Zhao Wang, Yue Wang, Zhang-Yi Wang, Chao-Kai He, Xiao-Li Pang

1Graduate School of Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China.2Peking Union Medical College Hospital, Beijing 100005, China.3School of nursing, Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China.

Abstract Psychosocial barriers for people with an enterostomy remain a huge challenge for the health system.Recent research findings have shown that peer support has a significant effect on the psychological support of patients undergoing permanent enterostomies.This paper explores the current state of research on peer support for patients with an intestinal stoma through a literature review approach to provide scientific evidence for researchers, clinicians, and policy makers in this field.The findings suggest that the innovative use of peer support in psychological interventions for colorectal cancer stoma patients can provide them with knowledge skills, resource information, emotional support, and assessment support, which can help to facilitate the adaptation of stoma patients to their role, improve their ability to manage their stoma and ensure their physical and psychological well-being.

Keywords: peer support; peer education; colorectal cancer; stoma; nursing

Background

Colorectal cancer is a common clinical malignancy.According to the International Agency for Research on Cancer (IARC), the number of new colorectal cancer cases worldwide in 2020 will be approximately 1.9 million, with the third highest incidence rate.The number of deaths is approximately 935,000, with the second highest mortality rate [1].The main treatment of colorectal cancer is surgery, including abdominal perineal combined radical resection, distal closure, low anterior resection, and transanal pull-out of the colon [2].About 60% of patients would carry stoma for life after operation [3].Although enterostomy improves the survival rate of patients with colorectal cancer, it also changes their body image and physical function.It can produce complications such as fatigue, loss of appetite, sexual life disorder, and sports inconvenience.Some patients can have negative emotions such as self aversion and shame, and even self-acceptance disorder and social disorder in severe cases [4].In addition, patients with permanent enterostomy have serious psychosocial adaptation barriers, which seriously affect patients' quality of life [5].Therefore, it has been a long-standing concern of medical professionals to help patients with colostomy to manage their colostomy better, improve their quality of life and help them return to normal family and social life.

Peer support refers to the emotional, evaluation, information, and other support provided by social network partners with empirical knowledge and similar personality to solve the health problems of the target population [6].Peer support lets patients manage their own lives under the supervision and encouragement of peers and get information and emotional support from peer support, so as to improve patients' self-management ability and improve their physical condition.Peer support is internationally recognized by the World Health Organization as an effective way of self-management of chronic diseases.Peer support can not only provide long-term psychosocial support and achieve the purpose of self-management, but also solve the problem of too high cost of medical professionals.The World Health Organization and the American Academy of family physicians have recommended peer support programs worldwide since 2010 [7].The research of introducing peer support into the colorectal cancer stoma population has gradually increased in recent years.Peer support aims to promote stoma patients' adaptation to their roles through mutual support among patients, improve patients' ability to manage stoma, and ensure patients' physical and mental health.

Mechanism of peer support

In 1975, peer support was first applied to the field of medicine [8].As time goes on, peer support is gradually applied to people with diabetes, cancer, and addiction [9–12].In 2002, researchers expounded the mechanism of peer support from the theoretical level and explained the way in which peer support produced beneficial results for individuals [13].The researchers point out that the mechanisms of peer support include social support, social comparison, social learning and empathy.The mechanism of peer support is shown in Figure 1.

Figure 1 Mechanism of peer support Social support: produce positive results for peers through psychosocial interaction based on mutual trust and respect.Social comparison: individuals are more willing to accept the support of their peers with similar characteristics.Social learning: As credible role models, peers can be imitated and learned by others.Empathy: peers' experience and knowledge of stressors enable them to show empathy and deal with concerns.

