J. Coloproctol. (Rio J.) vol.36 número1

w w w . j c o l . o r g . b r

Journal

of

Coloproctology

Original

Article

Sociodemographic

and

clinical

features

and

quality

of

life

in

stomized

patients

夽

Merifane

Januário

de

Sousa

,

Smalyanna

Sgren

da

Costa

Andrade

,

Karen

Krystine

Gonc¸alves

de

Brito

,

Suellen

Duarte

de

Oliveira

Matos

,

Hemílio

Fernandes

Campos

Coêlho

,

Simone

Helena

dos

Santos

Oliveira

a_{HospitalGeneralEdsonRamalho,JoãoPessoa,PB,Brazil}

b_{GrupodeEstudosePesquisasemTratamentodeFeridas(GEPEFE),JoãoPessoa,PB,Brazil} c_{Post-GraduatePrograminNursing,UniversidadeFederaldaParaíba(UFPB),JoãoPessoa,PB,Brazil} d_{GrupodePesquisaemDoenc¸asCrônicas(GEPDOC),JoãoPessoa,PB,Brazil}

e_{Post-GraduatePrograminHealthandDecisionModels,UniversidadeFederaldaParaíba(UFPB),JoãoPessoa,PB,Brazil} f_{DepartmentofStatistics,UniversidadeFederaldaParaíba(UFPB),JoãoPessoa,PB,Brazil}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received26July2015 Accepted6December2015 Availableonline10February2016

Keywords: Qualityoflife Ostomy Health

a

b

s

t

r

a

c

t

Objectives: Toidentifyuserswithanintestinalostomyconcerningtheirsociodemographic andclinicalcharacteristics,andtodeterminethescoresforqualityoflifeaccordingtothe domainsofthequestionnaireCityofHope.

Method:Thisisahousehold,descriptive,transversal,quantitative-approachsurvey, accom-plishedwith30registeredusersattheOstomyAssociationoftheStateofParaíba,Brazil.A specificformforostomypatientswasapplied,anddataanalysiswasperformedwiththe useofthesoftwareStatisticalPackageforSocialSciences(SPSS)version20.0.Thisstudy wasapprovedbyCAAENo.17224613.8.0000.5183.

Results:Mostparticipantswereover60years,wereCatholics,withelementaryeducation, anincomeuptothreeminimumwages,marriedorinastablerelationship,withalmost allqualityoflifescoresabovethemidpointoftherangeofthevariablesofthedomains surveyedbythequestionnaireCityofHope.

Conclusion: Thequestionnaireledtotheconclusionthattherespondentswithostomyhad asatisfactoryqualityoflife.

©2016SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.All rightsreserved.

夽

ResearcharisingfromMaster’sDissertation,“Qualidadedevidadepessoascomestomiaintestinal”,ProgramadePós-Graduac¸ãoem Enfermagem,UniversidadeFederaldaParaíba(UFPB),JoãoPessoa,PB,Brazil.

∗ _{Correspondingauthor.}

E-mail:smalyanna@hotmail.com(S.S.daCostaAndrade).

http://dx.doi.org/10.1016/j.jcol.2015.12.005

Características

sociodemográficas

e

clínicas

e

qualidade

de

vida

de

pessoas

com

estomia

intestinal

Palavras-chave: Qualidadedevida Estomia

Saúde

r

e

s

u

m

o

Objetivos: Caracterizarosusuárioscomestomiasintestinaisquantoaosaspectos sociode-mográficoseclínicosedeterminarosescoresdequalidadedevidasegundodomíniosdo questionárioCityofHope.

Método: Trata-sedeinquéritodomiciliar,descritivo,transversaledeabordagem quanti-tativa,realizadocom30usuárioscadastradosnaAssociac¸ãode OstomizadosdoEstado daParaíba.Utilizou-seformulárioespecíficoparaestomizadoseaanálisedosdadosfoi realizadacomoauxíliodoprogramaStatisticalPackagefortheSocialScience(SPSS),versão 20.0.ApesquisafoiaprovadacomCAAEn.17224613.8.0000.5183.

Resultados: Amaioriatinhamaisde60anos,católicos,comensinofundamental,rendade atétrêssalários,casadosouemuniãoestável,comquasetodososescoresdequalidade devidaacimadopontomédiodaescalaparaasvariáveisdosdomíniosexploradospelo questionárioCityofHope.

