Effectiveness of Health Education as a Nursing Intervention in Improving Quality of Life and Reducing Symptoms of Anxiety and Depression in Ostomy Patients Following Digestive Surgery: A Quasi-Experimental Study.
Phase: NA
Conditions: Colon Cancer, Inflamatory Bowel Disease (Crohn&#39;s and Ulcerative Colitis), Colitis Ulcerative
Sponsor: Hospital Clinico Universitario de Santiago

EFFECTIVENESS OF HEALTH 
EDUCATION AS A NURSING 
INTERVENTION IN 
INCREASING QUALITY OF LIFE 
AND REDUCING SYMPTOMS OF 
ANXIETY AND DEPRESSION IN 
PATIENTS UNDERGOING 
OSTOMATES AFTER DIGESTIVE 
SURGERY. A QUASI-
EXPERIMENTAL STUDY.
V2. September 26, 2024
Promoter: 
Mª Mercedes Andrade Roca
Researchers
Principal: Mª Mercedes Andrade Roca
Colaboradores:
Emilio Rubén Pego Pérez, 
Nuria Martínez Laranga,
Tomás Mendoza Caamaño (Doctorando)

1 
 
Table of Contents 
Summary ....................................................................................................................................... 2 
Background and justification ........................................................................................................ 2 
Objective ....................................................................................................................................... 5 
TYPE OF STUDY ........................................................................................................................ 5 
MATERIAL AND METHODS .................................................................................................... 5 
Population ................................................................................................................................. 6 
Patient Selection ........................................................................................................................ 6 
Variables ................................................................................................................................... 6 
Outcome measures .................................................................................................................... 6 
COLLECTION AND ARCHIVING OF INFORMATION. ......................................................... 7 
DATA ANALYSIS. ...................................................................................................................... 8 
Timeline .................................................................................................................................... 9 
Sample size justification............................................................................................................ 9 
Informed consent ..................................................................................................................... 10 
Ethical-legal aspects ................................................................................................................ 10 
Economic report .......................................................................................................................... 11 
Bibliography ................................................................................................................................ 11 
Data collection notebook ............................................................................................................. 13 
ANNEX I. Development of interventions ................................................................................... 29 
 
 
 

2 
 
Summary 
The project presented is a prospective quasi-experimental study that will be carried out in 
the Ostomy Clinic of the University Hospital Complex of Santiago de Compostela. The 
main objective is to evaluate the effectiveness of health education as a nursing 
intervention to reduce anxiety and depression and improve the quality of life of ostomy 
patients after digestive surgery. It will focus on adult patients who have undergone an 
ostomy elimination, excluding terminally ill patients and those with cognitive limitations. 
The study proposes a clinical follow-up of patients from admission until several months 
after receiving the health education program. Validated scales will be used to measure 
quality of life, anxiety, and depression. The intervention will include health education 
workshops and continuous monitoring by specialized nurses. 
MeSH Terms: Ostomy, Quality of Life, Anxiety, Depression, Nursing Care, Patient 
Education, Stoma Care. 
Background and justification 
Ostomy is defined as a route created by surgery, which, due to accidental or disease 
reasons, allows a patient to recover respiratory, eliminatory (feces or urine) or feeding 
function.1 
An elimination ostomy is the creation of a hole in the abdomen by surgical procedure to 
eliminate waste products, externalizing a portion of viscera, responsible for expelling 
feces, urine or any type of secretion into a bag, called a stoma. Bull 2.3 
The group of elimination ostomies are the most frequent, with similar numbers worldwide 
and nationally. The highest percentage is colostomies (~55%), followed by ileostomies 
(~31-35%) and urostomies (~14-10%). Overall, due to their permanence, temporary 
contracts predominate in 60-80% of cases and permanent contracts in 20-40%. The 
prevalence in Galicia can be seen in Table 1: 4.5 
Table 1. Prevalence of elimination ostomies in Galicia. 
 
A Coruña 
Ourense 
Pontevedra 
Santiago 
Temporary 
45,8% 
65% 
40.5% 
98% 
Definitive 
54,2% 
35% 
59.5% 
2% 
 
The etiologies that justify an ostomy are cancer (69.5%), Crohn's disease (8.1%), 
diverticulitis (7.2%), ulcerative colitis (3%) and other diseases (12%). In 2018, it was 
estimated that 70,0000 to 100,000 people with ostomates were estimated in Spain, with 

3 
 
an incidence of 0.34 thousand inhabitants/year, with a rate of 1.5 ostomates per 1,000 
inhabitants 4.5 
The creation of a removal ostomy affects the patient's quality of life in different aspects: 
- 
Physical factors: skin complications, difficulty in handling the stoma and devices, 
alterations in activities of daily living. 
- 
Social challenges: Social isolation and difficulties in interpersonal relationships. 
- 
Impact on spiritual well-being 
- 
Psychological Challenges: Anxiety, depression, sadness, changes in self-image 
and low self-esteem appear. 6, 7, 8 
Ostomy patients can manage the changes associated with their new condition through the 
use of adaptive mechanisms. Without these mechanisms, patients are at a higher risk of 
experiencing an increase in stress, anxiety, and depression. They also report anguish, low 
self-esteem, interruption of communication, stigma, loss of self-image, hopelessness, 
insecurity and, in very serious cases, suicidal ideation. This psychological affectation 
seriously harms the patient's quality of life and is related to the impact of the new reality 
and self-care, so the importance of interventions and supports that promote effective 
adaptation is justified. 9 
Initial support and health education in the ostomy consultation is a benchmark in the Good 
Clinical Practice Guidelines for a significant improvement in the patient's independence 
and quality of life thanks to the essential contributions of nursing care plans and patient 
guidance in their new reality.Acts 3, 10 
The stoma therapist nurse, through a comprehensive evaluation, design of personalized 
care plans and collaboration with a multidisciplinary team, offers pre- and post-operative 
training, marks the location of the stoma, evaluates and controls complications, and 
teaches the management of necessary devices and care, with continuous monitoring and 
nutritional advice to optimize the patient's health and self-efficacy.2 
94% of patients and 95% of nurses consider the existence of specialized ostomy care 
necessary, but it is estimated that 35% of ostomy patients do not have an ostomy 
consultation in their reference hospital, which represents a 50% increase in health 
expenditure compared to patients who do have a stoma therapist nurse.Acts 4, 5 
 