Peer supporters

Peer supporters are mainly patients with colorectal cancer many years after stoma.Peer supporters need to have a good cultural level and language expression ability.After the training of the medical team, the peer supporters master the communication technology and home follow-up skills.They are willing to share their experience and relevant knowledge of stoma nursing.As the core role of the peer project, peer supporter affects the educational effect of colorectal cancer patients and the quality of the whole peer project, and the choice of peer supporter is very important [14].The researchers identified peer supporters through telephone interviews with colorectal cancer patients in urban and local clinics in Australia and assigned them to different types of peer support groups according to the personality and preferences of educators [15].Peer supporters are trained by stomatologists, nurses, researchers and psychologists.The main contents of the training include the concept of peer support, the choice of food and materials for stoma patients, various types of stoma nursing, and communication skills.After the training, an assessment is conducted to determine the final peer supporters [16].

Content of peer support

Knowledge and skills

Through peer support, researchers can teach colostomy management knowledge and skills to colostomy patients, which can improve the health-related knowledge and psychological adaptation level of colostomy patients [17].In the peer support group, patients with colorectal cancer stoma can learn how to empty the gas and excreta in the pocket, the method of wearing the pocket, the use of stoma AIDS, reasonable diet, and precautions in daily life [18].Peer support can effectively help patients with colorectal cancer stoma actively manage themselves.

Resource information

Researchers provided resource information for patients with colorectal cancer stoma through peer support.The American Cancer Society's community network and the live chat rooms and forums set up by researchers have brought help to patients to meet the needs of more colorectal cancer patients for peer support [19, 20].Researchers can also regularly push the information resources of colorectal cancer peer supporters through relevant network channels.

Emotional support

Researchers provide emotional support for patients with colorectal cancer stoma through peer support, which can enhance their psychological resilience and help them cope with difficulties.Through the peer support of telephone follow-up of colostomy patients, the researchers found that patients are more willing to listen to the opinions of peer supporters.The role model and suggestions of peers help to increase the confidence of colostomy patients with colorectal cancer [21].Peer supporters are experienced colorectal cancer patients who have personal experience in managing symptoms, daily life, and emotions after a colostomy.Providing emotional support to patients, makes it easier for patients to learn and accept the impact of colostomy on life and reduce negative emotions [22].

Evaluation support

Evaluation support, also known as positive support, is a kind of information exchange related to self-assessment, including emotional confirmation, cognitive and behavioral appropriateness expression.Evaluation support makes the feelings of patients with colorectal cancer stoma accepted, affirmed, and respected by their peers, and get feedback in the establishment of social friendship.Evaluation support encourages the supporters to maintain their faith and have positive expectations for the future, so as to make them understand their ability to take care of themselves and actively face the disease [23].In addition, for supporters, sharing stories and experiences can improve their recognition of responsibility and compassion for patients and themselves, and enhance their sense of identity.These feelings of identity will react on the relationship between supporters and patients, and play a positive role in reshaping the identity of supporters [24].

Measuring scale

The specific assessment tools for patients with stoma mainly include the stoma patient self-efficacy scale, the self-management behavior scale for patients with a stoma, the stoma patient-specific psychosocial adaptation scale and the stoma quality of life scale [25–27].The details of the above scales are shown in Table 1.

Table1 Measuring scale

Peer support model

Face to face support mode

Patients with colorectal cancer stoma sometimes can't express their privacy directly in public.They will feel embarrassed when discussing private parts such as stoma among groups.Therefore, the face-to-face peer support model can effectively avoid this problem [28].Face-to-face peer support has the characteristics of flexible communication time, place and frequency, easy coordination and so on [29].Researchers explained the technique of changing the stoma pocket and preventing complications to the patients through a course of 2 hours per week for three weeks.They provided the patients with a self-management manual to educate the patients to become active stoma managers.Peer support was organized by experienced expert patients and discussed in a problem-oriented way, mainly including embarrassing problems encountered in life, how to deal with them in public places, churches and other places, and let the patients keep a diary.

Group support model

Group support mode refers to a group of people with the same experience sharing common problems, meeting regularly to exchange information, and giving and receiving psychological support [16].Group peer support is a social gathering organized by colostomy club staff and colostomy patients.Through multimedia education, lectures and encouraging patients to ask questions and share experiences, patients are made aware of the existence of similar cases and given the opportunity to communicate with other colostomy patients and their families [23].

