lot of delay." S9: "I use a convex ostomy bag, the model can not be bought in our hospital, can only go to the provincial hospital to prescribe, the amount of the ostomy bag with a maximum of 2 weeks, so it is very troublesome to often run to the hospital."

Subtheme 6: Information access barrier

Effective management information is the premise and guarantee of self-management of enterostomy patients. The obstacles to information access mainly include the following three reasons.

① Lack of access to information. Information about enterostomy for colorectal cancer may not be widely available and patients do not know how to find it. S7: "I don't know where to get other information except from the patient group." S5: "There are no easy-to-understand books specifically for enterostomy patients, such as how to care for the stoma, how to exercise, what to eat more, what to pay attention to."

② Lack of professional information. Professional books and medical staff guidance are effective ways for patients to obtain professional information about self-management. It is not easy for patients to accept information when the content of medical staff's education is abstract and general and there are professional terms. S9: "The nurse told me to eat less meat for fear of intestinal obstruction, but did not tell me how many times a week I can eat meat, very general." S8 "In the ostomy clinic, a nurse asked me if I had complications, I don't know what complications mean."

③ Non-professional information is complex. The management information obtained from the Internet and wechat is complex and lacks certain credibility and scientificity. S8: "The credibility of the information on the Internet is not very high. It says that after having an enterostomy, life has changed a lot. I can't work, I have to rely on my family, and I can't change my stomy bag by myself." Misinformation is rampant. There is a lot of misleading information in the management information that patients receive. S6 "The internet says that bathing is easy to get infected, so try not to take a bath, and I was afraid to take a shower when I first started having a stoma."

The objective of this study was to explore the barriers and facilitators to self-management in colorectal cancer patients with enterostomy. Colorectal cancer enterostomy patients are a special group of patients, they are under great pressure and distress physically and psychologically, especially in terms of self-management, they face many obstacles. Such as lack of ostomy knowledge and skills, adverse experience of disease, social negative environmental impact, family obstacles, limited medical conditions, access to information barriers, etc. Although colorectal cancer enterostomy patients face many barriers to self-management, there are many facilitators that can help them improve their self-management skills. Examples include the perceived benefits of self-management, the acquisition of knowledge and skills, positive psychological adjustment, the drive for family responsibility, and the improvement of the health care system.

Facilitators

In this study, we observed that patients' perception of self-management benefits was one of the facilitators at the micro level. This change at the cognitive level can stimulate their self-management willingness, thus promote the implementation of self-management behavior at the micro level. Patients will become more aware of their health, take the initiative to adopt a beneficial lifestyle to improve their condition, or become more actively involved in activities such as rehabilitation training and skill learning. Previous study [11] have shown that gaining autonomy is the key to improving the quality of life of postoperative colostomy participants, and providing health education and related training helps patients gain autonomy. Our study shows that the perceived benefits of self-management can stimulate patient autonomy, thus encouraging patients to actively participate in the self-management of enterostomy and actively seek to improve their knowledge and skills in order to better control their health and life. Therefore, healthcare professionals should help patients realize the benefits of self-management so that they can establish autonomy in the management of their enterostomy.

At the same time, our study found that acquiring enterostomy knowledge and skills is an important promoting factor for self-management, which is consistent with previous studies [23]. We also found that enterostomy patients can gain knowledge and skills through multiple and equally important means, including health care providers, online learning (video), other people's experiences, and professional books. This is different from the results of previous studies which only emphasized that medical staff is the main way for patients to acquire knowledge and skills of enterostomy [24, 25]. The qualitative study of 16 colostomy patients by Dalmolin et al. [26] also showed that online video is one of the important technologies for health education. Watching online videos enables patients to master the knowledge and skills of enterostomy care more intuitively and quickly and put them into practice directly. Secondly, communication and sharing of enterostomy nursing experience with patients with similar experiences can also help patients better understand and cope with the problems they encounter in the process of self-management, and take preventive measures in advance [27]. In addition, reading professional books is also an important way. However, it was learned from interviews that patients indicated that there were fewer relevant professional books available. Therefore, in order to meet the needs of patients, patients' enterostomy knowledge and skills can be improved through a combination of multiple approaches.

