Original Article

Psychological Adaptation to Alteration of Body

Image among Stoma Patients: A Descriptive Study

Umesh Jayarajah, Dharmabandhu Nandadeva Samarasekera

ABSTRACT
Background: Creation of an ostomy leads to significant change in the body image of the patient. However, adaptation
to this alteration of body image is necessary for rehabilitation following surgery. The objective of this study was to
identify the factors that influence adaptation to altered body image. Materials and Methods: An analytical cross‑sectional
study was conducted among 41 ostomy patients who were treated at a single tertiary care unit. Body image disturbance
questionnaire (BIDQ) was used to assess the perception of body image. Data were analyzed using independent samples
t‑test (unpaired), Chi‑square test, and Spearman’s correlation. Results: In our study, the mean BIDQ score was 2.22 (standard
deviation ± 0.88). The body image disturbance was significantly associated with younger age (P < 0.05). The prevalence
of body image disturbance was significantly higher among overweight patients (P < 0.05). Males had a higher BIDQ score
than females. Those who had temporary stoma had significantly higher BIDQ score (P < 0.05). Those who felt depressed
or had thoughts of self‑harm soon after surgery had significantly high body image disturbance score (P < 0.05). There
was a significant negative correlation with the perception of self‑efficacy and body image disturbance (P < 0.01). There
was no significant association between body image disturbance and the diagnosis, type of surgery, or time duration
after surgery. Conclusions: Poor adaptation to alteration of body image was associated with younger age, overweight,
and temporary stoma. Individuals at risk of poor adaptation should be identified before surgery and counseled before
surgery, after surgery, and during follow‑up visits.

Key words: Body image, contributory factors, stoma

INTRODUCTION lifestyle.[2] Furthermore, the quality of life of patients

is also significantly affected by ostomy creation.[3]
The worldwide increase in the incidence of colorectal
cancer has led to an increase in the ostomy creation Body image is the self‑perception of one’s physical
surgeries. [1] Many researches have described the well‑being regarding its attractiveness and function
psychosocial and emotional problems that arise due to
the creation of an ostomy and its impact on patients’ This is an open access article distributed under the terms of the
Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0
Access this article online License, which allows others to remix, tweak, and build upon the
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DOI: How to cite this article: Jayarajah U, Samarasekera DN. Psychological

10.4103/0253-7176.198944 adaptation to alteration of body image among stoma patients: A descriptive
study. Indian J Psychol Med 2017;39:63-8.

Department of Surgery, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka

Address for correspondence: Prof. Dharmabandhu Nandadeva Samarasekera

Department of Surgery, Faculty of Medicine, P. O. Box 271, Kynsey Road, Colombo 8, Sri Lanka.
E‑mail: samarasekera58@yahoo.co.uk

