Effects of Acceptance and Commitment Therapy on Postoperative Patients with Colorectal Cancer: A randomized controlled trial

Effects of Acceptance and Commitment Therapy on Postoperative Patients with Colorectal Cancer: A randomized controlled trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of Acceptance and Commitment Therapy on Postoperative Patients with Colorectal Cancer: A randomized controlled trial Na Liu, Lingyu Yao, Fuxia Li, Hongling Yin, Aihua Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8768115/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Objective This study evaluated a four-session acceptance and commitment therapy (ACT) intervention targeting the effects on health outcomes of postoperative patients with colorectal cancer. Method Participants were 100 adults (56% male; M = 59.3 years, SD = 8.7) with colorectal cancer who were randomized to the ACT intervention group or the usual care group. Psychological flexibility, stigma, disease acceptance, intestinal function, and quality of life were assessed at baseline and at 3 months and 6 months after the intervention. Results Of the 100 participants who started the intervention, 95% completed it and reported high satisfaction. Participants were randomized to four weekly sessions of acceptance and commitment therapy or routine nursing mode. Lost to follow-up cases were performed using a propensity score matching analysis. There was no significant difference at baseline between the intervention and control groups in terms of general information and various test indicators. Compared with the control group, the ACT group had a significant effect on psychological flexibility, stigma, disease acceptability, intestinal function, and quality of life. Conclusions ACT can improve the psychological flexibility and disease acceptance of postoperative patients with colorectal cancer, reduce stigma levels, improve intestinal function and quality of life. Acceptance and commitment therapy Colorectal cancer Disease acceptance Intestinal function Quality of life Psychological flexibility Oncology Stigma Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 1. INTRODUCTION According to the latest global cancer report in 2020, there were more than 1.9 million new cases of colorectal cancer, ranking third in cancer incidence rate, and approximately 935,000 deaths, ranking second in cancer mortality rate. 1 Today, the clinical treatment of colorectal cancer is still dominated by surgery, chemotherapy, and radiotherapy; however, surgery, chemoradiotherapy, and even permanent colostomy brings patients great physical and mental pain. Furthermore, patients may have a strong psychological reaction and experience anpleasant emotions, which will seriously affect their treatment and rehabilitation, leading to a decline in patients' quality of life. With the rise of positive psychology, the research paradigm of psychology has gradually turned to discussing the possible positive reactions of individuals after experiencing stress and trauma. In the face of setbacks, trauma, or life difficulties, some people are well adjusted and can successfully cope; however, others are maladjusted and are left with psychological trauma and may even find it difficult to return to society. Some studies have shown that individuals' psychological flexibility plays a decisive role in their response to a stress crisis. 2–5 That is, the higher the level of individuals' psychological flexibility, the more they can show positive adaptation to pressure, promote subjective well-being, and improve their quality of life. Individuals with a low level of psychological flexibility tend to exhibit maladaptive behaviours, such as anxiety, depression, and substance abuse. For patients with colorectal cancer, the treatment aims to help them quickly recover from negative postoperative effects, accept the disease and its impact, reduce stigma, improve intestinal function, and improve psychological flexibility and quality of life. During this process, it is important to assist patients in establishing a positive protection mechanism, developing their own psychological potential, and promoting the development of their mental health. In psychology, ‘psychological flexibility’ is defined as the ability to adapt to a changing environment, flexibly allocate psychological resources, change perspectives, and balance various needs and life areas. 6 Acceptance and commitment therapy (ACT) is one of the most representative treatments in the third wave of cognitive and behavioural therapy. It was founded in the 1980s by Steven C. Hayes. 7 It is based on six principles that work together and support two goals: to effectively deal with painful thoughts and emotions, and to create a rich, fulfilling, and meaningful life. Based on the philosophy of functional contextualism and the theory of relational framing, this therapy incorporates Eastern philosophy and aims to improve psychological flexibility through self-acceptance and commitment to actions based on self-worth. 8 There is considerable evidence that ACT may improve functional outcomes in patients, include anxiety and depression, 9–12 pain, 13–16 fear, 17–19 sleep disorders, 11,20 stigma 21–24 and so on. however, this therapy has rarely been tested in physical and mental measurements coping with colorectal cancer. 25, 2. METHODS 2.1 Participants The patients who met the following inclusion criteria were involved: have scores less than 26 in Montreal Cognitive Assessment (MoCA), which indicates the presence of cognitive impairment; ≥18 years of age ,able to read and write; and willing to participate. The study considered including both male and female patients. Exclusion criteria include (a) diagnosed with cognitive dysfunction or other mental illnesses; (b) combined with other vital organ dysfunction; (c). whose physical conditions were considered extremely weak or with a condition that was unstable or rapidly deteriorating. 2.2 Procedure This study was registered on Chinese Clinical Trial Register (ChiCTR) (ChiCTR2000031177) on March 23rd, 2020 and was conducted in accordancewith the Declaration of Helsinki. This study was approved by the Shandong First Medical University & Shan Dong Academy of Medical Sciences Institutional Review Board (2019114). Participants were recruited from the Second Affiliated Hospital of Shandong First Medical University (China) and Shandong Provincial Hospital Affiliated to Shandong First Medical University (China),recruitment took place from July 2020 until January 2022. They were recruited via outpatient oncology clinics by telephone or face-to-face invitation with oncologist approval. Participants were randomly assigned to the intervention or control group by a study coordinator, and they completed follow-up assessments at 3 and 6-months post-baseline. Informed consent was obtained for all participants. Figure 1 shows the procedural flow of this study. 2.3 Sample size and randomization We calculated posthoc power of the study based on a mixed design repeated measures ANOVA test comparing average total symptoms frequency and severity scores pre and post intervention with comparison between two groups. This study finally included 100 patients with colorectal cancer after surgery who met the criteria, and randomly divided the subjects into the intervention group (n = 50) and the control group (n = 50) by using random number table method. The sample size was determined using G*Power. 2.4 Interventions 2.4.1 ACT group The ACT intervention was developed based on the ACT psychotherapy model and the ACT reference books and training manuals for therapists 26,27 and previous ACT trials with patients with cancer. 11,18,28–30 On this basis, the intervention manual was modified based on the results of our qualitative interview of 15 patients with Colorectal Cancer. Finally, our study team members including two ACT experts, one nursing professor and two head nurses in the oncology ward. The effectiveness of the ACT intervention was demonstrated in one-on-one conversations. The baseline data survey was completed before surgery. The first intervention began within one month after the surgery. The ACT interventions were divided into four sessions, each lasting 60 to 90 minutes and occurring once weekly for 4 weeks.Each session was followed by an instant evaluation and a 6-month follow-up.Table 1 provides a summary of the ACT intervention components. For acceptance, we inspire patients through the metaphor of "crossing the swamp" to make patients understand that everything has advantages and disadvantages, bad experience and painful memory are also an important part of life, acceptance rather than resistance is the best choice of life. Learn cognitive defusion techniques through metaphorical and experiential exercises, avoiding linking the adverse factors with the disease itself. Finally, patients share the changes that have occurred so as to further clarify their self-worth and build confidence in accepting and coping with the disease. All the metaphors are quoted from ACT Made Simple:An Easy-to-Read Primer on Acceptance and Commitment Therapy. 31 Table 1 Summary of core components of ACT intervention condition Themes Outline ACT process targeted Session 1: (1)Patient self-introduction include the expectations of the intervention, clear intervention objectives and sign informed consent. (2)Introductions and overview of the intervention (3)inspire patients through the metaphor of "crossing the swamp" (4)Introduce and practice mindfulness Accept the fact of cancer Contact with the present moment Accept what cannot be changed Session 2: Keeping a distance from your thoughts (1)It included learning cognitive defusion techniques through metaphorical and experiential exercises (2)Help observe themselves in an objective way, treat the thoughts and feelings related to cancer objectively (3)Discuss how attempts to avoid thoughts, feelings and symptoms lead to actions not aligned with values and decreased quality of life (4)Consolidate strategies of acceptance and practice mindfulness Contact with present moment and cognitive defusion Accepting the psychological pain of illness Session 3: Observe yourself, living in the moment (1)Experiential exercise to support patients in flexibly choosing their focus in the present moment (2)Through "sky and weather metaphor" and "chess board metaphor" to learn observe own emotions and consciousness (3)Consolidate strategies of acceptance and practice mindfulness experience own emotions and consciousness Session 4: Clarifying your values, Putting your values into action and living a meaningful cancer life (1)Through the first few interventions, patients share the changes that have occurred, such as emotional pain, sense of worth, and sense of dignity (2)Clarify personal values and goals and share own values with others to promote their action (3)Patients are encouraged to live in the moment, be normal and follow their interests to live a meaningful and worthwhile life (4)Summary and feedback. Clarify values and build confidence in accepting and coping with the disease. 2.4.2 Control group Participants randomized to the control group received nursing care as usual, which involved dietary guidance, exercise guidance, bowel function recovery process and complications guidance information during hospitalization, and reexamination recommendation after discharge. 2.5 Measures 2.5.1 Demographics Demographic measures consisted of gender, age, nationality, educational level, occupation, source of medical expenses, monthly family income, post-sickness exercise, and disease-related characteristics such as disease type and stage. 2.5.2 Psychological flexibility Psychological flexibility was measured using the Acceptance and Action Questionnaire-2nd Edition (AAQ-II). 32 . Defusion, acceptance, and commitment to action are three of the fundamental processes that the items focus on.Greater psychological inflexibility is indicated by higher scores, which fall within the 7 − 49 total score range that is determined from the sum of the item responses. The Cronbach’s alpha was 0.88 in this study. 2.5.3 Stigma Stigma was assessed using the Social Impact Scale (SIS) developed by Fife et al. in 2000 based on labelling theory to measure the social response or personal stigma associated with disease in patients with cancer and AIDS. 33 In 2007, Taiwanese scholars Pan et al. 34 synoecised the original scale. The Chinese version of the scale consists of a total of 24 items and includes four dimensions: nine items of social exclusion, three items of economic instability, five items of internal shame, and seven items of social isolation. A 4-point Likert scale was used as the scoring method in the scale: 4 = strongly agree, 3 = agree, 2 = disagree, 1 = strongly disagree . The total score of the scale was the sum of the scores of the four dimensions. The higher the score, the stronger the perceived sense of shame was. The Cronbach’s alpha for the four dimensions range from 0.85 to 0.90. 