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Effective of education on quality of life and constipation severity in patients with primary constipation
Accepted Manuscript Title: Effective of education on quality of life and constipation severity in patients with primary constipationYour article is registered as a regular item and is being processed for inclusion in a regular issue of the journal. If this is NOT correct and your article belongs to a Special Issue/Collection please contact [email protected] immediately prior to returning your corrections.–> Authors: Mehmet Hayrullah Ozturk, Serap Parlar Kılıc PII: DOI: Reference:
S0738-3991(18)30715-8 https://doi.org/10.1016/j.pec.2018.09.011 PEC 6070
To appear in:
Patient Education and Counseling
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Title: Effective of Education on Quality of Life and Constipation Severity in Patients with Primary Constipation
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Short running title: Effective of Education In Primary Constipation
Mehmet Hayrullah Ozturk, Mardin
State
Hospital,
Department
of
Internal
Medicine
([email protected])
Mardin,
Turkey.
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orcid.org/0000-0003-1809-5039
Clinic,
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Serap Parlar Kılıc,
Turkey. ([email protected])
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orcid.org/0000-0003-3721-5083
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Fırat University Faculty of Health Sciences, Department of Internal Medicine Nursing, Elazığ,
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Address for correspondence: Serap KILIC,
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Fırat University Faculty of Health Sciences, Department of Internal Medicine Nursing, Elazığ Merkez, Elazığ, TURKEY. Postal code: 23119
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Telephone number: +90 424 2379139 Fax number: +90 424 2128891 E-mail: [email protected]
Effective of Education on Quality of Life and Constipation Severity in Patients with
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Primary Constipation
Hightlights
Constipation is one of the most frequent complaint related to the digestive system observed in general population.
Primary constipation affect the quality of life and health status of those who suffer from
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Primary constipation is a problem that can be remedied by independent nursing
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them.
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interventions.
Patient education in patients with constipation can contribute to reducing constipation
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ABSTRACT
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severity and enhance their quality of life.
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Objective: This study was conducted to examine the effect of education on quality of life and constipation severity in patients with primary constipation.
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Methods: This randomised controlled study was conducted with 80 patients who applied at the gastroenterology outpatient clinic of a university hospital. In the study, the Constipation Questionnaire, Constipation Quality-of-Life Questionnaire (PAC-QOL), and Constipation Severity Instrument (CSI) were used.
Results: It was that found after 4 weeks of education, the total PAC-QOL mean score decreased to 60.85±5.65 and total CSI mean score decreased to 20.17±4.05 in the intervention group (p<0.001). No change was observed in the patients in the control group (p>0.05). After 4 weeks, a statistical
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difference was found between the two groups in PAC-QOL mean score and CSI mean score (p<0.05).
Conclusion: It was determined that the education given to individuals with primary constipation decreased the constipation severity and increased the quality of life.
Practice Implications: Constipation education will make a contribution to the active use of follow-
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patient, and their active role in constipation management.
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up forms by nurses in the clinic for the diagnosis of constipation, individual assessment of each
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1. Introduction
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Key words: Constipation Severity, Education, Primary Constipation, Quality of Life
Constipation is an important health problem because it is frequently seen in the community
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and it impairs quality of life [1]. Constipation has no exact definition. Clinically, constipation is defined according to the Rome II and III criteria as a complex of at least two symptoms, including
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infrequent bowel movements (typically 25% of bowel movements), a subjective sensation of hard stools, and incomplete bowel evacuation [2]. When there is no underlying reason, the diagnosis of primary or idiopathic constipation is established. Pathophysiologically, primary constipation is divided into three main groups as normal transit constipation, slow transit constipation, and dyssynergic defecation disorders [3].
In the general populations of Europe and Oceania, the mean constipation rates were reported as 17.1% and 15.3%, respectively [4]. While the prevalence of constipation in North America varies between 15% and 20%, this rate can increase up to 50% among the elderly [5]. In
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a study conducted in Turkey, the overall rate of constipation was reported as 8.9%; among people aged more than 55 years, 12.5%; and, 16.3% among individuals aged 75 years and over [6]. In a study conducted by Uz et al. [7] among 1000 patients in Turkey, constipation was observed in 20% of the cases, and 75% of these cases were female and 60% were 50 years old and above.
Constipation is characterised by a diversity of symptoms, including bloating, straining,
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abdominal pain, lumpy or hard stools, sensation of incomplete evacuation, and infrequent
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defecation (fewer than three bowel movements per week) [8]. And, although constipation is not
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life-threatening, it is regarded as an important health problem because of its high rates and adverse
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effects on quality of life due to the social, economic, hygienic, and emotional pressures it brings on individuals [4,9]. In the study of Belsey et al. [10], they showed that individuals with
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constipation had lower health-related quality of life. In another study, it was observed that the
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economic burden brought by constipation on individuals negatively affected the health-related
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quality of life [9]. It is stated that since constipation causes labour loss and social and economic burden and increases healthcare costs, it is accepted as a significant problem for individuals and
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society [11]. The cost of treatment for constipation is also remarkable. Approximately 85% of the individuals with constipation require medical treatment, and they are using laxatives for this reason;
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thus, every year approximately 82 million dollars are spent for laxatives in the United States [12]. Although constipation is a common symptom, its care and treatment are still not at the
desired level. The purpose of care and treatment of constipation is to prevent constipation formation, and when constipation occurs, to provide comfort to the patients by increasing functionality and decreasing existing symptoms and constipation severity [13]. Because the
practices of constipation management will vary among individuals, the treatment of constipation should be individualised [14]. The education given concerning constipation includes making lifestyle changes (i.e., healthy nutrition, regular physical activity, good toilet habits, abdominal
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massage, daily fluid intake, and regular health control), relieving risk factors, and providing laxative treatment [15]. Determining descriptive characteristics and risk factors of constipation by preparing education plans is important to decrease the constipation severity and enhance the quality of life for patients [16]. Consequently, constipation may become a major health problem, as it has negative effects on health, such as impairment in quality of life, burnout, labour loss, and increased
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healthcare costs. The diagnosis of constipation and determining its severity level play a key role in
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the solution of the problem. However, as a result of a literature review, any similar study evaluating
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the effects of providing health education to patients with constipation to improve their quality of
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life and symptom severity has not been found. Thus, we aimed to reduce the symptoms and
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management education.
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constipation severity of patients and thus enhance their quality of life through constipation
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2. Methods
2.1. Study sample and design
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The study was designed and conducted as a randomised controlled trial in pretest-posttest pattern to examine the effects on quality of life and constipation severity as a result of education
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given to patients diagnosed with primary constipation. The study was conducted with 80 patients, including 40 patients in the experimental group and 40 individuals in the control group. The patients applied to the gastroenterology outpatient clinic of a state hospital and were diagnosed with primary constipation. As a result of power analysis, the minimum sample size required to find the increase of 15 units significant in the Constipation Quality of Life Questionnaire (PAC-QOL)
in the education group compared with the non-education group was found to be 32 for each group (α = 0.05, 1-β = 0.80). The adult patients who presented to our clinic with constipation due to organic diseases,
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drugs, and metabolic disorders were excluded from the study. All patients underwent examination by a specialist physician working in the gastroenterology outpatient clinic through examinations such as detailed medical history, physical examination, abdominal examination, and biochemistry. All of the patients diagnosed with primary constipation were referred by these specialist physicians to the researcher. The inclusion criteria for the patients were as follows:
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1. with a diagnosis of primary constipation
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2. Complaints of primary constipation starting at least 6 months ago and continuing
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intermittently or constantly in last 3 months according to Rome III diagnostic criteria [4,17]
4. No communication problems
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3. Age 18 years and older
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5. No mental confusion or other psychiatric problem
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6. Voluntarily agreed to participate in the study
2.2. Instruments
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2.2.1. Constipation Questionnaire (CQ) The CQ is a questionnaire with a total of 40 questions that obtain information about the
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socio-demographic characteristics of the individuals diagnosed with constipation, risk factors for constipation, onset time of constipation, defecation frequency, lifestyle of the individual (e.g. nutrition, fluid intake), and general health condition (e.g. drugs used, previous surgeries, other diseases) [6]. 2.2.2. Constipation Quality of Life Questionnaire (PAC-QOL)
The PAC-QOL was developed by Marquis et al. [18], and its validity and reliability study was conducted by Dedeli et al. [6] in Turkey. The questionnaire’s Cronbach alpha reliability coefficient was 0.91, and the test-retest reliability of the scale was r = 0.96, p<0.01. The
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questionnaire is a self-assessment scale with a total of 28 items including ‘worry/concern’ (11 items), ‘physical discomfort’ (four items), ‘psychosocial discomfort’ (8 items), and ‘satisfaction’ (five items) subscales. The questionnaire uses a 5-point Likert-type scale ranging from 1 to 5. The first and fifth parts of the questionnaire are answered by the patients as ‘not at all (1)’, ‘a little bit (2)’, ‘moderately (3)’, ‘quite a bit (4)’, and ‘extremely (5)’; conversely, in the second, third, fourth,
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and sixth parts, patients are asked to select the most suitable one among the options of ‘non of the
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time (1)’, ‘a little of the time (2)’, ‘some of the time (3)’, ‘most of the time (4)’, and ‘all of the time
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(5)’. The highest score that can be obtained on the questionnaire is 140, and the lowest score is 28.
