Effect of a Mobile Patient Education Application on Adjustment to Stoma and Development of Peristomal Skin Lesions: A Quasi-Experimental Study

Although stoma formation is a lifesaving surgical procedure, it may cause various physiological, social, and psychological problems for patients and their families that may potentially lead to a reduced quality of life.^1,2 Patient outcomes following stoma surgery have been widely discussed in wound care literature, including cross-sectional studies, reviews, qualitative studies, descriptive studies, and qualitative-meta analyses.³ Individuals with a stoma were found to experience anxiety, depression, stigma, sexual problems, deterioration in body image, deterioration in social relationships, and adjustment problems according to the results of 27 systematic reviews by Ayaz-Alkaya,⁴ who examined psychosocial problems associated with stoma formation. The results of another 13 qualitative meta-synthesis studies revealed that individuals with a stoma experienced physical, psychological, social, economic, and sexual problems as a result of stomal and peristomal complications. Many patients quit their jobs due to difficulties adjusting after stoma surgery.^5,6

Patient education plays a key role in adjusting to a stoma and maintaining quality of life. Interventions by stoma and wound care nurses are essential to increasing the psychosocial adjustment level of these patients.⁷ These interventions may include coordinating support from other health care professionals, telephone and text message follow-up of individuals with a stoma, and ongoing patient education initiatives (eg, web-based or multimedia training and planned group training).^6,8,9

Although there are several mobile applications (apps) developed for individuals with a stoma, the results of studies are limited. In a randomized, controlled trial, Wang et al¹⁰ investigated the effectiveness of a mobile app in the home care of individuals with a stoma. Although there was no difference between the experimental group (n = 100) and control group (n = 103) in the evaluation made before discharge, the psychosocial adjustment level and stoma self-efficacy scores of the experimental group were found to be significantly higher than those of the control group in the first, third, and sixth months after discharge (P < .05).¹⁰ The researchers also found that the incidence of complications tended to decrease when a mobile app was used to complement standard care. Other studies have shown the utility of mobile apps for guiding patients in managing diabetes (including diabetic foot ulcers), hypertension, obesity, cancer, and irritable bowel syndrome (IBS); such apps have been shown to help alleviate disease symptoms by increasing the level of patient self-care, quality of life, and adjustment.^11,12

In Turkey, stoma care training is commonly provided with printed training materials and face-to-face patient education. However, patients and their relatives cannot receive comprehensive training after stoma surgery because the patient feels nausea and pain after surgery, shortened hospital stays due to robotic and laparoscopic surgery, lack of appropriate training environments, and insufficient numbers of stoma and wound care nurses. Moreover, community health centers do not provide any service to support patients and families in stoma care after discharge. Individuals who travel to undergo stoma placement in large urban hospitals frequently experience difficulties in finding support after discharge because there are no stoma and wound care nurses in their hometowns.

Considering these issues, it is necessary to ensure continuity in educating individuals with a stoma, and at this point, mobile apps have emerged as an important component of stoma care as methods of improving patient education develop rapidly. Mobile health care practices offer opportunities to facilitate the processes of disease treatment, improve health literacy, and enable behavior change. Through appointment reminders and test result notifications, mobile apps enhance diagnosis, treatment, monitoring, and communication between health care professionals and patients.^13,14

There are several mobile apps offered by companies that produce stoma-related products and supplies. However, because these apps focus on products, they may not fully answer the questions faced by individuals with a stoma. The present study aimed to develop an educational mobile app that could meet the needs of individuals who have recently undergone stoma surgery and to evaluate the effectiveness of this app on psychosocial adjustment, self-care, and peristomal skin complications.

Study design. This study was conducted as quasi-experimental research with a posttest control group to evaluate the effect of a mobile patient education app on self care in individuals with a stoma. Assessment objectives included adjustment to the stoma and the incidence of peristomal skin lesions.

