KNOWLEDGE AND PRACTICE OF STOMA CARE AMONG OSTOMATES AT B . P . KOIRALA MEMORIAL CANCER HOSPITAL

Background: There are more than 1 million patients with a permanent colostomy and the number is increasing by the rate of 100 000 per year. Clients with a new stoma must master multiple psychomotor skills to remove their pouch, clean the stoma and peristomal skin and empty and dispose of effluent from the pouch. Stoma care self-efficacy has been positively related to ostomy adjustment. Objective: To assess knowledge and practice of stoma care among ostomates. Method: This is a simple ddescriptive cross sectional study. A total of 94 ostomates who met eligible criteria were purposively sampled. Stoma self care efficacy scale and semi-structured questionnaire was used and face to face interview was done. Data were analyzed using SPSS version 16 program. T test was used to see the mean difference. Result: The knowledge of ostomates on normal stoma and complication of stoma was adequate (61.7%). Majority (92.6%) respondents had good daily care practice like emptying pouch, hand washing before and after procedure and cleaning stoma. Majority of the ostomates suffered from physical problem (89.4%). Of which maximum 72.3% had peristomal skin irritation, then came leakage and odour. More than half (64.9%) of ostomates had higher efficacy. Conclusion: On the basis of findings, it is concluded that there was significant difference in mean knowledge of ostomates with variables pre-operative teaching, training on stoma care, living with stoma for more than 12 months. There was significant difference in mean self care efficacy with variables duration of living with stoma and training on stoma care. Thus training on stoma care should be provided frequently to further improve self care efficacy.


INTRODUCTION
the increasing incidence of colorectal cancer and urinary cancer, stoma surgery rate is also increasing.Teaching on stoma care and stoma skills given by enterostomal therapist during post-operative and discharge period enable clients to increase self-efficacy in ostomy management.A variety of gastrointestinal/ genitourinary etiologies may necessitate the creation of a fecal or urinary diversion.These may include colostomy for colon-rectal cancer, diverticular disease, inflammatory bowel disease, intestinal obstruction, gastrointestinal trauma, and gynecological cancers [1].Urostomy for Bladder Cancer and Congenital abnormalities and ileostomy for ulcerative colitis, crohn's disease, familial polyposis and complications of cancer [2].
According to hospital based cancer registry in Nepal 2007, Ca Urinary bladder is 6 th common in male >64yrs whereas Ca rectum is 6 th common in female 15-34 yrs and male 15-34 years [3].According to medical record unit of B.P. Koirara Memorial Cancer Hospital (BPKMCH), Age and site wise distribution of Cancer patient, 2010, Ca urinary bladder 91, Ca colon 59, Ca rectum 69.Surgery performed in Urology Unit, radical cystectomy with illeal conduit 8, low anterior resection of rectum 6, loop colostomy 4, hemicolectomy 7 [4].
Enterostomal Therapist Shanti Bajracharya first started stoma care in Nepal and opened a clinic in 1996.At the beginning, there were only seven ostomates [5].According to data of 2010 from stoma clinics of Patan, Nepal Ostomy Association and B&B, shows the total ostomy cases were 2085 of which colostomy 1000, Urostomy 400, Iliostomy 300 [6].There are more than 1 million patients with a permanent colostomy in China, and the number is increasing by the rate of 100 000 per year Clients with a new ostomy must master multiple psychomotor skills to remove their pouch, clean the ostomy and peristomal skin and empty and dispose of effluent from the pouch [7].The adverse impacts on stoma patients are physical, psychological and social.The physical problems of ostomates included leakage, skin problems, ballooning and odor [8,9].The most common physical problems with the stoma include leaking, peristomal skin problems, and the need for adaptation of stoma appliances and the need for adaptation of clothing to the presence and site of the stoma which has a significant impact on the patient's daily life [10].
It is generally understood that a stoma has a negative impact on people's quality of life.This negative impact can affect self-care practices that may result in inappropriate and costly use of supplies [11].Stoma care selfefficacy is defined as the conviction by patients that they can successfully manage their stoma to minimize adverse outcomes.Stoma care self-efficacy has been positively related to ostomy adjustment [12].
While no research exists to define a minimum post-operative skill set for clients with a new ostomy, a consensus conference of Ostomy Care and Management Wound, Ostomy and Continence Nurses in the United States, 2007 concluded that the minimum post-operative skill set for persons with an ostomy should include: 1) ability to manipulate the pouch clip or spout if present, and 2) independently empty the pouch.Additional skills that need to be taught, whenever possible, included: 1) bathing, clothing and activity restrictions, 2) review of influence of prescription and overthe-counter medications on ostomy function, 3) influence of diet on ostomy function, 4) peristomal skin care, 5) odour control, 6) monitoring for complications, and 7) sexual counseling [13].Any failure on the journey to achieving an effective return to normal life may make the treatment and its long term consequences, particularly the stoma, seem worse than the original illness [14].