Virtual community model

The virtual network provides a platform for colorectal cancer patients to communicate anonymously, so that they can talk about sensitive topics more freely, communicate anytime and anywhere, and don't care about social background [17, 30].There is no better way to relieve the psychological pressure and mental trauma of patients with colorectal cancer after a colostomy.The researchers invite peer supporters to join the research group for interview narration or interact with other colorectal cancer patients.Patients can interact and communicate anonymously with peer narrators on the forum [20].A Danish study found that through internet forums, live chat rooms and personal information systems, peer support groups can communicate and discuss content with colorectal cancer survivors in various regions around a common topic anytime, anywhere [31].The cancer survivors’ network in the United States is the largest peer support community network in the world.It provides a way for colorectal cancer patients and their peer educators to communicate with each other and reduce the stress, depression and trauma of colorectal cancer patients [19].

Successful application of peer support in other cancer patients

Researches has shown that peer support with the same experience can better help cancer patients cope with the disease and improve their quality of life.Lee et al.in a randomized controlled study, 64 breast cancer patients were given 1 time weekly peer support and discussed in group discussion sessions, with an average time of 20 min.The theme of the meeting is post-operative common problems and coping skills.Coffee shops are often selected to create a relaxed atmosphere for both sides.The results showed that peer support could effectively improve breast cancer patients self-efficacy and quality of life [32].Pierre et al.gave one-to-one telephone peer support to 12 cancer patients.The researchers forwarded the contact information and support needs of each supporter to the matching peer, and then the peer carried out telephone support [33].Most of the support contents were about surgery, rehabilitation, anxiety, impact on sexual behavior and breast loss.The telephone lasted about 45 minutes.The results showed that peer support based on the telephone could help patients obtain physiological, psychological and social information when facing the complex surgery decision.Wang et al.applied peer support to patients with nasopharyngeal carcinoma and they found that peer support can effectively reduce the incidence and degree of radiation stomatitis, improve oral comfort and improve the quality of life [34].

Conclusion

Peer support mainly provides knowledge and skills, resource information, emotional support and evaluation support for colorectal cancer patients with colostomy through peer supporters, so as to promote the adaptation of colostomy patients to their roles, improve the ability of patients to manage colostomy, and ensure the physical and mental health of patients.There are various forms of peer support for patients with colorectal cancer stoma, mainly including face-to-face single person support, group support and virtual community support.There is a growing body of research on peer support for people with colorectal cancer, but empirical studies are scarce and more research evidence is still needed to validate its clinical benefits.Future research needs to expand the sample size to study further the technical details, intervention modes, measurement tools and clinical effects of peer support.

References

1.Sung H, Ferlay J, Siegel RL, et al.Global cancer statistics 2020: GLOBOCAN Estimates of incidence and mortality worldwide for 36 cancers in 185 countries.CA Cancer J Clin.2021;71(3):209–249.https://doi.org/10.3322/caac.21660

2.Quintana JM, Anton-Ladislao A, Lazaro S, et al.Predictors of readmission and reoperation in patients with colorectal cancer.Support Care Cancer.2020;28(5):2339–2350.https://doi.org/10.1007/s00520-019-05050-2

3.Costas-Chavarri A, Nandakumar G, Temin S, et al.Treatment of patients with early-stage colorectal cancer: ASCO resource-stratified guideline.J Glob Oncol.2019;5:1–19.https://doi.org/10.1200/JGO.18.00214

4.Fingren J, Lindholm E, Petersen C, Hallen AM, Carlsson E.A prospective, explorative study to assess adjustment 1 year after ostomy surgery among swedish patients.Ostomy Wound Manage.2018;64(6):12–22.https://doi.org/10.25270/owm.2018.6.1222