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Higher scores signify impairment in quality of life. There should be no unanswered question in the questionnaire in order for accurate scoring [6,18,19]. In this study, the Cronbach alpha coefficient
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of the PAC-QOL was found to be 0.78.
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2.2.3. Constipation Severity Instrument (CSI) The Turkish validity and reliability study, the Constipation Severity Instrument (CSI),
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developed by Varma et al. [20], was conducted by Kaya and Turan [21]. It is a scale determining defecation frequency, intensity, and difficulty. It also aims to measure constipation symptoms.
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There are 16 questions in the instrument, with subscales, as follows: obstructive defecation, colonic inertia, and pain. The score to be obtained from the subscale ‘obstructive defecation’ is between 0 and 28; the score to be obtained from the subscale ‘colonic inertia’ is between 0 and 29; and the score to be obtained from the subscale ‘pain’ is between 0 and 16. While the lowest total score to be obtained from the CSI is 0, the highest total score is 73. High scores signify severe symptoms
[20,21]. Kaya and Turan [21] determined that the Cronbach alpha value of the instrument was between 0.92 and 0.93. In this study, the Cronbach alpha coefficient of the CSI was found to be
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0.89.
2.3. Randomisation
Patients were informed about the study, and they provided their informed consent prior to randomisation. After inclusion in the study, the patients were randomly allocated either to the intervention group or the control group. Randomisation was conducted by a statistics specialist
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who had no contact with the participants. The statistics specialist randomised participants to the
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intervention or the control group using a computerised random number generator (SPSS version
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20 software). All individuals involved in the study were blinded to the randomisation procedure.
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However, the researchers were not blinded to the constipation education they were to deliver, due to the nature of the intervention. Participants assigned to the control group continued to receive
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routine treatment, unaware they were in a constipation education programme. Participants in the
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intervention group were invited to be part of a constipation education programme. The present
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study lasted for approximately 6 months. There were no patients who left the study before completion. The education was given by the same researcher, and the training programme was
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delivered in a training room at a gastroenterology polyclinic at a state hospital. Thus, interaction
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of the patients between the two groups was prevented (Figure 1).
2.4. Data collection The data collection tools used to collect the study data were administered in two stages.
First stage: Before starting the study, written and verbal consents of all the patients were obtained regarding the administration of the questionnaire. CQ, PAC-QOL, and CSI were
applied to the patients in both groups. The data collection forms were applied using a faceto-face interview technique, and answers given by the patients were recorded near them. It took approximately 15 minutes to collect the data. After the first data were collected, the
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control group continued to receive its routine treatment, and education was not given to this group. After the questionnaires were completed, an education programme on constipation was given to the patients in the intervention group by the researcher. After the education, a ‘Constipation Education Booklet’ was given to every patient in the intervention group.
Second stage: Without giving education to the patients in the control group, the CQ, PAC-
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QOL, and CSI were repeated 4 weeks after the first assessment. After the first assessment,
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the constipation education was given to the patients in the intervention group, and the CQ,
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PAC-QOL, and CSI were repeated 4 weeks later.
2.5. Constipation education programme
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The education programme was given by the first author, who is a Clinical Nurse Specialist
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at another hospital in Turkey; he is assisted with the data collection and data analysis. The second
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author, a nurse instructor (associated professor), assisted with data analysis. Before the education was given, the explanation about ‘education’ was made to all patients, and permission for the study
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was requested. The study was conducted on a voluntary basis. It took approximately 45 to 60 minutes to carry out the education. The education programme given concerning constipation was
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conducted in a room located at the gastroenterology outpatient clinic of a state hospital. The education, which was taught interactively and individually to each patients, lasted for an average of 1 hour and was taught with the help of visual representation. A ‘Constipation Education Booklet’ on constipation management was prepared to be used during the education and to strengthen the education. The content of the education booklet prepared for patients with primary constipation
was developed under the guidance of the consultant academic members using information collected by the researcher [3,13,22-24] and arranged with the help of the experts. The education booklet consisted of two sections. The first section contained the definition of constipation, its reasons,
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drugs causing constipation, risk factors, some recommendations for the prevention of constipation (e.g. regular defecation, no delayed defecation, best position for defecation, avoiding straining for a long time), constipation treatment, and the importance of individual management in constipation. The second section contained information about healthy and balanced diet and nutrition types, sufficient fluid intake, benefit of exercise and selection of suitable exercise, abdominal massage,
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and toilet training including individual methods for preventing constipation. Appropriate
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behaviours displayed by the patients for eliminating constipation during the education were
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supported, and the individuals were interviewed about inappropriate behaviours to find solutions.
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Moreover, patients were prompted by the researcher on the information they wanted to learn about constipation, and their questions were answered.
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After the study was completed, the constipation education was interactively given to the
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patients in the control group by the researcher with the help of a PowerPoint presentation. During
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the education, information the patients wanted to learn about constipation and their questions were
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answered by the researcher; a ‘Constipation Education Booklet’ was given to each patient.
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2.6. Data analysis The statistical evaluation of the data obtained as a result of the study was performed using
the SPSS package programme, and p<0.05 was accepted as statistically significant. The Chi-square test, independent samples t test, paired samples t test, and the Pearson correlations analysis were used in the statistical evaluation of the data obtained as a result of the study.
2.7. Ethical consideration Before starting the study, written permission from the Gaziantep University Faculty of Medicine Scientific Ethics Committee (20.01.2014/47) and from the Turkish Public Hospitals
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Authority Gaziantep Office of General Secretary were given to conduct the study. Before the data were collected, the patients were informed about the purpose of the study, the administration method, and how the results would be obtained; each participant’s consent was obtained after
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required explanations were done and their questions were answered.
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3. Results
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3.1. Sample characteristics
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It was determined that most of the patients included in the study were female (intervention group = 77.5%, control group = 72.5%), married (intervention = 87.5%, control group = 92.5%),
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and their average age was 45.27±16.25 years in the intervention group and 48.25±12.58 years in
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the control group. In both groups, the constipation period of 65% (26 patients) of the patients was
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1 to 3 years. No statistically significant difference was found between the intervention and control groups in terms of the sample characteristics of the patients (p>0.05) (Table 1).
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3.2. Difference of the some results regarding the constipation questionnaire between intervention
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and control group Table 2 shows the comparison of the results related to the constipation questionnaire of the
intervention and control groups at baseline and after 4 weeks. After 4 weeks, both the defecation frequency increased and the straining period reduced in the patients in the intervention group. It was found that after 4 weeks, the frequencies of abdominal distension, dyspepsia, and flatulence problems of the patients in the intervention group decreased, and no patient saw blood in their stool
(p<0.05). No change was observed in the patients in the control group (p>0.05). After 4 weeks, a statistical difference was found between both groups in terms of frequency of defecation and the health problems related to defecation (p<0.05).
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3.3. Comparison of the PAC-QOL and CSI mean scores of both groups Although there was no statistically significant difference between the intervention and control groups (p>0.05) at baseline in terms of PAC-QOL total and subscale scores, a statistical difference was found between the groups after 4 weeks (p<0.05). And, although there was no statistically significant difference between the intervention and control groups (p>0.05) at baseline
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in terms of CSI total and subscale scores, a statistical difference was found between the groups
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after 4 weeks (p<0.05) (Table 3).
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3.4. Relationship between scores of the PAC-QOL and CSI
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When we examined the association of PAC-QOL total mean scores with CSI total mean
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scores, we found a significant and positive correlation (r = 0.629, p<0.001) (Table 4).
