key: cord-0945483-4utgiky5 authors: Du, Xixi; Wang, Dongyang; Du, Huiyong; Zou, Qiyun; Jin, Yan title: The correlation between intimate relationship, self-disclosure, and adaptability among colorectal cancer enterostomy patients date: 2021-05-14 journal: Medicine (Baltimore) DOI: 10.1097/md.0000000000025904 sha: 6a5ad7ded876db5b8a0d7a891bb9e645714fef08 doc_id: 945483 cord_uid: 4utgiky5 The postoperative physiological changes and psychological pressure of cancer patients affect the patient's adaptability to the disease, and thus affect the spousal intimate relationship. This study aimed to evaluate the correlation between spousal intimate relationship, self-disclosure, and adaptability among colorectal cancer (CCI) patients with enteric stoma. This cross-sectional study selected patients with CCI in Henan Province from February 2018 to October 2020. The Marital Adjustment Test (MAT), the Distress Disclosure Index scale, and the Ostomy adjustment inventory-20 scale were used to collect relevant data of the participants. A Pearson correlation analysis was used to test the correlation between variables, and multiple stepwise regression analysis was used to test the influence of general information on the intimate relationship, self-disclosure, and adaptability. Among the respondents, 42.6% had a spousal intimate relationship problem, 58.4% had a low or moderate level of self-disclosure, and 90.8% were at a low or moderate level of adaptation. Education background, self-care ability, and postoperative time were associated with a couple's intimate relationship. Average monthly household income, gender, and place of residence were associated with self-disclosure. Self-care ability, average monthly household income, postoperative time, and educational background were associated with adaptation. Healthcare workers should provide more health education training to guide CCI enterostomy patients to express their thoughts and feelings with each other increase self-disclosure, so as to enhance their intimate relationship then improve their adoption to ostomy, finally elevate their quality of life. Colorectal cancer (CRC) involves both the colon and rectum cancer. It is a relatively common malignant tumor of the digestive tract. In recent years, with the improvement of people's living standards, changes in dietary habits, and the aging of the population, the incidence of CRC is rising. [1] According to statistics from the World Health Organization in 2018, there were 1.8462 million new cases of CRC worldwide, accounting for 10.2% of all new cancer cases and an increase of 35.75% from 2012. [2] Besides, with the rapid development of medical technology, the survival rate of cancer patients has continued to increase. The 5-year survival rate of CRC patients in the United States is 64%, 41% in European countries, and 60% in China. [3] The increase in the five-year survival rate has made people gradually realize that CRC is a chronic disease that can be treated, controlled, and even cured. This change in understanding has had a positive impact on CRC tumor care, making nursing to involve not only anti-cancer treatment and care, but to pay more attention to the quality of life of patients with tumors. A stoma is the externalization of the bowel wall from the anterior abdominal wall during a surgical operation, which is used to transfer or decompress the remaining bowel. [4] According to the annual report on CRC by the National Bowel Cancer Audit in 2018, 84% of the diagnosed cases of rectal cancer in the United Kingdom will have a stoma during surgery, and 52% of the patients will still retain the stoma after 18 months. [5] Among the survivors of CRC, a considerable part of the population needs to undergo an enterostomy and live with a stoma. Enterostomy can help patients with CRC alleviate symptoms and prolong life, but the normal physiological functions of the intestines and anus of patients with a stoma and the normal position of defecation are Editor: Phil Phan. The authors have no conflicts of interest to disclose. The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. also changed. [6] Therefore, the quality of life of patients with a stoma is worthier of attention. The postoperative stoma may be permanent or temporary, depending on the condition of the patient. Although for patients undergoing ostomy and those living with them, whether permanent or temporary, there will be multiple challenges after surgery. Especially for married patients, cancer and stomas bring tremendous pressure on the patients and their spouses. The existence of a stoma has an inevitable impact on the quality of sexual life. A study from Sweden showed that 29% of women and 41% of men are sexually active after an enterostomy. It usually causes the patient cannot adapt for the new sexual life. Lubrication reduced while dyspareunia increased in women living with stomas, while erectile dysfunction increased from 46% to 55% in 1 year in men. [7] A Chinese study indicated that 63.1% of stoma patients have a moderate stigma in their sexual experience. It also demonstrates these patients cannot selfdisclose their embarrassment and difficulties in their life behaviors, which leads to conflicts between husband and wife [8] These problems will affect the spousal intimacy and require professional guidance from healthcare workers. [9] Multiple definitions of