In our study, religious affiliation (Buddhism) was also found to be a motivating factor for self-management in enterostomy patients. Previous studies have also found that among diabetic patients in Thailand, Buddhist women usually have the ability of self-management, which may be related to their religious belief [28]. Buddhists with diabetes may benefit from rethinking their lifestyle and prioritizing a balanced, compromised lifestyle that helps them manage their diabetes and reduces their worry, anxiety, and stress. Lukman et al. pointed out that religion is the driving force of self-care for immigrants with chronic diseases, and provides guidance and strength for healing and accepting diseases through the practice of prayer [29]. Therefore, religion (Buddhism) can be an effective means to help colorectal cancer enterostomy patients better manage their disease and make lifestyle changes, and healthcare professionals need to understand religious traditions and cultural contexts to help patients successfully integrate disease management into their lives.

The driving force of family responsibility is the promoting factor in the meso field. Previous studies have shown that family members can provide patients with important psychological and economic support [30], while our study found that patients not only need family support, but also hope to take the initiative to shoulder family responsibilities, and this initiative and sense of responsibility can promote patients to adopt a healthier lifestyle and self-management behavior in daily life. Jordan et al. [31] pointed out in their study on diabetes management among MexicAn-American adults that grandchildren, spouses and other family members are important sources of self-management motivation for diabetic patients. In the study, respondents were encouraged to try to manage their own health in order to better take care of themselves and their family's offspring. Yoon[32] et al. pointed out that by improving self-care to avoid the additional stress of becoming a burden on the family, the study found that by improving self-care ability, individuals can better manage their health status, reduce dependence on family members, and thus reduce the burden on the family, and this improvement can also promote individuals' mental health and overall quality of life. It is also important for patients with enterostomy to take the initiative to take on family responsibilities. Hence, health care professionals can help patients better adapt to treatment and daily life by encouraging them to take the initiative to take on family responsibilities.

The perfect medical security system is the promotion factor in the macro field. During our interviews, we found that most of the medical expenses related to enterostomy were covered due to the current good health insurance policy, and the rest were covered by them. This finding provides a valuable reference for the government and medical institutions, showing that existing health care policies play a positive role in helping patients relieve financial pressure, providing useful information for relevant policy makers, and is expected to prompt more health care policy adjustments to ensure that more patients who need enterostomy surgery can be financially supported.

Barriers

Adverse disease experience is a microobstacle to self-management ability of enterostomy patients. The study of Petersen C et al.[33] showed that enterostomy changed the normal physiological structure of patients, lost the control of intestinal function, and made patients live in uncertainty, and this uncertainty made patients' disease experience poor. Our results also show that patients have a significant psychological gap after enterostomy surgery, and this gap is due to comparison with healthy people and other patients with enterostomy. In the face of changes in body image and social life, patients may unconsciously compare their own situation with others, and the differences in physiological structure with those around them may lead to low self-esteem, anxiety and other emotions. In addition, patients may also compare their own enterostomy situation to that of other patients, and if their own situation is more severe or special than that of other patients, it will further aggravate their psychological stress and sense of disparity. This study also found that some patients did not adapt to the restrictions brought by disease management, such as dietary restrictions, which would increase patients' adverse disease experience in the process of self-management behavior change, which was consistent with the findings of Pei-Shan Lo[34] et al. Zhang et al. [35] showed that psychosocial adaptation level is closely related to quality of life. Therefore, in clinical practice, nurses should encourage patients to actively deal with the stoma, help patients and their families to accept the stoma and image change, and minimize their adverse experience of the disease.

