Abstract
Colorectal cancer is typically treated through surgery, and self‐care skills play a crucial role in disease adaptation and quality of life improvement. Therefore, this study aimed to investigate the effectiveness of a multimedia patient education intervention on enhancing the self‐care and quality of life among patients with a postoperative stoma as well as on establishing an easy‐to‐use ostomy self‐care skills assessment. The sample comprised 108 patients with new ostomies who were randomly assigned to two groups. Data were collected from June 2018 to March 2019. The conventional education service program group received individual education in the hospital environment, consisting of four 3‐h sessions delivered over 4 consecutive days. The multimedia group viewed a multimedia educational program using a laptop. Data were collected at baseline and 3 months after the intervention using a demographic questionnaire, an ostomy self‐care ability scale and the Stoma Quality of Life Scale. Before the intervention, there were no significant differences in self‐care ability and quality of life scores between the two groups (p = 0.764 and p = 0.466, respectively). However, 3 months after the intervention, the group that received the multimedia software intervention showed significantly higher self‐care ability and quality of life scores compared to the group that received conventional education services (p < 0.001). When a set threshold is reached, self‐care ability and a good quality of life can be met. The threshold value of the ostomy self‐care skill scale was determined to be 20 points, resulting in a sensitivity of 77.8% and a specificity of 75.5%. The results indicate that the multimedia education program enhanced home self‐care ability and quality of life among patients with enterostomy.
Keywords: education program, enterostomy, multimedia, quality of life, self‐care ability
1. BACKGROUND
Intestinal stomas result due to surgical interventions applied to the large intestine (colostomy) and small intestine (ileostomy). 1 , 2 A stoma is an artificial surgical opening created to divert faeces or urine to the skin surface for removal. 3 , 4 In Taiwan, colon cancer is the third most prevalent form of cancer, and the surgical formation of a stoma is a common treatment outcome. 5 Colostomy surgery typically results in a temporary change in bowel functions and can affect social, physical and mental health aspects of the patient for several months. Twenty to fifty percent of patients experience permanent difficulties, which can have serious deleterious effects on their quality of life if left untreated. 6 , 7 A recent systematic review describing ostomy‐related problems and their impacts on quality of life 8 included 14 studies, most of which were descriptive cross‐sectional studies (n = 12), whereas the remainder had a longitudinal design (n = 2). The results suggested that postoperative quality of life was affected in patients due to gas, constipation, depression, sexual problems, dissatisfaction with appearance, changes in clothing, travel difficulties, tiredness and concerns regarding the noise generated by ostomy.
Patients who undergo enterostomy have specific social and spiritual needs due to the physical and psychological barriers associated with stoma, which can gradually reduce one's confidence and influence social relations leading to eventual social isolation. If problems associated with intestinal stoma care remain untreated, the patient can experience an increased risk of depression; therefore, education regarding proper care and how to navigate stoma‐related challenges is extremely important for improving quality of life among patients who undergo enterostomy. 9
Operative education of both the patient and their family represents a key component of the stoma care process. The International Ostomy Guideline recommendations state that operative education for both the patient and their family (when possible) should include explanations that cover the stoma, the surgical procedure and an overview of postoperative stoma management. 10 , 11 Intestinal surgery nursing staff play an important role in patient education, self‐care promotion and emotional support following enterostomy procedures. Patients who are able to learn effective intestinal self‐care in a short period of time require shorter hospital stays. 12 , 13 The literature provides a sufficient evidence base to support the use of multimedia educational interventions as an alternative to education provided by health professionals when detailed education by a health professional is not feasible. 14 , 15 A systematic review evaluating the effectiveness of a multimedia learning education program (MLEP) demonstrated significant cost reductions and improved patient involvement in ostomy care, with improved self‐care capacity. However, limited research has examined whether MLEP interventions can improve patient self‐care and quality of life. 16 Lo et al. used a multimedia education strategy for patients with stoma to improve their knowledge and attitude. 17 Culha et al. found that self‐care education enhances stoma knowledge of patients with stoma. 18 Dalmolin et al. observed that people with colostomy and their families learned and developed their own methods of colostomy care by watching videos. 19 The aforementioned studies demonstrate the effectiveness of multimedia patient education for enhancing self‐care knowledge and skills in patients. Therefore, the present study adopted multimedia patient education as an intervention and explored its effectiveness in improving the self‐care knowledge and skills of patients with enterostomy.
