A Health Mobile Application for Self-Care of Colostomy Patients

Abstract Introduction and Objective  In most cases, due to the failure of nonsurgical methods in the treatment of diseases related to the colon, it is necessary to perform colostomy as the main treatment method. However, this surgery can cause a wide range of physical, social, and psychological problems in patients. Therefore, in order to prevent and treat the complications of colostomy, it is necessary to adopt measures in the field of self-care and continuous education for patients to control the complications of the disease, seek treatment, and experience improvements in their quality of life . Additionally, considering the role of mobile health (mHealth) applications in facilitating continuous and effective training, and improving self-care for these patients, the aim of the present study was to design and evaluate an mHealth application for self-care of colostomy patients. Materials and Methods  In the present applied research, first the functional requirements of the software were determined considering the self-care requirements of colostomy patients. Then, the software was designed based on object-oriented analysis, and according to it, the application was coded in Java and developed in the Android Studio environment. Finally, to evaluate the software, the opinions and comments of 5 gastroenterologists and 10 adult colostomy patients in the age range between 27 and 64 years who had at least a high school diploma were used as the basis of judgment at this stage. The instruments used in the evaluation included a checklist, derived from three standard questionnaires (the System Usability Scale [SUS], the mHealth App Usability Questionnaire [MAUQ], and the User Version of the Mobile Application Rating Scale [uMARS]) to measure the user-friendliness indicator, and a researcher-made checklist to measure the performance indicator of the various services provided. Results  The services of the software developed include the provision of medical information and self-care instructions regarding colostomy surgery, as well as alerts for the user to schedule an appointment with a doctor and the time to take medications. Based on the results of the evaluation stage, the users were generally satisfied with the interface, services, and general features of the software. In general, the software was evaluated at the “acceptable” level, with a rate of 85%. Discussion and Conclusion  Based on the findings of the current research, the software developed can be significantly effective in facilitating the education of colostomy patients and improving their self-care. Proper and continuous self-care and education for colostomy patients is necessary to prevent and control complications resulting from surgery and to improve their quality of life. Therefore, in addition to patients, all health care staff, organizations, and associations which support colostomy patients can also use this software to educate patients and improve the care provided to them.


Introduction
A colostomy is a surgical procedure in which one side of the large intestine or part of it is removed through an opening in the abdominal wall (called a stoma).2][3] Nowadays, due to the increase in diseases related to the colon and the failure of nonsurgical methods in relieving the severe symptoms of colon diseases, colostomy may be necessary to treat complications and improve the quality of life (QoL) of patients.Approximately 60% to 70% of patients with inflammatory bowel disease (ulcerative colitis and Crohn disease) will need this surgery, and among colon diseases, colorectal cancer is the most common cause of colostomy. 1Despite all the current medical advances, colostomy is still one of the main treatments for many patients with colon cancer. 4Based on figures reported by the World Health Organization (WHO) in 2020, colorectal cancer ranks third among the 10 most prevalent cancers, and presents the second highest mortality rate among men and women worldwide. 5It is worth noting that the number of patients who need a colostomy increases every year; in the United States, for example, 100 thousand patients need this surgery every year. 1 The international statistical information concerning colostomy has not yet been determined and published accurately.About 102 thousand residents of England and 100 thousand residents of Germany undergo colostomy each year. 6recise statistical information is not available on the number of ostomy patients in Iran; however, according to the Iranian Ostomy Association, about 30 thousand ostomy patients live in Iran, 70% of whom have undergone colostomy, 20%, ileostomy, and 10%, urostomy, with the total number of ostomy patients increasing every year. 7Colostomy can lead to a wide range of physical, psychological, and social problems for the patients.Given the significance of the problems and complications that can arise after surgery, self-care and patient education play important roles in ameliorating complications and improving adjustment and QoL.Therefore, access to a comprehensive and appropriate educational program can facilitate self-care, reduce complications from surgery, and improve the QoL of colostomy patients. 8,9Self-care, as defined by the WHO, refers to the ability of individuals, families, and societies to improve health conditions, and prevent and deal with diseases, which can be achieved with the support of health care staff, or without their presence.Self-care involves many aspects and activities, including health and hygiene (public and individual), nutrition, lifestyle (exercise and sports, leisure time activities etc.), environmental factors (living conditions, social habits etc.), and socioeconomic factors. 10ublic guidelines and statements, including the joint position statement of the American Society of Colorectal Surgeons, the Wound Nurses Society, and the guidelines for the care and management of ostomy published in 2009 by the Ontario Nursing Association, have all emphasized ostomy patient education and the education of their relatives and family members to prevent the possible complications of ostomy, especially during the preoperative period.2][13][14][15][16] Thus, it seems absolutely necessary that measures should be taken regarding self-care, continuing patient education, complication management and control, treatment, and improvements in the QoL of colostomy patients. 8In this regard, patients should be taught about stoma care, care for the skin around the stoma, the type and characteristics of secretions from the stoma (unusual color, amount, viscosity, and smell), how to empty and change the ostomy pouching system, how to change the bag and put it in place, how to rinse and cleanse the intestines, how to modify the diet, as well as about the effects of ostomy on sexual activity. 1,17,18A study 19 conducted in Canada has shown that mental disorders, anxiety, depression, and attention disorders can worsen the physical condition of these patients.Hence, ostomy patients need to receive constant counselling services for their psychological