Sample and setting. The study was conducted in the research hospitals of 3 universities in Istanbul, Turkey, from November 2018 through December 2019. Power analysis was performed to determine the sample size by using the G*Power (v3.1.7) software. The following statistical parameters were used: alpha reliability level (α) = 0.05, effect size = 0.58, and test strength (1-β) = 0.95. According to the results of the calculations, the minimum number of samples required was found to be 28 for each group. Considering the potential for withdrawal during the study, 30 patients were included in both the experimental and the control groups. 

Although the study was conducted in clinics at 3 different hospitals, patients in the same clinic usually knew each other. Therefore, participants in the experimental and control group were selected from different clinics. Patients who met the sampling inclusion criteria were included in the trial and control groups in turn. To meet these criteria, patients must have been aged 18 years or older and undergone stoma opening for the first time, were literate, had no physical/psychological disabilities, and were able to use smartphones (Figure 1). Participation in the study was voluntary.

Ethical considerations. Ethics committee permission (decision no. 357) was obtained for conducting the research, and institutional permission (decision no. 50200903-1999, 50, 16867222-604.01.01) was obtained from the institutions where the data would be collected. Permission was also obtained from the researchers who conducted the Turkish validity and reliability study of the Peristomal Skin Lesions Assessment and Classification Instrument (SACS) and the Ostomy Adjustment Inventory-23 (OAI-23), which were used to collect research data.

The purpose, plan, duration, and expectations of the study, as well as how and where data would be obtained and used, were explained to the individuals participating in the study through the informed consent form prepared in line with the Helsinki Declaration. Written and verbal consents were obtained separately for the experimental and control groups.

Instruments.

Individual characteristics assessment form. This form was developed through analysis of the literature and based on the experience of the researchers. The form consists of 6 questions related to sociodemographic characteristics (age, sex, marital status, education status, employment status, income status) and 10 questions related to stoma-related characteristics (stoma duration, type, structure of stoma, reason for stoma opening, stoma care status, stoma complications).

OAI-23. Simmons et al¹⁵ developed this scale to determine the level of adjustment of individuals with a stoma, and Karadağ et al¹⁶ assessed its Turkish validity and reliability. The inventory is multidimensional, consisting of 4 subscales: acceptance (inventory items 1, 3, 4, 6, 9, 14, 15, 19, and 23), anxious preoccupation (items 12, 13, 17, 20, and 21), social engagement (items 5, 7, 8, and 11), and anger (items 2, 10); 3 of the inventory items (16, 18, and 22) do not assess any of these 4 subscales. Each item in the inventory is evaluated using a 5-point Likert-type scale ranging from 0 to 4 (strongly agree, agree, unsure, disagree, strongly disagree); a high score obtained from each item indicates a higher level of adjustment. On the scale, 12 items include negative phrases; therefore, these items are scored inversely. Total scale scores range from 0 (worst adjustment) to 92 (best adjustment). In the present study, the overall reliability coefficient of the scale was found to be 0.874, and the correlation coefficient obtained by the test-retest method was found to be 0.766. The total Cronbach alpha was calculated as 0.862.

SACS. The SACS instrument was developed in Italy between 2003 and 2006 and a validity study was performed. Ay and Bulut¹⁷ further examined the validity and reliability of the Turkish version of the SACS instrument, and it was determined to be sufficient in terms of suitability and practical use; the compatibility between independent observers was found to range from 0.80 to 0.99.

The Turkish version of the SACS instrument consists of 3 main sections: evaluation of lesion types, evaluation of lesion areas, and documentation samples. Lesion types are classified as absence of peristomal skin complications (L0), hyperemic (L1: peristomal redness with intact skin), abrasive (L2: open lesion not extending to subcutaneous tissue; skin loss in partial thickness), ulcerative (L3: open lesion extending to subcutaneous tissue and under the skin; skin loss in full-thickness), ulcerative (L4: skin loss in full-thickness with dead tissue), and proliferative (L5: abnormal growth present; ie, hyperplasia, granulomas, neoplasms) lesions. Peristomal lesion areas are determined by a topographic (T) position scale in which TI reflects the left upper peristomal quadrant (12–3 o’clock), TII is the left lower peristomal quadrant (3–6 o’clock), TIII is the right lower peristomal quadrant (6–9 o’clock), TIV is the right upper peristomal quadrant (9–12 o’clock), and TV refers to all peristomal quadrants.