2. METHODS
This study was conducted as a randomized, single‐blind trial to measure the differences between the self‐care ability and quality of life in patients with stoma who engaged in an MLEP and those who engaged in a conventional education service program (CESP). Inclusion criteria stipulated patients who undergone routine operation and patients who undergone emergency operations were excluded. Patients who met the inclusion and exclusion criteria were invited to participate voluntarily, groups were determined randomly using a randomly distributed number table and all information was available only to the trial researchers. The test period lasted from June 2018 to March 2019. This study was approved by the Human Resource Ethics Committee of Chang Gung Medical Foundation (201800061B0C502).
The trial sample size was estimated using G*Power 3.1 software, which indicated that a sample size of 88 participants was necessary based on a repeated measures analysis of variance (ANOVA) including two groups, two measures, a 5% significance level, 80% statistical power and effect size of f = 0.6. To account for a 20% dropout rate, the estimated number of samples was established as 108, including 54 patients in the experimental MLEP group and 54 patients in the CESP control group.
Participants were recruited from the surgical unit of a 2000‐bed teaching hospital in Taiwan. Inclusion criteria were as follows: (1) any stoma patient admitted to the surgical unit; (2) at least 18 years old; (3) able to speak and read Chinese and (4) stipulated patients who undergone routine operation. Participants were excluded from the study if they met the following criteria: (1) poor level of consciousness; (2) serious comorbid conditions, such as haemodialysis; (3) any other comorbidity likely to interfere with the intervention, such as clinical depression; (4) poor postoperative pain relief and (5) patients who undergone emergency operations.
2.1. Instruments
Demographic and relevant clinical data were collected. The ostomy self‐care ability scale, a quantitative scale that allows nurses to evaluate the self‐care skills among patients with ostomy, was evaluated. The ostomy self‐care ability scale consists of seven items related to the patient's reaction to the stoma, removal of the pouching system, measurement of the stoma diameter, adjusting the size of the ostomy diameter when installing a new stoma appliance, skincare, fitting of a new stoma appliance and pouch‐emptying procedure. Each skill was rated using a 4‐point scale Likert scale (1: not ability at all, 2: somewhat able, 3: quite a lot of ability and 4: very able). The maximum score is 28 points, with higher scores indicating a higher level of patient self‐care skills and ability to change the ostomy pouching system. Cronbach's α was 0.94 for the ostomy self‐care ability scale in this study.
The Stoma Quality of Life Scale (Stoma‐QOL) comprises 30 questions regarding seven domains: sleep (four items), sexual activity (three items), relationships with family and close friends (nine items), activity (four items), social relationships other than with family and close friends (three items), psychological (four items) and physiological (three items). Each item is rated using a 4‐point Likert scale (1: not at all; 2: a little bit; 3: moderately and 4: extremely). Possible scores range from 30 to 120, with higher scores indicating improved quality of life for the patient. The validity of the Stoma‐QOL has been evaluated by Prieto et al. 20 and its reliability has also been confirmed (Cronbach's α = 0.92, Rasch specifications infit mean square <1.3 and test–retest reliability of r > 0.88). The reliability of the Stoma‐QOL was also measured using Cronbach's α at the beginning of this study: the sleep dimension scored 0.84, sexual activity scored 0.87, relationships with family and close friends scored 0.92, activity scored 0.77, social relationships other than with family and close friends scored 0.72, psychological scored 0.80 and physiological scored 0.77. The overall Cronbach's α was 0.81.
2.2. Study procedures
Informed consent was obtained, and all questionnaires, including demographic and relevant clinical data, the ostomy self‐care ability scale and the Stoma‐QOL, were completed. Participants were randomly allocated to two groups using a two‐block random allocation without permutation. Random numbers were assigned to the two groups using a random number table, and the numbers were written on four cards that were placed in an opaque envelope. The envelopes were placed in a box, and the statistician (who was unaware of the groups) selected one of the envelopes, which indicated how two patients were allocated to a group. The process continued until all four cards were selected, after which the cards were returned to the box, and the allocation process was repeated until the intended sample size was achieved.