© 2017 Indian Psychiatric Society | Published by Wolters Kluwer - Medknow 63

 Jayarajah and Samarasekera: Alteration of body image among stoma patients

which constantly changes during different stages Ethics Committee of the National Hospital of Sri Lanka.
in life.[4] Body image disturbance was defined as a All participants gave informed written consent, which
persistent report of dissatisfaction, concern, and distress included the right of withdrawing from the study at any
that is related to an aspect of appearance, some degree point without compromising their clinical treatment.
of impairment in social relations, social activities, or
occupational functioning.[5] Following ostomy creation, The study was conducted at the National Hospital of
the normal anatomy and function of the gastrointestinal Sri Lanka, Colombo. All patients who presented for
system are changed, and the intestinal contents are follow‑up at the Professorial Surgical Unit, National
diverted to the exterior by an abdominal opening Hospital of Sri Lanka over a period of 1 year were
which is created in the small or the large intestine. The considered for this study. All those who were aged
contents are collected by means of collecting appliances above 18 years, who were living with an enteral
which need to be changed regularly. Therefore, the ostomy and willing to participate were recruited.
stoma surgery creates a sense of alteration in body Those who underwent emergency surgery for ostomy
image and a change in awareness in both appearance creation or histor y of psychiatric illnesses were
and the function of an individual.[2,4] excluded from the study. Finally, 41 patients were
enrolled into this study.
Several studies have clearly shown that stoma patients
experience a perception of negative body image.[6‑10] The data were collected during clinic visits while the
Some studies have even shown that despite considerable patients were waiting for consultation. Details on
improvement in the quality of life, the problems related demographic characteristics, details of the disease and
to body image had only a slight improvement. This surgery‑related details were gathered. Demographic
fact indicates that this problem may persist without characteristics studied included, age, sex, marital
gradually fading away with time.[11] However, the status, ethnicity, educational level, body mass index,
factors that contribute to maladaptation to alteration and social and psychological support. The clinical
of body image have not been clearly studied. It records were used to gather data on related details on
is important to identify those factors as it will be ostomy, disease, and the treatment which included the
helpful to identify those who are at a greater risk of type of surgery and complications of ostomy. Validated
developing maladaptation to alteration of body image. instruments were used to measure perception of body
Furthermore, the modifiable contributory factors may image, depression, anxiety, and self‑efficacy.
be corrected to help the patient to cope with body
image problems. Study instruments
The perception of body image was measured using a
The studies done to identify possible contributory modified body image disturbance questionnaire (BIDQ).[5]
factors that may predict maladaptation to alteration This instrument was validated in a nonclinical setting,
of body image are very limited.[7,9,10,12] These studies and it demonstrated good internal consistency and
have compared those with or without stoma or before was free of impression‑management response bias.[13]
and after stoma closure. Furthermore, one study has The standard seven‑item BIDQ was modified so that
compared the alteration of body image among those the term “defect” was substituted with “ostomy.” This
who had temporary and permanent ostomies.[10] modified version of the BIDQ consisted of seven items,
i.e. concerns about appearance, mental preoccupation,
To the authors’ knowledge, there are no published experiences of emotional distress, impairment in social,
studies on perception of the body image among stoma occupational, or other important areas of functioning,
patients in the South Asian setting. Since cultural interference with social life, interference with school
and socioeconomic factors are different in the Asian work, job or ability to function in one’s role, and
communities, it may have a different impact on the avoidance of social activities.
adaptation to alteration of body image compared to
the Western population. Therefore, this study was The Patient Health Questionnaire‑9[14] and Generalized
aimed to describe the adaptation to alteration of body Anxiety Questionnaire‑7 [15] were used to assess
image in ostomy patients in the local setting and also depression and anxiety, respectively.
to identify the contributory factors which may predict
maladaptation to alteration of body image. The level of self‑efficacy on caring for stoma was
measured using the Stoma Care Self‑efficacy Scale,
MATERIALS AND METHODS which consisted of 13 items on self‑efficacy of managing
a stoma. It is designed to assess a general sense of
This is a descriptive cross‑sectional study carried perceived self‑efficacy with the aim to assess the coping
out with the ethical approval obtained from the with day‑to‑day difficulties of managing a stoma. The