Stoma care training evaluation form. Visual analog scale (VAS) was used to evaluate individual level of satisfaction with stoma care training. Patients were asked to rate the stoma training they received with a score from 1 to 10 using this scale. A score of 1 showed the least satisfaction whereas 10 showed the greatest satisfaction.

Study procedures. To the best of the authors’ knowledge, this is the first mobile app developed for individuals with a stoma in Turkey. The study was carried out in 2 stages.

Stage 1: Development of STOMA-M app. STOMA-M is an app prepared in Turkish for mobile phones with Android operating system. It runs offline without the need for an internet connection after being downloaded to the phone for free. The app was developed in line with the ADDIE (analysis, design, development, implementation, and evaluation) model. The care needs of individuals regarding stoma management were determined, and the content of the STOMA-M app was prepared by the researchers in accordance with evidence-based practices and guidelines after conducting a literature review.^18,19 For each part of the content, 15 experts (5 nursing lecturers who conducted research about ostomy, 4 general surgery lecturers, 5 stoma and wound care nurse who have specialist nursing, and 1 information technology lecturer) were consulted. Each expert was consulted separately. To test its intelligibility, 5 patient opinions were obtained. Modifications to the app made in response to the recommendations of experts and patients are as follows.

General surgery lecturer. In line with the suggestion that colostomy types that are frequently used in practice should be included in the animation video of the digestive system, transverse colostomy and sigmoid colostomy were added to the app.

Nursing lecturer. The stoma care animation video in the app was revised in line with the suggestions that content should be presented in order of use, and the care stages should be described first using positive language, then negative language and warnings (eg, the peristomal area should be cleaned with warm water precedes the warning that disinfectant should not be used). Medical terminology was revised to simpler language that the patient could more easily understand, and the religious practices section was expanded to be more comprehensive.

Information technologies lecturer. The navigation elements of the app were modified to allow the user to scroll downward (“swipe up”) for additional content on nutrition-related problems and complications. For these sections, an accordion-type design element was employed, expanding in place to reveal hidden content and collapsing again to minimize scrolling. The information technology lecturer also recommended enabling the use of pinch gestures to change font sizes; however, this change could not be implemented.

Patient opinion. In response to patient requests, an image depicting a stoma cap was added to the app. With the exception of the font change pinch gesture, all other suggestions were implemented during the software development process. The app was finalized by taking the opinions of 1 information technology consultant and 3 software development experts.

Software development process. A research scholarship was received to develop the mobile app and to receive professional technical service support. The mobile app development phase took about 7 months. Taking into account the mean age and education level of individuals with a stoma, as well as their comfort level with using a smartphone, the developers used animations and images heavily throughout the app, and medical terms were defined in simple terms to promote understanding. On the main page of the STOMA-M app, 6 menus are presented to the user. Of this menu, 2 are animation videos. The app has 14 submenus and 19 content pages. The first video was used to explain the anatomy and physiology of the digestive system; the definition, characteristics, and types of stomas (ileostomy and colostomy); where the abdominal wall was opened to form the stoma; typical stool consistency after ostomy surgery; and peristomal skin complications. The second video examined the critical elements of stoma care: emptying and changing the ostomy bag, cutting and removing the drain tube adapter, caring for the peristomal skin, and applying stoma paste to create a tight seal.

The app included 12 submenus and 5 content pages covering educational topics to help individuals with a stoma adjust to activities of daily life.  Some of the topics addressed included skincare, nutrition and dietary challenges, bathing, sexuality, religious practices, travel, sports participation, and pregnancy.

In addition, there were 2 submenus and 14 content pages providing definitions and images of stomas, peristomal complications and how they can be prevented. Care strategies for these complications were also detailed.

Finally, the app provided phone numbers for stoma care units and advocacy associations that patients and caregivers could contact.

