Study design. This randomized, controlled, quasi-experimental design study was conducted to examine the effects of phone counseling on sexual problems of individuals with a stoma.
Setting. The study was conducted at Çukurova University Balcalı Hospital, the largest hospital in Adana, Turkey, and the only one with a stoma therapy unit. The unit operates between 8 am and 5 pm on weekdays. Two (2) nurses work in the unit, and the study researchers are certified by the Turkish Ministry of Health regarding stoma care training. One researcher has worked in the stoma therapy unit as a nurse for 18 years, and the other has 10 years’ experience working with patients with a stoma. The stoma therapy unit serves individuals from other clinics of the hospital as well as people and families coming from other centers. Wound, ﬁstula, and incontinence care is performed as well.
Study sample. The study was conducted between March 12, 2017, and December 27, 2017. Eligible study participants had to be between 18 and 70 years old, have a sexual partner, and have undergone ileostomy or colostomy surgery. Persons who were illiterate (self-reported responses were considered more truthful than when a literate participant read and answered the scales independently), had a urostomy, were diagnosed with a psychiatric disease or used psychotropic medications (mental disorders and psychotropic agents can adversely affect sexual life, reducing sexual desire and leading to impotence and sexual arousal dysfunction4) were not eligible to participate. All patients who fit the criteria were recruited and randomized into 2 groups — an intervention group (provided telephone counseling) and a control group (did not have telephone counseling). A computer program generated random numbers (1 or 2) for participation. As a result of a power analysis conducted based on a similar study, sample size was determined to be a minimum of 35 individuals for each group.
The intervention group received telephone counseling in addition to the routine follow-up conducted by the stoma therapy unit at postop weeks 1, 2, and 4 and then once a month after discharge. Stoma care and adaptation training were provided to both groups in the stoma therapy unit. For consistent and similar telephone counseling, one researcher provided the counseling using a phone line dedicated for the study; no particular counseling method was employed. The telephone counselor focused on the sexual problems experienced due to the existence of stoma per the patient’s request.
During their first appointment at the stoma therapy unit 1 week after discharge, patients were encouraged to resume their sexual lives. Patients were informed they could call the dedicated telephone line if they experienced any problems or had any questions regarding their sexual lives any time throughout the day and guaranteed that the phone call would be answered promptly. Intervention group patients continued with their routine care, training, and check-up in the stoma therapy unit. Patients had an active role in telephone counseling by calling when they needed.
Control group participants were provided routine check-ups in the stoma therapy unit. Telephone counseling was not a routine practice in the stoma therapy unit.
Procedure. Patients planning to undergo stoma surgery were asked to participate in the study, provided written informed consent, and interviewed before the operation. They completed the Questionnaire for Individuals with Intestinal Stoma and the Golombok-Rust Inventory of Sexual Satisfaction (GRISS) instrument. At the first visit after surgery, intervention group members were interviewed, given the phone number for counseling, and encouraged to call concerning their sexual problems. Patients were informed they could request an extra appointment if they experienced problems or wished to receive counseling. The stoma therapy unit provided patients with training and counseling regarding the problems they might experience during stoma care and challenges in their daily lives with a stoma.17,18
During their follow-up visits in the stoma therapy outpatient clinic after discharge, intervention and control group members again completed the Questionnaire for Individuals with Intestinal Stoma as well as GRISS at postoperative weeks 6 and 12. The 12-week time frame was selected because temporary stomas are generally closed after week 12.
Data collection. The following instruments were used to collect data.
Questionnaire for Individuals with Intestinal Stoma. The Questionnaire for Individuals with Intestinal Stoma, developed by the researchers, consists of 2 sections regarding descriptive characteristics and stoma-related data. Descriptive characteristics were collected before surgery and stoma data were collected after surgery. The section on descriptive characteristics includes 14 questions about sociodemographic features such as gender, age, marital status, education level, occupation, and whether health care is provided by the government. The section on stoma-related data includes 10 questions regarding stoma status (temporary, permanent), type of stoma (ileostomy, colostomy), the reason for stoma creation, location (eg, low anterior resection, abdominoperineal resection), who is providing care (self, self with help, relative, caregiver), and the effect of the stoma on sexual life (open-ended question).
GRISS. GRISS is a 28-item relationship tool used to identify and monitor sexual issues. It is implemented among heterosexual individuals with a steady partner or married couples and also can be used to evaluate the effectiveness of sexual treatment methods. The instrument was tested for validity and reliability in Turkey by Tuğrul et al.19 The female version provides a total GRISS score along with subscale scores for anorgasmia (the extent to which a woman can achieve orgasm), vaginismus (vaginal tightness), noncommunication (how well a couple can discuss sexual problems), frequency (how often sex occurs), female avoidance (the extent to which the woman is having sex), female sensuality (how often the woman feels pleasure), and female satisfaction (the extent to which the woman is satisfied with her partner). The male version produces a total score along with subscale scores for impotence (ability to achieve an erection), premature ejaculation, frequency (how often sex occurs), male avoidance (whether the man is avoiding having sex), sensuality (whether the man experiences pleasure), and male satisfaction (how satisfied the man is with his partner).4,10 GRISS responses comprise a Likert-type scale where 0 = never, 1 = hardly ever, 2 = occasionally, 3 = frequently, and 4 = always. For consistency purposes, negatively structured questions are reversely coded while interpreting the scale.20 The reversely coded items in the women’s form are 2, 4, 5, 8, 9, 10, 11, 15, 16, 17, 19, 21, 22, 25, 26, 27, and 28. In the men’s version, the reversely coded items are 1, 2, 3, 4, 8, 9, 12, 13,15, 16, 19, 20, 21, and 25.19 The total score offers a general idea regarding the quality of sexual function, while subdimension scores provide detailed information about the various aspects of a sexual relationship. The raw scores gathered from the scale are later transformed into standard scores from 1 to 9; if the score is 5 or above, the sexual relationship or functions are hindered in that subdimension. GRISS was previously used in the literature for studies on the sexual satisfaction of stoma patients.4,10
Statistical analysis. Data were collected using paper-and-pencil forms and entered directly into IBM SPSS Statistics, version 22 (IBM Corp, Armonk, NY) by the researchers for data analysis. Compliance of the parameters with normal distribution was assessed by the Shapiro-Wilks test; it was determined the quantitative data were not compliant with normal distribution. In addition to descriptive statistical methods (mean, standard deviation, frequency), the Mann-Whitney U test was used for the comparison of quantitative data between the 2 groups to evaluate the study data (eg, the Kruskal-Wallis test was used for comparison of data between more than 2 groups). The Mann-Whitney U test also was used to identify the group that caused the difference. The Friedman test was used to compare the variables in interviews 1, 2, and 3, (ie, before surgery and at postoperative weeks 6 and 12), and the Wilcoxon signed ranks test was used to identify what caused any differences. Chi-squared test, Yates’s correction for continuity, and Fisher’s exact chi-squared test were used to compare qualitative data. The results were evaluated in the 95% interval; P <.05 indicated statistical signiﬁcance.
Ethical considerations. Ethics committee approval was received from Çukurova University Medicine Faculty Ethics Committee before the study was conducted (March 3, 2017; Number of meetings: 62; Decision No: 32). The informed consent form was read to study participants, and their written permission was obtained. The study was conducted in accordance with the principles of the Declaration of Helsinki.