 
Patients with ostomy 
consultation 
Patients 
without 
ostomy consultation 
 
 
Type of Cost 
Group I 
Group II 
Difference Group I vs Group II 
Direct healthcare 
 
 
-68% 
Materials 
 
 
-10% 

4 
 
Type of Cost 
Group I 
Group II 
Difference Group I vs Group II 
Total Direct Costs 
 
 
-48% 
 
Image 1 : Cost-Effectiveness Study of Specialty Ostomy Care 
 
All of the above justifies this work focused on increasing the patient's quality of life with 
health education and nursing interventions to reduce symptoms of anxiety and depression 
in patients with elimination ostomies. 
The increase in life expectancy and the success of cancer screening programmes, which 
in Galicia allow 7 out of 10 tumours to be detected early, mean that chronic diseases such 
as colorectal cancer or IBD are more prevalent. The surgeries necessary to treat these 
diseases and the ostomy resulting from the therapeutic process translate into increasing 
numbers of people with ostomies.4 
The ostomy has a psychological and social impact that can cause self-care problems, 
decreased self-esteem, changes in body image and alterations in family and work 
relationships. These changes require a great effort of adaptation on the part of the patient. 
Nurses play a crucial role in helping patients adjust to their new reality. This includes 
providing comprehensive and individualized care, as well as pre- and post-operative 
education for the patient and their family, a fundamental pillar to reduce postoperative 
complications, promoting dialogue and family cohesion and, consequently, improving 
quality of life. Continuous monitoring by the nurse is essential to ensure a correct 
adaptation of the patient to their new situation. 
However, ostomy patients cannot be pigeonholed, as they have different needs and 
concerns, they come from different social, cultural and religious circles where they have 
been taught different lifestyles and attitudes to face the disease, which will make the 
individual a unique being, who will require individualized care, and some will accept 
their stoma better than others.11 
Identifying and treating anxiety and depression in these patients is crucial to improving 
their quality of life and facilitating their adaptation to the new lifestyle. There are studies 
that identify other risk factors for increased anxiety and depression such as not having 
contact with other ostomates or not having a pre-surgery stoma marking and protective 
factors such as an active work situation.12 
Deepening the interventions that increase the quality of life of ostomy patients allows the 
creation of health education strategies and follow-up of patients according to their specific 
and personal needs, which will result in a reduction in symptoms of anxiety and 
depression after stoma is performed. 

5 
 
The aim of this study is to assess the interventions carried out to reduce or minimise the 
psychological impact of the stoma on ostomy patients and improve their quality of life, 
not only as a fundamental basis for care but also in post-discharge surveillance.11 
Study hypothesis 
The implementation of health education workshops will reduce the symptoms of anxiety 
and depression and improve the quality of life in ostomy patients. 
Objective 
General objective 
To assess the effectiveness of health education as a nursing intervention for the reduction 
of anxiety and depression symptoms and the increase in quality of life in patients 
ostomized after digestive surgery. 
Specific objectives 
1. To assess and compare the level of insomnia in ostomy patients before the 
educational intervention and at 3 months after the intervention. 
2. To assess and compare the levels of anxiety and depression before the intervention 
and at 3 months after the intervention, in ostomy patients. 
3. To assess and compare quality of life before surgery and at 3 months after surgery in 
ostomy patients. 
4. To assess and compare the risk of suicide before the intervention and at 3 months 
after the intervention in ostomy patients. 
5. To establish and compare symptoms of anxiety and depression before the 
intervention and at 3 months after the intervention in ostomy patients. 
6. To reduce the psychological impact of anxiety and depression in ostomy patients. 
TYPE OF STUDY 
A prospective quasi-experimental analytical study without randomization is proposed, to 
be carried out in the Ostomy Clinic of the University Hospital Complex of Santiago de 
Compostela belonging to the health area of Santiago and Barbanza. 
MATERIAL AND METHODS 
This is a quasi-experimental, longitudinal and prospective study, which will be 
carried out in patients who have been ostomized and treated in the ostomy unit at the 
University Hospital Complex of Santiago de Compostela, collected consecutively by 
physicians or nurses from the Ostomy and Digestive Surgery Service. 

