Relationships Among Body Perception, Life Satisfaction, and Attitude Toward Seeking Psychological Help in Patients With a Tracheostomy After Discharge: A Descriptive and Cross-sectional Study

Tracheostomy has been practiced for centuries as a life-saving method in upper respiratory tract blockages due to a foreign object, trauma, or infection.^1,2 Although tracheostomy is vitally important to provide airway patency, patients who are discharged with a tracheostomy experience numerous physical problems (pneumothorax, apnea, incorrect placement of the tube, peristomal skin problems, tracheal stenosis, infection, and nutritional problems due to a swallowing disorder), social problems (failing to fulfill their roles within the family and at work), and psychological problems (decrease in life satisfaction, trouble in establishing social relationships, impaired body perception, anxiety, and depression) associated with tracheostomy.^3–8 According to Freeman’s care guide⁹ and Dawson’s review article¹⁰ about tracheostomy care, the care necessary to prevent such problems involves a complex process that requires knowledge, skill, and time on behalf of patients and their caregivers. For these reasons, adapting to life with a tracheostomy can result in impaired body perceptions, reduced life satisfaction, and the need for psychological help.^8,11

Life satisfaction refers to a situation or outcome and how it compares to a person’s desires and achievements.¹² The term body perception covers numerous psychological concepts, including perception of physical appearance, state of the body, body contour, and gender-related body appearance.^13,14 Patients with a tracheostomy have to perform their breathing with a permanent stoma visible in the neck area, and saliva and sputum output from the stoma can affect patients’ perception of body image negatively. In addition, according to Barnett’s case study with a tracheostomy,¹⁵ Dawson’s review article,¹⁰ and the report by McCormick et al¹¹ regarding patients with tracheostomy and their families (84.1% of whom lived in North America) that encompassed multistakeholder international research involving qualitative and quantitative questions, life satisfaction may decrease because patients are unable to speak and experience interpersonal difficulties due to the removal of the vocal cords; the need for a caregiver and failure to fulfill their usual roles also negatively affects patients’ adaptation to social life.^10,11,15 Patients may need professional psychological help to identify the problems they encounter during the adaptation to the sudden or progressive body changes, to overcome these problems, and to improve their life satisfaction by learning how to cope.^16,17

There are several studies in the literature that identified factors affecting life satisfaction and body perception in different patient groups.^18,19 A descriptive study by Purutçuoğlu and Aksel¹⁸ evaluated body image perception and life satisfaction in 124 women with disabilities and found a positive correlation between body image perception and life satisfaction. In a descriptive study conducted by Erbay et al¹⁹ to evaluate the relationship between body perception and life satisfaction in 136 patients with morbid obesity, a positive correlation between body perception and life satisfaction was found. Although to the authors’ knowledge there are no studies investigating the relationships among body perception, life satisfaction, and attitude toward seeking psychological help in the literature, there are several studies investigating the relationship of life satisfaction and body perception with various other variables, especially subjective well-being.^20,21 The authors found no study in the literature that investigated the relationships among body perception, life satisfaction, and attitude toward seeking psychological help in patients with tracheostomy. The purpose of this descriptive study was to investigate these relationships in patients with tracheostomy after discharge in Turkey.

Study design and sample. In this descriptive and cross-sectional study, data were collected from patients who underwent tracheostomy in November and December 2019. The study was performed between November 2019 and January 2020. The study population consisted of 80 patients who underwent tracheostomy due to laryngeal carcinoma in a university hospital’s otorhinolaryngology service and were invited to participate in this descriptive and cross-sectional study prior to discharge. Patients who were not willing to participate in the study (12 patients), patients with psychiatric problems (2 patients), patients who died (3 patients), and patients whose tracheostomy was closed within 1 month after discharge (3 patients) were excluded from the study. Sixty (60) patients who agreed to participate in the study voluntarily, who had no sensory or hearing loss, who were 18 years of age or older, who were literate, who were discharged with a tracheostomy, and who continued home care for at least 1 month (maximum 3 months) after discharge were included in the study. Telephone numbers and addresses were supplied voluntarily by patients who had inclusion criteria, and interviews were conducted at patients’ homes within 1 to 3 months after discharge. Data for patients who met the criteria for participation were collected and are presented in the Results section. 