Social negative environmental influence is a mesosystem obstacle to self-management ability of enterostomy patients. Research by Yuan et al. [36] pointed out that Chinese people often use cursing phrases such as "May you give birth to a child without an anus" when expressing anger and dissatisfaction. This cursing discourse is a unique cultural feature of China, which implies strong dissatisfaction and anger against a certain behavior, exacerbating the stigmatization of enterostomy patients, making them feel discriminated against and excluded. In addition, our research also found that under the influence of traditional culture, most Chinese people believe that the body is born of the parents, so any change to the body will be regarded as bad luck. This traditional concept makes enterostomy patients feel more helpless and lonely in the face of social discrimination. In the face of socially negative environmental influences, enterostomy patients may feel inferior, helpless and lonely, which affects their ability to self-manage. Accordingly, medical staff should pay attention to the psychological status of patients, provide corresponding psychological support and counseling, help them overcome the negative social environment impact, improve self-management ability. Meanwhile, it is necessary to popularize the knowledge about enterostomy to the society, reduce the discrimination and exclusion of them, help them integrate into society, and improve the quality of life.

This study suggests that lack of knowledge of family members is a mesosystem obstacle to self-management in enterostomy patients. Previous studies have demonstrated that lack of knowledge of enterostomy patients is a barrier to self-management [37], but this study further shows that lack of knowledge of family members is also a key barrier. In the context of Chinese culture, family members play a crucial role in the care of patients. Caregivers are the patient's primary supporters in the home environment, and their level of knowledge and skill is critical to the patient's recovery and self-management. Zhi[38] conducted semi-structured interviews with caregivers of newborns who underwent enterostomy and found that the desire for professional support was an important theme for them, as well as for caregivers of adult patients with enterostomy, who needed professional guidance to help them understand and cope with the patient's physical condition and provide the necessary care and support. Therefore, the caregiver's enterostomy knowledge level has a significant impact on the patient's mental state, self-management ability, and quality of life. Therefore, it is suggested that medical staff should conduct health guidance based on family, encourage patients and their families to participate in health education courses, improve family members' attention to patients' self-management, enable patients and their families to master relevant knowledge and skills of enterostomy, and supervise and guide patients' long-term self-management outside the hospital.

The limited level of community nurses is the macrosystem factor of self-management obstacle. Studies have shown that [39] foreign ostomy nursing includes the whole process of patients from hospitalization to discharge, connecting hospitals and communities, and truly realizing seamless nursing for patients with ostomy. CWOCN nurses transfer patients' major nursing problems and nursing plans to nurses of community medical service institutions. The community nurses continue to administer care according to the hospital plans. However, due to the lack of professional knowledge of community nurses, the lack of unified planning and coordination, and the lack of number of community ostomy nurses, the continuous nursing of stomy patients in China has not achieved effective docking between hospitals and communities [40, 41]. Community nursing plays an important role in continuous care, and research shows that [42] community nursing is often the weakest link in rehabilitation. Most community nurses in China, as the main component of community health institutions, do not have the professional level of continuous care, and there is a certain gap compared with developed countries [43–44]. The results of this study show that due to the weak community nursing, there is a widespread phenomenon of patients seeking treatment in large hospitals. China's community nursing started relatively late, but at present, the community nursing in many developed countries has been relatively complete [45]. MA et al. [46] discussed the ostomy care in StMarks Hospital. In this model, medical staff provided education on ostomy care for patients in the pre-discharge stage, and community health care workers provided consultation, follow-up and other services in the following stages, so that patients could enjoy more systematic and comprehensive care. Pat Black et al. [47] point out that the transition from hospital to home is often a difficult time for ostomy patients, and in the long run, many patients require home visits and ongoing support from district care teams. Elissa Bradshaw et al. [48] pointed out that many community nurses did not have confidence in ostomy care, and Nazike Duruk et al. [49] showed that lay clinic staff did not consider ostomy care to be their responsibility. Therefore, we should strengthen the training of community nurses, improve their skill level and confidence in ostomy nursing, cultivate the sense of responsibility of community nurses, and encourage the patients with ostomy to seek medical treatment in the community.