intimacy relationships were found in previous studies (e.g. Vangelisti & Beck, 2003; Ross & Mirowsky, 2013) . [10, 11] However, this study is closer to the definition of Sternberg et al as intimate relationship was a kind of relationship between people with a strong sense of closeness, connection and bonding physical and psychological experience. [12] Theoretically, the two sides who establish intimate relationship produce psychological states as attachment, elementary pragmatic, and selfhood through intimate behaviors such as sexual activities. [13] Intimate relationship is not only an essential indicator for evaluating patients' subjective well-being and quality of life, but also a significant predictor of disease outcome. [14] Since the partner of a cancer patient is usually a husband-and-wife relationship, the intimate relationship referred to in this study is the spousal intimate relationship. Scholars like Walker proposed that establishing a good couple intimacy can bring support and comfort and cushion cancer patients' anxiety about death. [15] Although maintaining a good couple intimacy helps in alleviating the negative effects of cancer and stomas, many patients do not know how to adjust, which leads to unfavorable emotions, such as anxiety and depression. [16] While research on the couple's intimate relationship in the field of cancer has gradually deepened, the personal relationship model that helps couples adapt to cancer has gradually been applied to patients with a stoma. Nichols' research demonstrated that the adaptation level of stoma patients with a stable marital relationship is higher than that of patients with an unstable marriage, and intimacy is an essential factor in maintaining marital stability. Establishing intimacy can not only satisfy stoma patients' needs for love and belonging, but also relieve anxiety, enhance self-confidence and self-esteem, and improve the level of adaptation. [17] The conceptual model established by Manne et al. also demonstrated that the spousal intimate relationship was an important determinant of the psychological adaptation of patients and their partners to cancer. [18] The process of an individual sincerely sharing his or her secret thoughts with others is defined as self-disclosure. [19] Individuals who have experienced traumatic events convert vague events and opinions into a specific language in the process of trauma-related self-disclosure, helping them rebuild their cognitive structure, reduce the negative impact of traumatic events, and promote individual recovery. [20] Studies showed that the process of selfdisclosure would have a positive effect on the quality of intimate relationship, which in turn affects the meaning and content of self-disclosure. [21] Adaptation is the response of people to their environment to promote survival, growth, reproduction, and manipulation to adjust the individual. [22] The level of adaptation is not only an important issue that patients with a stoma need to face in their survival, but is also one of the crucial factors affecting their quality of life. [9] Relevant research results indicate that the largest source of social support received by patients is the family. As the core relationship in the family relationship, the husband-wife relationship can have an impact on the long-term or short-term adaptation process of stoma patients. [23] Through the literature review, spousal intimacy, self-disclosure, and adaptation level play a vital role in the quality of life of patients with CRC stoma, and there is an inevitable and complicated relationship between the three. Previous studies have shown that the various experiences and spousal intimate behaviors in intimate communication between breast cancer survivors and their partners are critical to the cancer adaptation of patients. [24] Besides, the interpersonal process model established for breast cancer patients also shows that the responsiveness of the patient's partner mediates the relationship between self-disclosure and spousal intimacy. [25] However, at present, studies on patient spousal intimacy, adaptation, and selfdisclosure are more common in breast cancer patients, but related studies on patients with stoma are still relatively limited. China's medical and health system divides hospitals into six levels. As the highest level, tertiary A hospitals are often the places where cancer patients receive the most treatment. These hospitals often have advanced diagnosis and treatment equipment and highly educated healthcare workers, but they bear a huge amount of inpatients. The heavy economic burden, psychological pressure and crowded medical environment brought by these hospitals pose challenges for the satisfaction and psychological adaptability of cancer patients after surgery. [26] Therefore, the patient's partner will play an auxiliary role in the postoperative adaptability and emotional recovery of the patient. At present, there are fewer similar studies in China, and more studies focus on the adaptability of cancer patients after surgery, but seldom focus on the spousal intimate relationship of cancer patients. In the previous research on the spousal intimate relationship of cancer patients, the influencing factors of the intimate relationship have certain limitations, which limits the interpretation of the conceptual framework of the intimate relationship