Research on the factors that influence patients with colorectal cancer participating in the prevention and control of surgical site infection: Based on the extended theory of planned behaviour

Abstract Background The most common and severe type of nosocomial infection in patients with colorectal cancer is surgical site infection (SSI). Patient‐related factors are an important components of SSI. So it is necessary to participate in SSI prevention and control. It is important to identify the factors that influence patients' participation behaviour and to explore the mechanism of these effects. Methods A total of 580 patients with colorectal cancer completed relevant measures. Based on the extended theory of planned behaviour, a structural equation model was used to analyse the relationship among the influencing factors. Results The factors influencing participation of patients with colorectal cancer in SSI prevention and control were participation intention, participation ability, self‐efficacy, participation attitude, perceived medical staff support, trust in physicians and social support. The direct effect coefficients of participation intention, participation ability and physician trust on SSI prevention and control behaviour were 0.67, 0.21 and 0.11, respectively. Self‐efficacy, participation attitude, perceived medical staff support and social support indirectly affect participation behaviour through participation intention, and their effect values are 0.21, 0.11, 0.11 and 0.08, respectively. Conclusions Based on the structural equation model developed in this study, targeted intervention measures should be implemented to mobilize the intention and enthusiasm of patients with colorectal cancer to participate in the prevention and control of SSI. Patient or Public Contribution Patients or public contribute to spreading research findings, and promote broad participation in the implementation of policies or strategies.


| BACKGROUND
Colorectal cancer (CRC) is a malignant tumour occurring in the colon or rectum, and it is the most common type of malignant tumour in the digestive tract. The incidence and mortality of CRC are still on the rise. According to the cancer statistical report of 2018, the incidence and mortality of CRC ranked third and fifth among malignant tumours in China, respectively, with 376,000 new cases and 191,000 deaths a year. 1 CRC is usually treated by surgical resection supplemented by radiotherapy and chemotherapy. The incidence of surgical site infection (SSI) is approximately 20% 2,3 ; the incidence of SSI is significantly higher in low-and middle-income countries than in high-income countries. 4 SSI is one of the most common health-related infections, but its importance as a global health priority is not fully understood. 5 CRC patients with SSI usually result in prolonged hospital stay, heavy expenditure, poorer life quality, higher mortality and lower long-term survival rate. A study showed that the risk of death in patients with SSI is 2-11 times higher than that of patients without SSI, and the annual cost of health care-related economic expenditure is approximately $3.5 billion to 10 billion.
Because of the time lag of returning to work, it will lead to indirect economic losses due to missing work or unemployment. 6 SSI is one of the most common health care-related infections worldwide and poses a heavy burden on health care systems and individual patients. Various risk factors for SSI have been identified, which can be divided into patient-and procedure-related risk factors and other risk factors. Among them, patient factors account for a large proportion. 7,8 Yokoe et al. 9 found that up to 60% of SSIs can be avoided through evidence-based interventions, and patients play an important role in these interventions. Wang et al. 10 also found that patient participation could significantly reduce the incidence of SSI and improve satisfaction. From an international point of view, the World Health Organization posited that 'patients have the right and responsibility to participate in their own health care' at the primary health care conference in 1978 and proposed the Patient for Patient Safety action plan in 2004 to encourage patients to participate in the improvement of care quality and safety. Patient participation is considered to be one of the main factors in improving quality and safety and is considered to be an effective intervention to promote safe care. 11 Patient is the center of medical practice. Ensuring the safety of patients is the bottom line to improve medical quality. Encouraging patients to participate in patient safety is the focus of continuous efforts in various countries and medical systems, and patients' participation in nosocomial prevention and control is the initial core content in patient safety. Participation is a vague concept in medical practice, and patient participation can be defined as a concept that involves three scientific concepts of care: learning, caring relationship and reciprocity (defined attributes). 12 At present, as the basic rights of patients and an important measure to ensure the safety of patients, patient participation has received increasing attention in the field of health. Increasing attention has been paid to patients' participation in the prevention and control of nosocomial infections, especially the high incidence of SSI, but there is a relative lack of research on the influencing factors and mechanism of patients' participation in the prevention and control of SSI.
The theory of planned behaviour (TPB) was developed by Ajzen on the basis of the rational behaviour theory. This theory holds that individual behaviour intention is the best predictor of behaviour and has a direct influence on behaviour; besides, intention is influenced by behaviour attitude, subjective norms and perceptual behaviour control. All of these have an indirect effect on behaviour through intention. In particular, perceptual behaviour control can also act directly on behaviour. In this study, support from medical personnel, relatives and friends reflects subjective norms. Perceptual behaviour control reflects patients' perception of factors that promote or hinder participation in behaviour, including their own knowledge, ability and health status. Self-efficacy and participation ability belong to this category. Wu 13 found that trust between medical staff and patients can affect patient participation, thus adding to the theoretical model.
Currently, perioperative nursing care has changed from a taskoriented, problem-centred discipline to a patient-centred professional discipline. This change involves the research and implementation of evidence-based practice to improve the quality of patient care. There is still a lack of literature that directly uses the TPB to describe and explain perioperative practice behaviour. Medical staff can use this theory to understand the intention behind the behaviour of surgical patients to ensure the safety of care and optimize clinical outcomes. 14 Therefore, this study is based on the extended TPB to establish a mechanism model for influencing factors of CRC patients' participation in the prevention and control of SSI to provide a reference basis for medical institutions and related departments to formulate strategies for SSI.