Ethical approval. Before the start of the study, institutional permission was obtained from the hospital where the research was conducted, and ethics committee approval was obtained from the Regional Public Hospital’s Ethics Committee for Non-Interventional Clinical Research. In addition, the purpose of the study, the methods of the study, and the expected benefits and risks were explained to the patients, and their written consents were obtained through the Informed Voluntary Consent Form.

Data collection methods. Data were collected by the researcher using paper-and-pencil questionnaires via face-to-face interviews with patients. Interviews were conducted during the home care of patients, and each interview took approximately 15 to 20 minutes. Interviews were conducted once, and all took place between 1:00 PM and 3:00 PM. In addition, patients were given the telephone number of the researcher to contact as needed regarding care practices and problems encountered.

Data collection tools

Sociodemographic Characteristics Form. This form was developed by the researchers according to the literatüre.^5,9,10,13,15 Expert opinions were obtained from one instructor in the Surgical Diseases Nursing Department, one instructor in the Fundamentals of Nursing Department, one instructor in the Department of Public Health Nursing, one instructor in the Psychiatric Nursing Department, and one physician in the Otorhinolaryngology Department regarding the items developed, and changes were made in line with their recommendations. The form contained 12 items encompassing patient-specific information about the date of tracheostomy, date of discharge with tracheostomy, regular outpatient care, age, sex, body mass index (BMI; calculated by measuring the height and weight by the same researcher and using the same measurement tools at each patient interview), education level, health insurance, income level, amount of money allocated to care, smoking status, and presence/absence of chronic disease.

Body Cathexis Scale. The Body Cathexis Scale (BCS), developed by Secord and Jourard in 1953,²² assessed one’s satisfaction with 40 separate body parts or functions. The Turkish adaptation of the Body Cathexis Scale was carried out by Hovardaoğlu in 1992.²³ The Turkish version of the questionnaire is a 5-point Likert type scale consisting of 40 items. The most positive expression is worth 1 point, and the most negative expression is worth 5 points (1 = I like it very much, 2 = I like it, 3 = I am indecisive, 4 = I do not like it, and 5 = I do not like it at all). Accordingly, the lowest and highest scores of the scale are 40 and 200, respectively. Higher scores reflect a lower satisfaction with one’s body parts or functions, whereas lower scores reflect higher satisfaction. The overall reliability coefficient of the Body Cathexis Scale was found to be 0.91 in a Turkish validity and reliability study carried out by Hovardaoğlu,²³ and it was highly reliable with a reliability coefficient of 0.94.

Satisfaction With Life Scale. The 7-point Likert-type Satisfaction With Life Scale was used in this study. This scale was developed by Diener et al in 1985²⁴ and adapted to Turkish by Köker in 1991.²⁵ It consists of 5 items with the following scoring sytem: 1 = strongly disagree, 2 = disagree, 3 = slightly disagree, 4 = neutral, 5 = slightly agree, 6 = agree, and 7 = strongly agree. The total score ranges between 5 and 35. Life satisfaction decreases as the total score decreases. The overall reliability coefficient of the Satisfaction With Life Scale was found to be 0.85 in a Turkish validity and reliability study carried out by Köker,²⁵ and it was highly reliable with a reliability coefficient of 0.94.

Attitude Scale toward Seeking Psychological Help. The short form of the Attitude Scale toward Seeking Professional Psychological Help (ATSPPH-SF), developed by Fischer and Turner in 1970,²⁶ was adapted into Turkish by Türküm in 1997.²⁷ This 5-point Likert type scale, in which individuals’ attitudes toward seeking professional help are measured, consists of 18 items (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree). Scores range from 18 to 90, and a higher score indicates a more positive attitude toward seeking psychological help. The overall reliability coefficient of the Attitude Scale toward Seeking Psychological Help was 0.88 in a Turkish validity and reliability study carried out by Türküm,²⁷ and the reliability coefficient of the scale was 0.81.

