A stoma is an opening in the abdomen for the purpose of excretion; it is created for a variety of reasons including cancer and trauma as well as inflammatory and obstructive conditions (Gozuyesil et al, 2017). Colorectal cancer is considered to be one of the main reasons for stoma formation. Among men, the three most prevalent cancers are pulmonary, prostate and colorectal; among women, breast and colorectal cancer are the commonest (Jemal et al, 2011). Intestinal stomas are created mostly in older people due to cancer; younger people may need a stoma because of inflammation in the small intestine (Bazalinski et al, 2014).
In Iran, there were 9864 new cases of colorectal cancer (9% of all cancers) in 2018 (World Health Organization (WHO), 2019a). Worldwide colorectal cancer accounts for 10.2% of all cancers (WHO, 2019b).
This disease is a problem in Iran because of the rise in the number of colorectal cancer cases and low survival rates due to the fact that diagnosis is often made at advanced stages (Adel Mehraban et al, 2008). It is assumed that 40 000 new stomas will be created annually in the US because of colorectal cancer (Ercolano et al, 2016); about 13 000 people in England and 100 000 people in the US will have colostomy surgery (Simmons et al, 2007; Sheetz et al, 2014).
Although stoma surgery seems a common operation, more than 70% of patients experience postoperative complications, which incur a high cost for healthcare systems because of the need for long-term hospitalisation (Sheetz et al, 2014). Difficulties experienced after colostomy formation include stress, long recovery times and concerns over remission after surgery (Follick et al, 1984).
Changes in the ability to excrete cause psychological and emotional problems in patients, and mostly affect self-esteem and sexual activity (Salome and de Almeida, 2014). Mental health difficulties affect various aspects of patients' lives and include poor body image, lower self-esteem and a greater risk of suicide (Knowles et al, 2013). Illness and negative changes in body image are important issues that can lower self-esteem (Gozuyesil et al, 2017). Poor self-esteem is associated with behavioural and communication problems, psychological disorders such as anxiety and depression, and physical illness (Johansson et al, 2018).
Self-esteem concerns the positive and negative feelings people have about themselves. In other words, it shows how valuable people consider themselves to be (Coopersmith, 1990). Without doubt, it affects mental health, and good self-esteem is linked to positive psychological health (Su et al, 2016).
Ostomy has a huge impact on social interaction. For example, social activities are reduced and relationships with friends and relatives are affected (Simmons et al, 2007). Social and psychosocial functions are reduced because of changes in body image and a lack of self-confidence in social relationships (Geng et al, 2017). Patients often reported having problems exercising, sleeping, being in a community, in their sexual relationships and with dressing (Su et al, 2016). A study involving Japanese and British patients with a colostomy found that they experienced social problems, such as disruption in social interactions to various degrees for up to 2 years after stoma surgery (Krouse et al, 2007). In Iran, Mahjoubi et al (2010) showed that psychological problems (like other complications) are very common among patients with an intestinal stoma. Ostomy often causes changes and difficulties in social interactions, with work and with daily activities.
Jain et al (2007), in their study on patients with an intestinal stoma, found that 80% of participants experienced changes in lifestyle, and more than 40% had sexual problems. Between 30% and 59% of patients with an intestinal stoma limit one or more of their daily routines and there are significant differences between the social interaction of patients with and without an intestinal stoma (Simmons, 2014). Patients with a stoma were more likely to avoid meeting new people, and less likely to take part in recreational activities or use public transport (Simmons, 2014).
According to the Iranian Ostomy Association, most patients do not access high-quality bags because of their high costs and a lack of standard ostomy equipment (Mahjoubi et al, 2009). The low number of enterostomal therapists means that stoma care is difficult (Mahjoubi et al, 2005; Naseh et al, 2012). Pouresmail et al (2017) found that 96% of patients had not received regular, planned education and 73.7% needed the help of someone while in hospital. Patients with an intestinal stoma often require continuing help with stoma care. Patients find this unpleasant and having to have help reduces their self-efficacy.
