Mean scores of participants on the OAI-23. In this study that aimed to assess the social adjustment of 135 patients with a stoma, the mean scores for the OAI-23 and its subdimensions demonstrated only limited change over the short study period. This finding is consistent with that of several studies assessing adjustment in stoma patients. In Cheng et al’s28 interventional study in which 92 colostomy patients were provided an Expert Patient Program (EPP) for 3 weeks, the mean adjustment inventory score increased from 47.59 before program participation to 53.37 after completing the program. The EPP included knowledge, stoma care self-efficacy, self-management, and psychosocial adjustment in patients who had a permanent colostomy. In a qualitative study performed in patients with stoma (N = 50) by Karabulut et al,23 the mean OAI-23 of patients in the study group was lower before planned group interactions for 6 weeks of sessions designed to enhance the adjustment to and living with a stoma in ostomy patients (53.04) and gradually increased following group meetings (70.91); however, no significant changes were noted in the scores of persons in the control group, whose averages were 51.07 and 53.07 at first and second evaluation, respectively.
Several previous investigations have reported high adjustment scores among patients with a stoma. Simmons et al26 randomly selected 570 persons with a colostomy, ileostomy, or urostomy with complete records from 3 national databases and found their mean adjustment score was 63.81. In a descriptive, experimental study by Martin,29 the adjustment scores of 20 patients (12 experimental group, 8 control group) with recent stomas in the sixth and eighth postoperative weeks were 82.42 in the experimental group and 78.58 in the control group. In their review article on ostomies in cancer patients, Hurny and Holland30 observed stomas led to anxiety and made it more difficult for patients to adapt to their new lives, thus extending their adjustment process and period. Adjusting to an ostomy is affective (ie, requires changes in the individual’s interest, attitude and emotions toward living with stoma); a slow, gradual progression over time is expected. Moreover, many factors influence adjustment to a stoma. Within this context, the adjustment of patients with a stoma can be expected to vary according to these different variables.
Participants’ sociodemographic attributes.
Age. Sociodemographic variables such as age, gender, education, and occupation have been found to influence adjustment to a stoma.12,31 The current study demonstrated the mean adjustment scores of patients 29 years old or younger decreased over time, while scores of patients in the 30–69 age group increased. In a cross-sectional study by Piwonka and Merino31 that studied the influence of age on social adjustment among 60 patients with a stoma, the most salient factors affecting adjustment to a stoma in patients under 62 years were the amount of time since the operation, body image, social support, and a low number of postoperative complications. The most relevant factors for patients 62 years of age and older were being able to take care of the stoma and body image. Many external factors are thought to influence adjustment in young and middle-aged patients, but as patients get older, external factors influencing adjustment have been known to decrease, with only the status of the disease and being able to assume care remaining important.23
Gender. In this study, the adjustment scores in the first OAI-23 assessment were lower in women than men; however, in the second assessment, the men’s scores remained unchanged, while women’s gradually increased and the difference between adjustment scores was statistically significant (P = 0.002). In a descriptive study by Karadağ and Baykara32 on 126 patients with a stoma, 35.7% of women and 58.4% of men reported the stoma made them dependent or semidependent (P <0.05) on others. Thus, the findings regarding the faster rate of adjustment to the stoma in women, relative to men, were expected.
Education and income status. Although mean scores increased over time depending on patient level of education and income and living status (ie, alone or with parents), the differences were not statistically significant (P >0.05) (see Table 4). When these factors were examined in relation to patient characteristics associated with the stoma, adjustment scores did not appear to change according to stoma type, although they increased over time, if not significantly (P >0.05) (see Table 4).
Working status. In the current study, the initial OAI-23 scores of unemployed patients were significantly lower than those of employed patients. These scores increased significantly in subsequent evaluation of adjustment (P <0.05). From these results, the authors inferred unemployed patients may have a tendency to constantly focus on their ostomy and hence may require a longer period to effectively adjust to their stoma
Marital status. Current results indicated significant improvements in adjustment among married patients over time. Support from one’s partner has been identified as being a contributing factor to adjustment.24 Social support provided by an individual’s family, children, or friends also had a positive influence on adjustment.31 In a descriptive study (N = 30), Altschuler et al33 found performing care together with one’s partner has a positive impact on psychosocial adjustment. Having a stoma presents a social issue that influences not only patients with the stoma, but also their partners, families, and close circles. Support from a partner is highly important to an individual’s adjustment to a stoma.