Data analysis. Data were gathered from the interviews and entered into SPSS v18.0 (IBM SPSS Statistics, Chicago, IL). BMI was grouped as follows: underweight (below 18.50 kg/m²), healthy (18.50–24.99 kg/m²), pre-obese (25.00–29.99 kg/m²), and obese (above 30.00 kg/m²). The minimum wage in Turkey is 373 USD, and the poverty threshold in Turkey is 185 USD; because of those factors, monthly income and monthly budget for tracheostomy care were grouped into 3 outcomes; 0–185 USD, 186–373 USD, and > 373 USD. According to the inclusion criteria, patients had been receiving home care for 1 to 3 months; therefore, time since discharge with tracheostomy was grouped into 2 outcomes (< 2 months and ≥ 2 months) and time since tracheostomy surgery was grouped into 2 outcomes (< 45 days and ≥ 45 days). Descriptive statistics, independent samples t-test, analysis of variance (ANOVA), and Pearson correlation analysis were used to analyze the data; P < .05 was accepted as the level of significance.

Telephone numbers and addresses were supplied voluntarily by 60 pateints who met the inclusion criteria, and interviews were conducted at patients’ homes within 1 to 3 months after discharge. Patients who agreed to participate in the study voluntarily, had no sensory or hearing loss, were 18 years of age or older, were literate, were discharged with a tracheostomy, and continued home care for at least 1 month (maximum 3 months) after discharge were included in the study. Of the 60 included patients, 75% were male, 55% were older than 65 years of age, 38.3% had normal BMI, 48.3% were primary school graduates, 82.7% had health insurance, 61.7% had a monthly income of 373 USD or more, 81.7% had an amount of money allocated to tracheostomy care that was less than 185 USD and regularly went to the hospital for outpatient care, 83.3% did not use tobacco, and 61.7% had a chronic disease. More than half (53.3%) were discharged more than 2 months ago, and 55% had tracheostomy surgery that had taken place more than 45 days previously (Table 1). 

The differences between patients’ BMI and life satisfaction, educational status and body perception, and life satisfaction and attitude toward seeking psychological help were statistically significant (P < .05). Satisfaction With Life scale scores of patients with a healthy weight (17.60 ± 6.47) and those who were pre-obese (17.80 ± 6.52) were higher than patients who were underweight (14.25 ± 7.41) or obese (11.33 ± 4.18). Body perception, life satisfaction, and attitude toward seeking psychological help scores of university graduates were higher than those in persons at other educational achievement levels. The difference between patients having health insurance and their body perception and life satisfaction was statistically significant (P < .05). Body perception and life satisfaction scores of patients who had health insurance were higher than those in patients who did not have health insurance. The mean body perception score in patients who had health insurance was 139.72 ± 25.¹⁷; in patients who did not have health insurance, it was 124.18 ± 29.50. The mean life satisfaction scores in patients who had health insurance were 16.89 ± 6.72; in patients who did not have health insurance, the scores were 13.09 ± 4.82. The difference between monthly income levels and life satisfaction was statistically significant (P < .05). Patients with a monthly USD income level of 186 to 373 had the highest life satisfaction scale scores (19.75 ± 8.95). The difference between the sex of the patients and their attitude toward seeking psychological help was statistically significant (P < .05). The attitude toward seeking psychological help scale scores of male patients were higher than female patients. The mean Body Cathexis Scale score of all 60 patients was 127.03 ± 29.02 (minimum 40; maximum 200), their mean score on the the Satisfaction With Life scale was 16.20 ± 6.55 (minimum 5; maximum 35), and the mean score on the Attitude Scale toward Seeking Psychological Help was 55.21 ± 12.19 (minimum 18; maximum 90) (Table 2 and Table 2 Continued).