The logo for the STOMA-M app was designed,²⁰ and the functionality of the app was tested.

Stoma care booklet. The content of the mobile app, which was provided to the experimental group, was also given to the control group as printed material. This stoma care educational booklet paralleled the videos, graphics, and text content of the app and aligned with the same literature.^18,19 The booklet included descriptions of the anatomy and physiology of the digestive system, definitions of stoma types (ileostomy and colostomy), and important steps of the stoma care process (emptying and the bag, cutting and removing the adapter, caring for the peristomal skin, and applying the paste). The booklet also contained information to help patients adjust to activities of daily life after stoma placement, including nutrition challenges, toileting, sexuality, religious practices, travel, sports participation, and pregnancy. Stoma complications were explained through the use of images and definitions. Finally, the booklet provided a list of telephone numbers of stoma care units that patients and caregivers could contact.

Fourteen (14) specialists (5 nursing lecturers, 4 general surgery lecturers, and 5 stoma and wound care nurses) were consulted to develop the booklet content. Page design and layout were performed by 3 graphic designers. To test its intelligibility, the authors asked individuals with a stoma and their relatives to read the booklet; after their feedback was received, revisions were made to make the medical terminology more accessible to a lay audience. Some images were also replaced because of resolution issues that arose during printing.

Stage 2: Evaluation of the app. To avoid prejudice and to give the same phone to every patient, 5 phones with Android operating system were provided. The STOMA-M app was installed on the phones by the software company. The STOMA-M app was explained to the patient before surgery by the stoma and wound care nurse. Written consent was received from patients who volunteered to participate in the study. The information in the app (the digestive system anatomy, definition, and maintenance of the stoma) was explained verbally to the patient and their relatives before surgery. Their questions were answered.

Implementation of the research. For each patient in both the experimental and the control groups, the patient’s general condition and stoma were evaluated 1 day after operation. The patient’s sociodemographic and stoma characteristics were recorded in the individual characteristics diagnosis form. In the postoperative period, the stoma and wound care nurse again explained the informational content of the STOMA-M app (stoma care, daily life activities, and possible complications) to the patients and their relatives,  and their questions were answered. During the patient’s stay in the hospital, the various elements of stoma care were explained to the patient and their relatives, and they were encouraged to participate in the care.

On the day of discharge, the stoma was re-evaluated, instructions for its care were repeated, and the patient’s questions were answered. Patients in the experimental group were instructed to use the mobile app at home for 3 months.

In the first and third months after discharge, researchers re-evaluated patients by using the OAI-23, the SACS instrument, and the stoma care training evaluation form. During these evaluations, stoma and peristomal skin were examined. Any additional questions that patients and caregivers had regarding stoma care were answered in the interview, which lasted about 30 minutes.

The control group was given the stoma care training booklet, and the research was implemented in the same way as in the experimental group.

Data analysis. Patients who could not complete the follow-up were excluded from the study, and any data obtained from them were not used. The distribution of data was examined using the Shapiro-Wilk test. The t test was used to compare 2 independent groups with normally distributed data, and the Mann-Whitney U test was used for 2 independent groups with data that were not normally distributed. The Wilcoxon test was used to compare dependent data. The McNemar test was used in categorical dependent 2 × 2 tables, and McNemar-Bowker test was used in 3 × 3 tables; the Fisher-Freeman-Halton test, Fisher’s exact test, and Pearson’s chi-square analysis were used to analyze the independent categorical data. Descriptive statistics of the data were explained as mean ± standard deviation, median (minimum-maximum), and frequency (percentage). All statistical analyses were conducted and reported at the significance level of 0.05 using the Statistical Package for the Social Sciences (SPSS) 22.0 software (IBM), licensed to Istanbul University-Cerrahpaşa.