6 
 
The period of inclusion of patients who will receive the health education program 
will be from the authorization of the ethics committee until approximately April 15, 2025 
(failing this, the inclusion period will be extended until 83 patients are obtained). For each 
patient, a clinical follow-up is carried out on admission, discharge, three months and after 
the completion of the health education program. 
Population 
For the preparation of this study, the target population has been taken as patients 
undergoing digestive surgery with the need for an elimination ostomy, treated in the 
ostomy consultation of the CHUS from the favorable resolution of the Ethics Committee 
until April 15 , 2025, in any case the study may be increased until the minimum sample 
size is completed. 
Patient Selection 
All patients with ostomy after digestive surgery who have an elimination ostomy 
and attend the Ostomy Clinic of the CHUS, recruited by these nurses, will be selected. 
The inclusion criteria will be  
- 
Adults 
- 
Patients who have undergone a permanent or permanent ostomy for more than 6 
months or have undergone a temporary ostomy for more than 6 months  
- 
Volunteers for the study with definitive digestive ostomy in the health area of 
Santiago and Barbanza 
- 
Patients who agree to participate in the study 
Exclusion criteria: 
- 
Hospice patients 
- 
Patients with cognitive limitations 
Variables  
- 
Socio-epidemiological data: sex, age, level of education, marital status, 
occupation, income level, race... 
- 
Data related to quality of life: physical function and role, body pain, general 
health, vitality, social function, emotional role, and mental health. 
- 
Data related to the ostomy: type, date of placement, function, type of surgery... 
- 
Main symptoms of anxiety and depression: Physical symptoms, Emotional 
symptoms, Cognitive symptoms and behavioral symptoms. 
- 
The patient's level of knowledge about their ostomy, addressing feeding, device 
management, and identification of stoma/skin complication and skills 
Instruments 
 

7 
 
BAI Scale (Beck Anxiety Inventory) 
This scale is used to measure the degree of anxiety, independently of those symptoms that 
may be shared with depression. It has mainly been designed for an adult target population. 
According to Cronbach's alpha value, the internal consistency of this scale is higher than 
0.8, which is a high value of internal validity. It consists of 21 items evaluated from 0 to 
3 points, thus its maximum score of 63 (15).  
Depending on the score obtained, four cut-off points are established (15): 
- 0-7 points: minimal anxiety. 
 - 8-15 points: mild anxiety. 
- 16-25 points: moderate anxiety. 
- 26-63 points: severe anxiety.  
BDI Scale (Beck Depression Inventory)  
This scale assesses the presence of depression-related symptoms in the individual (such 
as feelings of guilt, sadness, sense of failure, suicidal ideation, or pessimism) using 21 
items with 4 response options in each (corresponding to the absence of the symptom or a 
mild, moderate or severe condition). Each of the items has a value of 0 to 3 points, thus 
being possible to obtain a score between 0 and 63 points. This scale has adequate internal 
consistency, with Cronbach's alpha values ranging from 0.78 to 0.92 (16). 
 We can determine 4 cut-off points on this scale according to the score obtained (16): - 0-
13 points: minimal depression.  
- 14-19 points: mild depression.  
- 20-28 points: moderate depression.  
- 29-63 points: severe depression.  
EADG SCALE (Goldberg Anxiety and Depression Scale)  
This scale arises as a modification of the Psychiatric Assessment Schedule, in order to 
obtain a scale that is easier to perform. It is made up of two subscales, an anxiety subscale, 
and a depression subscale. This scale has a sensitivity of 83.1%, a specificity of 81.8%, 
and a positive predictive value of 95%. Its Cronbach's alpha value is 0.758 (17).  
Each subscale consists of 9 dichotomous response items (yes/no). It consists of two main 
cut-off points (17):  
- > 4 points on the anxiety scale  
- > 2 points on the depression scale  

8 
 
SF-36 Scale (Quality of Life) 
The SF-36 is scored in two steps. The pre-coded numeric values are first recoded 
according to the score key in Table 1. Note that each item is scored, and that a higher 
number indicates that the subject is in better overall health. In addition, each item is 
graded on a scale of 0 to 100, with 0 and 100 being the lowest and highest possible scores. 
The scores show the proportion of the possible score that was actually obtained. The 
scores of the eight scales are obtained in step 2 by averaging the items of the same scale. 
Table 2 shows the components that were averaged to obtain each scale. Scale scores are 
not based on items with omitted data (items that are left blank).  
Therefore, the scale scores represent the average of all the items on the scale to which the 
respondent has responded.  
Outcome measures  
-
 
 
 
values for depression are 2 points or less 
COLLECTION AND ARCHIVING OF INFORMATION. 
The data will be completed in all cases by the principal investigator and linked to 
SERGAS (Galician Health Service), and will only be accessible by the researcher himself 
and by the doctoral student who will carry out the analysis of the data. No one outside the 
investigator may make changes to the data collected relating to the patient. The doctoral 
student will not have identification data of the patients and will follow aspects related to 
their confidentiality. 
Data will be entered into a database created for this purpose in the Microsoft Excel 
2013 program. Prior to the start of the data analysis, the database will be validated to 
ensure its quality and once validated, it will be closed. Subsequently, the IBM SPSS 24 
statistical program will be used for data processing and analysis. 
The recruitment procedure will be carried out at the University Hospital Complex of 
Santiago de Compostela, patients with ostomies will be recruited in the ostomy nursing 
consultation. There is also the possibility of the collaboration of the surgeons who carry 
out the digestive surgery consultation in recruitment. 
DATA ANALYSIS. 
A descriptive analysis will be carried out using measures of central tendency 
(mean (M) or median) and dispersion (standard deviation (SD) when deemed appropriate 
for quantitative variables, and percentages for qualitative variables. To analyze the 
differences between groups, the Chi2 test was used for qualitative variables. ). To 
establish correlation between groups, the Chi2 test was used for qualitative variables and 

9 
 
the Kruskal-Wallis test for quantitative variables. To establish differences between the 
groups, the Mann Whitney U technique was used. A significance level of 0.05 was chosen 
to select the variables finally included in the binary logistic regression model. All analyses 
and calculations will be performed using the PASW statistical package (version 24.0; 
SPSS Inc., Chicago, Illinois). 
 