Conclusão: Oinstrumentopermitiuinferirqueosestomizadospesquisadospossuíam qual-idadedevidasatisfatória.

©2016SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda. Todososdireitosreservados.

Introduction

Themakingofastomaindicatesthetemporaryorpermanent externalizationofahollowviscusinthebody.Dependingon theexternalizedsegment,thetypeofostomyreceivesnames suchascolostomy,ileostomy,andurostomy,amongothers. Thistherapeuticprocedureiscausedbyvariousdiseases.1,2

AlthoughofficialinformationfromtheMinistryofHealth on the situation of ostomized people in Brazil are non-existent,3 _{data published by the Brazilian Association of} Ostomized People estimate that 33,864 people live with a stomainourcountry,with4,176livingintheNortheastRegion, ofwhich496areinthestateofParaiba.4

Thebiopsychosocialconsequencesofanostomyprocedure areassociatedwiththesurgicaltreatment,andinfluencethe livesofthesepeopleandoftheirfamilies.Thebowelostomy hasbeenidentifiedasthemainchangethatcouldaffect inter-personal,social,labor,sexandleisureaspects.5,6

Of all the changes caused by the stoma, the physi-calchanges stand out, notonly byaffectingthe intestinal physiological process,but by its impact on self-imageand self-esteem.Ontheotherhand,thepresenceofastomacan leadtomentalandemotionalimbalance,aswellas interfer-ing directly inthe quality oflife. Thephysicalappearance assumesincreasinglyconsiderabledimensionswhenitcomes tochronicwounds,giventhattheskinpossessesan essen-tialandalmostsymboliccharacteristiconthelivesofeach individual,representing aworld wherebody and spiritget together.Thus,theskinconfiguresitsself-wellness.7

Themultipletransformationsresultingfromthecolostomy deeplyaffectthequalityoflifeofpatientsundergoingthis pro-cedure,whichpromptedtostudiesonthissubject.8–11_Onecan observethat,inordertohaveagoodqualityoflife,itiscritical thatpeoplefeelsatisfiedinmanyways,includingmaintaining

theirphysicalintegrity,whichisbrokenduringtheprocessof makingthestoma.12

Therefore,theknowledgeofsocialandclinical character-isticsandofaspectsofqualityoflifeofostomypeoplemay facilitatetheplanningofassistanceinreliefprograms, consid-eringthemaintenanceofaconcomitantadjuvanttreatment andofdemandsofotherneedsarisingfromtheclinical con-ditionofthebowelostomizedpatient,which,aftertheradical change that occurred intheir pattern ofelimination,must relearntolivewithhimselfandwithhis/herfamily,friends andsociety.

Consideringthesensitivityofthesubject,weconsiderthat theinvestmentinresearchseekingfurtherclarificationonthe issueishighlyrelevant.Thus,theobjectivesoutlinedinthis studywere:tocharacterizeuserswithanintestinalostomyas sociodemographicand clinicalcharacteristics,and to deter-mine the quality of life scores according to the domains coveredinthequestionnaireCityofHope.

Method

Thisishouseholdsurvey,descriptive,cross-sectionalandof quantitativeapproachstudy.Theinitialcontributiontothis study came from the Ostomy Association of the State of Paraíba (AOEPB).AOEPB isconsidered a referral servicefor stomizedpeopleinthatState,beinglinkedtotheoutpatient departmentofateachinghospitalinthecityofJoãoPessoa.

peopleregisteredatAOEPBuptoDecember2012were identi-fied.Atfirst,telephonecontactattemptsweremade,but92 individuals couldnot bereachedforvarious reasons (non-existentphonenumber,orphonenumbernotfound).

Ofthe131remainingregisteredpeople,77individualsdid notmeetthe inclusion criteria, i.e.theywere excluded for beingunder legalage, byreversal ofthe colostomy and/or death. In addition, 24 refused a home visit, claiming that theydidnotfeelcomfortabletalkingaboutthissubject.Thus, 30individualsremainedinthesample.Afterconfirmingthe desiretoparticipate,avisitwasscheduledtoadministerthe questionnaireintheparticipant’shome.