of cancer patients. However, in this study, the interaction between spousal intimate relationship, self-disclosure, and adaptability was explored. Therefore, this study aimed to evaluate the correlation between spousal intimate relationship, self-disclosure, and adaptability among CCI patients with enteric stoma. In the conceptual model of this study, intimate relationship includes two behaviors: relationship strengthening and relationship compromise. Relationship strengthening includes selfdisclosure, spouse response and relationship involvement, which can promote intimate relationship and increase patients' adaptation; relationship compromise includes avoidance, criticism and pressure exit, which is not conducive to the intimate relationship and weakens patients' adaptation. This view emphasizes the understanding of the adaptation level of cancer A cross-sectional survey was conducted in Henan Province, China from February 2020 to March 2021. In this study, convenience sampling was used to select patients after CRC enterostomy who participated in the stoma clinic and the stoma patients' association of a tertiary first-class hospital in Henan Province. The inclusion criteria were: (1) married patients, (2) patients who underwent a CRC enterostomy, The exclusion criteria were: (1) patients with severe heart, liver, kidney, and other dysfunctions, respiratory failure, and other serious complications; (2) patients with advanced tumor cachexia; (3) patients whose spouses were deceased; and (4) dying patients. This study issued a total of 400 questionnaires; 390 were effectively recovered, and the effective recovery rate was 97.5%. This study collected data from participants based on a general information questionnaire, the Lock-Wallace Marital Adjustment Test (MAT), the Distress Disclosure Index Scale (DDI), and Ostomy adjustment inventory-20 scale (OAI-20). MAT is one of the two most commonly used marriage satisfaction measurement methods (as of January 2017, the citation rate is 3322). DDI is a commonly used self-disclosure short self measure to measure an individual's tendency to disclose disturbing information. OAI-20 is developed in English to measure the individual social and psychological adaptability of patients undergoing colostomy. The research tools used in this study have been translated into Chinese and evaluated by the index of item objective congruence (IOC) of three experts. The results showed that each item was greater than 0.5. The test-retest reliability of the Chinese version of the scale was tested. The general information questionnaire included two parts: sociodemographic data and disease-related information. Sociodemographic data included gender, age, education level, occupation, and per capita household monthly income. Disease-related information included postoperative time, presence or absence of stoma complications, history of chemotherapy, and whether to take care of the stoma by yourself. The MAT test was used to assess the degree of marriage adjustment and the quality of marriage between couples in a certain period. The scale consisted of 15 items, and the scale ranged from 2 to 158 points. The higher the score, the better the marriage adjustment and the higher the quality of the marriage. Those with a score of less than 100 were considered to have marriage disorders, and those with a score of ≥100 were considered with good marriage adjustments. According to www.md-journal.com reports, the Cronbach's alpha value of the scale was 0.92, which had a high internal consistency value. [27] The Cronbach's alpha value of the scale in this study was 0.697. The DDI scale was used to measure the degree to which an individual tells others about his troubles and other private information. The scale had a total of 12 items and used the Litter 5-level scoring method. Among them, the 1/3/6/7/11/12 items were entitled to positive scores for positive entries, ranging from strongly disagree to strongly agree scoring 1-5 points, respectively. The 2/4/5/8/9/10 items were negative questions scored in reverse (5-1 points), from strongly disagree to strongly agree, respectively. The scale has a total score of 12 to 60 points, and the quartile of the total score is used as the critical value for level classification, that is, 12 to 29 points are considered low level, 30 to 44 are considered medium level, and 45 to 60 are considered high level. Previous research showed that the Cronbach's alpha range of 12 items ranged from 0.89 to 0.95 (Mean = 0.93). [28] The Cronbach's a for this scale in this study was 0.918. The OAI-20 scale was used to measure the adaptation level of patients after an enterostomy. The scale included three dimensions: worry, acceptance, and positive attitude towards life. The Cronbach's a coefficients of the three dimensions were 0.704, 0.779, and 0.855, respectively. [29] The Cronbach's a coefficient of the scale was 0.886, and the Cronbach's a of the scale in this study was 0.826. The scale has a total score of 80 points; < 40 indicates a low adaptation level, 40-60 indicates a medium adaptation level, and ≥60 indicates a high adaptation level. The researchers strictly selected patients according to the inclusion and exclusion criteria, explained the purpose and significance of the survey face-to-face to the patients who met the requirements, and ensured that the data obtained