4. Discussion and conclusion
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4.1. Discussion
Constipation is not a disease but an important health problem for the individual and the
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community that is interpreted differently from person to person [25]. It is physically and mentally troublesome for many patients, can impair quality of life, causes labour loss, increases the healthcare costs, and is frequently associated with other medical problems [11]. In the literature, there are studies indicating that constipation negatively affects the quality of life of the individuals [2,10]. However, as a result of a literature review, it has been observed that there is no similar study
examining the effect of education on quality of life and constipation severity among patients with primary constipation in Turkey. In the present study, cognitive symptom management and related interventions enabling a decrease in constipation and its severity were learned. The primary aim of
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this study was to show that education generally provided useful results for patients with constipation and had positive effects, especially on the constipation severity and the quality of life. In the patients with constipation, the symptoms such as forceful defecation, feeling of incomplete evacuation, abdominal disorder, abdominal strain [23], painful defecation [26], rectal pain, and urgent defecation are frequently observed [2]. In the study of Uysal et al. [27], they
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observed that 68% of the students with gastrointestinal complains had abdominal distension, 63.4%
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had distension after meals, 48.2% had acid reflux, 43.0% had belching, and 19.0% had burning/pain
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in the epigastric area. In the present study, it was also determined that the patients had abdominal
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distension, dyspepsia, and flatulence problems.
Education for patients is an important component of treatment for primary constipation.
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Exercising, increasing the intake of liquid and high-fibre foods, and abdominal massage are
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included in the constipation therapy along with constipation education, leading to positive results
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[28,29]. In the present study, the patients in the intervention group obtained significantly positive results regarding health problems related to defecation after the education. This situation showed
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the positive effect of the education on the symptoms experienced due to constipation. In similar studies, it was shown that education reduced the health problems experienced due to constipation
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[17,30,31]. Akbayrak et al. [30] showed that massage applied in addition to the dietary recommendations and education was also effective in reducing the symptoms such as flatulence, distension, and pain in the form of cramps and in increasing the defecation frequency among the individuals with irritable bowel syndrome. One randomised controlled trial showed that fibre supplementation improved constipation better than placebo, especially in children with encopresis
[32]. Kaçmaz and Kaşıkcı [33] showed the results of their study that planned nursing interventions including bran supplements are more effective than routine nursing interventions for management of constipation problems in older orthopaedic patients. In a study, it was reported that the symptoms
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of the geriatric patients were alleviated by suitable diet and an exercise programme, and the use of laxatives was reduced [17]. In their study, Ayaz and Hisar [31] evaluated the efficacy of education and consultancy services in the elimination of constipation, and determined that 37.1% of the cases defined their constipation-related complaints (feeling of incomplete evacuation, feeling of anal discomfort and pain) as severe before the education and consultancy and stated a reduction in
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severity of their such complaints after the education and consultancy. Shen et al. [34] evaluated the
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effects of self-managed educational intervention on the symptoms of patients with functional
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constipation. It was found that the constipation score of all clinical symptoms (Bristol stool form
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scale, defecation interval, incomplete evacuation, evacuation difficulty) after 1 month were all significantly lower in the intervention group than in the control group.
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It is reported that constipation negatively affects the physical and emotional well-being,
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business and school life, life style, performance, and general quality of life of the individual [2,6].
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In the present study, it was determined that both constipation severity and quality of life of the patients were affected moderately. Previous studies showed that the quality of life of the patients
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with the complaint of functional constipation was significantly lower compared with healthy individuals [35,36]. In a study conducted with chronically constipated patients, it was determined
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that constipation severity of the patients was affected moderately, and the CSI was 40.24±8.76 in the experimental group and 39.96±9.03 in the control group [37]. In their study, Neri et al. [38] reported that the average constipation severity of patients with chronic constipation in the sample group was ‘moderate’ and that the average Patient Assessment of Constipation-Symptoms (PACSYM) score of the patients was 1.62±0.69.
In the present study, there was no difference between the PAC-QOL and CSI total mean scores of the patients in both groups at baseline; whereas, after 4 weeks, no change occurred in the control group, but there was a significant decrease in the intervention group. These findings showed
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that the education provided an increase in the quality of life and a decrease in the constipation severity among the patients. Ginsberg et al. [39] reported that primary constipation is amenable to dietary adjustments, education, and behavioural training, and laxatives when necessary. In the study conducted by Nour-Eldein et al. [22] among the individuals with constipation, it was shown that the education given regarding lifestyle changes (dietary pattern, fluid intake, regular physical
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activity, and the use of laxatives) had a positive effect both on constipation severity and the quality
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of life of the individuals. The study by Ostaszkiewicz et al. [40] included 27 community-dwelling
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adults aged 35 to 83 years who presented with lower urinary tract symptoms and constipation and
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received individualised conservative treatment (advice on dietary supplementation, fluid intake, exercise, position to defecate, the gastrocolic reflex, and over-the-counter laxatives) for
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constipation. They indicated that the intervention significantly reduced the severity of overall
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constipation symptoms measured by the PAC-SYM [40]. In the study of Sette et al. [41], they
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observed a positive change in QOL scores of patients with chronic functional constipation after the completion of the educational intervention, whereas the scores worsened in all dimensions in the
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control group. Ayaz and Hisar [31] reported that participants received an individual education programme that included advice on dietary consumption such as pulpy‐fibrous nutrient
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consumption, fluid intake, an exercise regime, and counselling about the optimal position for defecation. As a result, the CSI total mean scores decreased significantly after the education programme [31]. It could be asserted that when patients have knowledge about their condition and learn related management strategies, they have relief of constipation symptoms and an improved quality
of life. It is also important to increase sensitivity to health for health promotion and to ensure the continuity of the education for gaining positive health behaviours.
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4.2. Conclusion In the study, it was observed that the education provided positive results in the intervention group, improving the problems experienced by the patients due to constipation, and resulted in a decrease in constipation severity and an enhanced quality of life. According to these results, departments should provide education to patients with constipation. Additional studies including
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larger populations are warranted to show the benefits of education given to patient groups.
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4.3. Practice implications
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The educational intervention provides a therapeutic alternative to patients living with defecation disorders. Nurses, who are involved within the medical team, have a potentially
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significant part to play in both the prevention and management of constipation by providing
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lifestyle advice to the patients with constipation and information on high fibre intake, sufficient
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fluid intake, and regular exercise. An education provided by nurses or other health staff members offered to individuals diagnosed with constipation will providing the individuals with tools to
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reduce their constipation severity and increase their quality of life.
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Contributions of authors MHÖ and SPK designed and conducted the study, SPK analysed the data, MHÖ and SPK
drafted the manuscript. MHÖ collected the data, MHÖ and SPK critically revised the manuscript. All authors have approved the final version of the manuscript.
Conflicts of interest All authors certify that there is no conflict of interest with any personel, other relationships
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with other people and financial organisation.
Funding None
Acknowledgements
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The authors thank the participants in this study.
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12. R. De Giorgio, E. Ruggeri, V. Stanghellini, L.H. Eusebi, F. Bazzoli, G. Chiarioni, Chronic constipation in the elderly: A primer for the gastroenterologist, Brit. Med. J. Gastroenterol. 15 (2015) 130, doi: 10.1186/s12876-015-0366-3.
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13. G. Kyle, A proactive approach to the treatment of constipation, Continence 2 (2008) 36-44.
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14. N. Turan, N.T. Aşti, Konstipasyon yönetiminde abdominal masajın önemi [The importance
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18. P. Marquis, C. Loge De La, D. Dubois, A. McDermott, O. Chassany, Development and validation of the patient assessment of constipation quality of life, Scand. J. Gastroenterol. 40 (2005) 540-51, doi: 10.1080/00365520510012208.
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19. N. Turan, N. Kaya, H. Kaya, A. Öztürk, Z. Eskimez, N. Yalçın, Hemşirelik öğrencilerinin bazı değişkenler açısından konstipasyon sorunları [Constipation problems of nursing students with respect to certain variables], İstanbul Üniversitesi Florence Nightingale Hemşirelik Yüksekokulu Dergisi [Florence Nightingale Journal of Nursing] 19 (2011) 16878.
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20. M.G. Varma, J.Y. Wang, J.R. Berian, T.R. Patterson, G.L. McCrea, S.L. Hart, The
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21. N. Kaya, N. Turan, Konstipasyon Ciddiyet Ölçeğinin güvenilirlik ve geçerliliği [Reliability and validity of Constipation Severity Scale], Turkiye Klinikleri J. Med. Sci. 31 (2011)
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1491-501, doi: 10.5336/medsci.2010-22198.
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22. H. Nour-Eldein, H.M. Salama, A.A. Abdulmajeed, K.S. Heissam, The effect of lifestyle
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modification on severity of constipation and quality of life of elders in nursing homes at Ismailia city, Egypt, J. Family Community Med. 21 (2014) 100-6, doi: 10.4103/2230-
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8229.134766.
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23. S. Bleser, S. Brunton, B. Carmichael, K. Olden, R. Rasch, J. Steege, Management of chronic constipation: recommendations from a consensus panel, J. Fam. Pract. 54 (2005) 691-8.