Fordatacollection,twoinstrumentswereused:aform con-sistingofsociodemographicquestionsandclinicaldataofthe participants,andaquestionnaire,theCityofHope–Quality ofLifeQuestionnaireforaPatientwithanOstomy.13_Thetotal scorewasobtainedbythearithmeticmeanofthe43questions containedintheinstrument(i.e.,thesumofthescoresofall itemsoftheinstrument,dividedby43).Thearithmeticmean ofalldomainswasobtainedtakingintoaccountthenumber ofvariablesineachofthedomains.

Inthisstudy,ascoreof5wassetasthecutoffpoint.Thus, means>5indicateagoodQoL,andmeans<5suggestapoor QoL.Thescore5isthemidpointonthescaleofassessment ofthevariablesthatmakeuptheinstrumentapplied.13_For acorrectinterpretationoftheresults,someitemshadtheir scoresreversed;theseitemswere:1–12,15,18and19,22–30, 32–34and37.13_{Thecontactphasewascarriedout between} September2013andFebruary2014.Datacollectionoccurred fromFebruarytoApril2014.

Data were compiled and analyzed using the Statistical PackagefortheSocialSciences(SPSS)program,version20.0, usingdescriptive statistics (absolute frequency, percentage, andmean/standarddeviation).Theprojectwasapprovedby theResearchEthicsCommitteeunderreportnumber370838 andCertificateNo.17224613.8.0000.5183.Allparticipantswere informedaboutthepurposeoftheresearch,itssecrecy,the rightofwithdrawal,andsigningoftheFreeandInformed Con-sentform,bearing inmindthe requirementsofResolution 466/12oftheNationalHealthCouncil.14

Results

Participantshadameanageof60.67±11.76years,with preva-lenceintheagegroups51–59yearsand59–67years,bothwith 8(26.7%)respondents.Astogender,therewasequityinthe distribution,since15(50%)werewomenand15(50%)men, constitutingacoincidenceofequality,becausethisisnota controlledvariable,sinceourswasanonprobabilisticsample. Abouttheoccupation,fivecategorieswerecited:20(66.7%) retirees,4(13.3%)pensioners,3(10.0%)ofdomesticchores,6 (6.7%)autonomousand1(3.3%)unemployed.Onreligion,only twocategorieswerementioned:Catholicismpractitioners,26 (86.7%)andEvangelicalChurchattendants,4(13.3%).

Itwasfoundthat15(50%)participantshadprimary edu-cation,16(53%)receiveduptothreeminimumwages,were marriedorlivinginastableunion.Themeanfamilyincome rangedfrom<1(1)to>5(5)timestheminimumwage,with

Table1–MeanofscoresforCityofHopeQuestionnaire domains.JoãoPessoa,Paraíba,2015(n=30).

Domains Mean Standard-deviation Physicalwell-being 7.39 2.05 Psychologicalwell-being 7.05 1.25 Socialwell-being 7.06 1.56 Spiritualwell-being 7.65 2.13 Globalmeanofqualityoflife 7.26 1.21

prevalenceofthe group from 1to3 salarieswith15 (50%) participants.

Clinicallyitwasobservedthatmostofsurgerieshada ther-apeuticindication,forthetreatmentofbowelcancer(24;80%). Ofthe30respondents,22(73%)hadapermanentstoma,27 (90%)showedaninadequatepositionofthestoma,13(44.8%) hadacolostomyforovertenyearsand24(80%)didnotpresent anykindofcomplication.WithregardtoBMI,15(50%)were overweightand13(43%)remainedwiththeirweightwithin normallimits.

Consideringthe structureproposed bythe City ofHope questionnaire,wepresentedthemeansforeachdomainand fortheirvariables,aswellasthe totalscoreofQoLamong theparticipantsofthestudy.Onthebehaviorofvariablesof “physicalwell-being”domain,theoverallmeanwas7.39,and itwasobservedinitsvariablesthatthelowestmeanconcerns togases(5.77)andthehighestmeanrefersto“overallphysical well-being”(7.90)(Fig.1).

Forthedomain“socialwell-being”,theoverallmeanwas 7.06.Itisevidentthat, forthisdomain,alargernumberof variablesstaysclosertothemidpointofthescale(5);the low-est meanobtainedwasfor“interferencewiththe abilityto travel”(5.27)andthehighestmeanwasfor“privacyathome” (inrelationtothecareofthestoma)(8.93)(Fig.2).