Self-efficacy is a psychosocial concept derived from Albert Bandura's (1997) social learning theory (Pouresmail et al, 2017); it concerns a person's confidence about their ability in succeeding with a task or achieving desired results. Self-efficacy involves individuals judging their own ability, and their beliefs in their abilities affect their perseverance and effort. In other words, self-efficacy is the ‘belief of the individual’ in their ability to finish tasks. In patients with an intestinal stoma, higher self-efficacy is a predictor for fewer psychological problems in the early post-operative years. Stoma self-efficacy is defined as self-efficacy in the care of the ostomy and the expected social functioning of an individual (Rafii et al, 2012). Individuals with strong self-efficacy, while facing challenges, are more effective at regulating their emotions and more active in solving problems. They consider wider goals, make more effort and, in the face of such circumstances, are more determined; in contrast, those with low self-efficacy feel they are helpless and unable to control life events and believe their efforts are futile so, when faced with obstacles, if their initial efforts fail to deal with problems, they are quickly disappointed (Campbell and Ntobedzi, 2007).
The number of people who lose the ability to excrete normally is increasing, and the social and psychological consequences of this cannot be ignored. Extensive physical and psychological problems, such as self-efficacy and self-esteem disorders, arise following the creation of stoma. Psychosocial conditions in these patients have attracted the attention of researchers in fields such as nursing, mental health and social medicine (Simmons, 2014).
Disruption of self-efficacy and self-esteem is always a serious issue in these patients because they encounter the most important challenges shortly after ostomy surgery, which include how to care for their stoma, taking part in the community, engaging in everyday activities and pursuing their occupation. They also have to adapt to changes in body image and appearance, maintaining a positive attitude towards themselves and their sense of self-worth.
Practitioners, especially enterostomal nurses, who have the closest relationship with patients in the early postoperative period, need to pay attention to patients' levels of self-efficacy and self-esteem. This study's aim was to determine the correlation between self-efficacy and self-esteem in patients with an intestinal stoma.
Method
This descriptive-correlational study was conducted with patients with intestinal stoma who had been referred to the two hospitals affiliated to Iran University of Medical Sciences and the Iranian Ostomy Association in 2018. Sample size was defined using a 95% confidence interval and 80% power; the self-efficacy rate in relation to self-esteem in patients was taken as being at least 5%. The required sample size was determined to be 155.
Inclusion criteria
The inclusion criteria were literacy (reading and writing), being aged 18 years and above, being at least 1 month post-surgery and having an intestinal stoma such as an ileostomy or colostomy, which could be permanent or temporary.
Instruments
Tests used included the stoma self-efficacy scale, the Rosenberg self-esteem scale (RSES) (Ciarrochi and Bilich, 2006) and demographic form data.
The stoma self-efficacy scale has 28 items in two dimensions. There are: 14 items that measure the self-efficacy of the person in caring for their stoma and social self-efficacy and14 items that measure the efficacy of the person regarding social function. The scoring for responses on the Likert scale ranged from ‘I am not at all sure’ (1 point) to ‘I'm pretty sure’ (5 points). The lowest possible score was 28 points and the maximum 140 (highest self-efficacy). It also allows self-efficacy scores in each dimension (stoma care self-efficacy dimension and social self-efficacy dimension), with a minimum score of 14 (lowest self-efficacy) and a maximum of 70 (highest self-efficacy score). High scores are related to positive self-efficacy (Bekkers et al, 1996).
The RSES has 10 items, which use a 4-point Likert scale ranging from totally agree (3 points) to totally disagree (0 points). The overall score range is 0–30; for items 2, 5, 6, 8 and 9, ‘totally agree’ scores 0 points and ‘totally disagree’ scores 3 points. For items 1, 3, 4, 7 and 1, ‘totally agree’ scores 3 points and ‘totally disagree’ scores 0 points. A higher score is indicative of higher self-esteem (Ciarrochi and Bilich, 2006S).
The demographic information collected included age, sex, marital status, education level, contribution to ostomy care, change of job after surgery, diagnosis (the reason for stoma formation) and how long a patient had had the stoma.
Although the tools were valid and reliable, they were revalidated by three Iran University of Medical Sciences faculty members. To ensure the reliability of the instruments, 15 patients with an intestinal stoma who did not take part in the main study also completed the questionnaires; reliability was confirmed by internal consistency with Cronbach's alpha coefficient of 0.9 for the stoma self-efficacy scale and 0.86 for the RSES.
Ethical considerations and procedure
The study received approval from the ethics committee (ethics code IR.IUMS.REC. 1396.9511686003) of the Iran University of Medical Sciences and was granted jointly by the Iranian Ostomy Association and the hospitals.