The two groups were the (1) MLEP and (2) CESP groups. The control group was provided with CESP, including a standard information brochure on stoma care used by the surgical unit prior to discharge. The brochure is typically given to patients immediately during their initial hospital course before operation, along with the instructions for question‐asking. The CESP group members were educated individually in the hospital environment through four 30‐minute sessions for 4 consecutive days. The brochure is also given to the patient's family members. The experimental group received individual education regarding how to use multimedia software via a laptop computer. We also provided a guide to using the software. At the time of discharge, a multimedia educational CD was given to the experimental group to use and share with family and caregivers at home.
The teaching content was based on a combination of literature review and clinical experience/expertise. Author Mei‐Feng Wu is a nursing specialist in wound, ostomy and continence nursing; in addition, author Hsing‐Fang Ko has extensive experience in medical–surgical nursing. The education provided to the CESP and MLEP groups was carefully constructed to ensure consistency, with variation only in the method of delivery. The MLEP included two sections. The first section consisted of information regarding the ostomy preparation process, including the selection of stoma‐related materials and use. The second section focused on cleaning techniques, manual bag replacement steps and precautions. The educational content was presented to 5 experts, including 2 surgeons, 3 ostomy nurses and 10 patients with ostomy, who reviewed and evaluated the educational content. Their feedback led to several modifications in the educational content.
The MLEP software development was conducted in five phases. During phase 1, the content was developed and revised, as described. During phase 2, the multimedia content was produced based on principles of adult learning and using the Meyer multimedia design guide 21 and research findings in the field of e‐learning materials and quality evaluation. 22 , 23 Phases 3 and 4 involved the evaluation of the initial software by both users and experts. Phase 5 focused on the implementation of post‐evaluation changes to the educational software. The software was introduced to members of the MLEP group during their initial hospital course before operation. The MLEP group members were educated individually on how to use the multimedia software using a laptop computer. The video was evaluated by a team of experts in colostomy care using the content validity index to determine how much it addressed all the aspects of interest it was intended to cover. 24 The content validity index was 0.95, suggesting the video's content was appropriate.
We encouraged CESP members to apply the educational content delivered in the brochure on ostomy self‐care via telephone and contacted them twice during the first week following hospital discharge, once during post‐hospital discharge week 2 and every 2 weeks until 3 months after discharge. Three months after discharge, all participants completed the ostomy self‐care ability scale and the Stoma‐QOL a second time. Follow‐up data were collected in an ambulatory clinic setting. We provided the MLEP software to all participants after the final data collection phase was complete.
2.3. Data analysis
Analysis was performed using SPSS 22.0 statistical software. Descriptive statistics were used, including the number and percentage and the mean and standard deviation, and the distribution of data was described as the median and interquartile range. The Kolmogorov–Smirnov test was used to verify whether the data conforms to the normal distribution. The Mann–Whitney U test was used to compare differences in continuous data between the experimental and control groups. The Chi‐square test or Fisher's exact test was used to compare differences in categorical data between the experimental and control groups. Spearman's rank correlation method was used to observe the correlations between factors. Multiple binary logistic regression and the stepwise elimination methods were used to conduct multivariate analysis to identify important factors associated with multimedia engagement, personal attributes, self‐care ability and quality of life. A p‐value of <0.05 was considered significant. Receiver operating characteristic (ROC) curve analysis and Youden index were used to determine optimal cutoff points for important explanatory factors of self‐care and quality of life in both groups and to assess their sensitivity and specificity.
3. RESULTS
In total, 108 participants met the defined inclusion criteria and were randomly allocated to the two groups: MLEP and CESP. As shown in Table 1, no significant differences in demographic or clinical characteristics were observed between the two groups.
TABLE 1.