This study shows that information access disorder is a macrosystem factor of self-management disorder, which is a blank of previous studies. When health care professionals use technical terms for self-management education, patients may not understand it. Therefore, when conducting health education for patients, attention should be paid to improving patients' ability to transform knowledge and skills, teaching patients how to do it specifically, rather than simply telling patients what to do and avoiding the use of professional terms. In addition, Qi et al. [50] pointed out that when Chinese adolescents with disabilities acquire knowledge of sexual and reproductive health information, not knowing where to get accurate information and feeling embarrassed to seek information are the two most frequently mentioned obstacles. This study found that not knowing where to get accurate information is also a barrier to enterostomy, suggesting that information access barriers are an important aspect of self-management disorders that need to be addressed with more attention. In recent years, medical staff have provided patients with disease knowledge through Internet, wechat, mobile APP and other network platforms, which helps to improve patients' self-management ability [51]. However, this study found that the health management information obtained by enterostomy patients from the Internet and mobile news is complex and unreliable. In the face of misleading information spread by network platforms, if enterostomy patients do not seek evidence and blindly implement it, it may bring serious adverse consequences. Therefore, we need to take measures to solve this problem. According to W R Marti et al. [52], ostomy patients need long-term professional support after discharge, and this can be achieved through a network of ostomy nursing nurses, social workers and psychology professionals. Similarly, the Siddika A[53] study showed that a remote monitoring system after colorectal cancer surgery is a safe and cost-effective alternative to traditional clinic follow-up with high patient satisfaction. Therefore, it is suggested that China establish a self-management information platform for enterostomy patients, and build a professional ostomy website or wechat public platform. At the same time, medical staff should strengthen the guidance of patients' ability to obtain information, provide reliable network resources, and improve their ability to distinguish the authenticity of information, so as to avoid being misled by false information. In order to ensure that patients obtain reliable network resources, healthcare professionals should recommend reliable network platforms and medical professional websites to patients, such as the official website of the National Health Commission and the official website of various medical professional associations, to help patients correctly obtain health management information.

Limitations and Suggestion for Further Research

Because the research results are mainly based on the interpretation and analysis of the researcher, it is easy to be affected by subjective viewpoints and personal background of the researcher, and the sample size of the qualitative research is usually small, the results may not be representative enough to be generalized to a wider group, which limits the universality of the research results. Suggestions for further research include: first, large-scale sample sampling in multiple places across the country can be carried out in the future to make the study results more representative; second, the weighing and decision-making process of enterostomy and other treatment options for colorectal cancer patients when facing surgical decisions, and the changes in patients' attitudes and emotions before and after surgery can be investigated.

In this study, semi-structured interviews were used to explore the barriers and facilitators of self-management ability of colorectal cancer enterostomy patients. Future intervention programs for self-management of enterostomy patients should not only focus on patients themselves, but also include the teaching of personalized knowledge and skills and psychological status. It is also necessary to emphasize the common education of families, improve community nursing, provide comprehensive services, improve the convenience of community residents, establish a standardized health information network platform and apply it to patients' home guidance, and improve patients' self-management ability outside the hospital.

Author contributions

WENTING WANG is responsible for research and design, planning, data collection, data analysis, result interpretation and manuscript writing; manuscript review and editing.MENGYA XU is responsible for research and design, data collection and analysis, and manuscript review.ZHAOWEI XING ,FEI LU are responsible for the manuscript review.EMERSON GALANG ALISWAG is responsible for research and design, planning, outcome interpretation, manuscript review and editing.JIANGHUA WU is responsible for research and design, planning, outcome interpretation, manuscript review and editing. WENTING WANG and MENGYA XU contribute equally to this study. They should be considered as First Author.

Funding

The authors would like to thank all participants for their involvement.The present study was supported by grants from the National College Student Innovation and Entrepreneurship Training Program (202310439054);Shandong Province Higher Education Research Development Plan Project (Humanities and Social Sciences) (J18RA122).