2.5.4 Disease acceptance Disease acceptance was measured using the Acceptance of Illness Scale (AIS) . 35 The scale contains eight items and adopts a 5-point Likert-type scoring method. A total score of between 20 and 30 indicated moderate acceptance and a score of > 30 indicated full acceptance of one's condition. The higher the score, the higher the patient's degree of acceptance of the disease, suggesting that they can cope better with the disease and better adapt to the role of the patient. The lower the score, the worse the patient was able to adapt to the disease, thus, could not accept their current situation and may experience emotional problems and strong psychological discomfort. This scale was applicable to adult patients with any disease. 36 and the Cronbach’s alpha was 0.754 in this study. 2.5.5 Bowel function Bowel Function was measured using the Memorial Sloan-Kettering Cancer Center Bowel Function Instrument (BFI). 37 BFI have been applied in England, 38 Italy 39 and other Countries. There were 18 items in this questionnaire. The higher the total score, the better the intestinal function of the patients. The Chinese version of the questionnaire included three factors: frequency and urgency of defecation, influence of diet on defecation, and paraesthesia of defecation. The Cronbach’s alpha of the total score and each factor were measured to be 0.602 to 0.856. 2.5.6 Quality of life Quality of life was measured using the Functional Assessment Cancer Therapy-Colorectal (FACT-C) developed by Cella et al. 40 FACT-C was divided into 36 items and assessed five areas: physical status (seven items), social/family status (seven items), emotional status (six items), functional status (seven items), and additional attention (nine items). Each item was a five-level item. Furthermore, there were both positive and negative items on the scale. The higher the score of the forward item, the better the quality of life; the lower the score of the reverse item, the worse the quality of life. The Cronbach’s alpha was above 0.80 in all areas except for the additional focus area, which is 0.56. 2.6 Statistical analysis SPSS software (version 25.0) was used for data analysis. Descriptive statistical analysis and a chi-square test was used to compare the general demographic data of the intervention and control groups. The Shapiro–Wilk was used to verify the normality of distribution of variables and t-test was used to compare baseline levels of psychological flexibility, stigma, disease acceptance, intestinal function, and quality of life between the intervention and the control groups. Student t-test was used to compare categories for normally distributed quantitative variables while paired t-test comparing between pre and post in each group, Additionally, repeated measures analysis was used to compare the effects of the two groups at different time points after the intervention using ANOVE. .Significance of the obtained results was judged at the 5% level. 3. RESULTS 3.1 Characteristics of the participants. The baseline characteristics of the study participants are shown in Table 2 . The groups were balanced on demographic and disease-related characteristics. No statistical differences were found between the two groups across gender, age, educational level, occupational status, source of medical expenses, monthly family income, post-sickness exercise, disease stage, and disease type. Table 2 Characteristics of the participants. Demographic category Intervention(N = 50) Control(N = 50) χ 2 P value Gender Male 27(54%) 29(58%) 0.162 0.687 Female 23(46%) 21(42%) Age 60 30(60%) 34(68%) Education Under middle school 22(44%) 19(38%) 0.404 0.817 High school 12(24%) 14(28%) College degree or above 16(32%) 17(34%) Employment status Employed 12(24%) 11(22%) 0.392 0.822 Retirement 5(10%) 7(14%) Others 33(66%) 32(64%) Medical expenses Medical insurance for urban residents 38(76%) 36(72%) 0.794 0.373 Medical insurance for urban employees 12(24%) 14(28%) Family monthly income 2000–5000 15(30%) 15(30%) 0.059 0.971 5000–10000 21(42%) 20(40%) 10000 above 14(28%) 15(30%) Exercise after illness Every day 11(22%) 11(22%) 0.106 0.991 5–6 days a week 8(16%) 9(18%) 3–4 days a week 20(40%) 20(40%) 1–2 days a week 11(22%) 10(20%) Disease stage Tumour 1 4(8%) 6(12%) 0.586 0.900 Tumour 2 15(30%) 16(32%) Tumour 3 22(44%) 20(40%) Tumour 4 9(18%) 8(16%) Disease type Colon cancer 21(42%) 17(34%) 0.679 0.410 Rectal cancer 29(58%) 33(66%) 3.2 Baseline scores of each scale between the intervention and control group The baseline scores of each scale between the intervention and control groups are shown in Table 3 . The baseline comparison of scores of the AAQ, SIS, AIS, BFI, and FACT-C were compared; the results showed that there was no statistically significant difference between the two groups in each evaluation index. Table 3 Baseline Scores of Each Scale between the Intervention and Control Group Outcome Intervention(N = 50) Control(N = 50) t p AAQ total score 29.92 ± ± 9.396 27.78 ± 7.377 1.267 0.208 SIS total score 63.30 ± 10.328 62.08 ± 9.380 0.618 0.538 Social Exclusion 22.64 ± 4.355 22.06 ± 3.835 0.707 0.481 Economic uncertainty 8.82 ± 1.587 8.26 ± 1.397 1.873 0.064 • Inner shame 12.48 ± 2.957 13.00 ± 2.109 -1.012 0.314 Social isolation 19.36 ± 3.403 18.76 ± 3.526 0.866 0.389 AIS total score 21.36 ± 5.271 21.94 ± 5.069 -0.561 0.576 BFI total score 59.90 ± 9.157 61.30 ± 8.197 -0.806 0.422 Frequency and urgency of defecation 35.50 ± 6.500 36.28 ± 5.265 -0.659 0.511 • Defecation is affected by diet 12.34 ± 2.647 13.00 ± 2.650 -1.246 0.216 Abnormal sensation of defecation 12.06 ± 2.567 12.02 ± 2.511 0.079 0.937 FACT-C total score 70.66 ± 13.907 73.40 ± 13.378 -1.004 0.318 Physical condition 15.26 ± 5.114 16.02 ± 5.101 -0.744 0.459 Social/family status 16.62 ± 4.651 16.94 ± 4.744 -0.341 0.734 Emotional status 11.14 ± 4.522 11.68 ± 4.201 -0.619 0.538 Functional status 14.28 ± 5.079 14.90 ± 4.867 -0.623 0.535 Additional attention 13.36 ± 2.648 13.86 ± 2.532 -0.965 0.337 3.3 Intervention effects 3.3.1 Psychological flexibility ANOVA revealed that the difference in time effect of the AAQ scale scores between the intervention and control groups was statistically significant (P < 0.01); that is, patients' psychological flexibility gradually increased with the extension of postoperative time. Further analysis showed that the difference in AAQ scores between the intervention and control group at 6 months after the intervention was statistically significant (P < 0.01); that is, the psychological flexibility of patients in the intervention group significantly improved compared with the control group at 6 months after the intervention. Figure 2 shows the changes in psychological flexibility scores. 3.3.2 Stigma In comparing stigma scores, the difference in time effect in dimensions and total scores between the intervention and control groups were statistically significant (P < 0.01); stigma levels were reduced after the intervention. Furthermore, differences were found in the total scores of stigma, internal shame, and social isolation between the two groups. Further analysis revealed that 3 months after the intervention, the differences in the dimensions of internal shame and social isolation between the two groups were statistically significant (P < 0.05). Six months after the intervention, the social isolation dimension in the two groups was statistically significant (P < 0.01), with the social isolation dimension of the intervention group being significantly lower than the control group. Figure 3 shows the changes in stigma scores. 3.3.3 Disease acceptance The difference in time effect between the intervention and control groups were statistically significant (P < 0.01), indicating that the disease acceptability of the two groups increased with time after surgery. The effect difference between the treatment and control groups was also statistically significant (P < 0.01), indicating that the disease acceptability in the two groups varied with time. The difference of disease acceptance between the intervention group and the control group at 3 months and 6 months after intervention was statistically significant (P < 0.01), and the disease acceptance of the intervention group was significantly higher than the control group. Figure 4 shows the changes in acceptance scores. 3.3.4 Bowel function Analysis revealed that at 3 months after the intervention, the differences in the total score of intestinal function and the dimensions of bowel frequency, urgency, and defecation affected by diet between the two groups were statistically significant (P < 0.05); the intestinal function of the intervention group was generally higher than the control group. Six months after the intervention, no significant difference in intestinal function between the two groups was found. Figure 5 shows the changes in bowel function scores. 3.3.5 Quality of life The difference in time effect between the intervention and control groups were statistically significant (P < 0.01), and the postoperative life quality of patients in both groups improved, especially in terms of emotional status and functional status. Moreover, the effect difference between the two groups in physical and emotional conditions was statistically significant (P < 0.01, P < 0.05). Further analysis found that 3 months after the intervention, the differences in the total FACT-C score, physical status, and emotional status between the two groups were statistically significant, and the quality of life of the patients in the intervention group was significantly higher compared with the control group. At six months after the intervention, the differences in the total FACT-C score and the physical, family/social, emotional, and functional status scores between the two groups were statistically significant. The quality of life in the intervention group was significantly higher than that in the control group. Figure 6 shows the changes in quality of life scores. 4. DISCUSSION Mental health is not to negatively maintain a normal state, prevent mental illness, but to consciously understand themselves, promote self-growth of the best psychological state. ACT focuses not on the symptoms themselves, but on improving the individual's mental flexibility and helping the individual achieve the goal value as the core treatment goal. The reduction or disappearance of symptoms is the possible phenomenon after the individual improves the mental flexibility. 41–42 In this study, although both groups showed improvement in psychological flexibility with the extension of postoperative time, the trend observed was different between the two groups. That is, 6 months after the intervention, the psychological flexibility of the patients in the intervention group significantly improved compared with the control group, indicating that the ACT intervention improved the psychological flexibility of patients with colorectal cancer after surgery. At 3 and 6 months after the intervention, the disease acceptability of the intervention group was significantly higher than the control group, suggesting that the ACT significantly improved patients’ disease acceptability. Similarly, Anna et al. 43 found that in an intervention based on ACT for colorectal cancer patients, patients' psychological flexibility and disease acceptance level improved after the intervention. Ali et al. 25 also showed, in a study on patients with colorectal cancer, that ACT intervention can improve patients’ level of psychological flexibility and reduce empirical avoidance, the research focuses on patients' mental health, including psychological flexibility and cognitive levels. Based on the common factors affecting the psychological flexibility of patients with colorectal cancer after surgery, we ensured patients fully understood their own diseases by health education and other methods. Hereafter, the patients were encouraged to recognise and discuss current problems and ways to deal with them, guided to face the facts of their disease, and encouraged to reduce their avoidance behaviour. Concurrently, patients learnt cognitive defusion skills to dissociate the Unpleasant thoughts induced by the disease, were helped to correctly understand negative cognition in the mind to weaken its negative impact, and learnt to accept the disease; thus, improving psychological flexibility. Stigma is widespread among cancer patients and it causes more emotional distress to people than the cancer itself. The level of stigma in the two groups was reduced after the intervention; however, there were significant differences between the two groups which suggests that stigma level in patients after surgery was significantly reduced by the ACT intervention. Similarly, West et al. 45 showed that components of psychological flexibility can help prevent the effects of stigma, while value clarification can buffer its effects. Suyanti et al. 46 explored the effect of ACT on self-stigma and depression in AIDS patients and found that patients’ self-stigma and depression levels significantly improved after the ACT intervention. Patients with cancer are often stigmatised and discriminated against by the public and many patients internalise the stigma associated with the disease. To avoid the stigma caused by external evaluation, cancer patients usually adopt avoidance measures, which lead to empirical avoidance in the long-term. ACT, through acceptance and cognitive defusion techniques, enables patients to view the external world and their own evaluations of themselves as observers, and to adjust their relationship with these evaluations, rather than to associate themselves with them. Therefore, cognitive defusion techniques allow patients to understand that these assessments are linguistic symbols, not their true selves, and learn to distance themselves from them; thus, seeing themselves more authentically and reducing stigma levels over time. In view of the intestinal function after colorectal cancer surgery, modern medicine believes that surgical trauma, anesthesia, gastrointestinal lesions, and systemic conditions will all have an impact on gastrointestinal function, which is likely to cause intestinal dilation, flora imbalance, abdominal distension, and even serious complications such as intestinal adhesion and anastomotic leakage. 