5.Zhang Y, Xian HT, Yang Y, Zhang XX, Wang XR.Relationship between psychosocial adaptation and health-related quality of life of patients with stoma: a descriptive, cross-sectional study.J Clin Nurs.2019;28(15–16):2880–2888.https://doi.org/10.1111/jocn.14876

6.Kallio R, Jones M, Pietila I, Harju E.Perspectives of oncology nurses on peer support for patients with cancer.Eur J Oncol Nurs.2021;51:101925.https://doi.org/10.1016/j.ejon.2021.101925

7.Boothroyd RI, Fisher EB.Peers for progress: promoting peer support for health around the world.Fam Pract.2010;27(Suppl 1):i62–i68.https://doi.org/10.1093/fampra/cmq017

8.Apolloni T, Cooke TP.Peer behavior conceptualized as a variable influencing infant and toddler development.Am J Orthopsychiatry.1975;45(1):4–17.https://doi.org/10.1111/j.1939-0025.1975.tb01161.x

9.Boehm LM, Drumright K, Gervasio R, Hill C, Reed N.Implementation of a patient and family-centered intensive care unit peer support program at a veterans affairs hospital.Crit Care Nurs Clin North Am.2020;32(2):203–210.https://doi.org/10.1016/j.cnc.2020.02.003

10.Haines KJ, Beesley SJ, Hopkins RO, et al.Peer support in critical care: a systematic review.Crit Care Med.2018;46(9): 1522–1531.https://doi.org/10.1097/CCM.0000000000003293

11.Chien WT, Clifton AV, Zhao S, Lui S.Peer support for people with schizophrenia or other serious mental illness.Cochrane Database Syst Rev.2019;4(4):CD010880.https://doi.org/10.1002/14651858.CD010880.pub2

12.Fleming J, Nguyen K, Winston J, et al.Promoting sustained diabetes management: identifying challenges and opportunities in developing an alumni peer support component of the YMCA Diabetes Control Program.Patient Educ Couns.2021;S0738–3991(21):00614–00615.https://doi.org/10.1016/j.pec.2021.09.005

13.Salzer MS.Consumer-delivered services as a best practice in mental health care delivery and the development of practice guidelines.Psychiatr Rehabilit Ski.2002;6(3):355–382.https://doi.org/10.1080/10973430208408443

14.Sanchez-Moscona C, Eiroa-Orosa FJ.Training mental health peer support training facilitators: a qualitative, participatory evaluation.Int J Ment Health Nurs.2021;30(1):261–273.https://doi.org/10.1111/inm.12781

15.Joo JH, Bone L, Forte J, Kirley E, Lynch T, Aboumatar H.The benefits and challenges of established peer support programmes for patients, informal caregivers, and healthcare providers.Fam Pract.2022;Feb 1:cmac004.https://doi.org/10.1093/fampra/cmac004

16.Grant M, McCorkle R, Hornbrook MC, Wendel CS, Krouse R.Development of a chronic care ostomy self-management program.J Cancer Educ.2013;28(1):70–78.https://doi.org/10.1007/s13187-012-0433-1

17.Kramish Campbell M, Meier A, Carr C, et al.Health behavior changes after colon cancer: a comparison of findings from face-to-face and on-line focus groups.Fam Community Health.2001;24(3):88–103.https://doi.org/10.1097/00003727-200110000-00010

18.Gray M.Context for practice: pressure injuries, stoma Site marking, chronic constipation, nocturia, foot care education.J Wound Ostomy Continence Nurs.2020;47(3):211–212.https://doi.org/10.1097/WON.0000000000000649

19.Portier K, Greer GE, Rokach L, et al.Understanding topics and sentiment in an online cancer survivor community.J Natl Cancer Inst Monogr.2013;2013(47):195–198.https://doi.org/10.1093/jncimonographs/lgt025