Methods
Descriptive cross sectional research design was used in stoma clinic of B.P. Koirala Memorial Cancer Hospital (BPKMCH).Being a national level cancer care referral centre in Nepal, most of the colorectal cancer and urinary bladder cancer cases are treated with stoma surgery.Study population ostomates more than 19 yrs of age and performing self-care and who were attending stoma clinic during the time of data collection.A total of 94 respondents, who met eligible criteria were purposively sampled and interviewed face to face.A structured and semi-structured interview schedule consisting of demographic characteristics, knowledge and practice related questions developed by reviewing literature.The content validity of the instrument was established seeking opinion of oncologist and related experts nurses and doctors.The instrument was then translated into Nepali language and opinion of language expert was obtained for comprehensibility and simplicity of language and for consistency of the content.The study was conducted after obtaining approval from the concerned authority.
Anonymity, privacy and confidentiality were maintained during as well as after data collection.All patients who met the criteria and who gave informed consent were interviewed.Review of the patient's medical record file was done to confirm the diagnosis of ostometes.The collected data were reviewed daily for completeness and accuracy.Edited data were entered into the Statistical Package for Social Science Software (SPSS) version 16.0 for statistical analysis using descriptive and inferential statistics.The data illustrates that 56.4% ostomates knew it was not normal to have black coloured stoma, 59.6% knew it was not normal to have stoma protruded >2 inch and 80.9% knew it was not normal to have continued bleeding from inside the stoma for >10 min (Table 3).In the daily care practices of ostomates, 84% ostomates perform hand washing before cleaning stoma and changing stoma bag where as all of them perform hand washing after the procedure.Likewise 47.9% of ostomates empty the pouch when it is half filled, 43.6% of ostomates empty pouch whenever pouch is 1/3 rd filled, 4.3% empty it in <1/3 rd filled.Remaining 1.1% empty the pouch whenever they feel it uncomfortable.75.5% of ostomates clean stoma from periphery to centre and remaining clean from centre to periphery (Table 4).6).others do nothing to solve it (Table 5).Majority (92.6%) had good practice regarding daily care practices like hand washing before and after procedure, pattern of emptying the pouch and cleaning the stoma from periphery to centre.The mean score was 3.55 ± 0.63 (Table 8).The mean knowledge score of illiterate was 3.31 and that of literate was 3.87, which is slightly different but it is statistically insignificant since p value is 0.314.The mean knowledge score of ostomates receiving and not receiving pre-operative teaching were 4.40 and 3.48 respectively.The difference is statistically significant since p value is 0.03.The mean knowledge score of ostomates receiving training was 5.00 and that of not receiving training was 3.25, which is significantly significant as p value is 0.00.

RESULTS
The mean knowledge score of ostomates living with stoma for 12 months was 3.18 and that of living with stoma for >12 months was 4.30, which is significantly different as p value is 0.00 (Table 10).The mean self care efficacy of ostomates having inadequate knowledge was 31.58 whereas having adequate knowledge was 43.50, which is statistically significant as p value is 0.00 (Table 12).

Discussion
The socio-demographic findings of the study revealed that most of the respondents (61.7%) were male.The findings were similar to the study done among patients of colorectal cancer resulting in an ostomy, which was seen more in males and a urostomy for bladder cancer was predominately associated with males.(1) The mean age of the respondents was 48.9 years (range 21-80 years), which is similar to the study in Iran in which mean age was 57.49 years (SD 12.28 years) [15].
In a descriptive study done to examine adjustment and its relationship with stoma care self-efficacy, among patients using 13 point Self-efficacy Scale in UK.Higher scores correspond to higher levels of confidence.
Stoma-care self-efficacy accounted for 57.5% [12].The finding is similar to this study in which higher self care efficacy of ostomates comprises of 64.9%.
In this study there is no significant difference in mean self care efficacy between old adult and others, illiterate and literate.This is in contrast to the study done on self efficacy and quality of life among stoma patients in Hong Kong in which factors associated with lower self efficacy included increasing age, lower education level [17].
In a cross-sectional study done to assess Selfefficacy and the related factors in ostomates among patients with ostomy in Iran using personal information form and Stoma Self-Efficacy Scale (Stoma SE Scale), half of the participants gained at least half of the overall self-efficacy scores.The mean score of social self-efficacy was lower than the mean score of stoma care self-efficacy.Self-efficacy was associated with marital status, stoma status and stoma duration (P<0.05) but the relationship between self-efficacy and age, gender, educational level, type of stoma and reason of stoma was not statistically significant [18].These findings are similar to this study as there was significant difference in stoma duration but not with age and education level.In a study done to study peristomal skin disorder in patient with permanent stomas peristomal skin irritation accounts for 72.3% of physical problem due to stoma [19].This is similar to this study where physical problem due to stoma accounts for 89.4%.

Conclusion
This study finding shows majority of ostomates suffer from physical problem.Hence it is recommended to concerned authority to identify reason behind it and conduct package training program to reduce physical problem.

Table 1 : Socio-demographic information: N=94 Variables Frequency Percent
operative hospitalization of less than or equal to 15 days.Maximum duration of post-operative hospitalization was 90 days, minimum was 6 days.Regarding duration of living with stoma, 53.2% of ostomates were living with stoma for more than 12 months and the rest 46.8% for less than or equal to 12 months.The mean duration of living with stoma was 26.41 months and standard deviation was 3.2419.Maximum duration of living with stoma was 216 months (18 years).