47 Postoperative gastrointestinal dysfunction seriously affects the systemic nutritional status of patients, prolonging hospital stay, increasing additional hospitalization costs, bringing economic and mental pressure to patients, and seriously affecting postoperative rehabilitation and quality of life of patients. 48 Due to the complex etiology of postoperative intestinal dysfunction, there is still a lack of effective methods and drugs to promote postoperative gastrointestinal function. In clinical practice, fasting, gastrointestinal decompression and early functional exercise are mainly adopted for postoperative gastrointestinal dysfunction, but the effect is not satisfactory. 47 This study shows that ACT can improve the intestinal function of patients with colorectal cancer after surgery; however, the long-term effects of this improvement needs to be further verified. And after the ACT intervention, the overall quality of life of the intervention group improved significantly. Similarly, in a randomised controlled trial of breast cancer survivors, Shelley et al. 49 indicated that ACT intervention improve the quality of life of breast cancer patients. Additionally, after the intervention of Rose Michael R et al. 50 found that ACT could reduce anxiety and depression and significantly improve patients’ quality of life in patients with chronic muscle disease. Study limitations First, a convenience sampling method was adopted in this study. The sample size was obtained from two tertiary hospitals.Thus, the selection of the study population was biased by region. Second, due to time limitations, this study only observed the experimental effect 6 months after the intervention, the long-term effect of the intervention could not be verified. Third, only acceptance and action questionnaires were used to represent the intervention effect of ACT on psychological flexibility, which was not perfect. That is, ACT psychotherapy consists of six modules, AAQ-II only to avoid an empiric therapy effect. It is suggested to use a scale covering six modules of ACT psychotherapy in the future. 51 5. CONCLUSIONS This study supports a four-session ACT intervention for postoperative patients with colorectal cancer. The findings showed that ACT can improve the mental flexibility and disease acceptance of patients after colorectal cancer surgery, reduce the level of stigma, improve intestinal function and improve the quality of life of colorectal cancer patients. Declarations Conflicts of interest There are no conflicts of interest. Funding This project was funded by the Natural Science Foundation of Shandong Province (ZR2020MG005) and a project of the Shandong Province Higher Educational Science and Technology Program (J18RA103). Author Contribution Na Liu drafted the entire manuscript. Lingyu Yao performed part of the data analysis. Head nurses Fuxia Li and Hongling Yin were responsible for coordinating patients for data collection. Aihua Zhang reviewed and approved the overall paper. Acknowledgements We thank the research supervisor Ai-hua Zhang, and all the research assistants who made this study possible, particularly Ling-yu Yao, Fuxia Li, Hong-ling Yin and all of the clinical nurses and the study participants for their contributions to this project. References Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worcde for 36 Cancers in 185 Countries. CA Cancer J Clin . 2021;71(3):209-249. Kamody R C , Berlin K S , Rybak T M , et al. Psychological Flexibility Among Youth with Type 1 Diabetes: Relating Patterns of Acceptance, Adherence, and Stress to Adaptation[J]. Behavioral Medicine, 2017:1-9. Lin J, Klatt L I, Mccracken L M, et al. Psychological flexibility mediates the effect of an online-based acceptance and commitment therapy for chronic pain: an investigation of change processes[J]. Pain, 2017, c in press:1. Leonidou C , Panayiotou G , Bati A , et al. Coping with psychosomatic symptoms: The buffering role of psychological flexibility and impact on quality of life[J]. Journal of Health Psychology, （2016）. Cassar G E , Knowles S , Youssef G J , et al. Examining the mediational role of psychological flexibility, pain catastrophizing, and visceral sensitivity in the relationship between psychological distress, irritable bowel symptom frequency, and quality of life[J]. Psychology, Health & Medicine, 2018:1-14. Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1–25. https://doi.org/10.1016/j.brat.2005.06.006 Hayes, SC, Strosahl, KD, Wilson，KG. Acceptance and commitment therapy: An experiential approach to behavior change. 2003: The Guilford Press. Headley S. Acceptance and commitment therapy: model, processes and outcomes. [J]. Behaviour Research & Therapy, 2006, 44(1):1-25. Stergaard, Tom, Lundgren T, Zettle R , et al. Acceptance and Commitment Therapy preceded by an experimental Attention Bias Modification procedure in recurrent depression: study protocol for a randomized controlled trial[J]. Trials, 2018, 19(1):203. Mathew A, Doorenbos AZ, Jang MK, Hershberger PE. Acceptance and commitment therapy in adult cancer survivors: a systematic review and cocmodel. J Cancer Surviv . 2021;15(3):427-451. Rayner M , Muscara F , Dimovski A , et al. Take A Breath: study protocol for a randomized controlled trial of an online group intervention to reduce traumatic stress in parents of children with a life threatening illness or injury.[J]. Bmc Psychiatry, 2016, 16(1):1-12. García-Torres, Francisco et al. “Efficacy of a Combined Acceptance and Commitment Intervention to Improve Psychological Flexibility and Associated Symptoms in Cancer Patients: Study Protocol for a Randomized Controlled Trial.” Frontiers in psychology vol. 13 871929. 18 May. 2022. Casey, Máire-Bríd, Smart K , Segurado R , et al. Exercise combined with Acceptance and Commitment Therapy (ExACT) compared to a supervised exercise programme for adults with chronic pain: study protocol for a randomised controlled trial[J]. Trials, 2018, 19(1):194. Alonso-Fernández, Miriam, López-López, Almudena, Losada A , et al. Acceptance and Commitment Therapy and Selective Optimization with Compensation for Institutionalized Older People with Chronic Pain[J]. Pain Medicine, 2015:n/a-n/a. Mccracken L M , Jones R . Treatment for Chronic Pain for Adults in the Seventh and Eighth Decades of Life: A Preliminary Study of Acceptance and Commitment Therapy (ACT)[J]. Pain Medicine, 2012, 13(7):860–867. Godfrey E , Galea Holmes M , Wileman V , et al. Physiotherapy informed by Acceptance and Commitment Therapy (PACT): protocol for a randomised controlled trial of PACT versus usual physiotherapy care for adults with chronic low back pain[J]. BMJ Open, 2016, 6(6): e011548. Gloster A T, Sonntag R, Hoyer J, et al. Treating Treatment-Resistant Patients with Panic Disorder and Agoraphobia Using Psychotherapy: A Rancized Controlled Switching Trial[J]. Psychotherapy and Psychosomatics, 2015, 84(2):100-109. Mathew A, Doorenbos AZ, Jang MK, Hershberger PE. Acceptance and commitment therapy in adult cancer survivors: a systematic review and conceptual model. J Cancer Surviv . 2021;15(3):427-451. Mathew A, Doorenbos AZ, Jang MK, Hershberger PE. Acceptance and commitment therapy in adult cancer survivors: a systematic review and conceptual model. J Cancer Surviv . 2021;15(3):427-451. Wiklund T , Linton S J , Peter Alföldi, et al. Is sleep disturbance in patients with chronic pain affected by physical exercise or ACT-based stress management? – A randomized controlled study[J]. Bmc Musculoskeletal Disorders, 2018, 19(1):111. Clarke S , Taylor G , Bolderston H , et al. Ameliorating Patient Stigma Amongst Staff Working With Personality Disorder: Randomized Controlled Trial of Self-Management Versus Skills Training[J]. Behavioural and Cognitive Psychotherapy, 2015, 43(06):692-704. Masuda A, Hayes S C, Fletcher L B, et al. Impact of acceptance and commitment therapy versus education on stigma toward people with psychological disorders[J]. Behaviour Research & Therapy, 2007, 45(11):0-2772. Clarke S , Taylor G , Bolderston H , et al. Ameliorating Patient Stigma Amongst Staff Working With Personality Disorder: Randomized Controlled Trial of Self-Management Versus Skills Training[J]. Behavioural & Cognitive Psychotherapy, 2015, 43(06):692-704. Li T W , Fung P L , MatickaTyndale E , et al. Effects Of HIV stigma reduction interventions in diasporic communities: insights from the CHAMP study[J]. AIDS Care, 2017:1-7. Ali EA, Khedr MA, Alabdullah AAS, Farghaly Abdelaliem SM, El-Ashry AM. Effect of acceptance and commitment therapy-based interventions on mental health and cognitive impairment for patients with advanced colorectal cancer. Public Health Nurs . 2024;41(4):745-759. doi:10.1111/phn.13333 Luoma JB, Hayes SC, Walser RD. Learning ACT: An Acceptance and Commitment Therapy Skills-Training Manual for Therapists. Oakland: New Harbinger; 2007 Stoddard JA, Afari N. The Big Book of ACT Metaphors. A Practitioner's Guide to Experiential Exercises & Metaphors in Acceptance and Commitment Therapy. Oakland, CA: NeHarbinger Publications; 2014. S.A. Johns, P.V. Stutz, T.L. Talib, et al., Acceptance and commitment therapy for breast cancer survivors with fear of cancer recurrence: A 3-arm pilot randomized controlled trial, Cancer 126 (2020) 211–218. Wells-Di Gregorio SM, Marks DR, DeCola J, et al. Pilot randomized controlled trial of a symptom cluster intervention in advanced cancer. Psycho Oncol. 2019;28(1):76–84. Serfaty M, Armstrong M, Vickerstaff V, et al. Acceptance and commitment therapy for adults with advanced cancer (CanACT): a feasibility randomised controlled trial. Psycho Oncol. 2019;28(3):488–496. Harris, R. (2019). ACT made simple: An easy-to-read primer on acceptance and commitment therapy (2nd ed.). New Harbinger Publications. Fledderus M, Oude Voshaar MA, Ten Klooster PM, et al. Further evaluation of the psychometric properties of the Acceptance and Action Questionnaire-Ⅱ[J]. Psychol Assess, 2012, 26(5):377-381. Wright F E R . The Dimensionality of Stigma: A Comparison of Its Impact on the Self of Persons with HIV/AIDS and Cancer[J]. Journal of Health and Social Behavior, 2000, 41(1):50-67. Pan AW, Chung L, Fife BL, Hsiung PC. Evaluation of the psychometrics of the Social Impact Scale: a measure of stigmatization. Int J Rehabil Res .2007;30(3):235-238. Felton BJ，Revenson TA，Hinrichsen GA. Stress and coping in the explanation of psychological adjustment among chronically ill adults ［J］.Soc Sci Med，1984， 18（10）：889-898. Wright F E R . The Dimensionality of Stigma: A Comparison of Its Impact on the Self of Persons with HIV/AIDS and Cancer[J]. Journal of Health and Social Behavior, 2000, 41(1):50-67. Temple LK ,Bacik J ,Savatta SG, et al. The development of a validated instrument to evaluate bowel function after sphincter-preserving surgery for rectal cancer ［ J ］ .Dis Colon Rectum ， 2005 ,48（7）：1353-1365. Knowles G, Haigh R, McLean C, et al. Long term effect of surgery and radiotherapy for colorectal cancer on defecatory function and quality of life［ J ］. Eur J Oncol Nurs ,2013, 17（5）：570-577. Zotti P, Del BP, Serpentini S, et al. Validity and reliability of the MSKCC Bowel Function Instrument in a sample of Italian rectal cancer patients［ J ］. Eur J Surg Oncol ,2011 ,37 （7）：589-596. Ward W L, Hahn E A, Mo F, Hernandez L, Tulsky D S, Cella D. Reliability and validity of the Functional Assessment of Cancer Therapy-Colorectal (FACT-C) quality of life instrument.