Thedomain“psychologicalwell-being”hadameanof7.05, andwastheonlydomainaveraging<5ononeofitsvariables (anxiety,4.69).“Depression”wasthevariablethatcontributed forthehighestmean(8.63)(Fig.3).

Fig.4depictsthemeanscoresofthevariablesthatmake upthedomain“spiritualwell-being”.Thelowestmean corre-spondstothe“uncertaintyaboutpersonalfuture”(5.30)and the highest mean refersto the variable “spiritual support” (8.83).

Byobservingthedistributionoftheoverallmeansforthe four domains of the questionnaire, it was found that the domainwiththebestscoresforqualityoflifecorresponded to“spiritualwell-being”(7.65),andthatthemeansobtained forthedomains“psychologicalwell-being”(7.05)and“social well-being”(7.05)hadthelowestmeans.Astothestandard deviationofthedomains“psychologicalwell-being”andsocial well-being”,agreaterhomogeneityamongthemeansofthe variablesthatmakeupthesedomainswasconfirmed,in com-parisonwithotherdomains,whichshowedgreatervariability

(Table1).

Discussion

General physical well-being

Leakage of the bag

Diarrhea

Constipation

V

ar

iab

les

Odor

Gases

Pain or suffering

Interruptions of sleep

Skin around the stoma

Fatigue

Physical strength

Mean

7.90

6.83

7.37

7.60

7.47

5.77

7.70

7.61

7.77

7.63

7.17

9 8 7 6 5 4 3 2 1 0

Fig.1–Meanscoresofthevariablesthatmakeupthephysicalwell-beingdomainoftheCityofHopequestionnaire.João Pessoa,2015,n=30(mean=7.39,SD=2.05).

physiologicalprocessofthebody,illnessesorchronic condi-tionstendtoaffectpeople.Inthecaseofcancer,althoughthis diseasedoesnotresultofphysiologicalaging,itisobserved that,withincreasingage,thereisahigherincidenceof cer-taintypesofcancers,distributedbetweengendersinaspecific way.Colonandrectalcanceroccursinbothgenders.15

Regarding gender, the factof beinga woman or aman didnotinfluencethefactofbeingacolostomizedsubject.In theliterature,somestudiesshowapredominanceofmales,16 whileinothersthereisafemalepredominance.11,17_Thisfact relates to the diversity of the population and depends on theareasurveyed.Althoughsomeauthors18,19_claimthatthe

V

ar

iab

les

Enough privacy

Privacy at home

Interference in intimacy

Interference in social activities

Interference with recreational activities/sports

Support from friends and family

Isolation caused by stoma

Interference in personal relationships

Interference with the ability to travel

Distressing for the family

Resultant financial burden

Difficulty in meeting people

6.03

8.93

7.40

6.97

6.10

8.27

7.73

7.93

5.27

5.73

5.77

8.70

Mean

0 1 2 3 4 5 6 7 8 9 10

V

ar

iab

les

Fear of recurrence

Depression

Anxiety

Satisfaction with appearance

Control of life

Difficulty in taking care of ostomy

Difficulty in seeing the ostomy

Memory

Overall satisfaction level with QoL

Embarrassment

Satisfaction/enjoyment of life

7.53

8.63

4.69

6.73

8.03

8.00

7.93

6.17

7.27

7.13

7.66

Mean

0 1 2 3 4 5 6 7 8 9 10

Fig.3–Meanscoresofthevariablesthatmakeupthepsychologicalwell-beingdomainoftheCityofHopequestionnaire. JoãoPessoa,2015,n=30(mean=7.05,SD=1.25).

genderinfluencesthesocialadaptationoftheostomized indi-vidual,emphasizingthatwomenaremoreresilientandbest suitedtonewhabits.

Asforworkingoccupation,ingeneralallworkers,after con-tributingtoSocialSecurity, acquiretheright toenjoytheir labor retirement. In addition, the permanent condition of colostomyguaranteesretirementtotheindividual affected. Inthis study,this relationshiphasnot beenverified. How-ever,a similarstudy identifiedpredominanceofretirees in colostomizedgroups.20

Consideringthereligious aspect,it ispossibletoensure thatthisfactorstrengthensfaithandconsolidatesvaluesand beliefs thatdirectly affect the quality oflifeofastomized person,favoring his/her rehabilitation.21 _{It isbelieved that} religionisanimportantfactortoimprovehealth,by provid-ingspiritual support,regardlessofwhich religiouscreed is

followedbytheindividual,althoughinthepresentstudythe majorityofoursamplestatedtoprofessCatholicism(86.7%).