There were 295 patients with a stoma who were screened for possible inclusion in the study. A total of 94 patients who met the research criteria were included. Because 3 patients refused to continue the research and 10 patients could not be contacted, these patients were excluded at the beginning of the study. Fourteen (14) patients from the experimental group and 6 patients from the control group left the follow-up in the first month of the study, and 1 patient from the experimental group could not complete the study in the third month. Patients with newly created stoma were assigned to the group with fewer patients (Figure 1).

In the experimental group, the mean age was 50.97 ± 12.94 years, 50% (n = 15) were female, 12 (40%) were primary school graduates, 21 (70%) were unemployed, and 19 (63.3%) were low income. In the control group, the mean age was 54.70 ± 11.95 years, 56.7% (n = 17) were male, 20 (66.7%) were primary school graduates, 22 (73.3%) were unemployed, and 21 (70%) were low income. The reason for stoma opening in both groups was often cancer; 70% (n = 42) of patients had a related cancer diagnosis.

Twenty (20) patients (66.7%) in the experimental group had an ileostomy, whereas the majority of those in the control group (n = 18 [60%]) had a colostomy. A total of 47 (78.3%) patients across both groups had a temporary stoma opening. Sociodemographic characteristics of the participants in the experimental group and control group were similar, and a statistically significant difference between the groups was only found in terms of stoma type (n = 18 [60%]; P = .038) (Table 1 and Table 1 continued).

Considering the stoma care status of the individuals included in the study, the percentage of those patients performing their own self-care in both groups increased in the third month. However, the percentages of those performing their own stoma care at the first month (n = 12 [40.1%]; P = .029) and third month (n = 18 [60%]; P = .037) were significantly higher in the experimental group (Table 2).

On a scale of 0 to 92, with 92 representing the best possible adjustment following stoma placement,  the OAI-23 scores of the individuals in the experimental group were found to be 52.5 (range, 41–67) and 56 (range, 35–77) in the first and third months, respectively. The difference between the scores was found to be statistically significant (P = .05). In the third month, researchers found an increase in the social engagement subscale scores compared with the initial evaluation (P = .009) (Table 3).

In comparison, the OAI-23 scores of individuals in the control group were found to be 50 (range, 34–68) and 51 (range, 34–75) in the first and third months, respectively; and the difference between scores was not found to be statistically significant (P = .657). Considering the scores of items on the anger subscale (median, 2.50; range, 2–7; P = .002) and item 16, Caring for my stoma is difficult (median, 1.90; range, 0–3; P = .036), a significant decrease was noted in the third month compared with the baseline.

A statistically significant difference between the experimental and control groups was found in the anger subscale in the first month (P = .015) (Table 3).

According to the SACS instrument responses, peristomal skin lesions did not develop in the control group in the third month (n = 30; 100%; P = .011). While no lesion was observed in 76.7% (n = 23) of individuals in the experimental group, 13.3% (n = 4) of patients in this group showed hyperemic lesion (peristomal skin redness without tissue loss), 6.7% (n = 2) showed L2 changes (erosive lesion with tissue loss that did not extend to the dermis), and 3.3% (n = 1) showed L5 changes (proliferative lesions) (Table 4).

Considering the satisfaction of individuals with stoma care training, satisfaction rates of the individuals in the experimental group were found to have increased (median, 10; range, 8–10; P = .008), whereas there was no significant difference in the control group (median, 9; range, 7–10; P = .154). The comparison of the satisfaction levels of the individuals in the experimental group versus the control group revealed that the satisfaction rate of the experimental group was statistically significant in the third month (median,10; range, 8–10; P = .001) (Table 5).