The study goals and design were clearly explained to patients by the researcher and his assistant. Because patients can be reluctant to cooperate, it proved difficult to collect all the data from 155 patients. So, in addition to the researcher, data were collected by two nursing students. One of these assistants was a master's student who worked with ostomy patients, and the other was a bachelor's nursing student.
After patients' written consent had been obtained, the questionnaires were distributed, completed and collected on the same day. There are limitations to this method; some patients did not want to fill out questionnaires by themselves because of a psychological or physical condition. In such cases, the questions were read out by the researcher or research assistant, and patients' responses were entered into the questionnaire verbatim. Collection took place between August 2017 and January 2018 and no data were missing.
Data analysis
Data analysis was done using the SPSSv16 statistical package. To describe the sample's characteristics, descriptive statistics including absolute frequency distribution and frequency (for qualitative variables), mean and standard deviation (for quantitative variables), frequency distribution tables, calculation of numerical indices, and inferential statistics and t-test independent and variance ANOVA were used. Pearson's correlation coefficient was applied to determine the correlation between the two variables of self-efficacy and self-esteem.
Results
The mean age of the participants was 54.23 years (range 18–86 years). Of the subjects, 51% were men and 49% women; 74.2% were married and 25.8% were single. A majority (69%) needed at least one person to take care of them, while the remaining 31% looked after themselves without assistance. Nearly 53% stoma surgeries were carried out because of cancer and 47% were due to other causes, such as inflammation of the intestine, Crohn's disease, irritable bowel syndrome, bowel obstruction, trauma, constipation or chronic diarrhoea, incontinence and diverticulitis). Additional information is presented in Table 1.
| Variable | Response | Total | Percentage |
|---|---|---|---|
| Post-surgery job change | Yes | 37 | 24 |
| No | 117 | 76 | |
| Duration of ostomy | 1 month–1 year | 108 | 69.7 |
| 1–5 years | 21 | 13.5 | |
| >5 years | 26 | 16.8 | |
| Level of education | Academic (college and university) | 25 | 16.1 |
| Non-academic (school) | 130 | 83.9 |
The mean total self-efficacy score was 94.47 out of 140, with scores in the range 48–139 (Table 2). The mean self-esteem score was 19.10 out of 30, within a range of 0–30 (Table 3).
| Variable | Range | Mean | SD | Minimum | Maximum |
|---|---|---|---|---|---|
| Ostomy care | 14–70 | 53.61 | 9.92 | 28 | 70 |
| Social self-efficacy | 14–70 | 40.86 | 12.19 | 16 | 80 |
| Total self-efficacy | 28–140 | 94.47 | 19.06 | 48 | 139 |
| Variable | Mean | SD | Minimum | Maximum |
|---|---|---|---|---|
| Self-esteem | 19.10 | 4.26 | 7 | 30 |
Pearson's correlation coefficient showed that there was a positive, significant correlation between self-esteem and self-efficacy (P<0.001); there was also a positive, significant correlation between self-esteem and dimensions of self-efficacy (P<0.001). The highest correlation was found in social self-efficacy (r=0.53) and the least correlation in stoma self-efficacy (r=0.39) (Table 4).
| Stoma self efficacy | Social self-efficacy | Total self-efficacy | |
|---|---|---|---|
| Correlation | r=0.39 | r=0.53 | r=0.54 |
| P<0.001 | P<0.001 | P<0.001 |
The results of ANOVA and the independent t-test showed there was no relationship between self-efficacy and demographic characteristics except for marital status (Table 5). The results of ANOVA and the independent t-test showed there was no relationship between self-esteem with demographic characteristics (Table 6).
