SOCIODEMOGRAPHIC AND SANITATION AND HOUSING INDICATORS ON THE QUALITY OF LIFE OF PEOPLE WITH STOMA

Objectives: To analyze the relationships between the quality of life (QOL) of people with stoma with sociodemographic, clinical, lifestyle, sanitation, and housing indicators. Method: Cross-sectional study with a sample of 106 individuals with stoma interviewed from May to December 2019. A sociodemographic and clinical questionnaire and the City of Hope Quality of Life Ostomy Questionnaire were used. Results: Spiritual well-being (7.71 +/-1.09) was the best performing domain. Quality of life did not differ between men and women (p = 0.372), but was associated with education (< 0.001) and family income (p = 0.025), diabetes (p = 0.008) and alcoholism (p = 0.044), drinking water conditions (p < 0.001), garbage disposal (p = 0.021), having electricity (p = 0.034), housing type (p = 0.026), number of rooms (p = 0.023), and housing coverage (p = 0.021). Conclusion: worse socioeconomic, sanitation, and housing indicators appear to negatively impact the QOL of people with stomata.


INTRODUCTION
Stoma is a word of Greek origin that means opening or mouth and its confection is performed through surgery in order to build a new cavity, temporary or permanent, in the abdominal wall whose function is to eliminate feces, waste and/or urine 1,2 . Among the main causes for this condition are colon and rectal cancer, trauma (gunshot or stab wounds and automobile accidents) and inflammatory bowel diseases (ulcerative colitis and Crohn's disease) 3 .
After the surgical process, these patients go through a major reconfiguration of their anatomy and modifications in their routine and bodily functions. Evacuation and elimination of flatus occur in a completely different way, which is through an ostomy and totally uncontrolled, and they start living daily with a collecting bag attached to the abdomen to store the effluent 4,5 .
Such situations promote a strong emotional impact for people with stoma, because this process causes alterations in self-image and self-esteem, also determining other associated disorders. This change causes various disruptions in their lives that these people have to live with and that impair their quality of life (QOL) 6 . It is believed that social determinants of health, such as sanitation and housing type, impact the QOL of this population.
Quality of life is defined as a subjective evaluation of the positive and negative aspects of life. It is considered in a broad and multidimensional concept, encompassing the notion of holistic well-being, encompassing elements concerning health and extending beyond them. And, it also includes a personal assessment about their life experiences and social well-being 7 .
Patients who need to live with stoma go through an experience that is considered one of the most difficult of their lives, even with the possibility that it is a surgical intervention that can allow increased survival in the cases of cancer patients, as well as in situations that would condition a significant improvement in QOL, as in the case of inflammatory bowel diseases. Still, the making of the stoma is a phenomenon that generates multiple psychosocial effects that directly influence QOL 8 .
Among the changes in the body, the use of the collecting equipment makes it difficult to coexist, due to the concern with the elimination of gases, odor, leakage, and physical discomfort, causing the person with stoma to adopt a posture of detachment, isolation from social coexistence and the work environment, leading him/her to retirement by disability even 5 .
In addition, complications may arise, among them parastomal hernia, stoma prolapse, stenosis, fistula, dermatitis, or peristomal abscess. Or complications at a systemic level, mainly related to hydro-electrolyte disturbances in high output stomata, anemia, pneumonia, and sepsis 2,5 .
the understanding of the state of life of people with stoma and improving care by providing subsidies for better coping with problems and, consequently, improving QOL.

OBJECTIVE
To analyze the relationships between the QOL of people with stoma with sociodemographic, clinical, lifestyle, sanitation, and housing indicators.