Sung, H., et al., Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin, 2021. 71(3): p. 209-249.
Xia Tingting. Path analysis of the influence of stomostomy pressure on self-management in patients with permanent colostomy [D]. Qingdao University,2020.
Maglio A, Malvone AP, Scaduto V, Brambilla D, Denti FC. The frequency of early stomal, peristomal and skin complications. Br J Nurs. 2021;30(22):1272-1276.
Robitaille S, Maalouf MF, Penta R, et al. The impact of restorative proctectomy versus permanent colostomy on health-related quality of life after rectal cancer surgery using the patient-generated index. Surgery. 2023;174(4):813-818.
Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care. 1999;37(1):5-14.
Vas A, Devi ES, Vidyasagar S, et al. Effectiveness of self‐management programmes in diabetes management: a systematic review[ J]. Int J Nurs Pract, 2017, 23(5): e12571.
Seo HW. Effects of the frequency of ostomy management reinforcement education on self-care knowledge, self-efficacy, and ability of stoma appliance change among Korean hospitalized ostomates[ J]. Int Wound J, 2019, 16(Suppl 1): 21-28.
Tang Pingping, Luo Yulian. Research progress of self-management education for patients with chronic obstructive pulmonary disease [J]. Journal of Nursing, 2018, 33(15): 106-109. (in Chinese)
Foss C, Knutsen I, Kennedy A, et al. Connectivity, contest and the ties of self-management support for type 2 diabetes: a meta-synthesis of qualitative literature. Health Soc Care Community. 2016;24(6):672-686.
Song QF, Yin G, Guo X, Lv X, Yu K, Liu C. Effects of a Self-Management Program for Patients With Colorectal Cancer and a Colostomy: A Nonrandomized Clinical Trial. J Wound Ostomy Continence Nurs. 2021;48(4):311-317.
Stavropoulou A, Vlamakis D, Kaba E, et al. "Living with a Stoma": Exploring the Lived Experience of Patients with Permanent Colostomy. Int J Environ Res Public Health. 2021;18(16):8512. Published 2021 Aug 12.
He LJ, Zheng MC, Yuet Wong FK, Ying J, Zhang JE. Immediate postoperative experiences before discharge among patients with rectal cancer and a permanent colostomy: A qualitative study. Eur J Oncol Nurs. 2021;51:101911.
Sarabi N, Navipour H, Mohammadi E. Relative Tranquility in Ostomy Patients' Social Life: A Qualitative Content Analysis. World J Surg. 2017;41(8):2136-2142.
Petersén C, Carlsson E. Life with a stoma-coping with daily life: Experiences from focus group interviews. J Clin Nurs. 2021;30(15-16):2309-2319.
Lo PS, Lin YP, Hsu HH, et al. Health self-management experiences of colorectal cancer patients in postoperative recovery: A qualitative study. Eur J Oncol Nurs. 2021;51:101906.
Song Juqing, Dai Ailan, Chen Ling et al. Qualitative study of home self-care in elderly patients with permanent enterostomy [J]. Geriatrics and Health Care,2019,25(02):227-229+246. (in Chinese)
Charles Zastrow, Karen K. Coster-Ashman. Human Behavior and Social Environment (Sixth Edition)[M]. Shi Hailing, Sun Yue, et al. Trans. Beijing: China Renmin University Press, 2006 :15-17.
SODERLUND P D.The social ecological model and physical activity interventions for hispanic women with type 2 diabetes:a review[J].J Transcuh Nurs,2016,28(3):306-314.
MCDANIEL J T.Prevalence of chronic obstructive pulmonary disease:county-level risk factors based on the social ecological model[J].Perspeet Public Health,2018,138(4):200-208.
WOLD B,MITTELMARK M B.Health-promotion research over three decades:the social-ecological model and challenges in implementation of interventions[J].Scand J Public Heatth,2018,46(20 suppl):20-26.