64 Indian Journal of Psychological Medicine | January - February 2017 | Vol 39 | Issue 1

 Jayarajah and Samarasekera: Alteration of body image among stoma patients

total score is calculated to 100, whereas <50 = low had significantly higher body image disturbance score.
self‑efficacy and more than 50 = high self‑efficacy.[16] Similarly, those who had symptoms of depression
and anxiety at the time of data collection had higher
The questionnaires were administered as an disturbance of body image, and this factor was
interviewer‑administered questionnaire to minimize statistically significant. Furthermore, there was a
discrepancies. significant negative correlation with perception of
self‑efficacy and body image disturbance [rs = −0.655,
Data analysis P = 0.007, Table 5].
SPSS 20.0 statistical software (SPSS Inc., Chicago,
IL, USA) was used for data analysis. Continuous
variables were expressed using means ± standard
DISCUSSION
deviations (SDs). For inferential analysis, Spearman
It has been shown that stomas tend to have a negative
correlations were used to analyze the relationship
effect on the psychological well‑being of patients.[18,19]
between continuous variables. Independent samples
t‑test (unpaired) was used to analyze the relationship To date, only a few studies have analyzed body image
of continuous variables between two groups. Statistical disturbance among stoma patients. [7,9,10,12] Similar
testing was performed at <0.05 significance level. studies done to assess body image in ostomates have
shown that there was a considerably low perception
of body image, which implies that the adaptation to
RESULTS
the alteration of body image was poor and that the
Demographic factors psychological rehabilitation was suboptimal.[7,10,20]
The median age of the study participants was 45 (range,
18–83) years. The median follow‑up duration was Table 1: Demographic characteristics
37 (range, 6–183) months. The majority of the Number Percentage
participants were males (70.7%), unemployed (61%), sex
and married (65.9%) [Table 1]. Male 29 70.7
Female 12 29.3
Employment status
Characteristics of ostomy
Yes 16 39.0
The majority of patients had a colostomy (73.2%).
No 25 61.0
Around 56.1% had a permanent ostomy [Table 2].
Income
Comfortable income 5 12.2
The mean BIDQ score was 2.22 (SD ± 0.88) (range, 1–5). Enough to meet important needs 22 53.7
Of the participants, 17.07% (n = 7) had mean body Not enough to meet important needs 14 34.1
image disturbance higher than 3. The body image Marital status
disturbance had a significant negative correlation with Unmarried 10 24.4
age (rs = −0.325, P = 0.046). A significant association Married 27 65.9
with higher body image disturbance score was seen in widowed 3 7.3
overweight participants (P < 0.05). The cutoff used to separated 1 2.4
define overweight was 23 kg/m2, which is the WHO Education level
classification for the Asian population.[17] Furthermore, Below grade 11 16 39.0
males and those who cannot meet their daily needs had Grade 11 and above 25 61.0
higher body image disturbance, but this factor was not
statistically significant [P = 0.486, P = 0.534, Table 3]. Table 2: Characteristics of ostomy
Number Percentage
Analysis of ostomy related parameters revealed Ileostomy vs colostomy
that those who had a temporary ostomy and stoma Ileostomy 11 26.8
complications had significantly higher body image Colostomy 30 73.2
disturbance (P < 0.05). Those with ileostomies, Loop vs end
duration <2 years, defunctioning ostomies and those who Loop 25 61.0
did not receive perioperative counseling by a specialized End 16 39.0
stoma therapist had a higher disturbance of body image Surgery type
which was not statistically significant [Table 4]. Defunctioning colostomy 18 43.9
Others 23 56.1
Analysis of psychological parameters revealed that Permanent ostomy
Yes 23 56.1
those who claimed to have depressive thoughts and
No 18 43.9
those who had thoughts of self‑harm soon after surgery

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 Jayarajah and Samarasekera: Alteration of body image among stoma patients