Demographic data of the subjects (N = 108).
| Variable | N (%) | x 2/t | p | |
|---|---|---|---|---|
| Test group (N = 54) | Control group (N = 54) | |||
| Sex | ||||
| Male | 37 (68.5) | 31 (57.4) | 1.429 a | 0.232 |
| Female | 17 (31.5) | 23 (42.6) | ||
| Age | ||||
| ≥60 years | 3 (5.6) | 5 (9.3) | – | 0.716 |
| <60 years | 51 (94.4) | 49 (90.7) | ||
| Marital status | ||||
| Single | 4 (7.4) | 6 (11.1) | 0.565 a | 0.754 |
| Married | 40 (74.1) | 37 (68.5) | ||
| Other | 10 (18.5) | 11 (20.4) | ||
| Education level | ||||
| Below the national median (inclusive) | 22 (40.7) | 23 (42.6) | 0.438 a | 0.804 |
| High school | 17 (31.5) | 14 (25.9) | ||
| University | 15 (27.8) | 17 (31.5) | ||
| Employment status | ||||
| No | 28 (51.9) | 31 (57.4) | 0.741 a | 0.389 |
| Yes | 26 (48.1) | 23 (42.6) | ||
| Living condition | ||||
| Family living together | 50 (92.6) | 53 (98.1) | – | 0.363 |
| Living alone | 4 (7.4) | 1 (1.9) | ||
| Ostomy | ||||
| Ileum | 26 (48.1) | 14 (25.9) | 5.178 a | 0.017 |
| Ascending/transverse colon | 28 (51.9) | 40 (74.1) | ||
| Physiological index, median (IQR) | ||||
| Na | 138.0 (136.0–139.0) | 137.5 (134.2–140.0) | −0.156 b | 0.876 |
| K | 4.0 (3.6–4.3) | 4.0 (3.6–4.2) | −0.009 b | 0.993 |
| Cl | 106.0 (104.0–109.0) | 107.0 (103.0–108.0) | 0.011 b | 0.991 |
| Sugar | 146.5 (116.7–212.0) | 147.0 (119.0–215.0) | −313 b | 0.755 |
| WBC | 7400 (4900–10 000) | 7650 (6000–10 525) | −1.158 b | 0.250 |
Abbreviations: IQR, interquartile range; WBC, white blood cells.
Representative x 2 verification value.
Representative U (Mann–Whitney U test).
Comparisons were performed to examine differences in the baseline and post‐intervention scores between the experimental and control groups regarding overall stoma self‐care ability and overall quality of life (Table 2). To test the effectiveness of the MLEP, the Mann–Whitney U test was used to test changes in the overall ostomy self‐care ability, overall Stoma‐QOL scores and the intimacy domain of the Stoma‐QOL. Significant differences were identified between the experimental and control groups for overall stoma self‐care (U = 605.0, p < 0.001) and overall Stoma‐QOL scores (U = 632.0, p < 0.001), but no significant difference in the intimacy domain of the Stoma‐QOL was observed (U = 1402, p < 0.729).
TABLE 2.
Baseline and post‐intervention scores for the ostomy self‐care ability scale and Stoma Quality of Life Scale (Stoma‐QOL) in the control and experimental groups (N = 108).
| Variable | Median (IQR) | U | p | |
|---|---|---|---|---|
| Test group (n = 54) | Control group (n = 54) | |||
| Overall stoma care ability | ||||
| Baseline | 17.0 (12.0–26.0) | 20.0 (12.0–26.0) | 1462.5 | 0.764 |
| Post‐intervention | 24.0 (21.0–28.0) | 16.0 (12.0–20.0) | 605.0 | <0.001*** |
| Overall quality of life | ||||
| Baseline | 73.0 (63.0–91.0) | 72.0 (59.0–91.0) | 1390.5 | 0.466 |
| Post‐intervention | 105.5 (87.2–112.0) | 74.0 (65.7–92.5) | 632.0 | <0.001*** |
| Family and friends | ||||
| Baseline | 29.0 (23.0–34.0) | 26.0 (19.0–34.0) | 1294.5 | 0.192 |
| Post‐intervention | 35.0 (30.0–36.0) | 29.0 (23.3–33.8) | 840.0 | <0.001*** |
| Sleep | ||||
| Baseline | 9.0 (6.0–10.0) | 7.0 (6.0–10.0) | 1379.5 | 0.424 |
| Post‐intervention | 13.0 (11.0–15.2) | 9.5 (6.0–11.7) | 572.0 | <0.001*** |
| Activity | ||||
