Radical cystectomy and urinary diversion remain the main treatment procedures for muscle-invasive or high-risk non-muscle invasive bladder cancer . Postoperative urostomy education program is common and necessary, but most of patients were in a struggle to maintain well self-management in practice. The application of KAP is a way to inspect the changes in people’s thinking and behavior. Evidence showed that knowledge is the foundation of attitude and behavior changes, while positive attitude may further encourage positive changes in behavior [16, 17]. So, patients’ knowledge of disease may influence their attitudes and practices towards the disease. Because urostomy care has a long-lasting burden for patients and their caregivers, patients always lack of professional care support from medical institutions after discharge. Therefore, a urostomy education program for patients and their caregivers should be developed to meet this demand.
Relationships among a focal person (patients, P), another person (caregivers, O), and a media (urostomy care, X) were the main focus of the Heider balance (P-O-X model). There were eight possible component status, including four balanced and four unbalanced : If all three reciprocated relations were positive or two of them were negative, the triad unit were balanced, including “P + O, P + X, O + X”, “P + O, P − X, O – X”, “P − O, P + X, O – X”, “P − O, P − X, O + X”; If two of the three reciprocated relations were positive or all of them were negative, the triad unit were unbalanced, including “P + O, P + X, O – X”, “P + O, P − X, O + X”, “P − O, P + X, O + X”, “P − O, P − X, O – X”. In this model, relationships were either positive or negative according to the cognitive perceptions of others. Among these status, the “P + O, P + X, O + X” was considered as the best status of P-O-X model with a positive mutual influence. Any other balance or unbalance status can be turned by reversing anyone’s attitude, that can explain the feasibility of out-hospital intervention based on this model. For example, the triad unit were unbalanced with “P − O, P + X, O + X” status, supposing that the caregiver (O) was disgusted of uncomfortable features of pouch drainage from patients (X). Particularly, more attentions should be paid for “P − O”, a healthy education program or kind conversation would be carried out for caregivers and patients, so as to rectified the negative attitude.
After six months out-hospital intervention, the standard-reaching rate of the 6 items in knowledge, 5 items in attitude and 5 items in behavior of the observation group were significantly higher than those of the control group, those differences suggested that the out-hospital intervention based on Heider balance can obviously rectified the knowledge, attitude and practice comparing with the routine out-hospital intervention. A qualitative systematic review considered that  good family support had a positive impact on patients, which can promote positive health outcomes in many chronic diseases. Essentially, this viewpoint was in accordance with the principle of Heider balance, but the application of Heider balance were clearly presented with framework of three-body interactions consisted of patients, disease and caregivers, with the assumption thinking that any edge of triads was equivalent important in the dynamics of network . In a study on Heider balance and KAP model performed by Lou FL, et al , they also hold the view that the caregivers should be brought into the intervention, which can improve the level of knowledge and attitude towards pain management in cancer patients, and increase the intervention efficacy for them.
In this study, the findings demonstrated that most of items of WHOQOL-100 in the observation group were significant higher than those of the control group, especially in physical health, psychological, independence level, social relations domain. These results indicated that the out-hospital intervention based on Heider balance can obviously improve life quality of patients. No significant differences were observed in environment domain except for “health and social care: availability and quality”, the possible explanation may be that environment factors can not be changed within a short time. The WHOQOL-100 were commonly used in chronic diseases of its efficiency in measuring health-related quality of life, a increase or decrease of life quality after urinary diversion plays a important role in an individual's adaption to life with a stoma [23, 24]. A study reported that  a formal preoperative ostomy education program involved an interactive educational approach can make a promotion in patients’ ostomy self-management and post-ostomy life quality. Another study considered that  hospital-based home care teams should be created at least 6 months after discharge, so as to improve the patient’s life quality in discharged follow-up care. These findings from above studies were basically consistent with the results in our study. A previous study found that  a ostomy education program can decrease the rate of complication, this result in support of our findings that well out-hospital intervention can reduce the risk of complication after discharge. Indeed, as others reported [28, 29], patients may benefit from more education, and almost half of patients sought the help of an professional ostomy care, especially these patients with permanent urostomy.
In summary, the out-hospital intervention based on Heider balance can help to strengthen patients’ understanding and mastering on knowledge, improve attitude and practice, reduce the rate of stoma complications, consequently promote the life quality of patients. These merits make the Heider balance to be an attractive approach in guidance of out-hospital intervention in urostomy patients. However, this study was a preliminary exploration of the out-hospital intervention based on the Heider balance, which still has a certain distance for standardized application in clinical pathway. Therefore, the application procedure of Heider balance in out-hospital intervention needs to be supplemented in further study.