| Variable | Number | Mean | SD | Test result | |
|---|---|---|---|---|---|
| Age (years) | <30 | 7 | 84.85 | 15.94 | f=1.61 |
| 30–39 | 20 | 98.65 | 17.75 | ||
| 40–49 | 24 | 102.25 | 18.14 | ||
| 50–59 | 43 | 91.93 | 17.54 | ||
| 60–69 | 41 | 92.58 | 20.15 | ||
| >70 | 20 | 93.70 | 21.56 | ||
| Sex | Male | 79 | 95.48 | 2.21 | t=0.66 |
| Female | 76 | 93.43 | 2.12 | ||
| Marital status | Single | 15 | 96.53 | 18.77 | f=3.60 P=0.03 |
| Married | 115 | 83.80 | 21.01 | ||
| Widowed/divorced | 25 | 85.44 | 17.17 | ||
| Level of education | Elementary | 49 | 92.38 | 14.69 | f=1.93 P=0.12 |
| Middle school certificate | 41 | 90.41 | 19.00 | ||
| Diploma | 40 | 97.82 | 22.35 | ||
| Academic | 25 | 99.88 | 19.99 | ||
| Job change | Yes | 37 | 94.43 | 19.49 | t=0.08 df=152 P=0.93 |
| No | 117 | 94.73 | 18.91 | ||
df: degrees of freedom; f=ANOVA f-test
| Variable | Number | Mean | SD | Test result | |
|---|---|---|---|---|---|
| Age (years) | <30 | 7 | 16.85 | 2.26 | f=0.81 P=0.54 |
| 30–39 | 20 | 18.85 | 5.22 | ||
| 40–49 | 24 | 20.08 | 4.33 | ||
| 50–59 | 43 | 19.51 | 4.25 | ||
| 60–69 | 41 | 18.85 | 4.15 | ||
| >70 | 20 | 18.60 | 3.93 | ||
| Sex | Male | 79 | 18.77 | 4.28 | t=0.98 df=153 P=0.32 |
| Female | 76 | 19.44 | 4.24 | ||
| Marital status | Single | 15 | 19.40 | 4.13 | f=1.18 P=0.30 |
| Married | 115 | 18.46 | 4.79 | ||
| Widow/divorced | 25 | 18.08 | 4.50 | ||
| Level of education | Elementary | 49 | 18.44 | 3.78 | f=1.46 P=0.22 |
| Middle school degree | 41 | 18.63 | 4.78 | ||
| Diploma | 40 | 19.60 | 4.13 | ||
| Academic | 25 | 20.36 | 4.31 | ||
| Job change | Yes | 37 | 19.02 | 4.13 | t=0.11 df=152 P=0.90 |
| No | 117 | 19.11 | 4.33 | ||
df: degrees of freedom; f=ANOVA f-test
Discussion
There was a positive, significant correlation between total self-efficacy and its dimensions with self-esteem in patients with an intestinal stoma.
Evaluating the mean scores of self-efficacy and its dimensions showed that patients had weaker self-efficacy in the area of ostomy-related social activities. This is similar to the results of Wu et al (2007) and Rafii et al (2013). In a study by Dehvan et al (2019), the average self-efficacy score was similar to that in the present study.
Su et al (2016) found that 85.6% of patients had low or moderate self-efficacy in the dimension of stoma care, which required a focus on mental and social health as well as social support for patients.
Social self-efficacy concerns personal performance regarding social functions associated with having a stoma (Bekkers et al, 1996). High self-efficacy is associated with active coping strategies, seeking social support, problem-solving and optimism. On the other hand, low self-efficacy has been characterised by symptoms of anxiety and depression, as well as psychosomatic symptoms and poor wellbeing.
Social self-efficacy has a direct relationship with self-confidence, life satisfaction and optimism (Quintana et al, 2006). Therefore, the level of social self-efficacy of patients with an intestinal stoma in the present study needs to be further investigated and interventions are required in this regard. Ostomy often leads to changes and difficulties in social interactions, occupational considerations and daily activities (Mahjoubi et al, 2010). Patients often report problems with exercising, sleeping, being in a community, having sex and dressing (Su et al, 2016). Because self-efficacy is an aspect of coping, it can make it easier to accept an ostomy and live with it (Schwarzer et al, 2005); therefore, self-efficacy evaluation is important in these patients.
In this research, the mean score for self-esteem was 19.10 out of 30 (Table 3); 31.3% of the patients took care of their ostomy independently and 69.7% needed someone else's assistance.
In a study by Kiliç et al (2007) women who had had a mastectomy for breast cancer had a normal level of self-efficacy and a near to normal self-esteem level. In another study, patients with an intestinal stoma had moderate self-esteem, but experienced problems relating to sexual difficulties (Gozuyesil et al, 2017). About 54.3% of patients could not take care of themselves and 50.8% thought that the procedure had damaged their social lives. The study showed that 54.2% experienced fewer sexual relations and 44.1% had no sexual desire once they had a stoma (Gozuyesil et al, 2017).