| Baseline | 9.0 (7.0–12.0) | 8.0 (6.0–12.0) | 1392.0 | 0.469 |
| Post‐intervention | 13.0 (10.0–15.0) | 9.0 (7.0–11.0) | 716.0 | <0.001*** |
| Intimacy | ||||
| Baseline | 10.0 (6.0–11.0) | 10.0 (7.0–12.0) | 1272.0 | 0.143 |
| Post‐intervention | 7.5 (6.0–10.0) | 8.0 (5.2–9.0) | 1402.0 | 0.729 |
| Social | ||||
| Baseline | 6.0 (4.0–8.0) | 5.0 (4.0–9.0) | 1445.0 | 0.683 |
| Post‐intervention | 11.0 (8.7–12.0) | 6.5 (4.0–9.0) | 550.5 | <0.001*** |
| Physiological | ||||
| Baseline | 11.0 (7.0–13.0) | 10.0 (8.0–13.0) | 1502.5 | 0.952 |
| Post‐intervention | 15.0 (12.0–16.0) | 12.0 (10.0–13.0) | 771.5 | <0.001*** |
| Psychological | ||||
| Baseline | 5.0 (4.0–8.0) | 5.0 (4.0–7.0) | 1478.5 | 0.837 |
| Post‐intervention | 10.5 (7.7–12.0) | 6.0 (4.2–9.0) | 670.5 | <0.001*** |
Abbreviation: IQR, inter quartile range.
p < 0.001.
The scores for overall ostomy self‐care ability were significantly correlated (p = 0.035). The experimental group showed improved scores for overall ostomy self‐care ability, the sleep domain of the Stoma‐QOL and the social domain of the Stoma‐QOL compared with the control group. This indicates that the MLEP was able to improve the experimental group's outcomes in these categories (Table 3). Spearman's rank‐order correlation coefficient was used to analyse the correlations among the various Stoma‐QOL domains. Except for the correlations between the intimacy domain and the psychological domains, which showed relatively low correlation coefficients (0.2 < Spearman's r < 0.3, p < 0.05), most of the other domains were moderately highly correlated with each other (Spearman's r > 0.5, p < 0.001), indicating that quality of life, including domains other than the social domain, is likely to continue improving among those who receive the MLEP (Table 4).
TABLE 3.
Multivariate logistic regression analysis (N = 108).
| Variable | OR | 95% CI of OR | p |
|---|---|---|---|
| Overall stoma care ability | 1.102 | 1.007–1.207 | 0.035 |
| Quality of life—sleep | 1.196 | 0.998–1.433 | 0.052 |
| Quality of life—social | 1.242 | 1.000–1.543 | 0.050 |
Abbreviations: CI, confidence interval; OR, odds ratio.
TABLE 4.
Correlation analysis of various factors with overall quality of life.
| Family and friends | Sleep | Activity | Intimacy | Social | Physiological | |
|---|---|---|---|---|---|---|
| Sleep | 0.577*** | |||||
| Activity | 0.678*** | 0.705*** | ||||
| Intimacy relationship | 0.316*** | 0.289** | 0.337*** | |||
| Social | 0.706*** | 0.685*** | 0.747*** | 0.297** | ||
| Physiological | 0.686*** | 0.728*** | 0.821*** | 0.318*** | 0.731*** | |
| Psychological | 0.664*** | 0.664*** | 0.803*** | 0.172 | 0.677*** | 0.797*** |
p < 0.01.
p < 0.001.
The best indicator of overall quality of life was the sleep domain of the Stoma‐QOL, for which a cutoff point of 11 points resulted in an AUC of 80.0%, a sensitivity of 72.2% and a specificity of 75.5%. The best cutoff point for the social domain of the Stoma‐QOL was 9 points, with an AUC of 80.7%, a sensitivity of 63.0% and a specificity of 86.8% (Figure 1).
FIGURE 1.
Receiver operating characteristic curve of overall self‐care and quality of life. AUC, area under the curve, between 0 and 1. The larger the area, the better, representing the higher efficiency of the model; QOL, quality of life.