Results
The services of the software developed include the provision of medical information and self-care instructions regarding colostomy surgery, as well as alerts for the user to schedule an appointment with a doctor and the time to take medications.Based on the results of the evaluation stage, the users were generally satisfied with the interface, services, and general features of the software.In general, the software was evaluated at the "acceptable" level, with a rate of 85%.Discussion and Conclusion Based on the findings of the current research, the software developed can be significantly effective in facilitating the education of colostomy patients and improving their self-care.Proper and continuous self-care and education for colostomy patients is necessary to prevent and control complications resulting from surgery and to improve their quality of life.Therefore, in addition to patients, all health care staff, organizations, and associations which support colostomy patients can also use this software to educate patients and improve the care provided to them.
needs to detect and address any problems. 20Some problems, such as flatulence and excrement leakage, can be embarrassing for these patients, leading to further intensification of mental disorders, depression, anxiety, and isolation.Therefore, patients should be educated about how to expel gas from the colostomy site noiselessly, and how to alter their diets to minimize flatulence.Additionally, patients should receive precise instructions about the proper size of the colostomy bag opening, how to take care of it, and when to change it to minimize excrement leakage from the colostomy site. 9mprovements in the QoL of patients with a stoma is the responsibility of all health care personnel, including nurses, and they must know that knowledge and skills regarding preand postoperative self-care play an important role in enhancing the QoL of colostomy patients. 20To achieve favorable results in terms of patient self-care, appropriate instruments and solutionssuch as information technology and digital learning environments 21 -should be used to facilitate and promote patient education.Patient education using electronic devices is a novel method that can convey educational concepts and materials simply, widely, and intriguingly by making use of texts, sounds and voice, pictures and images, and movies and animations and can be used and published on a large scale. 22In recent years, developments in information and communication technologies along with the widespread availability of smartphones and internet connectivity that can be accessed at any time play a key role in providing modern health care solutions. 23Currently, there are mobile health (mHealth) applications with many different functions in the field of health care, which are often used as educational tools, to simplify patient self-care, and to provide proper information together with educational films and content about diseases and disorders. 24On the other hand, the widespread use of cell phones creates new paths to overcome the various barriers to coping behaviors and to the maintenance of self-care behaviors. 25Advances in cell phone technology has created many opportunities to promote the health and well-being of patients. 26Smartphones can assist in the management of medical conditions without direct monitoring by health care staff, which can enhance the QoL of patients, reduce costs, decrease hospital stay and re-hospitalizations, and, ultimately, empower the patients. 27Applications available on smartphones can enable nurses to remind patients through short message service (SMS) after the in-person sessions, and also motivate the patients to carry out the assigned tasks.Hence, smartphones eliminate the limitations regarding the access to mental health services and improve patient self-care. 28Moreover, patients who experience surgical complications and seek solutions may face difficulties in countries with inadequate numbers of health care centers and personnel.For instance, when patients are affected by peristomal dermatitis, they do not usually know which products they should use to treat it.On the other hand, lack of timely access to health care and delayed treatment can intensify complications, adversely affecting the patient physically, socially, and psychologically.[31] Therefore, it is crucial to make sure that patients have access to continuing education, and that their self-care skills improve.To achieve this purpose, it seems necessary to develop highly useful mHealth applications to improve the self-care required in the management of this medical condition.Despite the numerous problems and complications faced by colostomy patients, few studies have been conducted on the use of mobile applications in colostomy patient self-care, and the functionalities of smart phones have not been fully put to use in this field.Hence, considering the important points that were mentioned about the use of cell phones in facilitating patient education and self-care, the current study aimed to design and evaluate an mHealth application to improve the self-care of colostomy patients.

