Psychological aspects of patients with intestinal stoma: integrative review

ABSTRACT Objective: to analyze evidences of psychological aspects of patients with intestinal stoma. Method: integrative review with search of primary studies in the PsycINFO, PubMed, CINAHL and WOS databases and in the SciELO periodicals portal. Inclusion criteria were: primary studies published in a ten-year period, in Portuguese, Spanish or English, available in full length and addressing the theme of the review. Results: after analytical reading, 27 primary studies were selected and results pointed out the need to approach patients before surgery to prevent the complications, anxieties and fears generated by the stoma. The national and international scientific production on the experience of stomized patients in the perioperative moments is scarce. Conclusion: it is recomendable that health professionals invest in research on interventions aimed at the main psychological demands of stomized patients in the perioperative period, respecting their autonomy on the decisions to be made regarding their health/illness state and treatments.


Introduction
The increase in the prevalence of Colorectal

Cancer (CRC) along with Inflammatory Bowel Diseases
(IBD) implies the need to establish approaches that integrate the psychological aspects resulting from such pathologies to the other dimensions of the health care of this population. Both diseases are characterized as potentially disabling chronic conditions and present the same risk and prevention factors (1) .
As factors for the prevention of damages related to the abovementioned diseases, there is physical activity and consumption of dietary fiber-rich foods, that is, those of plant origin such as fruits, vegetables and whole grains. Risk factors include consumption of red meat, processed meats, alcoholic beverages, smoking, body fat and abdominal fat. Family history of CRC, genetic predisposition to development of chronic intestinal diseases and age are also factors that influence the increase in the incidence and mortality of this cancer (2) .
Surgical intervention is a modality of treatment indicated both for CRC and for IBD and may result in the need for intestinal ostomy. This procedure consists in the temporary or definitive deviation of the colonic effluent, with exteriorization either of the ileum (ileostomy) or the colon (colostomy). As a result of this surgery, it is necessary to use faecal collecting equipment (2) .
Patient have to face the challenge of acquiring skills to live with the altered body and experience a psychosocial transition. The use of collecting equipment is associated with negative feelings, such as fear, anguish, sadness and helplessness, which can prompt self-deprecating experiences, linked to feelings of mutilation, loss of health and self-esteem, and reduced self-efficacy and a sense of chronic uselessness and incapacitation, among other emotions. Stoma patients experience changes in their lives especially related to their social network (work and leisure) and to sexuality, aggravating their feelings of insecurity and fear of rejection (3) .
The possible negative psychological outcomes and emotional issues arising from the stoma make it essential the provision of comprehensive patient care, with an interdisciplinary and specialized approach to the needs of patients and their families, with a view to full physical, emotional and social recovery towards rehabilitation. It is necessary to prepare patients, mainly during the perioperative period, when they experience anxiety and distress before the unknown -the "stoma".
This preparation must include pre-operative education, demarcation of the stoma and guidance on self-care for patients and their families, in the postoperative period, as well as the referral to the Assistance Program for Stoma patients of the Unified Health System (SUS).
The assistance program aims to offers specialized professional support to patients outside the hospital environment, helping them in the transition from hospital to home care. Different strategies are used to assist them in developing skills for self-care and the required materials are provided. Therefore, it is imperative that the interdisciplinary team know the sociocultural and clinical characteristics of this clientele so so as to carry out proper planning and implementation of effective strategies for this approach (4) .
Individuals with chronic colorectal disease need psychological support and, in some cases, psychotherapeutic intervention with the objective to provide a space to work on aspects that may contribute to coping with the disease, through constant monitoring and guidance (5) .
In view of the complexity of the theme and the intense emotional experiences brought about by the need to live with a limiting condition, this study has the objective to analyze the evidence on the psychological aspects of patients with intestinal stoma.

Method
Integrative Review (IR) is the appropriate method to reach the proposed goal of analyzing and synthesizing research in a systematized way, to contribute to decision making, deepening the theme and improving clinical practice (6) .
To carry out the IR, the following steps were interpretation of results and synthesis of the main results evidenced in the analysis of the included articles (6) .
The guiding question of the present integrative review was: what is the recent scientific production on psychological aspects of patients with intestinal stoma? Spanish and available in full length. Exclusion criteria were: literature reviews, secondary studies (e.g., systematic reviews), letters, editorials, case reports, case studies, and primary studies whose participants were children and/or adolescents.
The selection of the primary studies was carried out by two reviewers with experience in the activity, and the results were then compared for the delimitation of the review sample. For the extraction of information from the studies included in the review, an instrument with the following items was used: identification of the study, methodological characteristics and methodological rigor assessment (7) . into six levels (level I -evidences from meta-synthesis of qualitative studies) (8) .
The descriptive form for the analysis of the evidenced results was adopted, in which the synthesis of each study included in the review was presented, as well as comparisons between the researches.

Results
We identified, preliminarily, 107 records in the search in the selected databases and in the periodicals portal. After reading the titles, 51 articles were excluded, as two articles focused on children, five articles were integrative reviews, 29 articles did not address the topic studied, three articles did not match the time cut established for the review, and 13 articles were duplicated. After this stage, the abstracts of 52 articles were read, of which 17 articles were excluded, because nine did not address the theme of the review, one was a case study and seven were not available in full length.

