82 Chapter 3 app may be a good alternative for internet (or responsive websites), offering additional functionalities such as personalisation of information or peer contact, and information on a hand-held device is considered to be both easily accessible and convenient by many. Surprisingly, our study showed that most patients prefer to have additional stoma-related information via the internet or on paper, which raise the question if an app is a needed addition for all patients. As reported in this study, patients with no or limited experience with mobile devices are significantly hesitant to use an app for their personal stoma care. It is important to acknowledge digital literacy, especially, since healthcare information and accessibility are digitalising fast and, in many aspects, with most hospital patient portals are now electronically operated. Patients may be still unaware of benefits of apps as described above, or just not used to accessing medical information via apps, as there is simply not much out there for them. An app is expected to be most commonly used by patients with a sufficient smartphone experience, and who had a stoma for less than 3 years, a high frequency of psychosocial or physical problems, or those who are not satisfied with their postoperative care. These patients were significantly more willing to use an app to provide additional information and support. It could be argued that an app would also be beneficial for patients undergoing emergency surgery, who usually receive less care and are, therefore, less satisfied. Although patients with low digital literacy are hesitant to use apps, an app should also suit the needs of those patients and be optimised for use by them. Adequate preoperative preparation and good contact with stoma nurses are important when implementing an app, as patients are more motivated to use an app. It is important to advocate the app as an information source that integrates in normal preoperative counselling. This is the first study to focus on patient satisfaction concerning stoma care and assess whether e-health may be beneficial. The strength of this study lies in the extensiveness of the questionnaire covering all relevant aspects of stoma care and determinants for an e-health intervention, and this study had a large sample size (N = 1868). Results may be biased, as participants were members of patient associations who may be more involved in their own stoma care, or perhaps better educated or skilled when compared to their peers who have decided not to join a patient association. Nevertheless, asking all members of stoma societies to give their opinions is the best way to include a significant number of patients, providing the best possible representation of the general stoma population. This study had some limitations. First, many patient questionnaires had incomplete data owing to the length of the questionnaire. Missing data was increasingly present over the course of the questionnaire. To improve the validity of the results, missing data used in the statistical analysis were corrected by multiple imputation. Second, most patients had a stoma for at least five years. This might implicate recall bias in the assessment of patient satisfaction concerning stoma care in the perioperative period. However, patient satisfaction was comparable across all time periods. Stoma care may not have improved
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