24. G. Bengi, M. Yalçın, H. Akpınar, Kronik Konstipasyona Güncel Yaklaşım [Current approaches to chronic constipation], Güncel Gastroenteroloji [Actual Gastroenterology] 18 (2014) 72-88.
25. J. Mclean Vickers, Bowel management and day surgery: A look at constipation, Day. Surg. Aust. 13 (2014) 22-4. 26. J. Tack, S. Müller-Lissner, V. Stanghellini, G. Boeckxstaens, M.A. Kamm, M. Simren, et
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al., Diagnosis and treatment of chronic constipation-a European perspective, Neurogastroenterol. Motil. 23 (2011) 697-710, doi: 10.1111/j.1365-2982.2011.01709.x.
27. N. Uysal, L. Khorshid, İ. Eşer, Sağlıklı genç bireylerde konstipasyon sorununun belirlenmesi [The identification of constipation problem in healthy young individuals], TAF Preventive Medicine Bulletin 9 (2010) 127-32.
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29. K. Krogh, G. Chiarioni, W. Whitehead, Management of chronic constipation in adults,
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United European Gastroenterol J. 5 (2017) 465-72. doi: 10.1177/2050640616663439. 30. T. Akbayrak, İ. Karakaya, G. Ekici, S. Kaya, Huzursuz barsak tedavisinde farklı bir
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yaklaşım-olgu sunumu [Different an approach on the treatment irritable bowel-case report],
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32. V. Loening-Baucke, E. Miele, A. Staiano, Fiber (glucomannan) is beneficial in the treatment of childhood constipation, Pediatrics, 113 (2004) 259-64.
33. Z. Kaçmaz, M. Kaşıkcı, Effectivenss of bran supplement in older orthopaedic patients with constipation, J. Clin. Nurs. 16 (2007) 928-36. doi: 10.1111/j.1365-2702.2006.01766.x.
34. Q. Shen, H. Zhu, G. Jiang, X. Liu, Nurse-Led Self-Management Educational Intervention Improves Symptoms of Patients With Functional Constipation, West. J. Nurs. Res. 40 (2018) 874-88. doi: 10.1177/0193945917701128.
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35. F.K. Friedenberg, A. Dadabhai, A. Palit, A. Sankineni, The impact of functional constipation on quality of life of middle-aged Black Americans: a prospective case-control study, Qual. Life Res. 21 (2012) 1713-7, doi: 10.1007/s11136-011-0089-z.
36. M. Mokhtare, S.M.S. Ghafoori, M.S. Khermanshahi, A.S. Boghratian, S. Agah, M. Sheikhvatan, Reliability and validity of the Persian version of patient assessment of
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constipation- quality of life (PAC-QOL) questionnaire, Gastroenterol. Hepatol. Bed.
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Bench. 10 (2017) 289-94, doi: 10.22037/ghfbb.v0i0.1190.
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37. C. Gürsen, M.K. Günel, S. Kaya, T. Kav, T. Akbayrak, Effect of connective tissue
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manipulation on symptoms and quality of life in patients with chronic constipation: A randomized controlled trial, J. Manipulative. Physiol. Ther. 38 (2015) 335-43,
doi:
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10.1016/j.jmpt.2015.06.003.
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38. L. Neri, G. Basilisco, E. Corazziari, V. Stanghellini, G. Bassotti, M. Bellini, et al.,
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Constipation severity is associated with productivity losses and healthcare utilization in patients with chronic constipation, United European Gastroenterol. J. 2 (2014) 138-47.
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39. D.A. Ginsberg, S.E. Phillips, J. Wallace, K.L. Josephson, Evaluating and managing constipation in the elderly, Urol. Nurs. 27 (2007) 191-200.
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40. J. Ostaszkiewicz, L. Hornby, L. Millar, C. Ockerby, The effects of conservative treatment for constipation on symptom severity and quality of life in community-dwelling adults, J. Wound Ostomy Continence Nurs. 37 (2010) 193-8, 10.1097/WON.0b013e3181cf7206.
doi:
41. G.C.S. Sette, A.M.T.S. Cavalcanti, M.W.L. Coriolano, G.A.P. Silva, M.E.F.A. Motta, L.S. Lima, Do Educational Interventions with Mothers Enhance the Quality of Life of their Children with Chronic Functional Constipation in a Randomized Trial? Comm. Pub. Health
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Nurs. 3 (2017) 1-6, doi: 10.4172/2471-9846.1000164.
Assessed for eligibility (n=86)
Excluded (n=4) - Not meeting inclusion crtiteria (n=3) - Declined to participate (n=1)
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Randomized (n=82)
Allocated to experimental group (n=42)
Allocated to control group (n=40) None excluded
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CQ, PAC-QOL and CSI was applied as posttest
Figure 1. Participant flowchart of the study
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One-to-one interview: Constipation Questionnaire (CQ), Constipation Quality of Life Questionnaire (PAC-QOL), and Constipation Severity Instrument (CSI) was applied as pretest. - None intervention.
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A
N
Baseline
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One-to-one interview: Constipation Questionnaire (CQ), Constipation Quality of Life Questionnaire (PAC-QOL), and Constipation Severity Instrument (CSI). - Constipation education booklet (constipation, some recommendations for the prevention of constipation) was presented.
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Declined to participate (n=2)
4 weeks
CQ, PAC-QOL and CSI was applied as posttest
Table 1 Constipation Questionnaire at before the education between intervention and control groups Control group (n=40) n (%)
9 (22.5) 31 (77.5) 45.27 ± 16.25
11 (27.5) 29 (72.5) 48.25 ± 12.58
0.606
37 (92.5) 3 (7.5)
0.456
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A
N
2 (5.0) 26 (65.0) 6 (15.0) 6 (15.0)
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EP
CC
A
p
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13 (32.5) 23 (57.5) 3 (7.5) 1 (2.5)
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35 (87.5) 5 (12.5)
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Gender Male Female Age (X ± SD) Marital status Married Single Educational status Literate Primary education High School University Period of constipation complaint 6 months – 1 year 1 year – 3 years 3 years – 5 years 5 years and above State of constipation to affect social life No effect Rarely affects Frequently affects Very frequently affects State of constipation to affect occupation No effect Rarely affects Frequently affects Very frequently affects State of constipation to affect sexual life No effect Rarely affects State of constipation to affect sleeping pattern Pain increases while sleeping Pain decreases while sleeping Pain does not change while sleeping
Intervention group (n=40) n (%)
12 (30.0) 23 (57.5) 5 (12.5) 6 (15.0) 26 (65.0) 3 (7.5) 5 (12.5)
10 (25.0) 17 (42.5) 9 (22.5) 4 (10.0)
10 (25.0) 21 (52.5) 8 (20.0) 1 (2.5)
13 (32.5) 17 (42.5) 8 (20.0) 2 (5.0)
19 (47.5) 17 (42.5) 4 (10.0) -
39 (97.5) 1 (2.5)
40 (100.0) -
8 (20.0) 2 (5.0) 30 (75.0)
8 (20.0) 3 (7.5) 29 (72.5)
0.363
0.673
0.228
0.516
0.216
0.314
0.897
Table 2 Difference of some results regarding the constipation questionnaire between intervention and control groups at the baseline and after 4 weeks
Dyspepsia
CC
EP
Never Sometimes Frequently Very frequently Always
2 (5.0) 13 (32.5) 21 (52.5) 3 (7.5) 1 (2.5)
2 (5.0) 23 (57.5) 12 (30.0) 2 (5.0) 1 (2.5)
1 (2.5) 1 (2.5) 4 (10.0) 25 (62.5) 9 (22.5)
3 (7.5) 4 (10.0) 27 (67.5) 6 (15.0)
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M
D
28 (70.0) 10 (25.0) 2 (5.0)
32 (80.0) 8 (20.0) -
5 (12.5) 2 (5.0) 13 (32.5) 16 (40.0) 4 (10.0)
6 (15.0) 10 (25.0) 23 (57.5) 1 (2.5)
2 (5.0) 12 (30.0) 21 (52.5) 5 (12.5)
3 (7.5) 8 (20.0) 25 (62.5) 4 (10.0)
p*
26 (65.0) 14 (35.0) -
29 (72.5) 11 (27.5)
36 (90.0) 4 (10.0) -
1 (2.5) 22 (55.0) 15 (37.5) 2 (5.0) -
0.001
0.613
4 (10.0) 33 (82.5) 3 (7.5) -
1 (2.5) 5 (12.5) 31 (77.5) 3 (7.5)
0.001
0.288
40 (100.0) -
32 (80.0) 8 (20.0) -
0.003
0.034
19 (47.5) 21 (52.5) -
1 (2.5) 3 (7.5) 15 (37.5) 20 (50.0) 1 (2.5)
0.001
0.692
6 (15.0) 12 (30.0) 20 (50.0) 2 (5.0) -
1 (2.5) 7 (17.5) 25 (62.5) 7 (17.5)
0.001
0.881
0.246
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1 (2.5) 27 (67.5) 12 (30.0)
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1 (2.5) 29 (72.5) 10 (25.0)
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Defecation frequency Every day A few times per week Once a week Straining period Less than one minute 1-5 minutes 6-10 minutes 11-20 minutes More than 20 minutes Abdominal distension Never Sometimes Frequently Very frequently Always Blood in the stool Never Sometimes Frequently
p*
After 4 weeks Intervention Control group group n (%) n (%)
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Baseline Intervention Control group group n (%) n (%)
0.001
Flatulence
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Never Sometimes Frequently Very frequently Always
*Chi-square test.