Preoperative preparation. The study found the initial mean adjustment scores of patients who were informed of the stoma operation and whose stoma site was marked were higher than those of patients who were not informed of the surgery and whose stoma site was not marked before surgery. Additionally, the current study reported adjustment in patients who underwent a planned operation and in persons who were not informed of the operation increased significantly with time (P <0.05). In a clinical study conducted by Person et al34 on 105 patients with a stoma (60 men, 45 women), quality of life and independence increased over time among patients whose stoma site was marked and their complications decreased significantly over time. Educating patients during the preoperative and postoperative stages of life about the stoma and its care and marking the site before surgery appears to facilitate acceptance of the stoma and adjustment to the postoperative process.
In a multicenter, retrospective, descriptive study (N = 748) conducted by Baykara et al35 involving individuals who underwent stoma site marking, the rates of peristomal complications were found to be significantly lower compared to individuals with no preoperative stoma site marking. The current authors believe stoma site marking will directly and indirectly increase adaptation. Thus, the low OAI-23 scores of patients whose stoma site was not marked before the operation was an expected finding.
Stoma type. The mean inventory scores of patients with a permanent stoma in the first and second evaluations were higher than those of patients with a temporary stoma (P <0.05). According to Karabulut et al,23 patients with a permanent stoma may make an effort to adjust more quickly because they know they will be experiencing this condition for the rest of their lives, whereas patients with a temporary stoma — aware the condition is temporary and the stoma will be closed — may not feel the need to adjust as urgently. As such, decreases in the OAI-23 scores from first to second measurement were anticipated. The literature26,31 notes characteristics of the stoma such as stoma duration, stoma type, and nature (ie, temporary or permanent) are among the variables most likely to affect adjustment. In Wade’s24 study on patients with colostomies, the incidence of depression was higher in patients with a temporary stoma (13%) compared to patients with a permanent stoma (6%). The authors believe the large majority (78.5%) of individuals with a temporary stoma in the current study might have negatively affected the mean OAI-23 score.
Stomal problems. Approximately 14.8% of the stoma patients in the study experienced stomal/peristomal complications (see Table 2). The rate of stomal/peristomal complications was measured at 32.8%, 35%, 24.1%, and 48%, respectively, in a retrospective descriptive study by Karadağ36 (N =128), a prospective, descriptive study by Ratliff et al37 (N = 220), a retrospective, descriptive study by Akçam et al38 (N = 120), and a retrospective study by Özaydın et al39 (N = 96). Stoma complications have been known to vary between 10% and 70%.3 In the current short-term study, although patients who experienced stomal and peristomal complications scored comparatively low on the OAI-23 first measurement, they showed marked improvements in adjustment when assessed at a subsequent point in time (second measurement). Descriptive, prospective studies6,40 in the literature demonstrated stomal and peristomal complications adversely impact adjustment to and living with the stoma.
Among patients experiencing stomal/peristomal complications in the current study, persons whose stoma care was performed by someone else scored the lowest on the OAI-23 initially (43.31). However, their scores increased significantly by the final assessment (55.68; P <0.05). Previous research26,31 shows many factors (such as status of performing stoma care, body image perception, amount of social support, the period following the surgery) influence the extent to which patients are able to adapt to the stoma. In their 4-year longitudinal study of 59 stoma patients and 64 bowel-resected nonstoma patients, Bekkers et al41 observed adjustment scores and the provision of stoma care were significantly affected by the occurrence of stoma-related complications within the 4 months following the creation of the stoma. In cases where no complications were observed, adjustment to the stoma was reported to take 2 years or longer, which could be extended by complications.
As these results and the literature demonstrate, many factors potentially enhance or inhibit adjustment among patients with a stoma. Furthermore, the relationships among these various factors significantly influence adjustment to the stoma. At times, many different factors can simultaneously influence a contributing factor. Given this information, an individual’s adjustment to the stoma may be influenced by the sum of his or her experiences rather than a single determinant.