The relationship between body perception and life satisfaction of patients with tracheostomy was statistically significant and negative (r = -0.419, P < .001). Life satisfaction decreases as body perception increases negatively, and lower life satisfaction scores correlated with the lower body perception scores. The relationship between body perceptions of patients with tracheostomy and their attitudes toward seeking psychological help was statistically significant and positive (r = 0.530, P < .001). Body perceptions of patients with tracheostomy and their attitudes toward seeking psychological help increased together. The relationship between the life satisfaction of patients with tracheostomy and their attitudes toward seeking psychological help was statistically significant and negative (r = -0.448, P < .001) (Table 3). Accordingly, life satisfaction decreases as attitudes toward seeking psychological help decreases. Patients with higher life satisfaction scores had more positive attitudes toward seeking psychological help. 

udy aimed to investigate the relationships among body perception, life satisfaction, and attitudes toward seeking psychological help in patients with tracheostomy after discharge. 

There are various studies in the literature that investigate life satisfaction, body image, attitudes toward seeking psychological help, and demographic characteristics in various patient groups, and these studies draw different conclusions.^28–36 In a study conducted by Arslan et al²⁸ in patients with cancer, a significant relationship was found between life satisfaction and marital status. In the same study, the life satisfaction scale averages of the married participants were found to be higher than unmarried participants. In their study of patients with chronic obstructive pulmonary disease, Kılınç et al³⁶ found no significant relationship between life satisfaction and marital status, income status, sex, and age variables. In a study investigating the relationship between body perceptions and demographic characteristics of patients hospitalized in an ear, nose, and throat service of a university hospital for tracheostomy, no significant relationship was found between educational status, age, income status, and body perception, but the relationship between body perception and marital status was found to be significant.²⁹ These results are similar to the results of the current study. In the literature it is stated that women have more positive behaviors and attitudes toward seeking psychological help; our study similarly shows a significant relationship between seeking psychological help and sex.^30–35 This situation can be caused by the fact that life satisfaction and body perception are affected by gender roles expected by the community.

The mean Body Cathexis Scale score of patients in this study was 127.03 ± 29.02. In the study conducted by Çınar et al²⁹ to determine the body perceptions of patients with tracheostomy, the scale score average was 145.66 ± 25.44. In the study by Aktaş and Göçmen³⁷ to determine body perception of individuals with a stoma, the average scale score was 133.15 ± 20.58. 

In patients undergoing tracheostomy, the change in normal respiratory function and the difficult care process suggest that time is an important factor in adapting to tracheostomy. Because this study included patients who continued home care for 1 to 3 months, it was anticipated that body image perception would improve with improved self-care and re-socialization. Nurses can contribute to improving patients’ body image perception by providing stoma-related information (eg, regarding nutrition, aspiration, use of drugs, home care, complications, and emergency situaitons), teaching stoma care, providing counseling, and helping to ensure patients’ independence.^9,10,29

The participant mean score on the Satisfaction With Life Scale was 16.20 ± 6.55 in the current study. Studies focusing primarily on the life satisfaction of patients with tracheostomy were not found in the literature. In studies investigating the life satisfaction of different groups of patients, the mean score of the Satisfaction With Life Scale was 24.3 ± 6.1 in patients with cancer, 18.70 ± 6.72 in patients with chronic obstructive pulmonary disease, and 21.7 ± 5.9 in patients in intensive care units.^28,36,38 The mean score (16.20 ± 6.55) of satisfaction in this study may have been due to the fact that the majority of patients (61.7%) had chronic diseases, and this increased the burden of care together with tracheostomy care. 

The average score on the Attitude Scale toward Seeking Psychological Help was 55.21 ± 12.19. Considering the literature about seeking help, it is seen that some studies have a sample of adults, whereas others have a sample of high school or university students, with a mean score on the Attitude Scale toward Seeking Psychological Help of 70.64 ± 10.75 in healthy adults, 75.01 ± 10.62 in university students, 67.20 ± 10.42 in male students, and 65.20 ± 8.16 in female students.^39–42 The sample of this study consisted of adult patients with tracheostomy, and the mean score on the Attitude Scale toward Seeking Psychological Help may be attributed to the fact that the majority (75%) of patients were female. Nurses should first determine the factors affecting patients’ attitudes toward seeking psychological help and investigate the reasons that prevent them from seeking help.⁴³ Thus, nurses can contribute to the improvement of psychological well-being in patients with tracheostomy.