Berger, R. (2015). Now I see it, now I don’t: Researcher’s position and reflexivity in qualitative research. Qualitative Research, 15(2), 219–234.
Korstjens I, Moser A. Series: Practical guidance to qualitative research. Part 4: Trustworthiness and publishing. Eur J Gen Pract. 2018;24(1):120-124.
Liu Y, Wang L, Zhu L. The impact of stoma management education on the self-care abilities of individuals with an intestinal stoma. Br J Nurs. 2023;32(6):S28-S33.
Zhang Y, Xian H, Yang Y, Zhang X, Wang X. Relationship between psychosocial adaptation and health-related quality of life of patients with stoma: A descriptive, cross-sectional study. J Clin Nurs. 2019;28(15-16):2880-2888.
Danielsen AK. Life after stoma creation. Dan Med J. 2013;60(10):B4732.
Cengiz B, Bahar Z. Perceived Barriers and Home Care Needs When Adapting to a Fecal Ostomy: A Phenomenological Study. J Wound Ostomy Continence Nurs. 2017;44(1):63-68. d
Dalmolin A, Girardon-Perlini NM, Coppetti LC, Rossato GC, Gomes JS, Silva ME. Educational video as a healthcare education resource for people with colostomy and their families. Vídeo educativo como recurso para educação em saúde a pessoas com colostomia e familiares. Rev Gaucha Enferm. 2017;37(spe):e68373. Published 2017 Apr 6.
Petersén C, Carlsson E. Life with a stoma-coping with daily life: Experiences from focus group interviews. J Clin Nurs. 2021;30(15-16):2309-2319.
Lundberg PC, Thrakul S. Religion and self-management of Thai Buddhist and Muslim women with type 2 diabetes. J Clin Nurs. 2013;22(13-14):1907-1916.
Lukman NA, Merry L. Religion, support and self-care experiences: A qualitative descriptive study with Indonesian adults with the chronic disease living in Montreal, Canada. J Adv Nurs. 2023;79(5):1765-1777.
He LJ, Zheng MC, Yuet Wong FK, Ying J, Zhang JE. Immediate postoperative experiences before discharge among patients with rectal cancer and a permanent colostomy: A qualitative study. Eur J Oncol Nurs. 2021;51:101911.
Jordan OJ, Benitez A, Burnet DL, Quinn MT, Baig AA. The Role of Family in Diabetes Management for Mexican American Adults [published online ahead of print, 2023 Oct 23]. Hisp Health Care Int. 2023;15404153231206086.
Yoon S, Kwan YH, Phang JK, Tan WB, Low LL. Personal Goals, Barriers to Self-Management and Desired mHealth Application Features to Improve Self-Care in Multi-Ethnic Asian Patients with Type 2 Diabetes: A Qualitative Study. Int J Environ Res Public Health. 2022;19(22):15415. Published 2022 Nov 21.
Petersén C, Carlsson E. Life with a stoma-coping with daily life: Experiences from focus group interviews. J Clin Nurs. 2021;30(15-16):2309-2319.
Lo PS, Lin YP, Hsu HH, et al. Health self-management experiences of colorectal cancer patients in postoperative recovery: A qualitative study. Eur J Oncol Nurs. 2021;51:101906.
Zhang Y, Xian H, Yang Y, Zhang X, Wang X. Relationship between psychosocial adaptation and health-related quality of life of patients with stoma: A descriptive, cross-sectional study. J Clin Nurs. 2019;28(15-16):2880-2888.
Yuan JM, Zhang JE, Zheng MC, Bu XQ. Stigma and its influencing factors among Chinese patients with stoma. Psychooncology. 2018;27(6):1565-1571.
Danielsen AK, Burcharth J, Rosenberg J. Patient education has a positive effect in patients with a stoma: a systematic review. Colorectal Dis. 2013;15(6):e276-e283.
Ni ZH, Ding S, Wu JH, Wang F. Family caregivers' experiences of caring for neonates undergoing enterostomy in China: A qualitative study. Nurs Open. 2023;10(2):817-827.
Dorothy D.Celebrating our achievements and“taking on”our challenges[C]//WOCN Mid-East Regional Confenrence,2011:29-30.