 
 
Timeline 
Task 
Previous
MONTH 
1 
MONTH 
2 
BREAK 
MONTHS 
BREAK 
MONTHS 
MONTH 
Literature 
review 
June 
2024 
 
 
 
 
 
Study design 
August 
2024 
 
 
 
 
 
Submission of 
documentation
 
September 
2024 
 
 
 
 
Database 
design 
 
 
September 
2024 
 
 
 
Patient 
recruitment 
 
 
 
November 
2024 
to 
April 
15, 
2025  
 
 
Statistical 
analysis 
 
 
 
 
December 
2024 
to 
May 2025 
 
Scientific 
dissemination 
 
 
 
 
 
June 
2025 
 
Sample size justification 
The CHUS serves 381,457 people (Annex I), taking into account the rate of 1.5 ostomized 
people per 1000 inhabitants we obtain a figure of 572 users with ostomy in the CHUS. 
Using the formula to calculate the sample size, with a confidence level of 95% and a 
margin of error of 10%, a minimum sample of 83 patients is estimated to ensure the 
representativeness and validity of the study results. 
Sample size =
 

10 
 
Informed consent 
The informed consent forms have been drafted, to be delivered individually to the 
participants. 
Ethical-legal aspects 
The review and approval of the research plan by the Santiago-Lugo Research 
Ethics Committee is requested, following local and international regulations in the field 
of medical research and the standards established by the Declaration of Helsinki. 
The development of this thesis will be carried out respecting the Declaration of 
Helsinki of the World Medical Association of 1964 and ratifications of the following 
assemblies on ethical principles for medical research on human beings, RD 1090/2015, 
of December 24, on clinical trials, specifically in the provisions of its article 38 on good 
clinical practices,  and the Convention on Human Rights and Biomedicine, signed in 
Oviedo on 4 April 1997 and subsequent proceedings. The researchers participating in this 
study undertake that all clinical data collected from the study subjects will be separated 
from the personally identifiable data, so that the anonymity of the patients is ensured; 
respecting the Law on the Protection of Personal Data and Guarantee of Digital Rights 
(Organic Law 3/2018, of 5 December), Law 41/2002, of 14 November (basic regulation 
of patient autonomy and rights and obligations in terms of clinical information and 
documentation), as well as Law 3/2001, of 28 May (regulating informed consent and 
clinical documentation),  as well as Law 3/2005, of 7 March, amending Law 3/2001 and 
Decree 29/2009 of 5 February, which regulates access to electronic medical records. The 
patient's data will be collected by the investigator in the study-specific data collection 
notebook (CRD). Each CRD will be encrypted, protecting the patient's identity. Only the 
research team and the health authorities, who have a duty to maintain confidentiality, will 
have access to all the data collected for the study. Information may only be transmitted to 
third parties that cannot be identified. 
An Information Sheet will be provided to the participants and informed consent.  
Information regarding the identity of patients will be and is considered 
confidential for all purposes. In order to properly maintain confidentiality with respect to 
patient information, an appropriate coding and identification dissociation will be carried 

11 
 
out in the database, so that only the researcher may associate such data with an identified 
or identifiable person. The database that will generate the study will not contain any 
identification of the patient. Once the study is complete, the database will be deleted. 
With regard to the data of the study, the provisions of the Organic Law on "Protection of 
Personal Data" in force will be followed. 
Commitment to dissemination of results 
The results of this study will be disseminated as communications or conference posters, 
potential scientific articles and as academic work regardless of the results obtained. 
 
Economic report 
Not applicable. 
Bibliography 
1. Álvarez Sariego M. Quality of life in patients with ostomies: Nursing intervention. 
Point. 
2022; 
Vol. 
V, 
No. 
47:52-77. 
Available 
in: 
https://www.npunto.es/content/src/pdf/6218a3fa0f6a6NPvolumen47.pdf?0.0909
1623938243054 
2. Álvarez González D, Crespo Fontán B, Fabeiro Mouriño MJ, et al. Nursing guide 
for the care of ostomy patients. Santiago de Compostela: Galician Proctology 
Group. 
Available 
in: 
https://sociga.net/wp-
content/uploads/2018/06/GU%C3%8DA-DE-ENFERMER%C3%8DA-PARA-
EL-CUIDADO-DEL-PACIENTE-OSTOMIZADO.docx 
 
3. 
Ontario; 2019. Disponible en: https://rnao.ca/bpg/language/apoyo-adultos-que-
esperan-o-viven-con-una-ostom%C3%ADa 
4. Cobos Serrano JL, ed. White Book of Ostomy in Spain. Madrid: Coloplast 
Medical 
Products; 
2018. 
Available 
in: 
https://www.coloplast.es/Global/Spain/Ostomia/Otros/PDF/Libro%20blanco%2
0de%20la%20Ostom%C3%ADa.pdf 
 
5. General Nursing Council. Framework of action of the Expert Nurse in 
Stomatherapeutic Care of Ostomized People, Relatives and/or Caregivers. 
Madrid: Spanish Institute of Nursing Research; 2022. Available in: 
https://www.colegioenfermeriahuesca.org/wp-
content/uploads/2022/07/MARCO-ACTUACION-ESTOMATERAPEUTICOS-
MARZO-2022.pdf 