MÉTODOS
This is an observational, descriptive, cross-sectional study with a quantitative approach. This study followed the Strengthening The study sample was by convenience, with individuals who proved to be more approachable, collaborative, and available, depending on factors such as availability and frequency of appointments. One hundred and six users with elimination stomata on a temporary or permanent basis, who underwent evaluation at the enterostomal therapy outpatient clinic, were interviewed.
Individuals were included who had elimination stoma (colostomy, ileostomy or urostomy), were 18 years old or older, and were registered with the county's orthotics and prosthetics program. Users with stoma for less than 6 months, hospitalized or with acute illnesses, and who did not undergo outpatient evaluation of stoma enterostomal therapy were excluded.
Data collection was carried out through interviews using two questionnaires with closed-ended questions. The first consisted of a structured questionnaire to assess clinical, sociodemographic, economic, housing and lifestyle data. This questionnaire, prepared by the study team, contained questions regarding age, gender, marital status, number of children, current occupation, religion, education (considered low until incomplete elementary school; medium when complete elementary and high school; and high when incomplete, complete, and post-graduate higher education), monthly income (considered low until two minimum wages; medium between three and four wages; and high when more than four minimum wages), number of residents per household, physical activity practice, and self-reported drinking and smoking. The clinical data investigated were: type of stoma, length of stay of the stoma, the cause of surgery and its respective date, presence of comorbidities, and complications presented.
The second tool used was the City of Hope Quality of Life Ostomy Questionnaire (COH-QOL-OQ), questionnaire developed by Grant and collaborators 10 from another instrument by the authors themselves, in order to assess the exclusive QOL of patients with stoma 11 . This questionnaire was translated, culturally adapted, and validated in Brazil by Gomboski 12 .
The COH-QOL-OQ is composed of 43 questions arranged into 4 domains: physical well-being (BEF), psychological wellbeing (BEP), social well-being (BES), and spiritual well-being (BEE), with answers presented on a scale of 0 to 10

RESULTS
A total of 106 people with stoma, with a mean age of 46.85 (± 15.46) years, participated in the study. Of those, 61 (57.55%) were male, 53 (50.00%) said they lived in the state capital, 70 (66.04%) said they were brown, and 41 (38.68%) were married.
In addition, 56 (52.83%) had a medium level of education (complete elementary and high school). Regarding family income, 86 (81.13%) said they received less than three minimum wages, and 61 (57.55%) said they were catholic (Table 1).   (Table 3). Pearson's linear correlation. * Black pits are holes with or without lining of the internal walls, in which human waste is dumped into the opening and comes into direct contact with the ground, without any kind of treatment; ** These are holes with lining of the internal walls, in which human waste does not come into contact with the ground and does not contaminate the water table; *** Flat structural element, usually horizontal, represented as a concrete plate.
As for QOL, spiritual well-being (7.71 ± 1.09) was the domain with the best rated performance, and social well-being (5.29 ± 1.80) was the most compromised domain among people with stoma (Table 4). There was no significant difference in QOL (p = 0,372) between men and women (Fig. 1). The variables analyzed that were significantly associated with the QOL of people with stomata were education, since people with higher education had higher QOL scores (p < 0.001); family income, since people with higher income had better QOL scores (p = 0,025); and predicted permanence of the ostomy, as people with definitive ostomies had higher mean scores compared to people with ostomies with undetermined prognosis (p = 0,021).
As for sanitation and housing indicators, the results showed that those who consumed untreated water had worse QOL levels (p < 0.001). Those who did not have public garbage collection had worse QOL (p = 0,021). The worse the housing (p = 0,026) and the fewer the number of rooms (p = 0,023), the worse the QOL. Housing with electricity conferred better QOL to this public (p = 0,034). Those who lived in a house with a straw roof obtained worse levels of QOL (p = 0,021).