Jiang Qixia, Zheng Meichun, Liu Yun, et al. Comparison of training and practice of wound ostomy incontinence nursing nurses in China and the United States [J]. Nursing Research,2013,27(4C):1139-1141.
Xu Na, Lu Guizhi, Zhang Yan, et al. Research progress of extended care for patients with enterostomy [J]. Journal of Nursing,2014,29(2):94-96. (in Chinese)
O'Flynn S K. Care of the stoma: complications and treatments[J]. Br J Community Nurs, 2018,23(8):382-387.
Liu XL, Wang L. A review of the development and current status of wound ostomy continence nurses in the mainland of China. Int J Nurs Sci. 2018;5(2):105-109. Published 2018 Mar 17.
Zhang M, Wei D, Zhu X, Chen Y. Training and Management Status of Wound, Ostomy, and Continence (WOC) Nurses: A Cross-Sectional Survey From China. Cureus. 2022;14(4):e23793. Published 2022 Apr 3.
Palmer SJ. Overview of stoma care for community nurses. Br J Community Nurs. 2020;25(7):340-344.
Peters GM, Kooij L, Lenferink A, van Harten WH, Doggen CJM. The Effect of Telehealth on Hospital Services Use: Systematic Review and Meta-analysis. J Med Internet Res. 2021;23(9):e25195. Published 2021 Sep 1.
Black P. Stoma care nursing management: cost implications in community care. Br J Community Nurs. 2009;14(8):350-355.
Bradshaw E, Collins B. Managing a colostomy or ileostomy in community nursing practice. Br J Community Nurs. 2008;13(11):514-518.
Duruk N, Uçar H. Staff nurses' knowledge and perceived responsibilities for delivering care to patients with intestinal ostomies: a cross-sectional study [published correction appears in J Wound Ostomy Continence Nurs. 2014 May-Jun;41(3):241]. J Wound Ostomy Continence Nurs. 2013;40(6):618-622.
Qi W, Li H, Lian Q, et al. Knowledge level and access barriers related to sexual and reproductive health information among youth with disabilities in China: a cross-sectional study. Reprod Health. 2023;20(1):84. Published 2023 Jun 6.
Wang Liping, YAN Qiaoyuan, Zhang Ning et al. Remote extended care for patients with enterostomy [J]. Journal of Nursing, 2019,36(13):108-110. (in Chinese)
Marti WR, Arpagaus G, Hamel ChT. Der Patient als Stomaträger [The patient with a stoma]. Ther Umsch. 2007;64(9):545-548.
Siddika A, Tolia-Shah D, Pearson TE, Richardson NG, Ross AH. Remote surveillance after colorectal cancer surgery: an effective alternative to standard clinic-based follow-up. Colorectal Dis. 2015 Oct;17(10):870-5.

No competing interests reported.

Supplementarymaterial.docx

Download PDF

Version 1

posted

You are reading this latest preprint version

Exploring the barriers and enablers of the self-management ability in colorectal cancer patients with enterostomy: a qualitative study based on social ecological model

Status:

Version 1

Abstract

Figures

Introduction

Materials and methods

Design

Theoretical framework

Setting and participants

Data collection

Data analysis

Ethical considerations

Rigour

Results

Facilitators

Subtheme 1: Perceive the benefits of self-management

Subtheme 2: Acquire enterostomy knowledge and skills

Subtheme 3: Positive mental adjustment

Subtheme 4: Family responsibility driven

Subtheme 5: The medical security system has been improved

Barriers

Subtheme 1: Lack of ostomy knowledge and skills

Subtheme 2: Adverse experience of disease

Subtheme 3: Social negative environmental impact

Subtheme 4: Family barrier

Subtheme 5: Limited access

Subtheme 6: Information access barrier

Discussion

Facilitators

Barriers

Limitations and Suggestion for Further Research

Conclusions

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1