2014/Turkey
Longitudinal, quasi-experimental, quantitative study III (Intervention/Treatment or Diagnosis/Test) Year/country Type of study Level of evidence/ clinical question

2016/Spain
Controlled observational study II (Prognosis/Prediction/Etiology) 27. Vural et al. (35) 2016/Turkey Qualitative study, with a phenomenologicalexistential approach II (Meaning) In another study from Germany, with 79 patients submitted to colorectal surgery, the correlation of quality of life with personality aspects was evaluated and personality was found to exert a strong and lasting effect on the quality of life after surgery, highlighting the influence of clinical variables (14) .
In another study developed in the United States, demographic and clinical variables, and quality of life were identified to be related to embarrassment in the case of people living with a colostomy bag and the study concluded that the feeling of embarrassment may negatively impact the person's quality of life (15) . if they did not have support from health professionals of different specialties who worked in an integrated and multiprofessional way (17) .
Another study, also from Brazil, with a qualitative approach, analyzed the perception of ten patients with colostomy in relation to the use of the collection bag.
The results showed that the life with the colostomy bag raises conflicting feelings, concerns and difficulties in dealing with the new situation (3) .
In a study carried out in Cuba, the adaptation was and, finally, the physical domain, especially in patients who had not received guidance before surgery on the stoma and those who did not have a sexual partner (19) .
In a study developed in Taiwan Patients with higher levels of knowledge about care achieved better adaptation when compared to people with less knowledge and greater dependence on other people to perform care (21) .
In another study conducted in Australia, the of focusing exclusively on the coping modes used by patients with stoma (22) .
In another study, Chinese patients with colostomy were evaluated and the relationships between adaptation, self-care ability, and social support were described. The results indicated a positive correlation between self-care ability and social support, linked to the adaptation to the stoma. On the other hand, concerns about the odor and possible rejection that the stoma might induce in other people significantly contributed to poorer adjustment to the stoma (23) .
In China, another study investigated the quality of life, access to knowledge and needs for colostomy self-care in 142 colorectal cancer patients, and concluded that the teaching of self-care, with clear and objective language and methods, favors learning and, consequently, quality of life (24) .
Four primary articles were categorized in the thematic axis "effects of different intervention strategies to optimize psychosocial adjustment".

The effects of a intervention in Chinese patients
with permanent colostomy who attended a support program were evaluated. In this study, it was shown that social support is fundamental for a better adaptation of patients with permanent colostomy and that participation in a program for people with stoma provides a support network that promotes significant improvement in knowledge, self-efficacy, self-management and psychosocial adjustment to the colostomy (25) .
Another study carried out in China evaluated the effect of telephone follow-up by the stoma therapist nurse and the adjustment levels of patients with colostomy who had been discharged from hospital. Follow-up through telephone calls after hospital discharge was effective in improving satisfaction with care, reducing the complications in the colostomy, improving self-care skills, and increasing patient self-confidence to cope with the colostomy. Although performed at a distance, followup became an extremely important factor for better adaptation to the colostomy bag and, consequently, for the achievement of social adjustment (26) .
In another study, also conducted in China, the effectiveness of a stress management program in stoma patients was tested. The postoperative period can trigger symptoms of stress, anxiety and depression, because it is a transition period that requires adjustment to the new physical condition. After the participation in the program, satisfactory results of reduction of stress, depression and anxiety in the stoma patients were evidenced (27) .
The patients' response to a type of supportive intervention was tested in another study, with some similar characteristics to the model evaluated in another research conducted in China (25) . In this study, carried out in Turkey, the effects of group interaction on the www.eerp.usp.br/rlae 7 Silva NM, Santos MA, Rosado SR, Galvão CM, Sonobe HM.
social adjustment of people with intestinal stoma were investigated. The interaction with other stoma patients was important, since group meetings and the exchange of experiences with other people who share similar situations favors better adaptation to the stoma (28) .
Five primary articles were included in the thematic axis "understanding of the subjective experience of disease/becoming ill", as described below.
In a Scottish study, the correlation between the changes brought about by the colostomy bag and the psychological aspects of patients in a sample of 86 people during the one to four months after surgery was evaluated. Half of the participants reported the sensation of having lost control of their own body and therefore avoided social and leisure activities, and the odor led them to social isolation. Specialized assistance from a stoma therapist, along with psychological support, helped in the rehabilitation of these patients (29) .

Discussion
The evidence on the psychological aspects of connected to a colostomy bag arouses negative feelings, impacting all aspects of the patient's life. These changes may or may not be irreversible, depending on the clinical condition of each patient, professional support, family support and the use of coping strategies (3,17,21) .
In order to achieve rehabilitation, specialized care should be interdisciplinary, including perioperative education, reception with professional support and individualized therapy, in order to promote a more satisfactory acceptance of the new condition (35) .  (16,24,29) .
Assistance for this clientele should be planned considering the physiological aspects along with psychological care, aiming at integral care of the patient' needs.It is essential that all professionals involved participate effectively in the care process, characterized as continuous follow-up during hospitalization for surgical treatment.
In this perspective, the results in this review confirmed the need to plan pre-and postoperative psychological interventions, for the preparation until the adaptation to the stoma. This makes it possible to know the individual perceptions about illness/becoming ill, rather than focusing exclusively on coping strategies that patients use after the surgical procedure (22) .

Strategies of group interaction among patients
experiencing the same problem can be used in clinical practice, mainly for greater proximity and approach to psychosocial issues. This recommendation was seen in several studies, showing the importance of specialized follow-up after hospital discharge, with emphasis on self-care, acceptance of emotional needs to ease the barriers and difficulties in resuming daily life (3,17,31) .
There is also a need for reflection on the Expanding the possibilities of active social life despite the need for adaptations is also important. In addition, spaces for discussion of social prejudice and stigmas can be disseminated in society for the implementation of integral care (31) .
Most of these studies were performed with ambulatory patient in the postoperativeperiod. However, the results that make up this review point to the importance of perioperative follow-up, because it is in this moment that the doubts about the surgery and its consequences should be clarified, as well as self-care to minimize fears and anxieties during surgical treatment and in prevention of future complications (19,21,25) .
Consequently, there is a need for future studies addressing the psychological aspects during surgical treatment, for scientific evidence on the importance of