20.Hwang KO, Ottenbacher AJ, Graham AL, Thomas EJ, Street RL Jr, Vernon SW.Online narratives and peer support for colorectal cancer screening: a pilot randomized trial.Am J Prev Med.2013;45(1):98–107.https://doi.org/10.1016/j.amepre.2013.02.024

21.Wang YT, Li SY, Gong JF, et al.Perceived stigma and self-efficacy of patients with inflammatory bowel disease-related stoma in China: a cross-sectional study.Front Med(Lausanne).2022;9:813367.https://doi.org/10.3389/fmed.2022.813367

22.Blixen C, Perzynski A, Kanuch S, et al.Training peer educators to promote self-management skills in people with serious mental illness (SMI) and diabetes (DM) in a primary health care setting.Prim Health Care Res Dev.2015;16(2):127–137.https://doi.org/10.1017/S1463423614000176

23.Altuntas YE, Kement M, Gezen C, et al.The role of group education on quality of life in patients with a stoma.Eur J Cancer Care(Engl).2012;21(6):776–781.https://doi.org/10.1111/j.1365-2354.2012.01360.x

24.MacLellan J, Surey J, Abubakar I, Stagg HR.Peer support workers in health: a qualitative metasynthesis of their experiences.PLoS One.2015;10(10):e0141122.https://doi.org/10.1371/journal.pone.0141122

25.Simmons KL, Smith JA, Maekawa A.Development and psychometric evaluation of the Ostomy Adjustment Inventory-23.J Wound Ostomy Continence Nurs.2009;36(1):69–76.https://doi.org/10.1097/WON.0b013e3181919b7d

26.Bekkers MJ, van Knippenberg FC, van den Borne HW, van Berge-Henegouwen GP.Prospective evaluation of psychosocial adaptation to stoma surgery: the role of self-efficacy.Psychosom Med.1996;58(2):183–191.https://doi.org/10.1097/00006842-199603000-00013

27.Szpilewska K, Juzwiszyn J, Bolanowska Z, et al.Acceptance of disease and the quality of life in patients with enteric stoma.Pol Przegl Chir.2018;90(1):13–17.https://doi.org/10.5604/01.3001.0011.5954

28.Stickel A, Gropper S, Pallauf A, Goerling U.Patients' knowledge and attitudes towards cancer peer support programs.Oncology.2015;89(4):242–244.https://doi.org/10.1159/000430918

29.Richardson LJ, Molyneaux V, Murray CD.Being a peer support mentor for individuals who have had a lower limb amputation: an interpretative phenomenological analysis.Disabil Rehabil.2020;42(26):3850–3857.https://doi.org/10.1080/09638288.2019.1611954

30.Grant M.Using creative arts therapy workshops to explore stoma patients' feelings.Br J Nurs.2020;29(22):S6–S8.https://doi.org/10.12968/bjon.2020.29.22.S6

31.Hoybye MT, Dalton SO, Deltour I, Bidstrup PE, Frederiksen K, Johansen C.Effect of Internet peer-support groups on psychosocial adjustment to cancer: a randomised study.Br J Cancer.2010;102(9):1348–1354.https://doi.org/10.1038/sj.bjc.6605646

32.Lee R, Lee KS, Oh EG, Kim SH.A randomized trial of dyadic peer support intervention for newly diagnosed breast cancer patients in Korea.Cancer Nurs.2013;36(3):E15–22.https://doi.org/10.1097/NCC.0b013e3182642d7c

33.St-Pierre D, Bouchard K, Gauthier L, Chiquette J, Dorval M; Centre ROSE.Perspectives of women considering bilateral prophylactic mastectomy and their peers towards a telephone-based peer support intervention.J Genet Couns.2018;27(1):274–288.https://doi.org/10.1007/s10897-017-0148-x

34.Wang J, Chen H, Ouyang ZZ, Deng J, Zhang HY.Effect of peer education on radiation stomatitis in patients with nasopharyngeal carcinoma.Contemp Nurses.2021;28(8):75–77.https://doi.org/10.19791/j.cnki.1006-6411.2021.22.027