was only used in this study. The questionnaire was collected at the home of the participants. After obtaining consent, the investigator personally issued the questionnaire. Uniform instructions were used to guide patients to complete the questionnaire, retrieve the survey date, and number the retrieved questionnaire. IBM SPSS Statistics 23.0 (IBM Corp., Armonk, NY) was used for data analysis. Descriptive statistics were used to analyze the general information of the participants. The measurement data were described by the average ± standard, and the counting data were described by frequency and percentage. A Pearson correlation analysis was used to test the correlation between variables. Linear regression analysis was used to explore the variation of independent variables on the intimate relationship, self-disclosure, and adaptation level of couples with CRC patients. This study was approved by the Academic Ethics Committee of * * * (IRB: * * * ). This study fully respects the participants' right to informed consent. The 390 patients participated in this study, the majority of participants were males (59.2%), and 60.2% of them were aged more than 60. More than half of the participants had an elementary school education and below (54.9%), and 52.8% of them were farmers. The score of the spousal intimacy was 109.7 ± 18.643 and the classification statistics showed that 224cases (57.4%) had a good marriage adjustment, and 166 cases (42.6%) had marriage disorders. The details are shown in Table 1 . The total score of self-disclosure of patients with CRC stoma was 39.74 ± 8.831. The classification statistics showed that 84 cases (21.5%) were at a low level of self-disclosure, 144cases (36.9%) Table 1 Score of the couple's intimate relationship (n = 390, X̄± s). Score range Score were at a medium level, and 162cases (41.5%) were at a high level ( Table 2) . The total score of adaptation level was 52.03 ± 7.066. Among the three dimensions of the adaptation level, the item with the highest average score was acceptance (2.99 ± 0.639), followed by positive attitude towards life (2.67 ± 0.648), and worry (2.34 ± 0.652). The classification statistics showed that 10.8% of patients were at a low adaptation level, 80.0% were at a moderate adaptation level, and only 9.2% were at a high adaptation level. 3.5. The influence of different factors on the spousal intimate relationship, self-disclosure, and adaptation level The results indicated that there were significant differences between the spousal intimacy and age, education background, postoperative time, and self-care ability. In terms of selfdisclosure, respondents had significant differences in gender, average monthly household income, and place of residence. Also, there were significant differences in the adaptation of the respondents in educational background, average monthly household income, postoperative time, and self-care ability ( Table 3) . The results showed that the correlation coefficient between selfdisclosure and spousal intimate relationship was 0.300, indicating that there was a significant positive correlation between them. The correlation coefficients between self-disclosure and adapta-tion level and worry, acceptance, and positive attitude towards life were 0.177, -0.157, 0.339, 0.280, respectively, indicating that self-disclosure had a significant positive correlation with the level of adaptation, and its dimensions of acceptance and a positive attitude toward life. Meanwhile, there was a significant negative correlation with continuous worry. The correlation coefficients between the spousal intimate relationship and the level of adaptation and worry, acceptance, and positive attitude towards life were 0.227, -0.208, 0.409, and 0.391, respectively, indicating that there was a significant positive correlation between spousal intimate relationship and the level of adaptation and the three dimensions of acceptance and positive attitude towards life, while there was a significant negative correlation with worry ( Table 4 ). The final model for predictors of the spousal intimate relationship, self-disclosure and adaptation are shown in Table 5 respectively. Spousal intimate relationship contains three significant predictors and explained 46.3% of the variance. Selfdisclosure contains three significant predictors and explained 18.7% of the variance. Adaptation contains four significant predictors and explained 28.8% of the variance. Education background (b = 0.676, P < .001), self-care ability (b = 0.887, P < .001), and postoperative time (b = 0.646, P < .001) were associated with spousal intimate relationship. Average monthly household income (b = 0.475, P < .001), gender (b = 0.848, P < .001), and place of residence (b = 0.512, P = .010) were associated with self-disclosure. Self-care ability (b = 0.388, P < .001), average monthly household income (b = 0.345, P < .001), postoperative time (b = 0.283, P < .001), and educational background (b = 0.295, P < .001) were associated with adaptation (Table 6 ). Intimacy between patients with a CRC stoma and their spouses is still a major challenge as seen in 42.6% of patients. [30] Whilst et al. reported that the intimacy of such couples was comparable with an American study by Reese. Presently, research on the spousal intimate relationship in the medical field is more concentrated in patients with gynecological