Materials and Methods
The current applied research was conducted in 2 main stages in 2022 and 2023.

First Stage: Development of the mHealth Software
First, articles, books, and global health websites were studied and analyzed to better understand the self-care needs of colostomy patients.Then, the functional requirements of the colostomy self-care software were determined, including the conveyance of comprehensive and understandable medical information and scientific content about colostomies, the provision of the necessary training and instructions related to the self-care of colostomy patients, and the display of warnings to remind patients to visit the doctor and when to take medicines based on the information collected.After the establishment of the functional requirements, a conceptual model of the software was designed based on object-oriented analysis and on the visual paradigm programing environment, which included the functional model, the structural model, and the behavioral model.Finally, the conceptual model was coded and developed using the Java programming language in the Android Studio environment.Then, it was tested and debugged in terms of execution accuracy.

Second Stage: Evaluation of the mHealth Software
After the development stage, the software was made available to 10 adult colostomy patients in the age range between 27 and 64 years, with at least a high school diploma, who owned smartphones running the Android operating system.To evaluate the user interface, the services, and general features, the software was also made available to five gastroenterologists.
• Data collection instrument: Evaluation data was collected using a checklist including 26 questions in 2 general categories.3][34][35] Eleven questions related to the services and general features of the software were designed by the research team based on the features of the software.
• Methods of data analysis: All items on the checklist had the same weight.Regarding the questions, each affirmative ('yes') answer was assigned a score of one point, and a score of zero was assigned to each negative ('no') answer.Moreover, in each scale, if the sum of the points was in the unacceptable range, the section related to that range in the software would be revised, and after the necessary corrections, the checklist was provided to the user again until an acceptable result was obtained.This situation did not occur during the present research, and the checklist was not provided to the user for revision.

Findings on Software Development
The functional requirements and services provided in the colostomy self-care software were determined based on a review of the literature.The main services provided include the conveyance of medical knowledge, self-care instructions, and alerts for when the user should consult with a doctor and take medications.The first part is related to medical knowledge, including familiarity with the colostomy surgery, the management of its gastrointestinal complications, and the performance of daily activities with the stoma.The second part is related to teaching self-care instructions, including how to change and empty the bag, how to wash the bowel, skin care of the area of the stoma, motivational materials, and an introduction to health insurance providers and the ostomy associations of Iran.In this section, all the necessary training related to the self-care instructions along with educational materials, as well as images and educational videos were provided to the user.By selecting each section and opening the corresponding page, the user can view the step-by-step tutorials with images and texts at the end, and also view the related video tutorial.Moreover, all the content of the first and second parts were compiled based on authoritative texts and authoritative global websites and were provided to the user in a simple and understandable way.In the third part, the user enters the information related to medicines and doctor appointments, and the software can remind and warn the user of the appropriate time and date to take the medicines and about their appointments with the doctor.

Findings of the Evaluation of the Software
The software was evaluated by 10 colostomy patients and 5 gastroenterologists.►Table 1 presents the frequency distribution of patient demographics, including age, gender, and level of schooling.►Table 2 summarizes the responses of the patients to items related to the evaluation of the user interface, which indicate that they were satisfied with it (87%).►Table 3 shows the opinions of gastroenterologists about the services and general features of the software, which indicate that they found them satisfactory (81%).►Table 4 presents a summary of the opinions of the patients about the services and general features of the software, which indicate that 85% of them were satisfied.Therefore, based on the results of the evaluations of the user interface and the services and general features of the software, and with the average total score obtained from them, the level of user satisfaction with the software was of 85%, which places the software at an acceptable level.