Education has an important role in maintaining patient quality of life following stoma surgery and improving adjustment to the stoma.²¹ The present study revealed that the STOMA-M app, as developed within the scope of this research, was a more effective educational tool than printed information for patients to adapt to their stoma and to care for their stoma in the early postoperative period. In the present study, the OAI-23 scores (median, 56; range, 35–77; P = .050), particularly the social engagement subscale scores (median, 8; range, 4–13; P = .009), of the experimental group that used the STOMA-M app were found to increase in the third month compared with baseline (Table 3). Although mobile apps used in the education of individuals with a stoma have been studied in the literature, there are few studies evaluating the effectiveness of self-care in patients who use such apps as an adjunct to standard care practices. In a randomized controlled study, Wang et al¹⁰ investigated the effectiveness of mobile apps in the home care of individuals with a permanent stoma in China. In their study, patients in the control group (n = 103) received routine stoma care education, whereas patients in the experimental group (n = 100) received both routine stoma care and supportive education at home via a mobile app. According to their results, there was no difference between the individuals in both groups in the evaluation made before discharge; they also found that the psychosocial adjustment level (F = 81.21; P < .001) and stoma self-efficacy scores (F = 23.16; P < .001) of the experimental group were higher than the control group in the first, third, and sixth months of follow-up, and the incidence of stoma complications tended to decrease over time.¹⁰ These results revealed that mobile health apps can be an appropriate training tool for individuals with a stoma in managing stoma after surgery, adapting to changes in their lives, and maintaining continuity of care.

No statistically significant increase was found in the OAI-23 scores of the control group (P = .657); however, there was a significant decrease in the scores of the anger subscale (P = .002) and item 16, Caring for my stoma is difficult, in the third month compared with the baseline (P = .036). Of the individuals in the control group, 36.7% (n = 11) performed their stoma care independently (Table 2). Their independence in stoma care may have led to a decrease in their anger toward the stoma. The anger subscale score of the experimental group was higher compared with the control group at the beginning of the research (P = .015; Table 3). It is known that when patients who have undergone ostomy surgery face their stoma for the first time, their feelings of sadness and surprise become prominent, and such emotions as anger, denial, and anxiety are normal.²²

Comparing the stoma care status of the individuals included in the study, researchers found that individuals using the STOMA-M app undertook their own stoma care (P = .029, P = .037, Table 2) These results indicate that independence in stoma care has a key role in the adjustment to the stoma. Findings of the current study suggest that individuals who use mobile apps as an adjunct to routine training have greater confidence in taking over their self-care and, consequently, accept the stoma more quickly as a part of their lives. It has been reported in the literature that psychosocial adjustment is related to self-care skills, and individuals who can care for themselves may also have a better adjustment to the stoma.^1,23,24 According to the results of a randomized, controlled study of 102 individuals with a stoma, Lo et al⁸ found that patients using a multimedia app had better self-care knowledge, attitudes, and behaviors than those who received traditional stoma care education. This result suggests that approaches that include multimedia apps may be more effective than those relying exclusively on printed information to improve patient outcomes. Because the STOMA-M app had visual and audio content, it may be an effective tool in improving self-care knowledge and skills of individuals with a stoma in the early postoperative period.

Crawford et al²⁵ compared traditional stoma care training (provided by nurses using verbal and printed materials) with education that included digital video discs (DVDs) in addition to verbal instructions from the nurse. The findings from this study showed that the nurse education plus DVD technique is as effective as the nurse education method we traditionally use in helping new ostomy patients gain knowledge, skills, and confidence. These authors also stated that using a DVD was beneficial in cases of shorter hospital stay due to laparoscopic and Enhanced Recovery After Surgery protocols. Similarly, such tools as the STOMA-M app may improve the knowledge and skills of individuals about stoma and support their adjustment to daily life in cases where the hospital stay is shortened.

Prevention of stoma complications can be difficult for patients, their families, and stoma and wound care nurses.²⁶ In the literature, stoma complications typically range from 21% to 70%.²⁷ Complications continue to occur even though advanced surgical techniques and innovative stoma materials are now available.²⁸ In the experimental group of the current study, the percentage of patients with peristomal skin complication was 23.3%, but the hyperemic lesion percentage was 13.3%. No patient in the control group showed a peristomal skin lesion. Menin et al²⁹ detected peristomal skin lesions in 35.5% of individuals with a stoma who were followed up using the SACS instrument, and 20% of these were hyperemic lesions. In a study using the SACS instrument to examine the incidence and risk factors of stoma complications in 1076 patients, Arolfo et al²⁷ frequently detected erosive lesions with tissue loss not extending to the dermis (L2) (55%) and ulcerative lesions (L3) (5%) extending to the dermis. These results are lower than those reported by Menin et al.²⁹ In the current study, participants in the control group did not develop any complications in the third month (n = 30; 100; P = .011). This can be attributed to the fact that the content of the booklet provided to the control group had exactly the same content as the mobile app.