12 
 
 
6. Alenezi A, McGrath I, Kimpton A, Livesay K. Quality of life among ostomy 
patients: A narrative literature review. J Clin Nurs. 2021; 30(21-22):3111-23. 
Disponible en: https://doi.org/doi:10.1111/jocn.15840 
7. Boraii S. A Descriptive Study to Assess Quality of Life in Egyptian Patients With 
a Stoma. Ostomy Wound Management. 2017; 63(7):28 33. Disponible en: 
https://www.hmpgloballearningnetwork.com/site/wmp/article/descriptive-study-
assess-quality-life-egyptian-patients-stoma 
8. Fingren J, Lindholm E, Petersén C, Hallén AM, Carlsson E. A prospective, 
explorative study to assess adjustment 1 year after ostomy surgery among 
Swedish patients. Ostomy Wound Management. 2018; 64(6):12-22. Disponible 
en: https://doi.org/10.25270/owm.2018.6.1222 
9. Alcaraz Castañeda G, Fernández Fernández P, Granados Pérez M, et al. 
Therapeutic education program aimed at ostomy patients. Digital Auditorium. 
2016; (23). Available in: http://www.index-f.com/para/n23/002.php 
10. Artola Etxeberría M, García Manzanares ME, García Moreno E, et al. Guide to 
practical recommendations. Ostomy in Primary Care. Madrid: IM&C; 2023. 
Available 
in: 
https://www.consejogeneralenfermeria.org/profesion/guias-
clinicas/send/67-guias-clinicas/2439-guia-de-recomendaciones-practica-en-
ostomia-en-atencion-primaria 
11. Gómez del Río N, Mesa Castro N, Caraballo Castro C, et al. Nursing care in the 
psychological impact of ostomy patients. JAN. Journal of Nursing. 2013; 7(3). 
Available 
in: 
http://ene-
enfermeria.org/ojs/index.php/ENE/article/view/279/pdf_18 
12. Andrés Gómez N, Ruiz Falo C, Crespo Redondo D, Oto Puyuelo I. Ostomy, 
anxiety and depression... Is there a relationship? Rev Paraninfo Digital. 2016;23. 
Available in: http://www.index-f.com/para/n23/013.php 
13. Khalilzadeh Ganjalikhani M, Tirgari B, Roudi Rashtabadi O, et al. Studying the 
effect of structured ostomy care training on quality of life and anxiety of patients 
with permanent ostomy. Int Wound J. 2019;16:1383-90. Disponible en: 
https://doi.org/10.1111/iwj.13201 
14. Krouse RS, Grant M, McCorkle R, et al. A chronic care ostomy self-management 
program for cancer survivors. Psychooncology. 2016 May; 25(5):574-81. 
Disponible en: https://doi.org/10.1002/pon.4078 
15. Spanish Researchers of the COF Group. Impact Study: Impact of expert nursing 
care on ostomy patient well-being. XI ECET Congress, Bologna 12-15 June, 
2011. Available in: https://www.coloplastprofessional.es/globalassets/hcp/pdf-
file/v2/spain/local-pages/estudio-impacto-todos-los-posters-en-espanol-1.pdf 
 
 

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Data collection notebook 
Patient Number:  
 
Age
Sex
I prefer not 
 
 
Gender
Non-
(specify)
I prefer not to 
 
 
Marital status
 
 
 
I prefer not to 
 
 
(specify)
Level of studies 
completed 
 
Secondary 
 
Vocational 
 
Univ. or higher 
 
Employment 
status 
 
(specify)
Type of surgery 
 
Type of ostomy
 
 
 
 
 
 
 
 
SF-36 HEALTH SURVEY 
Please mark only one answer: 
1. In general, would you say your health is: 
 
Excellent 
 
Very good 
 
Good 
 
Fair 
 
Poor 
2. How would you rate your current health compared to a year ago? 
 
Much better now than a year ago 
 
Somewhat better now than a year ago 

14 
 
About the same as a year ago
 
Somewhat worse now than a year ago 
 
Much worse now than a year ago 
The following questions refer to activities or things you might do on a normal day: 
3. Does your current health limit you in vigorous activities, such as running, lifting heavy 
objects, or participating in strenuous sports? 
 
Yes, it limits me a lot 
 
Yes, it limits me a little 
 
No, it does not limit me at all 
4. Does your current health limit you in moderate activities, such as moving a table, 
vacuuming, bowling, or walking more than an hour? 
 
Yes, it limits me a lot 
 
Yes, it limits me a little 
 
No, it does not limit me at all 
5. Does your current health limit you in carrying or lifting groceries? 
 
Yes, it limits me a lot 
 
Yes, it limits me a little 
 
No, it does not limit me at all 
6. Does your current health limit you in climbing several flights of stairs? 
 
Yes, it limits me a lot 
 
Yes, it limits me a little 
 
No, it does not limit me at all 
7. Does your current health limit you in climbing one flight of stairs? 
 
Yes, it limits me a lot 
 
Yes, it limits me a little 
 
No, it does not limit me at all 
8. Does your current health limit you in bending or kneeling? 
 
Yes, it limits me a lot 
 
Yes, it limits me a little 
 
No, it does not limit me at all 
9. Does your current health limit you in walking more than a kilometer? 
 
Yes, it limits me a lot 

15 
 
Yes, it limits me a little
 
No, it does not limit me at all 
10. Does your current health limit you in walking several blocks (hundreds of meters)? 
 