[J]. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation,1999,8(3). Hayes SC. Acceptance and commitment therapy，relational frame theory，and the third wave of behavioral and cognitive therapies ［J］. Behav Ther，2004，35 (4): 639 －665. Hayes SC，Luoma JB，Bond FW，et al. Acceptance and commitment therapy: model，processes and outcomes［J］. BehavＲes Ther，2006，44 (1): 1 －25. Hawkes AL, Pakenham KI, Chambers SK, Patrao TA, Courneya KS. Effects of a multiple health behavior change intervention for colorectal cancer survivors on psychosocial outcomes and quality of life: a randomized controlled trial. Ann Behav Med . 2014;48(3):359-370. Qstergaard, Tom, Lundgren T , Zettle R , et al. Acceptance and Commitment Therapy preceded by an experimental Attention Bias Modification procedure in recurrent depression: study protocol for a randomized controlled trial[J]. Trials, 2018, 19(1):203. West L M , Graham J R , Roemer L .Functioning in the face of racism: Preliminary findings on the buffering role of values clarification in a Black American sample[J].Journal of Contextual Behavioral Science, 2013, 2(1-2):1-8. Sri Suyanti T , Anna Keliat B , Catharina Daulima N H . Effect of logo-therapy, acceptance, commitment therapy, family psychoeducation on self-stigma, and depression on housewives living with HIV/AIDS[J]. Enfermería Clínica, 2018, 28:98-101. Lam D, Jones O. Changes to gastrointestinal function after surgery for colorectal cancer. Best Pract Res Clin Gastroenterol . 2020;48-49:101705. doi:10.1016/j.bpg.2020.101705 Seow-En I, Chok AY, Matchar DB, Yoon S, Chong DQ, Tan EK. Long-term quality of life, sexual health and gastrointestinal function following colorectal cancer resection in an Asian cohort. Colorectal Dis . 2021;23(9):2348-2360. doi:10.1111/codi.15768 Johns Shelley A,Stutz Patrick V,Talib Tasneem L,Cohee Andrea A,Beck-Coon Kathleen A,Brown Linda F,Wilhelm Laura R,Monahan Patrick O,LaPradd Michelle L,Champion Victoria L,Miller Kathy D,Giesler R Brian. Acceptance and commitment therapy for breast cancer survivors with fear of cancer recurrence: A 3-arm pilot randomized controlled trial.[J]. Cancer,2020,126. Rose Michael R,Norton Sam,Vari Chiara,Edwards Victoria,McCracken Lance,Graham Christopher D,Radunovic Aleksandar,Chalder Trudie. Acceptance and Commitment Therapy for Muscle Disease (ACTMus): protocol for a two-arm randomised controlled trial of a brief guided self-help ACT programme for improving quality of life in people with muscle diseases.[J]. BMJ open,2018,8(10). Rayner M , Muscara F , Dimovski A , et al. Take A Breath: study protocol for a randomized controlled trial of an online group intervention to reduce traumatic stress in parents of children with a life threatening illness or injury[J]. Bmc Psychiatry, 2016, 16(1):1-12. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 10 May, 2026 Reviewers invited by journal 03 Mar, 2026 Editor assigned by journal 03 Mar, 2026 Submission checks completed at journal 05 Feb, 2026 First submitted to journal 02 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8768115","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":601818805,"identity":"bd51841c-1d9b-4228-87a0-04c99c44ea42","order_by":0,"name":"Na Liu","email":"","orcid":"","institution":"Shandong Provincial Hospital affiliated to Shandong First Medical University， Jinan","correspondingAuthor":false,"prefix":"","firstName":"Na","middleName":"","lastName":"Liu","suffix":""},{"id":601818806,"identity":"3f1146ac-0aee-4b74-a257-14293112440c","order_by":1,"name":"Lingyu Yao","email":"","orcid":"","institution":"Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Lingyu","middleName":"","lastName":"Yao","suffix":""},{"id":601818807,"identity":"3e0b5896-21dd-4339-b9d3-b6dcbaa11e48","order_by":2,"name":"Fuxia Li","email":"","orcid":"","institution":"Shandong Provincial Hospital affiliated to Shandong First Medical University， Jinan","correspondingAuthor":false,"prefix":"","firstName":"Fuxia","middleName":"","lastName":"Li","suffix":""},{"id":601818808,"identity":"d6f75e7f-50d8-40fd-b343-19398b1a9ba1","order_by":3,"name":"Hongling Yin","email":"","orcid":"","institution":"Shandong Provincial Hospital affiliated to Shandong First Medical University， Jinan","correspondingAuthor":false,"prefix":"","firstName":"Hongling","middleName":"","lastName":"Yin","suffix":""},{"id":601818809,"identity":"5878d700-0702-45ed-a139-f729500c8324","order_by":4,"name":"Aihua Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYDACCTB5QI6NvfnAgQ8/SNBizMdzLPHgzB4StCTOk8gxPszBRoQO+dnNzx5+qbljzMZz5sNhBh4GeX6xA/i1MM45Zm4sc+wZ0C+9Gw4XWDAYzpydgF8Ls0SCmbQE22GgLWc3HJ7Bw5BgcJuAFjaJ9G/SEv8OJ7ZJ5Dw4zMNGhBYeiRwzyY9tYC0MxGmRkMgpk2bsAznsmAEwkCUI+0V+Rvo2yR/fDsvJtzc//vDhh408vzQBLSDAzINkK2HlIMBIVDIZBaNgFIyCkQsAqZhHEqRpwpkAAAAASUVORK5CYII=","orcid":"","institution":"Shandong First Medical University \u0026 Shan Dong Academy of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Aihua","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2026-02-02 18:23:43","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8768115/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8768115/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104779509,"identity":"325815ec-7015-48e4-b4b2-2b7f961ffef6","added_by":"auto","created_at":"2026-03-17 07:41:08","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":100635,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow diagram of this study\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8768115/v1/7f430f1bc8c6551f7a29e2b1.jpg"},{"id":104779680,"identity":"42815166-f85c-4204-a556-3c436d7e9871","added_by":"auto","created_at":"2026-03-17 07:44:26","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":35542,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChanges in psychological flexibility scores\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8768115/v1/947390faee75141ebd4955b5.jpg"},{"id":104273788,"identity":"97ec680e-362a-416f-a576-336695129d9b","added_by":"auto","created_at":"2026-03-10 00:44:36","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":35260,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChanges in stigma scores\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8768115/v1/9266c9196e12598b786bb03d.jpg"},{"id":104404871,"identity":"11e1dc2b-5224-488f-86c8-6f968af8f8cb","added_by":"auto","created_at":"2026-03-11 12:21:16","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":34368,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChanges in Acceptance scores\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8768115/v1/2f0c96d94144b8f61c779884.jpg"},{"id":104273791,"identity":"ec427002-11bc-4513-ad42-5011384923e6","added_by":"auto","created_at":"2026-03-10 00:44:36","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":39377,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChanges in Bowel function scores\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8768115/v1/b5f250d0cdb7742af189872b.jpg"},{"id":104779670,"identity":"d8ebfd31-d0e8-48d2-8e61-a02733f82b54","added_by":"auto","created_at":"2026-03-17 07:44:14","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":36281,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChanges in quality of life scores\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8768115/v1/b772a181db7bb0be7cc73b47.jpg"},{"id":104785634,"identity":"64f0692e-e14d-44f1-9912-3d32eb11447c","added_by":"auto","created_at":"2026-03-17 08:12:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1327919,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8768115/v1/5ea8d572-b545-415c-ae9b-4027da5debb4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of Acceptance and Commitment Therapy on Postoperative Patients with Colorectal Cancer: A randomized controlled trial","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eAccording to the latest global cancer report in 2020, there were more than 1.9\u0026nbsp;million new cases of colorectal cancer, ranking third in cancer incidence rate, and approximately 935,000 deaths, ranking second in cancer mortality rate. \u003csup\u003e1\u003c/sup\u003e Today, the clinical treatment of colorectal cancer is still dominated by surgery, chemotherapy, and radiotherapy; however, surgery, chemoradiotherapy, and even permanent colostomy brings patients great physical and mental pain. Furthermore, patients may have a strong psychological reaction and experience anpleasant emotions, which will seriously affect their treatment and rehabilitation, leading to a decline in patients' quality of life.\u003c/p\u003e \u003cp\u003eWith the rise of positive psychology, the research paradigm of psychology has gradually turned to discussing the possible positive reactions of individuals after experiencing stress and trauma. In the face of setbacks, trauma, or life difficulties, some people are well adjusted and can successfully cope; however, others are maladjusted and are left with psychological trauma and may even find it difficult to return to society. Some studies have shown that individuals' psychological flexibility plays a decisive role in their response to a stress crisis. \u003csup\u003e2\u0026ndash;5\u003c/sup\u003e That is, the higher the level of individuals' psychological flexibility, the more they can show positive adaptation to pressure, promote subjective well-being, and improve their quality of life. Individuals with a low level of psychological flexibility tend to exhibit maladaptive behaviours, such as anxiety, depression, and substance abuse. For patients with colorectal cancer, the treatment aims to help them quickly recover from negative postoperative effects, accept the disease and its impact, reduce stigma, improve intestinal function, and improve psychological flexibility and quality of life. During this process, it is important to assist patients in establishing a positive protection mechanism, developing their own psychological potential, and promoting the development of their mental health. In psychology, \u0026lsquo;psychological flexibility\u0026rsquo; is defined as the ability to adapt to a changing environment, flexibly allocate psychological resources, change perspectives, and balance various needs and life areas. \u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAcceptance and commitment therapy (ACT) is one of the most representative treatments in the third wave of cognitive and behavioural therapy. It was founded in the 1980s by Steven C. Hayes. \u003csup\u003e7\u003c/sup\u003e It is based on six principles that work together and support two goals: to effectively deal with painful thoughts and emotions, and to create a rich, fulfilling, and meaningful life. Based on the philosophy of functional contextualism and the theory of relational framing, this therapy incorporates Eastern philosophy and aims to improve psychological flexibility through self-acceptance and commitment to actions based on self-worth.\u003csup\u003e8\u003c/sup\u003e There is considerable evidence that ACT may improve functional outcomes in patients, include anxiety and depression, \u003csup\u003e9\u0026ndash;12\u003c/sup\u003epain, \u003csup\u003e13\u0026ndash;16\u003c/sup\u003efear, \u003csup\u003e17\u0026ndash;19\u003c/sup\u003esleep disorders, \u003csup\u003e11,20\u003c/sup\u003estigma\u003csup\u003e21\u0026ndash;24\u003c/sup\u003eand so on. however, this therapy has rarely been tested in physical and mental measurements coping with colorectal cancer. \u003csup\u003e25,\u003c/sup\u003e\u003c/p\u003e"},{"header":"2. METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Participants\u003c/h2\u003e \u003cp\u003eThe patients who met the following inclusion criteria were involved: have scores less than 26 in Montreal Cognitive Assessment (MoCA), which indicates the presence of cognitive impairment; \u0026ge;18 years of age ,able to read and write; and willing to participate. The study considered including both male and female patients. Exclusion criteria include (a) diagnosed with cognitive dysfunction or other mental illnesses; (b) combined with other vital organ dysfunction; (c). whose physical conditions were considered extremely weak or with a condition that was unstable or rapidly deteriorating.