cancer and prostate cancer. In the study by Manne et al., 21.6% of the spouses of prostate cancer patients expressed dissatisfaction with their couple intimacy. [31] In a study on breast cancer, lack of spousal intimacy was also a factor related to the quality of life after breast cancer surgery. [32] The results of this study are significantly higher than those of the above scholars. This may be related to the location of the CRC and stoma in this study. Cancer damages the intimate relationship. According to reports, the risk of divorce for cancer patients is 1.77 times that of healthy people. [33] The changes in physiological function, self-image disorder, and its impact on the quality of sexual life brought about by the stoma will cause great harm to the spousal intimate relationship. [17] Moreover, several studies have also shown that cancer patients and their partners have lower scores in FACT and FACIT-SP scores, which increases the risk of depression, anxiety Table 2 Score of each item of the self-disclosure scale (n = 162, X̄± s). 3.29 ± 1.140 9. I rarely look for people to talk with when I am having a problem. 3.24 ± 0.939 10. When I'm distressed I don't tell anyone. 3.23 ± 1.122 11. I usually seek out someone to talk to when I am in a bad mood. 3.17 ± 1.017 12. I am willing to tell others my distressing thoughts. 3.15 ± 1.144 13. Total score 39.74 ± 8.831 Table 3 Score of each item of adaptation. Table 4 The influence of different sociodemographic and disease-related factors on the couple's intimate relationship, self-disclosure, and adaptation ability. Intimate relationship between couples Self-disclosure Adaptation ability Table 5 Correlation analysis results between variables. and violence against partners. [34] The stigmatization of cancer and sex is the current challenge in home care for patients after cancer surgery. More educated patients are better at using effective communication skills, better at resolving conflicts, having more ways to relieve stress, and more actively seeking outside help to promote agreement on certain issues. [35] The intimacy relationship of patients over one year is significantly higher than that of patients within one year. It may be that the pressure brought by the disease gradually weakened after one year. In addition, the husband and wife could have gradually adapted to the common pressure after constant running-in, and it is related to the establishment of a coping mechanism. [36] Furthermore, for patients with high selfcare ability, because their self-satisfaction is better, their families feel less guilt, and their spouses feel less pressure and burden. These help in maintaining a closer spousal intimacy relationship. [37] Therefore, in improving the sexual stigma of cancer patients, clinical and family nurses should give more health education to patients and their families during the return visit to promote their cognition of intimate relationship and sexual concept. Social support is also a good way to reduce stigma and promote adaptation. This requires more social assistance from local communities and psychological institutions to promote the psychological response ability and self-efficacy of patients and their families. Moreover, the civil affairs departments and marriage support institutions, as decision-makers and regulators of marriage system, need to provide necessary training and cognitive education for patients and their families in terms of social support, so as to promote the continuity and recovery of intimate relationship. The overall self-disclosure level of the patients was moderate. Besides, Rabin's study also mentioned the self-disclosure rate of cancer patients is much lower than that of the general population t(115) = -5.84, P < .001. [38] According to specific items, the patients usually found someone to chat with when in a bad mood, when sad, or in pain, but they were unwilling to describe in detail the events leading to the bad emotions and express their true inner thoughts. This may be related to the unwillingness of their own illness and bad mood to increase the pressure on their spouses, or the belief that their spouses do not have effective measures to help them solve their problem. The self-disclosure score of female patients was significantly higher than that of males, which may be related to the fact that female patients are more inclined to gain a sense of security, feel intimacy in self-disclosure, and the link between venting and expression and social identity of women's roles. However, the social role of men is linked with being mostly brave, firm, and steady. [39] The degree of self-disclosure of patients living in cities was significantly higher than that of patients living in villages and towns. Patients in villages and towns may be more conservative in their thinking; are restricted by their economic ability, living, and working environment; have fewer available social resources; a limited understanding of disease-related knowledge; more negative and pessimistic treatment of diseases; insufficient understanding and attention to self-disclosure; lack of learning of relevant knowledge; and limited help available. [40] Patients with a high average monthly household income had a higher level of self-disclosure because, patients with a high monthly income per capita have a lighter financial burden and do not need to worry