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Table 3
Comparison of PAC-QOL and CSI mean scores of both groups the baseline and after 4 weeks
15.42 ± 1.59 15.57 ± 4.56 37.85 ± 3.97 14.82 ± 1.55 83.67 ± 7.27
ED
M
15.62 ± 1.49 17.07 ± 5.00 38.07 ± 3.85 14.57 ± 1.93 85.35 ± 7.03
19.85 ± 2.76 17.82 ± 2.34 5.75 ± 2.40 43.42 ± 5.46
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PAC-QOL subscales Physical discomfort Psychosocial discomfort Worry /concern Satisfaction PAC-QOL Total score CSI subscales Obstructive defecation Colonic inertia Pain CSI Total score
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Mean scores baseline Intervention Control group group X±SD X±SD
19.45 ± 3.19 17.75 ± 2.50 5.40 ± 1.94 42.60 ± 6.66
Mean scores after 4 weeks Intervention Control group group X±SD X±SD
t
p*
0.577 1.399 0.257 -0.638 1.046
0.565 0.166 0.798 0.525 0.299
9.70 ± 1.71 8.75 ± 1.37 24.35 ± 3.68 18.05 ± 1.21 60.85 ± 5.65
0.598 0.138 0.716 0.605
0.551 0.890 0.476 0.547
10.17 ± 2.06 7.97 ± 1.84 2.02 ± 0.91 20.17 ± 4.05
t
p*
15.80 ± 1.22 13.55 ± 3.54 39.52 ± 2.38 13.62 ± 1.67 82.50 ± 4.94
-18.328 -7.987 -21.870 13.513 -18.243
0.001 0.001 0.001 0.001 0.001
20.37 ± 2.02 18.50 ± 1.73 5.65 ± 1.59 44.52 ± 4.05
-22.342 -26.240 -12.458 -26.842
0.001 0.001 0.001 0.001
A
CC E
PAC-QOL, Constipation Quality of Life Questionnaire; CSI, Constipation Severity Instrument; *Independent samples t-test.
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Table 4 Correlation between PAC-QOL total mean scores and CSI total mean scores of the patients. Total CSI score Pearson Correlation (r) 0.629
A
CC E
PT
ED
M
A
N
U
SC RI
PT
PAC-QOL Total score
p 0.001
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S0738-3991(18)30715-8 https://doi.org/10.1016/j.pec.2018.09.011 PEC 6070
To appear in:
Patient Education and Counseling
Received date: Revised date: Accepted date:
19-4-2018 17-8-2018 9-9-2018
Please cite this article as: { https://doi.org/ This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title: Effective of Education on Quality of Life and Constipation Severity in Patients with Primary Constipation
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Short running title: Effective of Education In Primary Constipation
Mehmet Hayrullah Ozturk, Mardin
State
Hospital,
Department
of
Internal
Medicine
([email protected])
Mardin,
Turkey.
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orcid.org/0000-0003-1809-5039
Clinic,
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Serap Parlar Kılıc,
Turkey. ([email protected])
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orcid.org/0000-0003-3721-5083
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Fırat University Faculty of Health Sciences, Department of Internal Medicine Nursing, Elazığ,
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Address for correspondence: Serap KILIC,
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Fırat University Faculty of Health Sciences, Department of Internal Medicine Nursing, Elazığ Merkez, Elazığ, TURKEY. Postal code: 23119
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Telephone number: +90 424 2379139 Fax number: +90 424 2128891 E-mail: [email protected]
Effective of Education on Quality of Life and Constipation Severity in Patients with
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Primary Constipation
Hightlights
Constipation is one of the most frequent complaint related to the digestive system observed in general population.
Primary constipation affect the quality of life and health status of those who suffer from
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Primary constipation is a problem that can be remedied by independent nursing
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them.
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interventions.
Patient education in patients with constipation can contribute to reducing constipation
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ABSTRACT
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severity and enhance their quality of life.
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Objective: This study was conducted to examine the effect of education on quality of life and constipation severity in patients with primary constipation.
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Methods: This randomised controlled study was conducted with 80 patients who applied at the gastroenterology outpatient clinic of a university hospital. In the study, the Constipation Questionnaire, Constipation Quality-of-Life Questionnaire (PAC-QOL), and Constipation Severity Instrument (CSI) were used.
Results: It was that found after 4 weeks of education, the total PAC-QOL mean score decreased to 60.85±5.65 and total CSI mean score decreased to 20.17±4.05 in the intervention group (p<0.001). No change was observed in the patients in the control group (p>0.05). After 4 weeks, a statistical
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difference was found between the two groups in PAC-QOL mean score and CSI mean score (p<0.05).
Conclusion: It was determined that the education given to individuals with primary constipation decreased the constipation severity and increased the quality of life.
Practice Implications: Constipation education will make a contribution to the active use of follow-
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patient, and their active role in constipation management.
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up forms by nurses in the clinic for the diagnosis of constipation, individual assessment of each
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1. Introduction
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Key words: Constipation Severity, Education, Primary Constipation, Quality of Life
Constipation is an important health problem because it is frequently seen in the community
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and it impairs quality of life [1]. Constipation has no exact definition. Clinically, constipation is defined according to the Rome II and III criteria as a complex of at least two symptoms, including
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infrequent bowel movements (typically 25% of bowel movements), a subjective sensation of hard stools, and incomplete bowel evacuation [2]. When there is no underlying reason, the diagnosis of primary or idiopathic constipation is established. Pathophysiologically, primary constipation is divided into three main groups as normal transit constipation, slow transit constipation, and dyssynergic defecation disorders [3].
In the general populations of Europe and Oceania, the mean constipation rates were reported as 17.1% and 15.3%, respectively [4]. While the prevalence of constipation in North America varies between 15% and 20%, this rate can increase up to 50% among the elderly [5]. In
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a study conducted in Turkey, the overall rate of constipation was reported as 8.9%; among people aged more than 55 years, 12.5%; and, 16.3% among individuals aged 75 years and over [6]. In a study conducted by Uz et al. [7] among 1000 patients in Turkey, constipation was observed in 20% of the cases, and 75% of these cases were female and 60% were 50 years old and above.
Constipation is characterised by a diversity of symptoms, including bloating, straining,
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abdominal pain, lumpy or hard stools, sensation of incomplete evacuation, and infrequent
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defecation (fewer than three bowel movements per week) [8]. And, although constipation is not
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life-threatening, it is regarded as an important health problem because of its high rates and adverse
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effects on quality of life due to the social, economic, hygienic, and emotional pressures it brings on individuals [4,9]. In the study of Belsey et al. [10], they showed that individuals with
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constipation had lower health-related quality of life. In another study, it was observed that the
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economic burden brought by constipation on individuals negatively affected the health-related
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quality of life [9]. It is stated that since constipation causes labour loss and social and economic burden and increases healthcare costs, it is accepted as a significant problem for individuals and
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society [11]. The cost of treatment for constipation is also remarkable. Approximately 85% of the individuals with constipation require medical treatment, and they are using laxatives for this reason;
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thus, every year approximately 82 million dollars are spent for laxatives in the United States [12]. Although constipation is a common symptom, its care and treatment are still not at the
desired level. The purpose of care and treatment of constipation is to prevent constipation formation, and when constipation occurs, to provide comfort to the patients by increasing functionality and decreasing existing symptoms and constipation severity [13]. Because the
practices of constipation management will vary among individuals, the treatment of constipation should be individualised [14]. The education given concerning constipation includes making lifestyle changes (i.e., healthy nutrition, regular physical activity, good toilet habits, abdominal
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massage, daily fluid intake, and regular health control), relieving risk factors, and providing laxative treatment [15]. Determining descriptive characteristics and risk factors of constipation by preparing education plans is important to decrease the constipation severity and enhance the quality of life for patients [16]. Consequently, constipation may become a major health problem, as it has negative effects on health, such as impairment in quality of life, burnout, labour loss, and increased
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healthcare costs. The diagnosis of constipation and determining its severity level play a key role in
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the solution of the problem. However, as a result of a literature review, any similar study evaluating
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the effects of providing health education to patients with constipation to improve their quality of
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life and symptom severity has not been found. Thus, we aimed to reduce the symptoms and
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management education.