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Procedure\u003c/h2\u003e \u003cp\u003e This study was registered on Chinese Clinical Trial Register (ChiCTR) (ChiCTR2000031177) on March 23rd, 2020 and was conducted in accordancewith the Declaration of Helsinki. This study was approved by the Shandong First Medical University \u0026amp; Shan Dong Academy of Medical Sciences Institutional Review Board (2019114). Participants were recruited from the Second Affiliated Hospital of Shandong First Medical University (China) and Shandong Provincial Hospital Affiliated to Shandong First Medical University (China),recruitment took place from July 2020 until January 2022. They were recruited via outpatient oncology clinics by telephone or face-to-face invitation with oncologist approval. Participants were randomly assigned to the intervention or control group by a study coordinator, and they completed follow-up assessments at 3 and 6-months post-baseline. Informed consent was obtained for all participants. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the procedural flow of this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Sample size and randomization\u003c/h2\u003e \u003cp\u003eWe calculated posthoc power of the study based on a mixed design repeated measures ANOVA test comparing average total symptoms frequency and severity scores pre and post intervention with comparison between two groups. This study finally included 100 patients with colorectal cancer after surgery who met the criteria, and randomly divided the subjects into the intervention group (n\u0026thinsp;=\u0026thinsp;50) and the control group (n\u0026thinsp;=\u0026thinsp;50) by using random number table method. The sample size was determined using G*Power.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Interventions\u003c/h2\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.4.1 ACT group\u003c/h2\u003e \u003cp\u003eThe ACT intervention was developed based on the ACT psychotherapy model and the ACT reference books and training manuals for therapists\u003csup\u003e26,27\u003c/sup\u003eand previous ACT trials with patients with cancer. \u003csup\u003e11,18,28\u0026ndash;30\u003c/sup\u003eOn this basis, the intervention manual was modified based on the results of our qualitative interview of 15 patients with Colorectal Cancer. Finally, our study team members including two ACT experts, one nursing professor and two head nurses in the oncology ward.\u003c/p\u003e \u003cp\u003eThe effectiveness of the ACT intervention was demonstrated in one-on-one conversations. The baseline data survey was completed before surgery. The first intervention began within one month after the surgery. The ACT interventions were divided into four sessions, each lasting 60 to 90 minutes and occurring once weekly for 4 weeks.Each session was followed by an instant evaluation and a 6-month follow-up.Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e provides a summary of the ACT intervention components. For acceptance, we inspire patients through the metaphor of \"crossing the swamp\" to make patients understand that everything has advantages and disadvantages, bad experience and painful memory are also an important part of life, acceptance rather than resistance is the best choice of life. Learn cognitive defusion techniques through metaphorical and experiential exercises, avoiding linking the adverse factors with the disease itself. Finally, patients share the changes that have occurred so as to further clarify their self-worth and build confidence in accepting and coping with the disease. All the metaphors are quoted from ACT Made Simple:An Easy-to-Read Primer on Acceptance and Commitment Therapy. \u003csup\u003e31\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of core components of ACT intervention condition\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOutline\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eACT process targeted\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSession 1:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e(1)Patient self-introduction include the expectations of the intervention, clear intervention objectives and sign informed consent.\u003c/p\u003e \u003cp\u003e(2)Introductions and overview of the intervention\u003c/p\u003e \u003cp\u003e(3)inspire patients through the metaphor of \"crossing the swamp\"\u003c/p\u003e \u003cp\u003e(4)Introduce and practice mindfulness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAccept the fact of cancer\u003c/p\u003e \u003cp\u003eContact with the present moment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccept what cannot be changed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSession 2:\u003c/p\u003e \u003cp\u003eKeeping a distance from your thoughts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(1)It included learning cognitive defusion techniques through metaphorical and experiential exercises\u003c/p\u003e \u003cp\u003e(2)Help observe themselves in an objective way, treat the thoughts and feelings related to cancer objectively\u003c/p\u003e \u003cp\u003e(3)Discuss how attempts to avoid thoughts, feelings and symptoms lead to actions not aligned with values and decreased quality of life\u003c/p\u003e \u003cp\u003e(4)Consolidate strategies of acceptance and practice mindfulness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eContact with present moment and cognitive defusion\u003c/p\u003e \u003cp\u003eAccepting the psychological pain of illness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSession 3:\u003c/p\u003e \u003cp\u003eObserve yourself,\u003c/p\u003e \u003cp\u003eliving in the moment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(1)Experiential exercise to support patients in flexibly choosing their focus in the present moment\u003c/p\u003e \u003cp\u003e(2)Through \"sky and weather metaphor\" and \"chess board metaphor\" to learn observe own emotions and consciousness\u003c/p\u003e \u003cp\u003e(3)Consolidate strategies of acceptance and practice mindfulness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eexperience own emotions and consciousness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSession 4:\u003c/p\u003e \u003cp\u003eClarifying your values, Putting your values into action and living a meaningful cancer life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(1)Through the first few interventions, patients share the changes that have occurred, such as emotional pain, sense of worth, and sense of dignity\u003c/p\u003e \u003cp\u003e(2)Clarify personal values and goals and share own values with others to promote their action\u003c/p\u003e \u003cp\u003e(3)Patients are encouraged to live in the moment, be normal and follow their interests to live a meaningful and worthwhile life\u003c/p\u003e \u003cp\u003e(4)Summary and feedback.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClarify values and build confidence in accepting and coping with the disease.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.4.2 Control group\u003c/h2\u003e \u003cp\u003eParticipants randomized to the control group received nursing care as usual, which involved dietary guidance, exercise guidance, bowel function recovery process and complications guidance information during hospitalization, and reexamination recommendation after discharge.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Measures\u003c/h2\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e2.5.1 Demographics\u003c/h2\u003e \u003cp\u003eDemographic measures consisted of gender, age, nationality, educational level, occupation, source of medical expenses, monthly family income, post-sickness exercise, and disease-related characteristics such as disease type and stage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e2.5.2 Psychological flexibility\u003c/h2\u003e \u003cp\u003ePsychological flexibility was measured using the Acceptance and Action Questionnaire-2nd Edition (AAQ-II). \u003csup\u003e32\u003c/sup\u003e. Defusion, acceptance, and commitment to action are three of the fundamental processes that the items focus on.Greater psychological inflexibility is indicated by higher scores, which fall within the 7\u0026thinsp;\u0026minus;\u0026thinsp;49 total score range that is determined from the sum of the item responses. The Cronbach\u0026rsquo;s alpha was 0.88 in this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e2.5.3 Stigma\u003c/h2\u003e \u003cp\u003eStigma was assessed using the Social Impact Scale (SIS) developed by Fife et al. in 2000 based on labelling theory to measure the social response or personal stigma associated with disease in patients with cancer and AIDS. \u003csup\u003e33\u003c/sup\u003eIn 2007, Taiwanese scholars Pan et al. \u003csup\u003e34\u003c/sup\u003esynoecised the original scale. The Chinese version of the scale consists of a total of 24 items and includes four dimensions: nine items of social exclusion, three items of economic instability, five items of internal shame, and seven items of social isolation. A 4-point Likert scale was used as the scoring method in the scale: \u003cem\u003e4\u0026thinsp;=\u0026thinsp;strongly agree, 3\u0026thinsp;=\u0026thinsp;agree, 2\u0026thinsp;=\u0026thinsp;disagree, 1\u0026thinsp;=\u0026thinsp;strongly disagree\u003c/em\u003e. The total score of the scale was the sum of the scores of the four dimensions. The higher the score, the stronger the perceived sense of shame was. The Cronbach\u0026rsquo;s alpha for the four dimensions range from 0.85 to 0.90.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e2.5.4 Disease acceptance\u003c/h2\u003e \u003cp\u003eDisease acceptance was measured using the Acceptance of Illness Scale (AIS) .\u003csup\u003e35\u003c/sup\u003eThe scale contains eight items and adopts a 5-point Likert-type scoring method. A total score of between 20 and 30 indicated moderate acceptance and a score of \u0026gt;\u0026thinsp;30 indicated full acceptance of one's condition. The higher the score, the higher the patient's degree of acceptance of the disease, suggesting that they can cope better with the disease and better adapt to the role of the patient. The lower the score, the worse the patient was able to adapt to the disease, thus, could not accept their current situation and may experience emotional problems and strong psychological discomfort. This scale was applicable to adult patients with any disease.\u003csup\u003e36\u003c/sup\u003e and the Cronbach\u0026rsquo;s alpha was 0.754 in this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e2.5.5 Bowel function\u003c/h2\u003e \u003cp\u003eBowel Function was measured using the Memorial Sloan-Kettering Cancer Center Bowel Function Instrument (BFI).\u003csup\u003e37\u003c/sup\u003e BFI have been applied in England, \u003csup\u003e38\u003c/sup\u003e Italy\u003csup\u003e39\u003c/sup\u003eand other Countries. There were 18 items in this questionnaire. The higher the total score, the better the intestinal function of the patients. The Chinese version of the questionnaire included three factors: frequency and urgency of defecation, influence of diet on defecation, and paraesthesia of defecation. The Cronbach\u0026rsquo;s alpha of the total score and each factor were measured to be 0.602 to 0.856.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e2.5.6 Quality of life\u003c/h2\u003e \u003cp\u003eQuality of life was measured using the Functional Assessment Cancer Therapy-Colorectal (FACT-C) developed by Cella et al. \u003csup\u003e40\u003c/sup\u003e FACT-C was divided into 36 items and assessed five areas: physical status (seven items), social/family status (seven items), emotional status (six items), functional status (seven items), and additional attention (nine items). Each item was a five-level item. Furthermore, there were both positive and negative items on the scale. The higher the score of the forward item, the better the quality of life; the lower the score of the reverse item, the worse the quality of life. The Cronbach\u0026rsquo;s alpha was above 0.80 in all areas except for the additional focus area, which is 0.56.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Statistical analysis\u003c/h2\u003e \u003cp\u003eSPSS software (version 25.0) was used for data analysis. Descriptive statistical analysis and a chi-square test was used to compare the general demographic data of the intervention and control groups. The Shapiro\u0026ndash;Wilk was used to verify the normality of distribution of variables and t-test was used to compare baseline levels of psychological flexibility, stigma, disease acceptance, intestinal function, and quality of life between the intervention and the control groups. Student t-test was used to compare categories for normally distributed quantitative variables while paired t-test comparing between pre and post in each group, Additionally, repeated measures analysis was used to compare the effects of the two groups at different time points after the intervention using ANOVE. .Significance of the obtained results was judged at the 5% level.