Table 3: Association with demographic parameters Table 5: Association with psychological parameters
N Mean BIDQ score Standard Deviation P value N Mean BIDQ Standard P value
Sex score Deviation
Male 29 2.28 0.95 0.486 Depressive thoughts soon after
Female 12 2.07 0.69 surgery
BMI Yes 18 2.58 1.03 0.017
High 17 2.76 0.96 0.014 No 23 1.93 0.62
Low 24 1.99 0.78 Thoughts of self‑harm soon after
surgery
Income
Yes 5 3.28 1.49 0.003
Cannot meet 14 2.1 0.87 0.534
daily needs No 36 2.07 0.67
Others 27 2.28 0.89 Anxiety symptoms at present
Marital status No 29 1.99 0.73 0.01
Married 27 2.12 1.02 0.313 Yes 12 2.76 0.99
Others 14 2.41 0.49 Depression symptoms at present
Education No 23 1.88 0.57 0.005
Below O/L 33 2.19 0.87 0.73 Yes 18 2.65 1.03
O/L or above 8 2.32 0.94 Perception of self‑efficacy of stoma
care
low 6 3.04 1.2 0.011
Table 4: Association with ostomy related parameters High 35 2.08 0.73
N Mean BIDQ Standard P value
score Deviation
Type
shown that high BMI is associated with impaired body
Ileostomy 11 2.44 1.15 0.343 image even in otherwise healthy individuals.[21] Those
Colostomy 30 2.14 0.76 who were overweight may have additional problems
Permanent related to caring for ostomy and also have problems
Yes 23 1.92 0.76 0.011 related to the style of clothing which could have
No 18 2.6 0.89 indirectly influenced the perception of body image.
Surgery Type
Defunctioning 18 2.39 0.8 0.293 Males had higher disturbance of body image, but the
Others 23 2.09 0.93 association was not statistically significant. The higher
Complications
disturbance may be because, in our setting, males are
Yes 9 2.77 1.16 0.031
the usual breadwinners who need to socialize more
No 32 2.06 0.73
Duration
compared to females who are generally at home. Creation
2 years or less 20 2.36 1.006 0.323 of an ostomy can also have negative effects on their
more than 2 years 21 2.08 0.74 livelihood and also affect their productivity. Our findings
Peri‑operative counseling are comparable to a similar study done by Hong et al.,[10]
by stoma therapist which showed that males have a significantly higher body
Yes 15 2.02 0.76 0.29 image disturbance. In the same study, those who were
No 26 2.33 0.93 married had lesser body image disturbance compared
to those who were single, divorced, or separated.
In our study, the mean body image disturbance score A descriptive cross‑sectional study by Aktas and Gocman
was 2.22 (SD ± 0.88). Of the participants, 7 (17.07%) Baykara[22] showed that involving the partner in stoma
out of 41 patients had a mean body image score of more care had significant positive influence on the body image
than 3. We found several factors that were significantly of ostomates. This may be because emotional and social
associated with body image disturbance. Analysis of support by the partner had a positive impact on the
demographic factors showed a significant negative perception of body image. Similarly, in our study, we
correlation with age (P < 0.05) which implies that noted that the body image disturbance was low in those
younger patients have higher body image disturbance. who were married. However, the association was not
This may be because younger individuals are more statistically significant. Similar to a previous study,[10]
conscious of their appearance as they are more engaged we did not find a statistically significant association
in social and sexual activities compared to older with other demographic parameters such as income or
individuals in our setting. level of education.

Those with high BMI had significantly higher body In our study, of the ostomy‑related parameters,
image disturbance score (P < 0.05). Studies have clearly significantly higher body image disturbance was noted

66 Indian Journal of Psychological Medicine | January - February 2017 | Vol 39 | Issue 1

 Jayarajah and Samarasekera: Alteration of body image among stoma patients

among those with a temporary ostomy and those poor psychological adaptation to body image among
who developed complications of ostomy (P < 0.05). stoma patients.
However, a study that compared the body image
disturbance among temporary and permanent ostomies CONCLUSIONS
noted higher impairment among permanent ostomies
which was not statistically significant.[10] The higher Poor adaptation to alteration of body image may be
disturbance among temporary ostomies in our study predicted by younger age, overweight, and temporary
may be due to several reasons. In our study, the follow‑up stoma. A significant association was noted with
duration for permanent ostomy was higher (although psychological parameters such as depression, anxiety,
not statistically significant), and this may have allowed and also with reduced self‑efficacy. We recommend that
sufficient time for acceptance. Furthermore, most of individuals at risk of poor adaptation should be identified
the permanent ostomies were done for malignancies, before surgery and counseled regarding psychological
and this factor may have influenced the score of adaptation before surgery, after surgery, and during
the body image, as the life‑threatening malignancy follow‑up visits to facilitate psychological rehabilitation.
was removed as opposed to temporary ostomies, They should also be screened for depression and anxiety
which were commonly done for inflammatory bowel and may be referred to psychological interventions as
disease and trauma in our participants. Furthermore, needed. Furthermore, importance should be given to
those with temporary ostomies were younger which establish good psychological well‑being to achieve a
may have caused a bias in our results. Those who higher quality of life, in this group of patients.
had perioperative counseling by a specialized stoma
therapist had lower body image disturbance, but it Financial support and sponsorship
was not statistically significant. This may imply that Nil.
counseling on psychological aspects such as body image
needs further attention and should be made routine. Conflicts of interest
There are no conflicts of interest.
In this study, those with depressive symptoms and
thoughts of self‑harm soon after surger y had a
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