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constipation severity of patients and thus enhance their quality of life through constipation
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2. Methods
2.1. Study sample and design
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The study was designed and conducted as a randomised controlled trial in pretest-posttest pattern to examine the effects on quality of life and constipation severity as a result of education
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given to patients diagnosed with primary constipation. The study was conducted with 80 patients, including 40 patients in the experimental group and 40 individuals in the control group. The patients applied to the gastroenterology outpatient clinic of a state hospital and were diagnosed with primary constipation. As a result of power analysis, the minimum sample size required to find the increase of 15 units significant in the Constipation Quality of Life Questionnaire (PAC-QOL)
in the education group compared with the non-education group was found to be 32 for each group (α = 0.05, 1-β = 0.80). The adult patients who presented to our clinic with constipation due to organic diseases,
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drugs, and metabolic disorders were excluded from the study. All patients underwent examination by a specialist physician working in the gastroenterology outpatient clinic through examinations such as detailed medical history, physical examination, abdominal examination, and biochemistry. All of the patients diagnosed with primary constipation were referred by these specialist physicians to the researcher. The inclusion criteria for the patients were as follows:
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1. with a diagnosis of primary constipation
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2. Complaints of primary constipation starting at least 6 months ago and continuing
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intermittently or constantly in last 3 months according to Rome III diagnostic criteria [4,17]
4. No communication problems
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3. Age 18 years and older
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5. No mental confusion or other psychiatric problem
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6. Voluntarily agreed to participate in the study
2.2. Instruments
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2.2.1. Constipation Questionnaire (CQ) The CQ is a questionnaire with a total of 40 questions that obtain information about the
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socio-demographic characteristics of the individuals diagnosed with constipation, risk factors for constipation, onset time of constipation, defecation frequency, lifestyle of the individual (e.g. nutrition, fluid intake), and general health condition (e.g. drugs used, previous surgeries, other diseases) [6]. 2.2.2. Constipation Quality of Life Questionnaire (PAC-QOL)
The PAC-QOL was developed by Marquis et al. [18], and its validity and reliability study was conducted by Dedeli et al. [6] in Turkey. The questionnaire’s Cronbach alpha reliability coefficient was 0.91, and the test-retest reliability of the scale was r = 0.96, p<0.01. The
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questionnaire is a self-assessment scale with a total of 28 items including ‘worry/concern’ (11 items), ‘physical discomfort’ (four items), ‘psychosocial discomfort’ (8 items), and ‘satisfaction’ (five items) subscales. The questionnaire uses a 5-point Likert-type scale ranging from 1 to 5. The first and fifth parts of the questionnaire are answered by the patients as ‘not at all (1)’, ‘a little bit (2)’, ‘moderately (3)’, ‘quite a bit (4)’, and ‘extremely (5)’; conversely, in the second, third, fourth,
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and sixth parts, patients are asked to select the most suitable one among the options of ‘non of the
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time (1)’, ‘a little of the time (2)’, ‘some of the time (3)’, ‘most of the time (4)’, and ‘all of the time
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(5)’. The highest score that can be obtained on the questionnaire is 140, and the lowest score is 28.
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Higher scores signify impairment in quality of life. There should be no unanswered question in the questionnaire in order for accurate scoring [6,18,19]. In this study, the Cronbach alpha coefficient
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of the PAC-QOL was found to be 0.78.
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2.2.3. Constipation Severity Instrument (CSI) The Turkish validity and reliability study, the Constipation Severity Instrument (CSI),
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developed by Varma et al. [20], was conducted by Kaya and Turan [21]. It is a scale determining defecation frequency, intensity, and difficulty. It also aims to measure constipation symptoms.
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There are 16 questions in the instrument, with subscales, as follows: obstructive defecation, colonic inertia, and pain. The score to be obtained from the subscale ‘obstructive defecation’ is between 0 and 28; the score to be obtained from the subscale ‘colonic inertia’ is between 0 and 29; and the score to be obtained from the subscale ‘pain’ is between 0 and 16. While the lowest total score to be obtained from the CSI is 0, the highest total score is 73. High scores signify severe symptoms
[20,21]. Kaya and Turan [21] determined that the Cronbach alpha value of the instrument was between 0.92 and 0.93. In this study, the Cronbach alpha coefficient of the CSI was found to be
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0.89.
2.3. Randomisation
Patients were informed about the study, and they provided their informed consent prior to randomisation. After inclusion in the study, the patients were randomly allocated either to the intervention group or the control group. Randomisation was conducted by a statistics specialist
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who had no contact with the participants. The statistics specialist randomised participants to the
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intervention or the control group using a computerised random number generator (SPSS version
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20 software). All individuals involved in the study were blinded to the randomisation procedure.
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However, the researchers were not blinded to the constipation education they were to deliver, due to the nature of the intervention. Participants assigned to the control group continued to receive
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routine treatment, unaware they were in a constipation education programme. Participants in the
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intervention group were invited to be part of a constipation education programme. The present
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study lasted for approximately 6 months. There were no patients who left the study before completion. The education was given by the same researcher, and the training programme was
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delivered in a training room at a gastroenterology polyclinic at a state hospital. Thus, interaction
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of the patients between the two groups was prevented (Figure 1).
2.4. Data collection The data collection tools used to collect the study data were administered in two stages.
First stage: Before starting the study, written and verbal consents of all the patients were obtained regarding the administration of the questionnaire. CQ, PAC-QOL, and CSI were
applied to the patients in both groups. The data collection forms were applied using a faceto-face interview technique, and answers given by the patients were recorded near them. It took approximately 15 minutes to collect the data. After the first data were collected, the
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control group continued to receive its routine treatment, and education was not given to this group. After the questionnaires were completed, an education programme on constipation was given to the patients in the intervention group by the researcher. After the education, a ‘Constipation Education Booklet’ was given to every patient in the intervention group.
Second stage: Without giving education to the patients in the control group, the CQ, PAC-
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QOL, and CSI were repeated 4 weeks after the first assessment. After the first assessment,
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the constipation education was given to the patients in the intervention group, and the CQ,
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PAC-QOL, and CSI were repeated 4 weeks later.
2.5. Constipation education programme
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The education programme was given by the first author, who is a Clinical Nurse Specialist
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at another hospital in Turkey; he is assisted with the data collection and data analysis. The second
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author, a nurse instructor (associated professor), assisted with data analysis. Before the education was given, the explanation about ‘education’ was made to all patients, and permission for the study
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was requested. The study was conducted on a voluntary basis. It took approximately 45 to 60 minutes to carry out the education. The education programme given concerning constipation was
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conducted in a room located at the gastroenterology outpatient clinic of a state hospital. The education, which was taught interactively and individually to each patients, lasted for an average of 1 hour and was taught with the help of visual representation. A ‘Constipation Education Booklet’ on constipation management was prepared to be used during the education and to strengthen the education. The content of the education booklet prepared for patients with primary constipation
was developed under the guidance of the consultant academic members using information collected by the researcher [3,13,22-24] and arranged with the help of the experts. The education booklet consisted of two sections. The first section contained the definition of constipation, its reasons,
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drugs causing constipation, risk factors, some recommendations for the prevention of constipation (e.g. regular defecation, no delayed defecation, best position for defecation, avoiding straining for a long time), constipation treatment, and the importance of individual management in constipation. The second section contained information about healthy and balanced diet and nutrition types, sufficient fluid intake, benefit of exercise and selection of suitable exercise, abdominal massage,
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and toilet training including individual methods for preventing constipation. Appropriate
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behaviours displayed by the patients for eliminating constipation during the education were
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supported, and the individuals were interviewed about inappropriate behaviours to find solutions.
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Moreover, patients were prompted by the researcher on the information they wanted to learn about constipation, and their questions were answered.
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After the study was completed, the constipation education was interactively given to the
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patients in the control group by the researcher with the help of a PowerPoint presentation. During
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the education, information the patients wanted to learn about constipation and their questions were
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answered by the researcher; a ‘Constipation Education Booklet’ was given to each patient.
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2.6. Data analysis The statistical evaluation of the data obtained as a result of the study was performed using
the SPSS package programme, and p<0.05 was accepted as statistically significant. The Chi-square test, independent samples t test, paired samples t test, and the Pearson correlations analysis were used in the statistical evaluation of the data obtained as a result of the study.