| Study design, setting and participants
The current study used a cross-sectional design and a questionnaire survey. The inclusion criteria were as follows: Colonoscopy or pathological examination that finally led to the diagnosis of colon cancer or rectal cancer, and elective laparoscopic surgical treatment; age over 18 years; without mental disorder; stable physical status; and provision of agreement to participate in this study. The exclusion criteria were as follows: Patients who underwent laparotomy or robot-assisted surgery, or withdrew from the study due to unexpected reasons.

| Measures
In addition to the general information questionnaire, the following measures were used in this study: The promoting patient participation scale, the intention and behaviour measures of CRC patients participating in the prevention and control of SSI, the Chinese patient participation ability scale, the patient participation attitude questionnaire, the Wake Forest physician trust scale, the general self-efficacy scale and the perceived social support scale. 13,[16][17][18][19][20][21] These measures have been shown to have good reliability and validity.

| Statistical analysis
The statistical software package IBM SPSS Statistics 23.0 (IBM Corp.) was used for data entry and analysis. The demographic data of the patients were described by frequency and percentage. The Pearson correlation coefficient was used to estimate the correlation between variables. Confirmatory factor analysis (CFA) was used to test the relationship between latent variables and observed variables of the measurement model. We used IBM SPSS Amos 24.0 software to build the model, used the maximum likelihood estimation method to estimate the model parameters and optimized the model according to the revised index. p < .05 was considered statistically significant.

| Demographic characteristics
In this study, a total of 608 questionnaires were distributed, and 580 valid questionnaires were collected, with an effective response rate of 95.39%.
Among the respondents, there were 346 males (59.66%) and 234 females (40.34%). A total of 125 patients (21.55%) were over 71 years old; 44.83% had an abnormal body mass index and 54.31% had complications. Only 47 (8.10%) CRC patients accepted preoperative neoadjuvant therapy, including radiotherapy, chemotherapy and radio-and chemotherapy in combination, as shown in Table 1.

| Correlation coefficients among variables
Physician trust, participation attitude, perceived medical staff support, perceived social support, participation ability and self-efficacy were positively correlated with the intention and behaviour of infection prevention and control at the surgical site, as detailed in Table 3.   Table 5. 15 The final model is shown in Figure 2. Female, well-educated and healthy individuals were more likely to play an active role in decision participation. 22 The previous research 24 found that, because of the gradient of authority and patients' concern that the appeal will affect the harmonious relationship between medical staff and patients, the score of appeal participation is generally low and the scores of information interaction and caring participation are rather high; however, we obtained different results. With the concept of 'patient-centred care' deeply rooted in the hearts of the people and due to the renewed focus on patients' awareness of rights, the behaviour of CRC patients attitude of CRC patients, to strengthen medical support and social support, to directly improve participation intention and indirectly promote their participation in SSI prevention and control.

| Analysis of the influence of participation attitude on behaviour
This study found that participation attitude indirectly positively af-

| Analysis of the influence of medical support on behaviour
Medical staff who promote patient participation and patient perception to support their participation in medical care is an important embodiment of 'patient-centred' practice. In this study, the score of the perceived medical support of CRC patients was 30.64 ± 3.96.

| CONCLUSION
In this study, structural equation modelling revealed that the total effect of participation intention was the largest among the influencing factors of CRC patients participating in SSI prevention and control behaviour, which directly affected participation behaviour. Participation ability and physician trust directly positively predict participation behaviour. Self-efficacy, participation attitude, perceived medical staff support and social support indirectly positively predict participation behaviour by influencing the intention to participate in SSI prevention and control. It is suggested that to promote the implementation of CRC patients' participation in the prevention and control of SSI, it is necessary to maximize their willingness to participate, pay attention to the relationship between family and social networks and strengthen social support and medical staff support. CRC patients should be encouraged to develop a desire to participate in the prevention and control of SSI and strengthen their sense of self-efficacy.
Effective measures can be taken to intervene directly and improve the trust and communication between medical staff and patients. In addition, based on the model constructed in this study, controllable and effective policies can be implemented to ensure that CRC patients participate in the prevention and control of SSI.

| LIMITATIONS
A limitation of this study is that we adopted convenience sampling instead of random sampling. The representativeness of the sample may be insufficient, and there are certain limitations in the extrapolation of results. In addition, due to limited time, resources and funding, only one medical institution was investigated. In future studies, the sample size should be expanded, and multicentre and large-sample surveys should be conducted.