Salomé and de Almeida (2014) showed that it was important for these patients to overcome psychological problems. This study also indicated that patients with an intestinal stoma had low self-esteem and a poor body image. Low self-esteem can be associated with behavioural and communication problems, anxiety and depression, as well physical and psychological problems (Johansson et al, 2018). Therefore, studying self-esteem levels in patients with an intestinal stoma is important because of the links with mental health.
There was a significant correlation between self-efficacy and its dimensions with self-esteem in patients. The strongest correlation was observed in social self-efficacy and the weakest in the dimension of stoma care. Connolly (1989) showed that there was a positive correlation between social self-efficacy and self-esteem, social harmony and mental health. Najafi and Foladjang (2007) found self-efficacy had a significant, positive relationship with good mental health. In a study by Pouresmail et al (2017), the mean score for self-efficacy correlated significantly with the total adjustment score. Research by Bazalinski et al (2014) found a statistically significant positive correlation between self-efficacy and satisfaction with life. Samadi et al's (2013) results showed a direct, positive relationship between self-esteem and quality of life.
Self-esteem is related to changes in self-efficacy (Lane et al, 2004). In addition, individual characteristics and self-esteem provide a context for self-efficacy (Di Giunta et al, 2013). People's expectations regarding efficacy in performing a given task could influence their self-esteem when success and failure are closely linked to self-worth (Bandura, 1997; Lane et al, 2004).
Individuals who have higher self-efficacy are more likely to succeed in overcoming problems and leading a contented life than those with a low self-efficacy (Bandura, 2017). They are also likely to persevere more and perform better in challenging situations (Sepahmansour et al, 2013).
It can be concluded that self-efficacy and self-esteem have a positive correlation, because how successful a person is achieving their personal goals largely depends on these two variables (Mone et al, 1995). Wu et al (2007), who examined self-efficacy and quality of life in patients with a stoma, found a positive relationship between self-efficacy and with level of education and gender, with higher self-efficacy among men. They also found a positive correlation between social self-efficacy and both psychological wellbeing and social wellbeing.
Su et al (2016), who studied self-efficacy and associated factors in patients with temporary ostomies, found that self-efficacy was associated with education level and type of ostomy. They found that patients with higher levels of education had higher self-efficacy.
Therefore, the relationship between demographic characteristics and self-efficacy needs to be considered in further research.
In the present study, no specific relationship was observed between self-esteem and demographic characteristics. Noghani et al (2006), who investigated levels of self-esteem in men and women with cancer, found no specific relationship between gender and self-esteem. Gozuyesil et al (2017) also found no difference between levels of self-esteem in female and male patients. Moreover, other components related to self-esteem were affected by stoma surgery: 50.8% of these patients did not want to be out in the community and preferred to stay at home; and 54.2% reported having less sexual activity and 44.1% reported that they had no sexual desire, with no differences found between men and women (Gozuyesil et al, 2017).
Limitations
Respondents were recruited by convenience sampling from three centres. This research looked at correlation, so conclusions cannot be drawn regarding causation. To investigate this, longitudinal studies are needed.
In addition, differences in individual patient characteristics when answering questions could have affected the results of this study.
Conclusion
Self-efficacy and self-esteem are important factors in patients with an intestinal stoma. Self-efficacy was positively correlated with self-esteem in these patients; social self-efficacy had the greatest influence on self-esteem. Therefore, educational and supportive interventions should be designed to improve patients' self-esteem and social interaction.
Most of the patients in this study had had their stoma for less than 1 year. Therefore, it is recommended that healthcare teams should plan to provide educational interventions as early as possible. These interventions should include: replacing the stoma bag correctly at appropriate intervals; leakage prevention; obstruction; skin problems and damage; correct use of stoma auxiliary equipment (such as paste, elastic tape and baseplates); following the advice of enterostomal therapists and doctors; and taking care of stoma during illness. In addition, an educational programme on social self-efficacy should be designed to prepare patients not only to communicate with others but also to talk about their stoma with other people.
The goals of social self-efficacy training should include: continuing activities at home and outdoors; wearing favourite clothes; travelling by public transport; attending parties and entertainment; going out to public places; having sexual relationships with sexual satisfaction to the same extent as before surgery; and being the person in charge of managing the stoma.
In setting educational goals and choosing the teaching method, the psychological dimension must be considered in addition to the practical aspects because self-efficacy, especially social self-efficacy, and self-esteem have psychosocial dimensions.
Additional research is needed to investigate the efficiency of interventions to improve self-efficacy and self-esteem in patients with an ostomy.