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. RESULTS","content":"\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Characteristics of the participants.\u003c/h2\u003e \u003cp\u003eThe baseline characteristics of the study participants are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The groups were balanced on demographic and disease-related characteristics. No statistical differences were found between the two groups across gender, age, educational level, occupational status, source of medical expenses, monthly family income, post-sickness exercise, disease stage, and disease type.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervention(N\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControl(N\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29(58%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.687\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23(46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21(42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3(6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.333\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17(34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13(26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30(60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34(68%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnder middle\u0026nbsp;school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22(44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19(38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.404\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.817\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14(28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollege degree or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16(32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17(34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment\u0026nbsp;status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11(22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.822\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetirement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7(14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33(66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32(64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical expenses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedical insurance for urban residents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38(76%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36(72%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.794\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.373\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedical insurance for urban employees\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14(28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily monthly income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2000\u0026ndash;5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15(30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.971\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5000\u0026ndash;10000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20(40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10000 above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14(28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15(30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExercise after illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEvery day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11(22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.991\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u0026ndash;6 days a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9(18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;4 days a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20(40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;2 days a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisease stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTumour 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6(12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.586\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.900\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTumour 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16(32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTumour 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22(44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20(40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTumour 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8(16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisease\u0026nbsp;type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eColon\u0026nbsp;cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17(34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.679\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.410\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRectal cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29(58%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33(66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Baseline scores of each scale between the intervention and control group\u003c/h2\u003e \u003cp\u003eThe baseline scores of each scale between the intervention and control groups are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The baseline comparison of scores of the AAQ, SIS, AIS, BFI, and FACT-C were compared; the results showed that there was no statistically significant difference between the two groups in each evaluation index.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Scores of Each Scale between the Intervention and Control Group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention(N\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl(N\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAAQ total score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e29.92\u0026thinsp;\u0026plusmn;\u0026thinsp;\u0026plusmn;\u0026thinsp;9.396\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e27.78\u0026thinsp;\u0026plusmn;\u0026thinsp;7.377\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.267\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.208\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSIS total score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e63.30\u0026thinsp;\u0026plusmn;\u0026thinsp;10.328\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e62.08\u0026thinsp;\u0026plusmn;\u0026thinsp;9.380\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.618\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.538\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Exclusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e22.64\u0026thinsp;\u0026plusmn;\u0026thinsp;4.355\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e22.06\u0026thinsp;\u0026plusmn;\u0026thinsp;3.835\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.707\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.481\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEconomic uncertainty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e8.82\u0026thinsp;\u0026plusmn;\u0026thinsp;1.587\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e8.26\u0026thinsp;\u0026plusmn;\u0026thinsp;1.397\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.873\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.064\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Inner shame\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e12.48\u0026thinsp;\u0026plusmn;\u0026thinsp;2.957\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e13.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.314\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial\u0026nbsp;isolation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e19.36\u0026thinsp;\u0026plusmn;\u0026thinsp;3.403\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e18.76\u0026thinsp;\u0026plusmn;\u0026thinsp;3.526\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.866\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.389\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAIS total score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e21.36\u0026thinsp;\u0026plusmn;\u0026thinsp;5.271\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e21.94\u0026thinsp;\u0026plusmn;\u0026thinsp;5.069\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.561\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.576\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBFI total score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e59.90\u0026thinsp;\u0026plusmn;\u0026thinsp;9.157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e61.30\u0026thinsp;\u0026plusmn;\u0026thinsp;8.197\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.806\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.422\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency and urgency of defecation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e35.50\u0026thinsp;\u0026plusmn;\u0026thinsp;6.500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e36.28\u0026thinsp;\u0026plusmn;\u0026thinsp;5.265\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.659\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.511\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Defecation is affected by diet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e12.34\u0026thinsp;\u0026plusmn;\u0026thinsp;2.647\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e13.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.650\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.246\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.216\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbnormal sensation of defecation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e12.06\u0026thinsp;\u0026plusmn;\u0026thinsp;2.567\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e12.02\u0026thinsp;\u0026plusmn;\u0026thinsp;2.511\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.079\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.937\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFACT-C total score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e70.66\u0026thinsp;\u0026plusmn;\u0026thinsp;13.907\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e73.40\u0026thinsp;\u0026plusmn;\u0026thinsp;13.378\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.318\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical condition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e15.26\u0026thinsp;\u0026plusmn;\u0026thinsp;5.114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e16.02\u0026thinsp;\u0026plusmn;\u0026thinsp;5.101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.744\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.459\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial/family status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e16.62\u0026thinsp;\u0026plusmn;\u0026thinsp;4.651\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e16.94\u0026thinsp;\u0026plusmn;\u0026thinsp;4.744\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.341\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.734\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e11.14\u0026thinsp;\u0026plusmn;\u0026thinsp;4.522\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e11.68\u0026thinsp;\u0026plusmn;\u0026thinsp;4.201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.619\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.538\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunctional status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e14.28\u0026thinsp;\u0026plusmn;\u0026thinsp;5.079\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e14.90\u0026thinsp;\u0026plusmn;\u0026thinsp;4.867\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.623\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.535\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdditional attention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e13.36\u0026thinsp;\u0026plusmn;\u0026thinsp;2.648\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e13.86\u0026thinsp;\u0026plusmn;\u0026thinsp;2.532\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.965\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.337\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Intervention effects\u003c/h2\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1 Psychological flexibility\u003c/h2\u003e \u003cp\u003eANOVA revealed that the difference in time effect of the AAQ scale scores between the intervention and control groups was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01); that is, patients' psychological flexibility gradually increased with the extension of postoperative time. Further analysis showed that the difference in AAQ scores between the intervention and control group at 6 months after the intervention was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01); that is, the psychological flexibility of patients in the intervention group significantly improved compared with the control group at 6 months after the intervention. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the changes in psychological flexibility scores.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2 Stigma\u003c/h2\u003e \u003cp\u003eIn comparing stigma scores, the difference in time effect in dimensions and total scores between the intervention and control groups were statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01); stigma levels were reduced after the intervention. Furthermore, differences were found in the total scores of stigma, internal shame, and social isolation between the two groups. Further analysis revealed that 3 months after the intervention, the differences in the dimensions of internal shame and social isolation between the two groups were statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Six months after the intervention, the social isolation dimension in the two groups was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), with the social isolation dimension of the intervention group being significantly lower than the control group. Figure\u0026nbsp;3 shows the changes in stigma scores.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003e3.3.3 Disease acceptance\u003c/h2\u003e \u003cp\u003eThe difference in time effect between the intervention and control groups were statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), indicating that the disease acceptability of the two groups increased with time after surgery. The effect difference between the treatment and control groups was also statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), indicating that the disease acceptability in the two groups varied with time. The difference of disease acceptance between the intervention group and the control group at 3 months and 6 months after intervention was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and the disease acceptance of the intervention group was significantly higher than the control group. Figure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the changes in acceptance scores.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section3\"\u003e \u003ch2\u003e3.3.4 Bowel function\u003c/h2\u003e \u003cp\u003eAnalysis revealed that at 3 months after the intervention, the differences in the total score of intestinal function and the dimensions of bowel frequency, urgency, and defecation affected by diet between the two groups were statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); the intestinal function of the intervention group was generally higher than the control group. Six months after the intervention, no significant difference in intestinal function between the two groups was found. Figure\u0026nbsp;5 shows the changes in bowel function scores.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003e3.3.5 Quality of life\u003c/h2\u003e \u003cp\u003eThe difference in time effect between the intervention and control groups were statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and the postoperative life quality of patients in both groups improved, especially in terms of emotional status and functional status. Moreover, the effect difference between the two groups in physical and emotional conditions was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Further analysis found that 3 months after the intervention, the differences in the total FACT-C score, physical status, and emotional status between the two groups were statistically significant, and the quality of life of the patients in the intervention group was significantly higher compared with the control group. At six months after the intervention, the differences in the total FACT-C score and the physical, family/social, emotional, and functional status scores between the two groups were statistically significant. The quality of life in the intervention group was significantly higher than that in the control group. Figure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e6\u003c/span\u003e shows the changes in quality of life scores.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eMental health is not to negatively maintain a normal state, prevent mental illness, but to consciously understand themselves, promote self-growth of the best psychological state. ACT focuses not on the symptoms themselves, but on improving the individual's mental flexibility and helping the individual achieve the goal value as the core treatment goal. The reduction or disappearance of symptoms is the possible phenomenon after the individual improves the mental flexibility. \u003csup\u003e41\u0026ndash;42\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn this study, although both groups showed improvement in psychological flexibility with the extension of postoperative time, the trend observed was different between the two groups. That is, 6 months after the intervention, the psychological flexibility of the patients in the intervention group significantly improved compared with the control group, indicating that the ACT intervention improved the psychological flexibility of patients with colorectal cancer after surgery. At 3 and 6 months after the intervention, the disease acceptability of the intervention group was significantly higher than the control group, suggesting that the ACT significantly improved patients\u0026rsquo; disease acceptability. Similarly, Anna et al.\u003csup\u003e43\u003c/sup\u003e found that in an intervention based on ACT for colorectal cancer patients, patients' psychological flexibility and disease acceptance level improved after the intervention. Ali et al.\u003csup\u003e25\u003c/sup\u003ealso showed, in a study on patients with colorectal cancer, that ACT intervention can improve patients\u0026rsquo; level of psychological flexibility and reduce empirical avoidance, the research focuses on patients' mental health, including psychological flexibility and cognitive levels.\u003c/p\u003e \u003cp\u003eBased on the common factors affecting the psychological flexibility of patients with colorectal cancer after surgery, we ensured patients fully understood their own diseases by health education and other methods. Hereafter, the patients were encouraged to recognise and discuss current problems and ways to deal with them, guided to face the facts of their disease, and encouraged to reduce their avoidance behaviour. Concurrently, patients learnt cognitive defusion skills to dissociate the Unpleasant thoughts induced by the disease, were helped to correctly understand negative cognition in the mind to weaken its negative impact, and learnt to accept the disease; thus, improving psychological flexibility.\u003c/p\u003e \u003cp\u003eStigma is widespread among cancer patients and it causes more emotional distress to people than the cancer itself. The level of stigma in the two groups was reduced after the intervention; however, there were significant differences between the two groups which suggests that stigma level in patients after surgery was significantly reduced by the ACT intervention. Similarly, West et al. \u003csup\u003e45\u003c/sup\u003e showed that components of psychological flexibility can help prevent the effects of stigma, while value clarification can buffer its effects. Suyanti et al. \u003csup\u003e46\u003c/sup\u003eexplored the effect of ACT on self-stigma and depression in AIDS patients and found that patients\u0026rsquo; self-stigma and depression levels significantly improved after the ACT intervention.\u003c/p\u003e \u003cp\u003ePatients with cancer are often stigmatised and discriminated against by the public and many patients internalise the stigma associated with the disease. To avoid the stigma caused by external evaluation, cancer patients usually adopt avoidance measures, which lead to empirical avoidance in the long-term. ACT, through acceptance and cognitive defusion techniques, enables patients to view the external world and their own evaluations of themselves as observers, and to adjust their relationship with these evaluations, rather than to associate themselves with them. Therefore, cognitive defusion techniques allow patients to understand that these assessments are linguistic symbols, not their true selves, and learn to distance themselves from them; thus, seeing themselves more authentically and reducing stigma levels over time.\u003c/p\u003e \u003cp\u003eIn view of the intestinal function after colorectal cancer surgery, modern medicine believes that surgical trauma, anesthesia, gastrointestinal lesions, and systemic conditions will all have an impact on gastrointestinal function, which is likely to cause intestinal dilation, flora imbalance, abdominal distension, and even serious complications such as intestinal adhesion and anastomotic leakage. \u003csup\u003e47\u003c/sup\u003ePostoperative gastrointestinal dysfunction seriously affects the systemic nutritional status of patients, prolonging hospital stay, increasing additional hospitalization costs, bringing economic and mental pressure to patients, and seriously affecting postoperative rehabilitation and quality of life of patients. \u003csup\u003e48\u003c/sup\u003e Due to the complex etiology of postoperative intestinal dysfunction, there is still a lack of effective methods and drugs to promote postoperative gastrointestinal function. In clinical practice, fasting, gastrointestinal decompression and early functional exercise are mainly adopted for postoperative gastrointestinal dysfunction, but the effect is not satisfactory. \u003csup\u003e47\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis study shows that ACT can improve the intestinal function of patients with colorectal cancer after surgery; however, the long-term effects of this improvement needs to be further verified. And after the ACT intervention, the overall quality of life of the intervention group improved significantly. Similarly, in a randomised controlled trial of breast cancer survivors, Shelley et al. \u003csup\u003e49\u003c/sup\u003e indicated that ACT intervention improve the quality of life of breast cancer patients. Additionally, after the intervention of Rose Michael R et al. \u003csup\u003e50\u003c/sup\u003efound that ACT could reduce anxiety and depression and significantly improve patients\u0026rsquo; quality of life in patients with chronic muscle disease.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStudy limitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFirst, a convenience sampling method was adopted in this study. The sample size was obtained from two tertiary hospitals.Thus, the selection of the study population was biased by region. Second, due to time limitations, this study only observed the experimental effect 6 months after the intervention, the long-term effect of the intervention could not be verified. Third, only acceptance and action questionnaires were used to represent the intervention effect of ACT on psychological flexibility, which was not perfect. That is, ACT psychotherapy consists of six modules, AAQ-II only to avoid an empiric therapy effect. It is suggested to use a scale covering six modules of ACT psychotherapy in the future. \u003csup\u003e51\u003c/sup\u003e\u003c/p\u003e"},{"header":"5. CONCLUSIONS","content":"\u003cp\u003eThis study supports a four-session ACT intervention for postoperative patients with colorectal cancer. The findings showed that ACT can improve the mental flexibility and disease acceptance of patients after colorectal cancer surgery, reduce the level of stigma, improve intestinal function and improve the quality of life of colorectal cancer patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflicts of interest\u003c/h2\u003e \u003cp\u003eThere are no conflicts of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis project was funded by the Natural Science Foundation of Shandong Province (ZR2020MG005) and a project of the Shandong Province Higher Educational Science and Technology Program (J18RA103).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eNa Liu drafted the entire manuscript. Lingyu Yao performed part of the data analysis. Head nurses Fuxia Li and Hongling Yin were responsible for coordinating patients for data collection. Aihua Zhang reviewed and approved the overall paper.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003e We thank the research supervisor Ai-hua Zhang, and all the research assistants who made this study possible, particularly Ling-yu Yao, Fuxia Li, Hong-ling Yin and all of the clinical nurses and the study participants for their contributions to this project.