Yes, it limits me a lot 
 
Yes, it limits me a little 
 
No, it does not limit me at all 
11. Does your current health limit you in walking one block (about 100 meters)? 
 
Yes, it limits me a lot 
 
Yes, it limits me a little 
 
No, it does not limit me at all 
12. Does your current health limit you in bathing or dressing yourself? 
 
Yes, it limits me a lot 
 
Yes, it limits me a little 
 
No, it does not limit me at all 
The following questions refer to problems in your work or daily activities: 
13. During the past 4 weeks, have you had to reduce the time spent on work or other daily 
activities due to your physical health? 
 
Yes 
 
No 
14. During the past 4 weeks, have you done less than you would have liked to do because 
of your physical health? 
 
Yes 
 
No 
15. During the past 4 weeks, have you stopped doing some tasks at work or other daily 
activities due to your physical health? 
 
Yes 
 
No 
16. During the past 4 weeks, have you had difficulty performing work or daily activities 
(e.g., it was more difficult than usual) due to your physical health? 
 
Yes 
 
No 

16 
 
17. During the past 4 weeks, have you had to reduce the time spent on work or other daily 
activities due to any emotional problems (such as feeling depressed, anxious, or 
nervous)? 
 
Yes 
 
No 
18. During the past 4 weeks, have you done less than you would have liked due to 
emotional problems (such as feeling depressed, anxious, or nervous)? 
 
Yes 
 
No 
19. During the past 4 weeks, have you not done your work or daily activities as carefully as 
usual due to emotional problems (such as feeling depressed, anxious, or nervous)? 
 
Yes 
 
No 
20. During the past 4 weeks, to what extent have physical health or emotional problems 
interfered with your usual social activities with family, friends, neighbors, or others? 
 
Not at all 
 
Slightly 
 
Moderately 
 
Quite a bit 
 
Extremely 
21. Did you have pain in any part of your body during the past 4 weeks? 
 
No, none 
 
Yes, very little 
 
Yes, a little 
 
Yes, moderate 
 
Yes, a lot 
 
Yes, very severe 
22. During the past 4 weeks, how much did pain interfere with your normal work 
(including both work outside the home and housework)? 
 
Not at all 
 
Slightly 
 
Moderately 
 
Quite a bit 

17 
 
Extremely
The following questions refer to how you have been feeling and how things have been going 
for you during the past 4 weeks. For each question, please answer what most closely matches 
how you have felt: 
23. During the past 4 weeks, how often did you feel full of energy? 
 
Always 
 
Almost always 
 
Often 
 
Sometimes 
 
Occasionally 
 
Never 
24. During the past 4 weeks, how often did you feel very nervous? 
 
Always 
 
Almost always 
 
Often 
 
Sometimes 
 
Occasionally 
 
Never 
25. During the past 4 weeks, how often did you feel so down that nothing could cheer you 
up? 
 
Always 
 
Almost always 
 
Often 
 
Sometimes 
 
Occasionally 
 
Never 
26. During the past 4 weeks, how often did you feel calm and peaceful? 
 
Always 
 
Almost always 
 
Often 
 
Sometimes 
 
Occasionally 

18 
 
Never
27. During the past 4 weeks, how often did you feel full of energy? 
 
Always 
 
Almost always 
 
Often 
 
Sometimes 
 
Occasionally 
 
Never 
28. During the past 4 weeks, how often did you feel downhearted and blue? 
 
Always 
 
Almost always 
 
Often 
 
Sometimes 
 
Occasionally 
 
Never 
29. During the past 4 weeks, how often did you feel worn out? 
 
Always 
 
Almost always 
 
Often 
 
Sometimes 
 
Occasionally 
 
Never 
30. During the past 4 weeks, how often did you feel happy? 
 
Always 
 
Almost always 
 
Often 
 
Sometimes 
 
Occasionally 
 
Never 
31. During the past 4 weeks, how often did you feel tired? 
 
Always 

19 
 
Almost always
 
Often 
 
Sometimes 
 
Occasionally 
 
Never 
32. During the past 4 weeks, how often have physical health or emotional problems 
interfered with your social activities (such as visiting friends or relatives)? 
 
Always 
 
Almost always 
 
Often 
 
Sometimes 
 
Occasionally 
 
Never 
Please indicate whether you think the following statements are true or false: 
33. I seem to get sick easier than other people. 
 
Absolutely true 
 
Mostly true 
 
 
 
Mostly false 
 
Absolutely false 
34. I am as healthy as anybody I know. 
 
Absolutely true 
 
Mostly true 
 
 
 
Mostly false 
 
Absolutely false 
35. I expect my health to get worse. 
 
Absolutely true 
 
Mostly true 
 
 
 
Mostly false 

20 
 
Absolutely false
36. My health is excellent. 
 