2.7. Ethical consideration Before starting the study, written permission from the Gaziantep University Faculty of Medicine Scientific Ethics Committee (20.01.2014/47) and from the Turkish Public Hospitals
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Authority Gaziantep Office of General Secretary were given to conduct the study. Before the data were collected, the patients were informed about the purpose of the study, the administration method, and how the results would be obtained; each participant’s consent was obtained after
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required explanations were done and their questions were answered.
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3. Results
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3.1. Sample characteristics
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It was determined that most of the patients included in the study were female (intervention group = 77.5%, control group = 72.5%), married (intervention = 87.5%, control group = 92.5%),
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and their average age was 45.27±16.25 years in the intervention group and 48.25±12.58 years in
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the control group. In both groups, the constipation period of 65% (26 patients) of the patients was
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1 to 3 years. No statistically significant difference was found between the intervention and control groups in terms of the sample characteristics of the patients (p>0.05) (Table 1).
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3.2. Difference of the some results regarding the constipation questionnaire between intervention
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and control group Table 2 shows the comparison of the results related to the constipation questionnaire of the
intervention and control groups at baseline and after 4 weeks. After 4 weeks, both the defecation frequency increased and the straining period reduced in the patients in the intervention group. It was found that after 4 weeks, the frequencies of abdominal distension, dyspepsia, and flatulence problems of the patients in the intervention group decreased, and no patient saw blood in their stool
(p<0.05). No change was observed in the patients in the control group (p>0.05). After 4 weeks, a statistical difference was found between both groups in terms of frequency of defecation and the health problems related to defecation (p<0.05).
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3.3. Comparison of the PAC-QOL and CSI mean scores of both groups Although there was no statistically significant difference between the intervention and control groups (p>0.05) at baseline in terms of PAC-QOL total and subscale scores, a statistical difference was found between the groups after 4 weeks (p<0.05). And, although there was no statistically significant difference between the intervention and control groups (p>0.05) at baseline
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in terms of CSI total and subscale scores, a statistical difference was found between the groups
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after 4 weeks (p<0.05) (Table 3).
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3.4. Relationship between scores of the PAC-QOL and CSI
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When we examined the association of PAC-QOL total mean scores with CSI total mean
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TE
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scores, we found a significant and positive correlation (r = 0.629, p<0.001) (Table 4).
4. Discussion and conclusion
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4.1. Discussion
Constipation is not a disease but an important health problem for the individual and the
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community that is interpreted differently from person to person [25]. It is physically and mentally troublesome for many patients, can impair quality of life, causes labour loss, increases the healthcare costs, and is frequently associated with other medical problems [11]. In the literature, there are studies indicating that constipation negatively affects the quality of life of the individuals [2,10]. However, as a result of a literature review, it has been observed that there is no similar study
examining the effect of education on quality of life and constipation severity among patients with primary constipation in Turkey. In the present study, cognitive symptom management and related interventions enabling a decrease in constipation and its severity were learned. The primary aim of
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this study was to show that education generally provided useful results for patients with constipation and had positive effects, especially on the constipation severity and the quality of life. In the patients with constipation, the symptoms such as forceful defecation, feeling of incomplete evacuation, abdominal disorder, abdominal strain [23], painful defecation [26], rectal pain, and urgent defecation are frequently observed [2]. In the study of Uysal et al. [27], they
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observed that 68% of the students with gastrointestinal complains had abdominal distension, 63.4%
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had distension after meals, 48.2% had acid reflux, 43.0% had belching, and 19.0% had burning/pain
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in the epigastric area. In the present study, it was also determined that the patients had abdominal
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distension, dyspepsia, and flatulence problems.
Education for patients is an important component of treatment for primary constipation.
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Exercising, increasing the intake of liquid and high-fibre foods, and abdominal massage are
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included in the constipation therapy along with constipation education, leading to positive results
EP
[28,29]. In the present study, the patients in the intervention group obtained significantly positive results regarding health problems related to defecation after the education. This situation showed
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the positive effect of the education on the symptoms experienced due to constipation. In similar studies, it was shown that education reduced the health problems experienced due to constipation
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[17,30,31]. Akbayrak et al. [30] showed that massage applied in addition to the dietary recommendations and education was also effective in reducing the symptoms such as flatulence, distension, and pain in the form of cramps and in increasing the defecation frequency among the individuals with irritable bowel syndrome. One randomised controlled trial showed that fibre supplementation improved constipation better than placebo, especially in children with encopresis
[32]. Kaçmaz and Kaşıkcı [33] showed the results of their study that planned nursing interventions including bran supplements are more effective than routine nursing interventions for management of constipation problems in older orthopaedic patients. In a study, it was reported that the symptoms
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of the geriatric patients were alleviated by suitable diet and an exercise programme, and the use of laxatives was reduced [17]. In their study, Ayaz and Hisar [31] evaluated the efficacy of education and consultancy services in the elimination of constipation, and determined that 37.1% of the cases defined their constipation-related complaints (feeling of incomplete evacuation, feeling of anal discomfort and pain) as severe before the education and consultancy and stated a reduction in
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severity of their such complaints after the education and consultancy. Shen et al. [34] evaluated the
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effects of self-managed educational intervention on the symptoms of patients with functional
A
constipation. It was found that the constipation score of all clinical symptoms (Bristol stool form
M
scale, defecation interval, incomplete evacuation, evacuation difficulty) after 1 month were all significantly lower in the intervention group than in the control group.
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It is reported that constipation negatively affects the physical and emotional well-being,
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business and school life, life style, performance, and general quality of life of the individual [2,6].
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In the present study, it was determined that both constipation severity and quality of life of the patients were affected moderately. Previous studies showed that the quality of life of the patients
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with the complaint of functional constipation was significantly lower compared with healthy individuals [35,36]. In a study conducted with chronically constipated patients, it was determined
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that constipation severity of the patients was affected moderately, and the CSI was 40.24±8.76 in the experimental group and 39.96±9.03 in the control group [37]. In their study, Neri et al. [38] reported that the average constipation severity of patients with chronic constipation in the sample group was ‘moderate’ and that the average Patient Assessment of Constipation-Symptoms (PACSYM) score of the patients was 1.62±0.69.
In the present study, there was no difference between the PAC-QOL and CSI total mean scores of the patients in both groups at baseline; whereas, after 4 weeks, no change occurred in the control group, but there was a significant decrease in the intervention group. These findings showed
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that the education provided an increase in the quality of life and a decrease in the constipation severity among the patients. Ginsberg et al. [39] reported that primary constipation is amenable to dietary adjustments, education, and behavioural training, and laxatives when necessary. In the study conducted by Nour-Eldein et al. [22] among the individuals with constipation, it was shown that the education given regarding lifestyle changes (dietary pattern, fluid intake, regular physical
U
activity, and the use of laxatives) had a positive effect both on constipation severity and the quality
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of life of the individuals. The study by Ostaszkiewicz et al. [40] included 27 community-dwelling
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adults aged 35 to 83 years who presented with lower urinary tract symptoms and constipation and
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received individualised conservative treatment (advice on dietary supplementation, fluid intake, exercise, position to defecate, the gastrocolic reflex, and over-the-counter laxatives) for
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constipation. They indicated that the intervention significantly reduced the severity of overall
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constipation symptoms measured by the PAC-SYM [40]. In the study of Sette et al. [41], they
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observed a positive change in QOL scores of patients with chronic functional constipation after the completion of the educational intervention, whereas the scores worsened in all dimensions in the
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control group. Ayaz and Hisar [31] reported that participants received an individual education programme that included advice on dietary consumption such as pulpy‐fibrous nutrient
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consumption, fluid intake, an exercise regime, and counselling about the optimal position for defecation. As a result, the CSI total mean scores decreased significantly after the education programme [31]. It could be asserted that when patients have knowledge about their condition and learn related management strategies, they have relief of constipation symptoms and an improved quality
of life. It is also important to increase sensitivity to health for health promotion and to ensure the continuity of the education for gaining positive health behaviours.
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4.2. Conclusion In the study, it was observed that the education provided positive results in the intervention group, improving the problems experienced by the patients due to constipation, and resulted in a decrease in constipation severity and an enhanced quality of life. According to these results, departments should provide education to patients with constipation. Additional studies including
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larger populations are warranted to show the benefits of education given to patient groups.
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4.3. Practice implications
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The educational intervention provides a therapeutic alternative to patients living with defecation disorders. Nurses, who are involved within the medical team, have a potentially
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significant part to play in both the prevention and management of constipation by providing
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lifestyle advice to the patients with constipation and information on high fibre intake, sufficient
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fluid intake, and regular exercise. An education provided by nurses or other health staff members offered to individuals diagnosed with constipation will providing the individuals with tools to
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reduce their constipation severity and increase their quality of life.