DISCUSSION
The results showed that the majority of people with stoma were male and aged between 40 and 50 years, this finding meets the evidence of another study, showing the same prevalence of gender and age 14 . These results may be justified by the fact that the male population uses health services and preventive measures less frequently, leading them to seek medical care late, when they present manifestations of worsening diseases 15 . In addition, men have greater exposure to accidents and injuries due to external causes 14,15 .
Regarding marital status, most were married and the self-reported skin color was brown, results that corroborate similar studies 16,17 . Although most are married, there is a feeling of fear and insecurity regarding the partner, due to the new condition in which they find themselves physically, living with the stoma and the collecting equipment generate psychological and emotional problems, bringing feelings of shame and lack of sexual interest 14,16 .
Regarding education and monthly family income, the results showed a situation of difficulty and social exclusion experienced by this clientele, which may make it impossible and difficult to acquire the materials needed for treatment as people with stomata, as well as basic life items, such as food, health, housing, education, leisure, and safety, which are indispensable to have QOL 18 . The results pointed out that people with education and high income had better QOL scores, in the same direction as a US study in which people with higher income had better QOL 19 .
With regard to education level, there was a predominance of low education, as in other similar studies 14,16,20 .
The low level of education is a worrisome factor when it comes to citizenship and rights, since the lower the level of knowledge, the more difficult it is to understand and learn about the health problem and the ability to assimilate guidelines for self-care 21 . However, it is important to emphasize that this variable is not an obstacle to the professional work with this population, because they have sought strategies for the translation of knowledge to this public through practical interaction and the use of a more accessible vocabulary, facilitating the compression of the treatment.
The predominantly catholic religious-spiritual bond was observed in the sample, as was the highest-scoring QOL domain. Spiritual support is extremely important in this phase of change and adaptation for people with stomata, because in it they find a source of resilience and coping with their physical and psychological problems related to the stoma 20 .
Regarding the clinical data, the prevalent type of ostomy was colostomy, caused by intestinal cancer, and the majority was temporary. These findings were also found in previously conducted studies 6,22 . Among the complications, the main ones cited were dermatitis and prolapse, similar to data found in other national research 5,6,14,17 .
As for QOL, spiritual well-being was the domain with the best rated performance, and social well-being was the most compromised domain among people with stoma, in agreement with a study in the Chinese population 23 .
Our results did not indicate significant differences in QOL between men and women, but one study noted that women had lower scores compared to men 23 . A recent systematic review pointed out that stomata negatively impact the QOL of this population, however there were no conclusive evidences that indicators such as age, gender, and length of treatment have a specific effect on the QOL of people with stomata, corroborating our findings 24 .
The associations found between the indicators of basic sanitation and housing reflect the perception that people from lower socioeconomic conditions have about their QOL, this is due both to the low education and worse access to health services more evident in this social stratum 14,20 , as well as may be related to the good fit of the ostomy, independent of other factors 25 .
This study found significant associations between socioeconomic, demographic, clinical, and sanitation factors with the QOL of individuals with stomata. Having low income, low education, no sanitation services, and worse housing contributed to worse QOL scores for these individuals when compared to individuals with better income and education. This represents the need for more effective public policies that impact not only the treatment of the disease that caused the stoma, but that improve the socioeconomic conditions of the population.
From the perspective of social determinants in health, the QOL of the general population can be affected by sanitation and housing conditions, especially individuals living with stomata 5 . Factors related to living conditions, education, employment, availability of food, medicines, and access to health services are directly related to the health-disease process of this population, and indicate that socially disadvantaged people have different exposures and degrees of vulnerability to health risks.
Given this scenario, the importance of implementing public policies capable of guaranteeing minimum survival conditions and ensuring the human rights of citizenship for this population is emphasized, in view of the need to resignify habits of life and care, requiring extra costs with medication, hygiene, proper food, transportation for treatment, and access to quality health services, in order to optimize their survival 17 .

Study limitations
The main limitation of the study was the convenience sample; however, studies with large samples for this public are not found in the literature, given the logistical and management difficulties of the stomata. Another limitation was the cross-sectional design, longitudinal studies with analyses of QOL before and after the stomata could bring more consistent findings.
Contributions to the field of nursing, health or public policy

AVAILABILITY OF RESEARCH DATA
All data were generated and analyzed in the present study.

FUNDING
Not applicable.