Withregardtoeducation,halfofthesamplestudiedonly uptoprimaryschool.Schoolingisarelevantaspectfor under-standingtheguidelinesforthecareofthestoma,thedevice forwastecollection,theregularmonitoringofhealth, nutri-tionandhygiene,aswellasthevariousconditionssettledfrom thesurgery.

Aboutmaritalstatus,itisassumedthatthefactthat53.4% of respondentsare married or ina stablerelationship can haveapositiveinfluenceonthe waythe ostomizedperson dealswithhis/hernewstateofhealth,thankstotheemotional supportofferedbyhis/herpartner.Regardingthisaspect,our studyconfirmsthatmanyoftheostomizedpeoplearemarried and livingwithhis/herspouse,but noassociationbetween resilienceandmaritalstatuswasproved.11,22

Positive changes

Religious support

Spiritual support

V

ar

iab

les

Hope

Inner peace

Reason to be alive

Uncertainty in future

Mean

0 1 2 3 4 5 6 7 8 9 10 6.60

7.50

8.83

7.87

8.80

8.67

5.30

Asformonthlyincome,itisknownthatthefinancial situa-tionmayinfluencethewayoflivingwithacolostomy,because thisstaterequiresspecialcareandtheacquisitionofmaterials thatburdenthefamilybudget.Astooursample,wefoundthat 50%livewithanincomeof1–3minimumwages.Theincome caninterferewiththe acquisition ofconsumablematerials relatedtoostomycare,reallyaffectingthequalityoflife.10

Withregardtotheclinicalcharacterization,most partici-pantsshowanimproperpositioningofthestomaandhigh bodymassindexes.Perhapsthesetwovariablesmaybelinked. However,itwasnotpossibletosaywhethertheinadequacyof thestomacomesfromweightgain(whichcollaborateswithan increaseofabdominalcircumference),orwhetherthis inade-quacyisaresultoflack/inadequacyinthedemarcationofthe stomaduringsurgery.Thisfindingonlywouldbepossibleif theassessmentwasperformedimmediatelyaftersurgeryand oftheedemaregression,commonlyoccurringpostoperatively, oraftersurgicalhealinghavebeenoccurred.

Mostoftheparticipantsdidnotpresent post-colostomy complications,and only10% reporteddermatitis.Thismay suggest that: the surgery was successful, the physicians conducted their guidelines efficiently, and/or the family care/self-carewasadequate.

Onthe permanenceofthe stoma, 73.3% ofparticipants claimed to have a permanent colostomy, which can be observedinotherstudies.3,23_{Withreferencetothereasonfor} thesurgery,cancerhasbeen themostfrequentlycondition cited.Otherstudieshaveshowntheprevalenceofcolostomies inassociationwithcasesofcolorectalcancer.24–26

About colostomy time, mostparticipantsreported more than ten years of surgery. During the development ofthis study,itbecameclearthat,overtime,theseindividualshave founda parsimoniouswaytolive withtheir current state, thanks for their religious faith, the seemingly irreversible definitivecondition,orsimplyforthefactofbeingalive.This attitudeseemstocontributetoimprovingthequalityoflifeof theseindividuals.

Regardingthe domain“physicalwell-being,”itisknown that gases cause bloating, which can lead to viewing the prominencebelowthegarment,ortheaccidentaldetachment ofthebag.Therefore,flatulencecancausediscomfort,since theyare anuncontrollable phenomenon,and althoughthe non-externalizationoftheodor,thankstotheclosureofthe device,yetthesoundcausedbygasesmayresult embarras-singforostomypatientsorpersonswhowitnessthissituation. Thus, it ispossible that these reasons justify the smallest meanofthedomain,anditsclosestpositionwithrespectto themidpointofthescaleforthevariable“gases”(Fig.1).

Forthedomain“socialwell-being”,travelscanbeaform ofrecreation(Fig.2).However,the colostomyimplies some peculiarities,suchastheneedforaplaceandspecial materi-alsforcleaningthedevicebytheostomizedperson,aswellas theneedforprivacytoremovethecollectorbag,andlastbut notleast,thenuisancecausedbythecuriosityofother wit-nessespresent.Consideringallthat,implicationscanaccrue forhowostomizedpeopleperceiveandexperiencethesocial coexistence.