Discussion and Conclusion
The statistical results of previous studies show that mobilebased software can play an effective role in facilitating education and improving the self-care of colostomy patients.> 64 0 0%

Mean percentage 87%
7][38][39] Therefore, in the present research, a software was designed and developed to improve the self-care of colostomy patients.All the services provided in the software are in line with the self-care goals of colostomy patients.
In their study, Kim et al. 40 discussed the provision of educational information as one of the important services offered by mHealth software, which can positively affect the self-care of patients.Moreover, Grainne et al., 41 who examined mHealth applications in the management of chronic wounds, showed that the provision medical information and educational tips is an important feature of mobile-based software that can be effective in the selfmanagement of chronic wounds.To achieve this goal, the provision of medical information related to the colostomy surgery and self-care instructions to patients in a simple and understandable manner were considered the main services offered by the software developed in the present study.All medical and educational content in the application was based on scientific texts, and it was supervised by the experts of the research team to help users improve their self-care.
Yin et al. 42 examined the effectiveness of electronic health applications to improve knowledge, QoL, and disease management among inflammatory bowel patients.The reminder system in mHealth software is considered an important factor for adherence to treatment and to improve patient self-care.In this regard, providing reminders and alerts to take drugs and consult with a doctor was another service that was implemented in the software developed in the current study.
The results of the present study show that the average percentage of user satisfaction with the interface was of 87%, which shows attests to its proper and principled design .According to the responses of the users, all parts of the software could be easily accessed, and the main operations could be easily run.In addition, the rate of 85% of positive evaluation of the services and general features of the software shows that all the services provided are in accordance with the basic needs of the users.Finally, the average total score of the two evaluated sections showed that the rate of user satisfaction was of 85%, suggesting that users were satisfied with the visual and graphic features, the medical

Mean percentage 81%
and educational content, the warnings and reminders, and that the software developed is at an acceptable level.
It is worth noting that in countries like Turkey, Brazil, and the United States, software similar to the application produced in the present study has been produced with the aim of providing knowledge and information to colostomy patients.However, none of them include a medication reminder service for patients [36][37][38] such as the one provided in the software produced in the present study.Considering that, before the present study, there was no such software in the Iranian society, and its use can facilitate education, increase awareness, and improve the health and self-care of colostomy patients.

Suggestions
Based on the findings of the current research, we recommend that health care organizations support the production of selfcare software to improve the care provided to patients.Additionally, considering the problems that colostomy patients face postoperatively and the fact that their treatment should be pursued on an ongoing basis, the software developed in the present study can be essential in the achievement of these goals.On the other hand, the mobile-based software developed in the present study could be used in countries that face a shortage of stoma therapy centers and stoma care nurses.Additionally, by using said software, the problems of forgetting the provided training could be solved.Finally, we recommend that all medical staff use the software produced in the present study to improve patient self-care to provide patients with easy and continuous access to necessary training and reduce learning time, and to make it available to all patients under their care and encourage them to use it.

Funding
The authors declare that they have received no funding from agencies in the public, private or non-profit sectors for the conduction of the present research.

1 .
Additionally, three scales were designed to analyze the results obtained from the checklist as follows: Total evaluation scale: Three intervals were considered in the design of this scale: unacceptable (score ranging from 0 to 13), relatively acceptable (score ranging from 13 to 20.8), and acceptable (score ranging from 20.8 to 26) (►Fig. 1). 2. User-friendliness indicator scale: In this scale, three intervals were also considered: unacceptable (score ranging from 0 to 7.5), relatively acceptable (score ranging from 7.5 to 12), and acceptable (score ranging from 12 to 15) (►Fig.2). 3. Performance indicator scale for the types of services provided by the software: As the previous two, this scale is also based on three intervals: unacceptable (score ranging from 0 to 5.5), relatively acceptable (score ranging from 5.5 to 8.8), and acceptable (score ranging from 8.8 to 11) (►Fig. 3).

Fig. 3
Fig.3Performance indicator scale for the services provided by the software.

Table 1
Frequency distribution of the demographic characteristics of the patients participating in the software evaluation

Table 2
Scores and their frequency distributions assigned by patients in the evaluation of the user interface of the colostomy selfcare software

Table 3
Frequency distribution and scores assigned by experts regarding the evaluation of the services and general features of the colostomy self-care software

Table 4
Frequency distribution and scores assigned by patients about the evaluation of the services and general features of the colostomy self-care software In general, is the educational content of the software, including medical knowledge and self-care advice taught through videos and pictures, sufficient and appropriate to the needs of patients?In general, is the educational content of the software useful to improve the care of patients with colostomy?