about costs. They have a lighter psychological burden and are more willing to talk about self-expression and disease-related topics. In fact, under the new normal of COVID-19, China is committed to promoting the improvement of public health policy. Regular healthcare workers' Rural visit program is promoting the health consultation service for rural patients in the convalescence period and the psychological disorder patients in the convalescence period. Male nurses as a new group of healthcare workers, their empathy ability is helpful to express the problems related to their own diseases to male patients in rural areas, and provide them with appropriate health promotion programs In a Turkish study, patients with a stoma were at a moderate level of adaptation (Mean 49.39 ± 14.62 of the Ostomy Adjustment Inventory Scale-23), which is like this study. [9] Several studies have shown that the higher the adaptation level of stoma patients, the better the quality of life. [17, 41] Therefore, patients with CRC need healthcare workers to help them improve their adaptation level after an enterostomy. In this study, higher adaptability exists in the highly educated population. This may be related to the fact that the more educated patients have more extensive information acquisition methods, a stronger understanding and adaptability, and are better at learning related stoma knowledge and skills. [29] Cancer survivors are more likely to report financial difficulties than the general population, which results in patients with less adaptability in terms of postoperative social relations, disease recovery, and medical burden [42] The adaptation level of patients with a stoma more than 1 year after surgery was significantly higher than that of patients within 1 year after operation, which may be related to the patient's need for sufficient time to recover and overcome the physical changes brought about by the operation, spiritual trauma, and recovery of family and social life. [43] In addition, the patient's level of adaptation is significantly related to self-care ability, because self-care with the help of healthcare workers can help colostomy patients make necessary daily and social adjustments, thereby building self-confidence and social relationships. [44] 4.4. Interaction between spousal intimate relationship, self-disclosure and adaptation Several studies have shown that trauma-related self-disclosure can have a positive impact on individuals experiencing trauma and promote physical and mental growth. Sex-related selfdisclosure can help improve the quality of the patients' sexual life; stress-related self-disclosure can reduce negative emotions, help release stress, form a positive cycle in the spousal relationship, and enhance mutual intimacy. [45, 46] Self-disclosure is the basis for establishing spousal intimate relationships, which affects the formation and development of intimate relationships, and ultimately affects the quality of spousal intimate relationships and quality of life; spousal intimate relationships can in turn affect the content, meaning, and degree of individual selfdisclosure. For patients with a CRC stoma, the spousal intimate relationship has a significant positive effect on their adaptation level. As the core relationship in the family, the husband-wife relationship directly affects the social support that patients can obtain. Roy pointed out in his adaptation model that social support can neutralize the main stimulus during the patient's adaptation process and act as a positive stimulus to improve the level of individual adaptation. [47] A previous study indicated that the higher the degree of spousal intimacy between a husband and wife, the stronger the ability to cope and adapt to the two strong stressors of cancer and stoma. An increase in the level of adaptation often indicates an improvement in self-management behavior and the quality of life. [48] In addition, clinicians and responsible nurses have less chance to get the active and beneficial patient's self-disclosure during patient visits. Studies have shown that most health workers share personal beliefs or experiences to guide patients in self-disclosure attempts, so as to understand patients' adaptability to the disease and family status. However, this has not effectively improved patient self-disclosure. [49] Health workers need to increase empathy, understanding and compassion to establish effective self-disclosure conditions to improve and understand the patient's adaptability, family and mental state. Based on our knowledge, this might be the first study on the spousal intimate relationship, self-disclosure, and adaptability of stoma patients in China. The strength of this study lies in the cross-sectional methods of the interaction between spousal intimacy, adaptation and self-disclosure thereby laying the foundation for the conceptual model and theoretical research of intimacy among cancer patients. However, it also has certain limitations needing future research. The research questionnaires were designed as standard scales, failing to explore the subjective feelings of patients in depth. Therefore, future research can add qualitative research strategies. Moreover, due to the influence of time and funding, this study was unable to conduct a long-term dynamic observation of patients. Therefore, it is necessary to carry out