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Contributions of authors MHÖ and SPK designed and conducted the study, SPK analysed the data, MHÖ and SPK
drafted the manuscript. MHÖ collected the data, MHÖ and SPK critically revised the manuscript. All authors have approved the final version of the manuscript.
Conflicts of interest All authors certify that there is no conflict of interest with any personel, other relationships
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with other people and financial organisation.
Funding None
Acknowledgements
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References
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The authors thank the participants in this study.
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40. J. Ostaszkiewicz, L. Hornby, L. Millar, C. Ockerby, The effects of conservative treatment for constipation on symptom severity and quality of life in community-dwelling adults, J. Wound Ostomy Continence Nurs. 37 (2010) 193-8, 10.1097/WON.0b013e3181cf7206.
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41. G.C.S. Sette, A.M.T.S. Cavalcanti, M.W.L. Coriolano, G.A.P. Silva, M.E.F.A. Motta, L.S. Lima, Do Educational Interventions with Mothers Enhance the Quality of Life of their Children with Chronic Functional Constipation in a Randomized Trial? Comm. Pub. Health
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Nurs. 3 (2017) 1-6, doi: 10.4172/2471-9846.1000164.
Assessed for eligibility (n=86)
Excluded (n=4) - Not meeting inclusion crtiteria (n=3) - Declined to participate (n=1)
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Randomized (n=82)
Allocated to experimental group (n=42)
Allocated to control group (n=40) None excluded
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CQ, PAC-QOL and CSI was applied as posttest
Figure 1. Participant flowchart of the study
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One-to-one interview: Constipation Questionnaire (CQ), Constipation Quality of Life Questionnaire (PAC-QOL), and Constipation Severity Instrument (CSI) was applied as pretest. - None intervention.
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A
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Baseline
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One-to-one interview: Constipation Questionnaire (CQ), Constipation Quality of Life Questionnaire (PAC-QOL), and Constipation Severity Instrument (CSI). - Constipation education booklet (constipation, some recommendations for the prevention of constipation) was presented.
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Declined to participate (n=2)
4 weeks
CQ, PAC-QOL and CSI was applied as posttest
Table 1 Constipation Questionnaire at before the education between intervention and control groups Control group (n=40) n (%)
9 (22.5) 31 (77.5) 45.27 ± 16.25
11 (27.5) 29 (72.5) 48.25 ± 12.58
0.606
37 (92.5) 3 (7.5)
0.456
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A
N
2 (5.0) 26 (65.0) 6 (15.0) 6 (15.0)
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EP
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p
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13 (32.5) 23 (57.5) 3 (7.5) 1 (2.5)
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35 (87.5) 5 (12.5)
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Gender Male Female Age (X ± SD) Marital status Married Single Educational status Literate Primary education High School University Period of constipation complaint 6 months – 1 year 1 year – 3 years 3 years – 5 years 5 years and above State of constipation to affect social life No effect Rarely affects Frequently affects Very frequently affects State of constipation to affect occupation No effect Rarely affects Frequently affects Very frequently affects State of constipation to affect sexual life No effect Rarely affects State of constipation to affect sleeping pattern Pain increases while sleeping Pain decreases while sleeping Pain does not change while sleeping
Intervention group (n=40) n (%)
12 (30.0) 23 (57.5) 5 (12.5) 6 (15.0) 26 (65.0) 3 (7.5) 5 (12.5)
10 (25.0) 17 (42.5) 9 (22.5) 4 (10.0)
10 (25.0) 21 (52.5) 8 (20.0) 1 (2.5)
13 (32.5) 17 (42.5) 8 (20.0) 2 (5.0)
19 (47.5) 17 (42.5) 4 (10.0) -
39 (97.5) 1 (2.5)
40 (100.0) -
8 (20.0) 2 (5.0) 30 (75.0)
8 (20.0) 3 (7.5) 29 (72.5)
0.363
0.673
0.228
0.516
0.216
0.314
0.897
Table 2 Difference of some results regarding the constipation questionnaire between intervention and control groups at the baseline and after 4 weeks
Dyspepsia
CC
EP
Never Sometimes Frequently Very frequently Always
2 (5.0) 13 (32.5) 21 (52.5) 3 (7.5) 1 (2.5)
2 (5.0) 23 (57.5) 12 (30.0) 2 (5.0) 1 (2.5)
1 (2.5) 1 (2.5) 4 (10.0) 25 (62.5) 9 (22.5)
3 (7.5) 4 (10.0) 27 (67.5) 6 (15.0)
A
M
D
28 (70.0) 10 (25.0) 2 (5.0)
32 (80.0) 8 (20.0) -
5 (12.5) 2 (5.0) 13 (32.5) 16 (40.0) 4 (10.0)
6 (15.0) 10 (25.0) 23 (57.5) 1 (2.5)
2 (5.0) 12 (30.0) 21 (52.5) 5 (12.5)
3 (7.5) 8 (20.0) 25 (62.5) 4 (10.0)
p*
26 (65.0) 14 (35.0) -
29 (72.5) 11 (27.5)
36 (90.0) 4 (10.0) -
1 (2.5) 22 (55.0) 15 (37.5) 2 (5.0) -
0.001
0.613
4 (10.0) 33 (82.5) 3 (7.5) -
1 (2.5) 5 (12.5) 31 (77.5) 3 (7.5)
0.001
0.288
40 (100.0) -
32 (80.0) 8 (20.0) -
0.003
0.034
19 (47.5) 21 (52.5) -
1 (2.5) 3 (7.5) 15 (37.5) 20 (50.0) 1 (2.5)
0.001
0.692
6 (15.0) 12 (30.0) 20 (50.0) 2 (5.0) -
1 (2.5) 7 (17.5) 25 (62.5) 7 (17.5)
0.001
0.881
0.246
U
1 (2.5) 27 (67.5) 12 (30.0)
N
1 (2.5) 29 (72.5) 10 (25.0)
TE
Defecation frequency Every day A few times per week Once a week Straining period Less than one minute 1-5 minutes 6-10 minutes 11-20 minutes More than 20 minutes Abdominal distension Never Sometimes Frequently Very frequently Always Blood in the stool Never Sometimes Frequently
p*
After 4 weeks Intervention Control group group n (%) n (%)
SC RI PT
Baseline Intervention Control group group n (%) n (%)
0.001
Flatulence
A
Never Sometimes Frequently Very frequently Always
*Chi-square test.
N U SC RI PT
Table 3
Comparison of PAC-QOL and CSI mean scores of both groups the baseline and after 4 weeks
15.42 ± 1.59 15.57 ± 4.56 37.85 ± 3.97 14.82 ± 1.55 83.67 ± 7.27
ED
M
15.62 ± 1.49 17.07 ± 5.00 38.07 ± 3.85 14.57 ± 1.93 85.35 ± 7.03
19.85 ± 2.76 17.82 ± 2.34 5.75 ± 2.40 43.42 ± 5.46
PT
PAC-QOL subscales Physical discomfort Psychosocial discomfort Worry /concern Satisfaction PAC-QOL Total score CSI subscales Obstructive defecation Colonic inertia Pain CSI Total score
A
Mean scores baseline Intervention Control group group X±SD X±SD
19.45 ± 3.19 17.75 ± 2.50 5.40 ± 1.94 42.60 ± 6.66
Mean scores after 4 weeks Intervention Control group group X±SD X±SD
t
p*
0.577 1.399 0.257 -0.638 1.046
0.565 0.166 0.798 0.525 0.299
9.70 ± 1.71 8.75 ± 1.37 24.35 ± 3.68 18.05 ± 1.21 60.85 ± 5.65
0.598 0.138 0.716 0.605
0.551 0.890 0.476 0.547
10.17 ± 2.06 7.97 ± 1.84 2.02 ± 0.91 20.17 ± 4.05
t
p*
15.80 ± 1.22 13.55 ± 3.54 39.52 ± 2.38 13.62 ± 1.67 82.50 ± 4.94
-18.328 -7.987 -21.870 13.513 -18.243
0.001 0.001 0.001 0.001 0.001
20.37 ± 2.02 18.50 ± 1.73 5.65 ± 1.59 44.52 ± 4.05
-22.342 -26.240 -12.458 -26.842
0.001 0.001 0.001 0.001
A
CC E
PAC-QOL, Constipation Quality of Life Questionnaire; CSI, Constipation Severity Instrument; *Independent samples t-test.
27
Table 4 Correlation between PAC-QOL total mean scores and CSI total mean scores of the patients. Total CSI score Pearson Correlation (r) 0.629
A
CC E
PT
ED
M
A
N
U
SC RI
PT
PAC-QOL Total score
p 0.001
28