4. DISCUSSION
Our results clearly showed that the MLEP group of patients with stoma displayed a significant increase in self‐care ability and significantly improved quality of life compared with patients who received CESP. The types of enterostomy in the basic attributes were significantly different but did not affect the analysis results. There were no significant differences between the two groups in terms of intimacy, which may be related to an overall decline in demand for a sexual life among patients with stoma. The MLEP group of 54 patients found the self‐directed program worth reviewing completely, and 36 returned to parts multiple times. Our findings were consistent with the findings reported by Lo et al. 17 who used a multimedia education program to promote awareness of stoma care and postoperative colostomy care among ostomy patients. Our results were also consistent with those reported by Hsueh et al. 25 who used a multimedia CD‐ROM with health information to provide information regarding colonoscopy procedures, which was associated with reduced anxiety and examination‐related pain among patients. According to the social learning theory posited by Bandura, enhanced self‐confidence and self‐efficacy among learners can lead to changes in expected health behaviours and the maintenance of expected behaviours. 26 Patient education can lead to improved outcomes, including enhanced adherence to care, improved quality of life and an increase in the patients' awareness of their illness and self‐management needs. 27
An MLEP represents an especially salient intervention because it does not require large amounts of documentation and can be easily replicated in other groups to validate outcomes. In addition to evaluating the effectiveness of MLEPs, several groups have attempted to identify which outcome measures can be combined to provide a single score to best capture the intervention results. 28 Commonly assessed outcomes for MLEP interventions include participant's knowledge, care self‐efficacy, self‐care ability and symptom management. 29 , 30 Stoma education should begin as soon as possible following surgical procedures and it would be considerably interesting to compare the effectiveness of an early intervention such as that in this study with longer term stoma care interventions by specialist nurses, for example. 31 Our findings agree with the findings of others who have examined the effects of multimedia education. Heidari‐Beni et al. found that multimedia education resulted in higher levels of adjustment than face‐to‐face education, 32 and similar work reported by Wofford et al. 33 showed a clear trend towards increased positive health attitudes in patients exposed to computer‐based health education interventions. Our findings also complement the work performed by Behboudifar et al. 34 who used an MLEP to improve self‐care ability among patients with cancer.
4.1. Strengths and limitations
The main limitation of this study was the slight difference in contents between the MLEP and CESP. Although similar images and information, as used in the CESP, were included in the MLEP, the MLEP also included animated images with slight modifications to present regular care techniques. Therefore, some improvements observed between groups may be due to the presentation of different images and information. However, MLEP use significantly increased outcome scores compared with regular care. Another limitation is that participants were only followed for 3 months. Stoma complications may develop after discharge, and future studies should include 6‐ and 12‐month follow‐up points to identify whether these differences persist. In addition, participants were only recruited from a single medical centre, which may limit the generalizability of the findings. These results should be validated in a multicentre trial. Another limitation is that the outcome indicators were all self‐reported, without correlating actual stoma care with self‐reported behaviour. Therefore, future studies should include direct observations of stoma self‐care behaviour to ensure that self‐reporting is accurate.
5. CONCLUSION
The results of the study suggest that the MLEP enhanced the in‐home self‐care ability and quality of life among patients with enterostomy. In view of these findings, decision‐makers should consider using more detailed multimedia education materials in place of written information and include MLEP‐based self‐care education as part of the early education in the postoperative process for patients with stoma. For better self‐care efficacy, we also recommend that further research evaluate the application of media education in community settings and how educational measures improve home care experiences and social support for patients with stoma. Finally, qualitative evaluation of multimedia interventions should be incorporated into study designs to evaluate patient satisfaction and quality of life improvements.
CONFLICT OF INTEREST STATEMENT
All authors declare that they have no conflicts of interest.
ETHICAL APPROVAL
This study was approved by the Human Resource Ethics Committee at Chang Gung Medical Foundation (201800061B0C502), and the clinical trial protocol was registered at https://register.clinical trials.gov (Clinical Trials.gov ID NCT04966286).
STATEMENT OF INFORMED CONSENT
Informed consent was obtained from all individual participants included in the study.
Ko H‐F, Wu M‐F, Lu J‐Z. A randomized control study: The effectiveness of multimedia education on self‐care and quality of life in patients with enterostomy. Int Wound J. 2023;20(10):4244‐4252. doi: 10.1111/iwj.14326
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.