The relationship between body perceptions and life satisfaction of patients with tracheostomy was statistically significant and negative (r = -0.419, P < .001). Accordingly, life satisfaction decreases as body perception decreases. The results of this study are in line with the findings of Güler,⁴⁴ Çetinkaya,⁴⁵ and Purutçuoğlu et al.¹⁸ In the study by Güler,⁴⁴ which was conducted with 110 university students in Istanbul and investigated the relationship among body perception and hopelessness and life satisfaction levels, individuals who liked their body were found to have higher levels of life satisfaction. In a study of 531 healthy adult individuals living in Adana and Mersin Provinces in Turkey, Çetinkaya⁴⁵ found that individuals with high body perception scores also have higher life satisfaction scores. With the increased value of physical appearance in our society, individuals’ feelings and thoughts about their bodies have started to play an effective role in their lives. Body perception is a serious challenge, especially for individuals with physical disabilities, because this is an important factor that negatively affects an individual’s perception.⁴⁶ Therefore, it can be stated that decreasing life satisfaction was correlated with decreasing body perception.

The relationship between body perceptions of patients with tracheostomy and their life satisfaction and attitudes toward seeking psychological help was statistically significant and positive (r = 0.530, P < .001). There are no studies in the literature that examine the relationships among body perception, life satisfaction, and attitudes toward seeking psychological help, but there are descriptive studies in which the relationships among body perception, life satisfaction, and social support were found to be statistically significant and positive.^20,42,47 It can be considered that as a person’s life satisfaction and body perception increase, the desire to get support from other individuals and psychological well-being also increases. Providing adequate support positively affects both body perception and self-esteem of patients and increases their life satisfaction.⁴⁸ According to this perspective, it can be said that individuals with good body perception and higher life satisfaction are expected to have a positive attitude toward seeking psychological help to maintain their well-being. 

The total sample size of the current study is acceptable. However, because tracheostomy care management processes are difficult, time-consuming, and have individual differences, a larger sample size should be considered to study the effects of the tracheostomy care management process on these patients in particular and to generalize the study results. In addition, the sample was taken from one hospital only, and the duration of the study did not extend to an entire year. This may create a bias that affects generalizability. Selection bias is also possible because of the refusal rate. Twenty (20) patients (of a sample of 60 patients) refused to participate in the study. Finally, the use of a questionnaire may not always be sufficient. Because body perception, life satisfaction, and attitude toward seeking psychological help are variables that can be affected by physical, psychological, social, and cultural situations, the relationship of the variables can be revealed by using qualitative methods as well as using questionnaires.

In the process of adaptation to care of patients with tracheostomy after discharge, depending on various variables in terms of physiological, psychological, and social aspects, body image and life satisfaction may be affected and may reveal the need to seek psychological help to cope with these situations. Because of that, in this study the authors aimed to investigate the relationships among body perception, life satisfaction, and attitude toward seeking psychological help in patients with a tracheostomy after discharge. In this study, individuals with a tracheostomy and with good body perception and higher life satisfaction had a more positive attitude toward seeking psychological help. This may indicate that individuals with tracheostomy with bad body perception and lower life satisfaction should be supported and guided in seeking psychological help. Awareness about this relationship may help nurses improve outcomes of care. The data available for comparison might have been limited, which raises the possibility of other factors influencing the study either positively or negatively. Additional studies are needed to confirm these results and to examine the effect of correlations on life satisfaction and body perception in persons with a tracheostomy.

Dr. Altınbaş is an assistant professor, Adıyaman University, Faculty of Health Sciences, Surgical Nursing Department, Adıyaman, Turkey. Dr. Aslan is an assistant professor, Batman University, School of Health, Nursing Department, Batman, Turkey. Dr. Karaca is an associate professor, Adıyaman University, Faculty of Health Sciences, Nursing Department, Adıyaman, Turkey. Please address correspondence to: Dr. Yasemin Altınbaş, Adıyaman University, Faculty of Health Sciences, Surgical Nursing Department, 02040 Adıyaman/Turkey; tel: 0416 2233800-4620; fax: 0416 2233005; email: altinbasyasemin@gmail.com. 

None disclosed