Absolutely true 
 
Mostly true 
 
 
 
Mostly false 
 
Absolutely false 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

21 
 
BECK ANXIETY INVENTORY (BAI) 
Indicate the degree to which you have been affected by each of the following symptoms 
during the past week and at the present moment. Choose the option that best corresponds: 
 
0 = Not at all 
 
1 
 
 
2 = Moderately, it was very unpleasant, but I could bear it 
 
3 = Severely, I could hardly bear it 
Symptom
0
1
2
3
1. Tingling or numbness 
 
 
 
 
2. Feeling of heat 
 
 
 
 
3. Shaking legs 
 
 
 
 
4. Inability to relax 
 
 
 
 
5. Fear that something terrible will happen 
 
 
 
 
6. Dizziness or lightheadedness 
 
 
 
 
7. Palpitations or tachycardia 
 
 
 
 
8. Feeling of instability or physical insecurity 
 
 
 
 
9. Terrors 
 
 
 
 
10. Nervousness 
 
 
 
 
11. Feeling of suffocation 
 
 
 
 
12. Hand tremors 
 
 
 
 
13. Generalized shaking or trembling 
 
 
 
 
14. Fear of losing control 
 
 
 
 
15. Difficulty breathing 
 
 
 
 

22 
 
Symptom 
0 
1 
2 
3 
16. Fear of dying 
 
 
 
 
17. Startling 
 
 
 
 
18. Digestive or abdominal discomfort 
 
 
 
 
19. Pallor 
 
 
 
 
20. Facial flushing 
 
 
 
 
21. Sweating (not due to heat) 
 
 
 
 
TOTAL: 
A.F.: 
A.S.: 
BECK DEPRESSION INVENTORY (BDI) 
This questionnaire contains several groups of statements. Please read each group carefully. 
Indicate which of the statements in each group best describes how you have felt during the 
past week, including today. If more than one statement in a group applies to you, mark them 
as well. Make sure to read all the statements in each group before making your choice. 
 
1. 
 
 I do not feel sad. 
 
 I feel sad. 
 
 I feel sad all the time and I can't snap out of it. 
 
 I feel so sad and unhappy that I can't bear it. 
 
2. 
 
 I am not particularly discouraged about the future. 
 
 I feel discouraged about the future. 
 
 I feel I have nothing to look forward to. 
 
 I feel that the future is hopeless and things cannot improve. 
 
3. 

23 
 
I do not feel like a failure.
 
 I feel I have failed more than most people. 
 
 As I look back, I see a lot of failures. 
 
 I feel I am a complete failure as a person. 
 
4. 
 
 I get as much satisfaction out of things as I used to. 
 
 I don't enjoy things as much as I used to. 
 
 I don't get real satisfaction out of anything anymore. 
 
 I am dissatisfied or bored with everything. 
 
5. 
 
 I don't feel particularly guilty. 
 
 I feel guilty a good part of the time. 
 
 I feel guilty most of the time. 
 
 I feel guilty all the time. 
 
6. 
 
 I don't feel I am being punished. 
 
 I feel I may be punished. 
 
 I expect to be punished. 
 
 I feel I am being punished. 
 
7. 
 
 I am not disappointed in myself. 
 
 I am disappointed in myself. 
 
 I am disgusted with myself. 
 
 I hate myself. 
 
8. 

24 
 
I don't feel I am worse than anybody else.
 
 I am critical of myself for my weaknesses or mistakes. 
 
 I blame myself all the time for my faults. 
 
 I blame myself for everything bad that happens. 
 
9. 
 
 I don't have any thoughts of killing myself. 
 
 I have thoughts of killing myself, but I would not carry them out. 
 
 I would like to kill myself. 
 
 I would kill myself if I had the chance. 
 
10. 
 
 I don't cry any more than I used to. 
 
 I cry more now than I used to. 
 
 I cry all the time now. 
 
 I used to be able to cry, but now I can't, even though I want to. 
 
11. 
 
 I am no more irritated by things than I ever was. 
 
 I am slightly more irritated now than usual. 
 
 I feel irritated all the time. 
 
 I am not irritated at all by things that used to irritate me. 
 
12. 
 
 I have not lost interest in other people. 
 
 I am less interested in other people than I used to be. 
 
 I have lost most of my interest in other people. 
 
 I have lost all interest in other people. 
 
13. 

25 
 
I make decisions about as well as I ever could.
 
 I put off making decisions more than I used to. 
 
 I have greater difficulty in making decisions than before. 
 
 I can't make decisions at all anymore. 
 
14. 
 
 I don't feel that I look any worse than I used to. 
 
 I am worried that I am looking old or unattractive. 
 
 I believe there are permanent changes in my appearance that make me look 
unattractive. 
 
 I believe that I look ugly. 
 
15. 
 
 I work about as well as before. 
 
 It takes extra effort to get started at doing something. 
 
 I have to push myself very hard to do anything. 
 
 I can't do any work at all. 
 
16. 
 
 I can sleep as well as usual. 
 
 I don't sleep as well as I used to. 
 
 I wake up 1-2 hours earlier than usual and find it hard to get back to sleep. 
 
 I wake up several hours earlier than usual and cannot get back to sleep. 
 
17. 
 
 I don't feel more tired than usual. 
 
 I get tired more easily than I used to. 
 
 I get tired from doing almost anything. 
 
 I am too tired to do anything. 
 

26 
 
18.
 
 My appetite is no worse than usual. 
 
 I don't eat as much as I used to. 
 
 I have a much smaller appetite now. 
 
 I have no appetite at all anymore. 
 
19. 
 
 I haven't lost much weight, or I have gained weight recently. 
 
 I have lost more than 2.5 kilograms. 
 
 I have lost more than 4 kilograms. 
 
 I have lost more than 7 kilograms. 
Are you on a diet to lose weight? 
 
 YES 
 
 NO 
 
20. 
 
 I am no more concerned about my health than usual. 
 
 I am concerned about physical problems like aches, pains, upset stomach, or 
constipation. 
 
 I am so concerned about my physical problems that it is hard to think of much else. 
 
 I am so concerned about my physical problems that I cannot think of anything else. 
 
21. 
 
 I have not noticed any recent change in my interest in sex. 
 