Factors that increase the risk of developing stoma and peristomal complications include irritable bowel syndrome, stoma type, surgeon’s experience, poor intestinal quality, ischemic colitis, failure to mark the preoperative stoma area, and lack of skilled stoma and wound care nurses on staff.^30,31 Many factors, including BMI, weight follow-up, chemotherapy/radiation therapy status, and stoma height, were not examined in this study. Richbourg et al³² found that most individuals with a stoma had difficulty in maintaining the adapter/bag system despite intensive training. Aktaş and Baykara²² reported that 93.3% of individuals with a stoma had difficulty in stoma care, particularly during peristomal skin cleansing, even though they received training.

It was observed that the satisfaction rates of the individuals in the experimental group increased significantly in the third month compared with baseline (median, 10; range, 8–10; P = .008). Comparing the satisfaction levels of the patients in the experimental group (median, 10; range, 8–10)  and control group (median, 9; range, 7–10), the satisfaction rates of the individuals in the experimental group were found to be higher in the third month of follow-up (P = .001; Table 5). According to the prospective and retrospective studies and systematic reviews on this subject, nursing interventions increase the adjustment, quality of life, and self-management skills of the individuals with a stoma, and they improve patient knowledge, skills, and attitudes about stoma.^6,18,21-33 It has been determined that individuals using the STOMA-M app performed suitable stoma care and adapted to the stoma. Therefore, it may suggest that the satisfaction rates of individuals using the STOMA-M app are high.

There are some limiations to the current study. First, the app only ran on the Android operating system, and the software supported only the Turkish language. Second, the routine care processes in the stoma therapy units in the 3 hospitals where the study was conducted may vary despite stoma and wound care nursing certification programs being provided by a single center in Turkey. Third, individuals participating in the study may have accessed information resources on stoma care through YouTube or unverified websites. Fourth, the follow-up period of the study was limited to 3 months.

The present study revealed that the experimental group’s OAI-23 scores, particularly social engagement scores, increased during the follow-up period, and patients were satisfied with the education provided. In the control group, on the other hand, there was no significant change in the OAI-23 scores over time; in particular, the scores of the anger subscale and item 16, Caring for my stoma is difficult, decreased compared with baseline. According to the evaluation made using the SACS, no patients in the control group developed peristomal skin lesion in the third month. The results revealed that the use of mobile applications in self-care training improved patient adjustment to the stoma and their independence in caring for the stoma themselves.

The authors thank the Vehbi Koc Foundation for its financial support. In addition, the authors would like to thank the experts who shared their valuable opinions, Özlem Aksöz for the animations, Alperen Yillikçi for the mobile software, Dr Metin Ertem for the logo, and all the individuals with a stoma and their families who agreed to participate in the study despite the difficulties of the treatment processes. ν

Financial support was provided by Koç University, Vehbi Koç Foundation Nursing Project Support Program, Turkey (No. 2017.2.10). Istanbul University-Cerrahpasa, Institute of Graduate Studies, Fundamentals of Nursing Department, PhD Thesis, Istanbul. (https://tez.yok.gov.tr/UlusalTezMerkezi/tezSorguSonucYeni.jsp Thesis number: 651694).

Dr Yiğitoğlu is an enterostomal therapy nurse, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty Hospital, Istanbul, Turkey. Dr Şendir is a professor, Hamidiye Faculty of Nursing, University of Health Sciences, Istanbul, Turkey. 

Address all correspondence to: Eylem Toğluk Yiğitoğlu, RN, PhD, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty Hospital, Post Code 34098, Istanbul, Turkey; tel: +90 506 330 34 48; email: e.togluk@gmail.com.