The social non-isolation is an imperative factor in the restorationofself-esteemofostomizedpeople.Social inter-actioncancontributetoovercomingthefeelingofmutilation,

as a network ofrelationships will provide distraction and momentsofjoy,favoringrecoveryandraisinghopesforthe continualseekingforabetterqualityoflife.27

Asforthedomain“psychologicalwell-being”,itisknown thatanxietyispartofthefieldofemotions,andthatitmay arise inneworunexpectedsituations.Thescorebelowthe midpoint5indicatesanegativeinterferenceinthequalityof lifeoftheparticipants,despitethefindingofameanofthe domainabove7,whichmaybeattributedtothevalueofthe othervariables’means,which,inthreecases,wassuperiorto 8(Fig.3).

Ontheotherhand,thecolostomycanbeseenasa“breath oflife”,ahopesignal,orasanewopportunityafterapainful diagnosisofcancer.Inthisstudy,itissuggestedthatthe rela-tionshipbetweenthecolostomytimeandthesadnessfeltby theostomizedindividualisinverselyproportional,thatis,over time,theindividualcangetusedtothecolostomy,not allow-inghim/herselftobedepressed,andneitherthatitinterferes withhis/herqualityoflife.

Onthissubject,astudyfoundthatfeelingsofdenialand depressionweremorefrequentintheearlystagesofthenew condition, becausethesadnesswascausedbythe shockof thechangeinbodyesthetics,orbytheseverityoftheclinical picture.Overtheyears,therewasadecreaseinthefrequency ofreportsoffeelingsofsadness.11

Regardingthedomain“spiritualwell-being”,itisbelieved thattheimpactcausedbyanegativediagnosiscanleadtofear ofdeath,frustrationaboutupcomingplans,anddoubtsasto theeventsoflife.

However,religiouspracticesmaybeimportantresources intheprocessofminimizationofthenegativeshockcaused bythestoma,forhelpinginthesubject’sfidelitytotreatment, reducingstress/anxiety,andinthesearchofameaningforthe newsituation.28,29

Thus,itisunderstandablethatthegrouphadobtaineda lowermeanforuncertaintyinthefuture,thankstothenature ofthediseaseanditstreatment;butneverthelessthesepeople showedgoodmeansforspiritualsupportandinnerpeace,as theseaspectsinteractwitheachother(Fig.4).

The resultsin Table 1indicate that, despitethe means above 7, some variables evaluated in the fields presented resultsclosetothemidpointoftherange,underwhichthe qualityoflifeisnotevaluatedatagoodlevel,whichisinline withstudies performed inTeresina,PI16 _{and Iran,}30 _whose meansandstandarddeviationsobtainedwere6.16(SD=2.83) and7.48(SD=0.9),respectively.

Thus,awatchfuleyetotheaspectswhichcancause dam-agetothequalityoflifeofstomizedpeopleiscritical,because in this way new perspectives may emerge and favor the proposition ofactions, be they educational or therapeutic, bydifferenthealthprofessionalsandinrelatedfields.These dimensionswouldculminateinimprovementsinaspectsthat revealedmorefragilityinthegroupstudied.

Conclusion

profile,astoqualityoflifescores.Infact,onecannothidethe physical,social,economic andpsychologicaldisorders that involve the process oflearning and livingwiththe stoma. Therefore,itiscriticaltostronglyemphasizetheimportance ofhealthteamsinallinstances,inordertoencourage inter-ventionsthatwillbeconvertedintovaluableimpulsesforthe lifeofostomizedpeople.

Weemphasizethe importanceofthe work ofthe team inchargeoftheserviceintheusers’care,stressingthatthe supportandhealth educationare unique waysinthe self-acceptanceprocess.Thelackoftelephonedataupdatinginthe sectorresearchedandthedifficultaccessthroughhousehold surveyswerelimitationsinthisstudy.Newresearchshould beencouraged,inorder toacquireadeeperunderstanding ofthe physical,psychologicaland spiritual conditionsthat functionassubsidiesfortheestablishmentofmoreeffective strategiesaimedatimprovingthequalityoflifeofstomized people.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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