 I am less interested in sex than I used to be. 
 
 I am much less interested in sex now. 
 
 I have lost all interest in sex. 
TOTAL: 
 
 

27 
 
EADG (Goldberg Anxiety and depression scale) 
"If you don't mind, I would like to ask you some questions to find out if you have 
experienced any of the following symptoms in the last two weeks." Symptoms lasting less 
than two weeks or of mild intensity will not be scored. 
 
ANXIETY SUBSCALE 
1. Have you felt very excited, nervous, or tense? 
 
 Yes 
 
 No 
2. Have you been very worried about something? 
 
 Yes 
 
 No 
3. Have you felt very irritable? 
 
 Yes 
 
 No 
4. Have you had difficulty relaxing? 
 
 Yes 
 
 No 
 
If there are 2 or more affirmative answers, continue asking: 
5. Have you slept poorly or had difficulty sleeping? 
 
 Yes 
 
 No 
6. Have you had headaches or neck pain? 
 
 Yes 
 
 No 
7. Have you experienced any of the following symptoms: tremors, tingling, dizziness, 
sweating, or diarrhea? (vegetative symptoms) 
 
 Yes 
 
 No 
8. Have you been worried about your health? 

28 
 
Yes
 
 No 
9. Have you had any difficulty falling asleep or staying asleep? 
 
 Yes 
 
 No 
 
DEPRESSION SUBSCALE 
1. Have you felt low on energy? 
 
 Yes 
 
 No 
2. Have you lost interest in things? 
 
 Yes 
 
 No 
3. Have you lost confidence in yourself? 
 
 Yes 
 
 No 
4. Have you felt hopeless? 
 
 Yes 
 
 No 
 
(If there are affirmative answers to any of the above questions, continue asking): 
5. Have you had difficulty concentrating? 
 
 Yes 
 
 No 
6. Have you lost weight (due to lack of appetite)? 
 
 Yes 
 
 No 
7. Have you been waking up too early? 
 
 Yes 
 
 No 

29 
 
8.
Have you felt slowed down?
 
 Yes 
 
 No 
9. Do you feel you tend to feel worse in the mornings? 
 
 Yes 
 
 No 
 
ANXIETY SCORE: 
DEPRESSION SCORE: 
 
Applicability and dissemination of results 
 
Publication in scientific journals and conferences/posters. 
ANNEX I. Development of interventions 
Session 1 (60 minutes) 
1. Review of the patient's level of knowledge about their ostomy, addressing feeding, device 
management and early identification of stoma and skin complications. 
2. Feedback on what they have learned in the ostomy consultation and theoretical support if 
necessary in those areas in which patients need more help. 
3. Ostomy Management Skills Training Workshop: 
 
It will increase confidence and self-efficacy in daily care. 
 
It reduces anxiety related to possible accidents or complications. 
Session 2 (60 minutes) 
1- Anxiety and Depression - Identifying and Managing Symptoms/Improving Quality of 
Life 
2- Inform patients about the relationship between ostomy and mental health. 
3- Identify symptoms of anxiety and depression. 
4- Provide strategies for managing anxiety and depression. 
5- To promote healthy lifestyle habits adapted to the needs of ostomy patients. 
6- Facilitate social integration and participation in daily activities. 
7- Workshops to be carried out, abdominal breathing and guided visualization. 
1- Introduction and emotional check-in 
 
Welcome and brief presentation of the purpose of the workshop 
 
Quick round of how participants feel 
2- Mindfulness and relaxation techniques: 
 
It helps manage stress and anxiety related to daily ostomy care. 
 
Improvement in the acceptance of the new body situation. 
 
Mindfulness and Mindful Breathing 

30 
 
A brief explanation of mindfulness and its benefits
 
Guided Breath Attention Exercise 
 
Emphasis on the acceptance of bodily sensations 
3- Skills Training: Managing Stress in Everyday Situations 
 
Brief discussion of common situations that generate stress 
 
Teaching a quick stress management technique (e.g., breathing) 
 
Examples of how to apply it in ostomy-related situations 
4- Guided visualization for acceptance and trust 
 
Guidance through visualization focused on body acceptance and confidence 
building 
 
Incorporating Healing and Strength Imagery 
5- Closure and personal action plan 
 
Summary of the techniques learned 
 
Invitation to participants to choose a technique to practice regularly 
 
Short round of sharing about how they feel at the end of the session 
Additional considerations: 
1. Provide a summary booklet with the techniques practiced and suggestions for their daily 
application. 
2. Adapt language and instructions to be inclusive and responsive to the needs of ostomy 
patients. 
3. Be prepared to handle possible emotional reactions during the session. 
4. Offer additional resources or support group information upon completion. 
5. Offer a communication channel (e.g., a WhatsApp group) for questions between sessions 
Session 3. Workshop: Full Life with Ostomy: Healthy Habits and Social Integration 
1. Introduction 
   - Welcome and brief explanation of the objective of the workshop. 
2. Adapted Healthy Lifestyle Habits 
   a) Food 
   b) Physical Exercise 
   c) Rest and Stress Management 
3. Social Integration and Activities of Daily Living 
   a) Effective Communication 
   b) Participation in Activities 
   c) Construction of Support Network 
4. Closure and Additional Resources 
Facilitation Techniques: 
1. Use an interactive approach: Ask quick questions to the group to maintain participation. 
2. Use concrete and relatable examples for each point. 
3. Provide a summary booklet with key points and additional resources. 
4. Encourage participants to briefly share their own experiences or advice, if time permits.