longitudinal studies to further confirm and supplement the research results. Colorectal Cancer in the Young Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries Epidemiology of colorectal cancer: incidence, mortality, survival, and risk factors Technical considerations in stoma creation Effect of public reporting of surgeons' outcomes on patient selection, "gaming," and mortality in colorectal cancer surgery in England: population based cohort study Ostomy management: a model of interdisciplinary care Self-reported sexual dysfunction in patients with rectal cancer Sexual experience and stigma among chinese patients with an enterostomy: a cross-sectional, descriptive study Family functioning, perceived social support, and adaptation to a stoma: a descriptive, cross-sectional survey L'Abate L. Intimacy and Fear of Intimacy. Low-Cost Approaches to Promote Physical and Mental Health Theory and modeling in the study of intimate relationships and health A triangular theory of love Evaluating three models of intimate relationships Evaluating a couple-based intervention addressing sexual concerns for breast cancer survivors: study protocol for a randomized controlled trial Mood, sexuality, and relational intimacy after starting androgen deprivation therapy: implications for couples Adjusting to sex and intimacy: gynecological cancer survivors share about their partner relationships Problems experienced by spouses of Turkish patients with a stoma: a descriptive, cross-sectional study Intimacy and relationship processes in couples' psychosocial adaptation to cancer Self-disclosure and social media: motivations, mechanisms and psychological well-being Self-disclosure versus self-presentation on social media Self-disclosure on SNS: do disclosure intimacy and narrativity influence interpersonal closeness and social attraction? I am as normal as everyone now . . . : examination of experiences of patients undergoing bariatric surgery according to roy's adaptation model: a qualitative study Family resilience in the oncology setting: development of an integrative framework Adapting a couple-based intimacy enhancement intervention to breast cancer: a developmental study The interpersonal process model of intimacy: the role of self-disclosure, partner disclosure, and partner responsiveness in interactions between breast cancer patients and their partners Outpatient Satisfaction with Tertiary Hospitals in China: The Role of Sociodemographic Characteristics Marital adjustment, convergent communication patterns, and psychological distress in women with early and late marriage The Distress Disclosure Index: a research review and multitrait-multimethod examination A descriptive, crosssectional study among chinese patients to identify factors that affect psychosocial adjustment to an enterostomy Emotional approach coping and depressive symptoms in colorectal cancer patients: the role of the intimate relationship Holding back, intimacy, and psychological and relationship outcomes among couples coping with prostate cancer A cohort study of quality of life in partners of young breast cancer survivors compared to partners of healthy controls Marriage and divorce among young adult cancer survivors Constructions of sex and intimacy after cancer: Q methodology study of people with cancer, their partners, and health professionals Intimate relationship development during the transition to adulthood: differences by social class A systematic review and meta-analysis of couple-based intervention on sexuality and the quality of life of cancer patients and their partners [published correction appears in Support Care Cancer Online intimacy and well-being in the digital age Cancer-related self-disclosure in the workplace/school by adolescent and young adult cancer survivors Gender role attitudes, relationship efficacy, and self-disclosure in intimate relationships Facilitating HIV disclosure across diverse settings: a review Cancer survivorship at the intersections of care and personhood Inequality in income change among cancer survivors five years after diagnosis: evidence from a French national survey Psychological adaptation to alteration of body image among stoma patients: a descriptive study Self-care of elderly people with ostomy by colorectal cancer Effects of self-and partner's online disclosure on relationship intimacy and satisfaction The effect of self-disclosure skill training on communication patterns of referred couples to counseling clinics The roy adaptation model: a theoretical framework for nurses providing care to individuals with anorexia nervosa I-We' boundary fluctuations in couple adjustment to rectal cancer and life with a permanent colostomy Physician Self-disclosure in primary care visits: enough about you, what about me? Medicine (2021) 100:19 www.md-journal This study highlighted the association between spousal intimate relationship, self-disclosure, and adaptability of stoma patients. Health workers should focus on health education to strengthen the adaptability of patients, and social support departments should provide more social practice activities and psychological support to enhance and improve patients' self-disclosure levels. Health care institutions should provide more online and offline rehabilitation training to improve patients' self-care level, thereby improving the intimate relationship between couples.