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worcde for 36 Cancers in 185 Countries. \u003cem\u003eCA Cancer J Clin\u003c/em\u003e. 2021;71(3):209-249. \u003c/li\u003e\n\u003cli\u003eKamody R C , Berlin K S , Rybak T M , et al. Psychological Flexibility Among Youth with Type 1 Diabetes: Relating Patterns of Acceptance, Adherence, and Stress to Adaptation[J]. Behavioral Medicine, 2017:1-9.\u003c/li\u003e\n\u003cli\u003eLin J, Klatt L I, Mccracken L M, et al. Psychological flexibility mediates the effect of an online-based acceptance and commitment therapy for chronic pain: an investigation of change processes[J]. Pain, 2017, c in press:1.\u003c/li\u003e\n\u003cli\u003eLeonidou C , Panayiotou G , Bati A , et al. Coping with psychosomatic symptoms: The buffering role of psychological flexibility and impact on quality of life[J]. Journal of Health Psychology, （2016）.\u003c/li\u003e\n\u003cli\u003eCassar G E , Knowles S , Youssef G J , et al. Examining the mediational role of psychological flexibility, pain catastrophizing, and visceral sensitivity in the relationship between psychological distress, irritable bowel symptom frequency, and quality of life[J]. Psychology, Health \u0026amp; Medicine, 2018:1-14.\u003c/li\u003e\n\u003cli\u003eHayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., \u0026amp; Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1\u0026ndash;25. https://doi.org/10.1016/j.brat.2005.06.006\u003c/li\u003e\n\u003cli\u003eHayes, SC, Strosahl, KD, Wilson，KG. Acceptance and commitment therapy: An experiential approach to behavior change. 2003: The Guilford Press.\u003c/li\u003e\n\u003cli\u003eHeadley S. Acceptance and commitment therapy: model, processes and outcomes. [J]. Behaviour Research \u0026amp; Therapy, 2006, 44(1):1-25.\u003c/li\u003e\n\u003cli\u003eStergaard, Tom, Lundgren T, Zettle R , et al. Acceptance and Commitment Therapy preceded by an experimental Attention Bias Modification procedure in recurrent depression: study protocol for a randomized controlled trial[J]. Trials, 2018, 19(1):203.\u003c/li\u003e\n\u003cli\u003eMathew A, Doorenbos AZ, Jang MK, Hershberger PE. Acceptance and commitment therapy in adult cancer survivors: a systematic review and cocmodel. \u003cem\u003eJ Cancer Surviv\u003c/em\u003e. 2021;15(3):427-451. \u003c/li\u003e\n\u003cli\u003eRayner M , Muscara F , Dimovski A , et al. Take A Breath: study protocol for a randomized controlled trial of an online group intervention to reduce traumatic stress in parents of children with a life threatening illness or injury.[J]. Bmc Psychiatry, 2016, 16(1):1-12.\u003c/li\u003e\n\u003cli\u003eGarc\u0026iacute;a-Torres, Francisco et al. \u0026ldquo;Efficacy of a Combined Acceptance and Commitment Intervention to Improve Psychological Flexibility and Associated Symptoms in Cancer Patients: Study Protocol for a Randomized Controlled Trial.\u0026rdquo; \u003cem\u003eFrontiers in psychology\u003c/em\u003e vol. 13 871929. 18 May. 2022. \u003c/li\u003e\n\u003cli\u003eCasey, M\u0026aacute;ire-Br\u0026iacute;d, Smart K , Segurado R , et al. Exercise combined with Acceptance and Commitment Therapy (ExACT) compared to a supervised exercise programme for adults with chronic pain: study protocol for a randomised controlled trial[J]. Trials, 2018, 19(1):194.\u003c/li\u003e\n\u003cli\u003eAlonso-Fern\u0026aacute;ndez, Miriam, L\u0026oacute;pez-L\u0026oacute;pez, Almudena, Losada A , et al. Acceptance and Commitment Therapy and Selective Optimization with Compensation for Institutionalized Older People with Chronic Pain[J]. Pain Medicine, 2015:n/a-n/a.\u003c/li\u003e\n\u003cli\u003eMccracken L M , Jones R . Treatment for Chronic Pain for Adults in the Seventh and Eighth Decades of Life: A Preliminary Study of Acceptance and Commitment Therapy (ACT)[J]. Pain Medicine, 2012, 13(7):860\u0026ndash;867.\u003c/li\u003e\n\u003cli\u003eGodfrey E , Galea Holmes M , Wileman V , et al. Physiotherapy informed by Acceptance and Commitment Therapy (PACT): protocol for a randomised controlled trial of PACT versus usual physiotherapy care for adults with chronic low back pain[J]. BMJ Open, 2016, 6(6): e011548.\u003c/li\u003e\n\u003cli\u003eGloster A T, Sonntag R, Hoyer J, et al. Treating Treatment-Resistant Patients with Panic Disorder and Agoraphobia Using Psychotherapy: A Rancized Controlled Switching Trial[J]. Psychotherapy and Psychosomatics, 2015, 84(2):100-109.\u003c/li\u003e\n\u003cli\u003eMathew A, Doorenbos AZ, Jang MK, Hershberger PE. Acceptance and commitment therapy in adult cancer survivors: a systematic review and conceptual model. \u003cem\u003eJ Cancer Surviv\u003c/em\u003e. 2021;15(3):427-451. \u003c/li\u003e\n\u003cli\u003eMathew A, Doorenbos AZ, Jang MK, Hershberger PE. Acceptance and commitment therapy in adult cancer survivors: a systematic review and conceptual model. \u003cem\u003eJ Cancer Surviv\u003c/em\u003e. 2021;15(3):427-451. \u003c/li\u003e\n\u003cli\u003eWiklund T , Linton S J , Peter Alf\u0026ouml;ldi, et al. Is sleep disturbance in patients with chronic pain affected by physical exercise or ACT-based stress management? \u0026ndash; A randomized controlled study[J]. Bmc Musculoskeletal Disorders, 2018, 19(1):111.\u003c/li\u003e\n\u003cli\u003eClarke S , Taylor G , Bolderston H , et al. Ameliorating Patient Stigma Amongst Staff Working With Personality Disorder: Randomized Controlled Trial of Self-Management Versus Skills Training[J]. Behavioural and Cognitive Psychotherapy, 2015, 43(06):692-704.\u003c/li\u003e\n\u003cli\u003eMasuda A, Hayes S C, Fletcher L B, et al. Impact of acceptance and commitment therapy versus education on stigma toward people with psychological disorders[J]. Behaviour Research \u0026amp; Therapy, 2007, 45(11):0-2772.\u003c/li\u003e\n\u003cli\u003eClarke S , Taylor G , Bolderston H , et al. Ameliorating Patient Stigma Amongst Staff Working With Personality Disorder: Randomized Controlled Trial of Self-Management Versus Skills Training[J]. Behavioural \u0026amp; Cognitive Psychotherapy, 2015, 43(06):692-704.\u003c/li\u003e\n\u003cli\u003eLi T W , Fung P L , MatickaTyndale E , et al. Effects Of HIV stigma reduction interventions in diasporic communities: insights from the CHAMP study[J]. AIDS Care, 2017:1-7.\u003c/li\u003e\n\u003cli\u003eAli EA, Khedr MA, Alabdullah AAS, Farghaly Abdelaliem SM, El-Ashry AM. Effect of acceptance and commitment therapy-based interventions on mental health and cognitive impairment for patients with advanced colorectal cancer. \u003cem\u003ePublic Health Nurs\u003c/em\u003e. 2024;41(4):745-759. doi:10.1111/phn.13333\u003c/li\u003e\n\u003cli\u003eLuoma JB, Hayes SC, Walser RD. Learning ACT: An Acceptance and Commitment Therapy Skills-Training Manual for Therapists. Oakland: New Harbinger; 2007\u003c/li\u003e\n\u003cli\u003eStoddard JA, Afari N. The Big Book of ACT Metaphors. A Practitioner\u0026apos;s Guide to Experiential Exercises \u0026amp; Metaphors in Acceptance and Commitment Therapy. Oakland, CA: NeHarbinger Publications; 2014.\u003c/li\u003e\n\u003cli\u003eS.A. Johns, P.V. Stutz, T.L. Talib, et al., Acceptance and commitment therapy for breast cancer survivors with fear of cancer recurrence: A 3-arm pilot randomized controlled trial, Cancer 126 (2020) 211\u0026ndash;218.\u003c/li\u003e\n\u003cli\u003eWells-Di Gregorio SM, Marks DR, DeCola J, et al. Pilot randomized controlled trial of a symptom cluster intervention in advanced cancer. Psycho Oncol. 2019;28(1):76\u0026ndash;84.\u003c/li\u003e\n\u003cli\u003eSerfaty M, Armstrong M, Vickerstaff V, et al. Acceptance and commitment therapy for adults with advanced cancer (CanACT): a feasibility randomised controlled trial. Psycho Oncol. 2019;28(3):488\u0026ndash;496. \u003c/li\u003e\n\u003cli\u003eHarris, R. (2019). ACT made simple: An easy-to-read primer on acceptance and commitment therapy (2nd ed.). New Harbinger Publications.\u003c/li\u003e\n\u003cli\u003eFledderus M, Oude Voshaar MA, Ten Klooster PM, et al. Further evaluation of the psychometric properties of the Acceptance and Action Questionnaire-Ⅱ[J]. Psychol Assess, 2012, 26(5):377-381.\u003c/li\u003e\n\u003cli\u003eWright F E R . The Dimensionality of Stigma: A Comparison of Its Impact on the Self of Persons with HIV/AIDS and Cancer[J]. Journal of Health and Social Behavior, 2000, 41(1):50-67.\u003c/li\u003e\n\u003cli\u003ePan AW, Chung L, Fife BL, Hsiung PC. Evaluation of the psychometrics of the Social Impact Scale: a measure of stigmatization. \u003cem\u003eInt J Rehabil Res\u003c/em\u003e.2007;30(3):235-238. \u003c/li\u003e\n\u003cli\u003eFelton BJ，Revenson TA，Hinrichsen GA. Stress and coping in the explanation of psychological adjustment among chronically ill adults ［J］.Soc Sci Med，1984， 18（10）：889-898.\u003c/li\u003e\n\u003cli\u003eWright F E R . The Dimensionality of Stigma: A Comparison of Its Impact on the Self of Persons with HIV/AIDS and Cancer[J]. Journal of Health and Social Behavior, 2000, 41(1):50-67.\u003c/li\u003e\n\u003cli\u003eTemple LK ,Bacik J ,Savatta SG, et al. The development of a validated instrument to evaluate bowel function after sphincter-preserving surgery for rectal cancer ［ J ］ .Dis Colon Rectum ， 2005 ,48（7）：1353-1365.\u003c/li\u003e\n\u003cli\u003eKnowles G, Haigh R, McLean C, et al. Long term effect of surgery and radiotherapy for colorectal cancer on defecatory function and quality of life［ J ］. Eur J Oncol Nurs ,2013, 17（5）：570-577.\u003c/li\u003e\n\u003cli\u003eZotti P, Del BP, Serpentini S, et al. Validity and reliability of the MSKCC Bowel Function Instrument in a sample of Italian rectal cancer patients［ J ］. Eur J Surg Oncol ,2011 ,37 （7）：589-596.\u003c/li\u003e\n\u003cli\u003eWard W L, Hahn E A, Mo F, Hernandez L, Tulsky D S, Cella D. Reliability and validity of the Functional Assessment of Cancer Therapy-Colorectal (FACT-C) quality of life instrument.[J]. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation,1999,8(3).\u003c/li\u003e\n\u003cli\u003eHayes SC. Acceptance and commitment therapy，relational frame theory，and the third wave of behavioral and cognitive therapies ［J］. Behav Ther，2004，35 (4): 639 －665.\u003c/li\u003e\n\u003cli\u003eHayes SC，Luoma JB，Bond FW，et al. Acceptance and commitment therapy: model，processes and outcomes［J］. BehavＲes Ther，2006，44 (1): 1 －25.\u003c/li\u003e\n\u003cli\u003eHawkes AL, Pakenham KI, Chambers SK, Patrao TA, Courneya KS. Effects of a multiple health behavior change intervention for colorectal cancer survivors on psychosocial outcomes and quality of life: a randomized controlled trial. \u003cem\u003eAnn Behav Med\u003c/em\u003e. 2014;48(3):359-370. \u003c/li\u003e\n\u003cli\u003eQstergaard, Tom, Lundgren T , Zettle R , et al. Acceptance and Commitment Therapy preceded by an experimental Attention Bias Modification procedure in recurrent depression: study protocol for a randomized controlled trial[J]. Trials, 2018, 19(1):203.\u003c/li\u003e\n\u003cli\u003eWest L M , Graham J R , Roemer L .Functioning in the face of racism: Preliminary findings on the buffering role of values clarification in a Black American sample[J].Journal of Contextual Behavioral Science, 2013, 2(1-2):1-8. \u003c/li\u003e\n\u003cli\u003eSri Suyanti T , Anna Keliat B , Catharina Daulima N H . Effect of logo-therapy, acceptance, commitment therapy, family psychoeducation on self-stigma, and depression on housewives living with HIV/AIDS[J]. Enfermer\u0026iacute;a Cl\u0026iacute;nica, 2018, 28:98-101.\u003c/li\u003e\n\u003cli\u003eLam D, Jones O. Changes to gastrointestinal function after surgery for colorectal cancer. \u003cem\u003eBest Pract Res Clin Gastroenterol\u003c/em\u003e. 2020;48-49:101705. doi:10.1016/j.bpg.2020.101705\u003c/li\u003e\n\u003cli\u003eSeow-En I, Chok AY, Matchar DB, Yoon S, Chong DQ, Tan EK. Long-term quality of life, sexual health and gastrointestinal function following colorectal cancer resection in an Asian cohort. \u003cem\u003eColorectal Dis\u003c/em\u003e. 2021;23(9):2348-2360. doi:10.1111/codi.15768\u003c/li\u003e\n\u003cli\u003eJohns Shelley A,Stutz Patrick V,Talib Tasneem L,Cohee Andrea A,Beck-Coon Kathleen A,Brown Linda F,Wilhelm Laura R,Monahan Patrick O,LaPradd Michelle L,Champion Victoria L,Miller Kathy D,Giesler R Brian. Acceptance and commitment therapy for breast cancer survivors with fear of cancer recurrence: A 3-arm pilot randomized controlled trial.[J]. Cancer,2020,126.\u003c/li\u003e\n\u003cli\u003eRose Michael R,Norton Sam,Vari Chiara,Edwards Victoria,McCracken Lance,Graham Christopher D,Radunovic Aleksandar,Chalder Trudie. Acceptance and Commitment Therapy for Muscle Disease (ACTMus): protocol for a two-arm randomised controlled trial of a brief guided self-help ACT programme for improving quality of life in people with muscle diseases.[J]. BMJ open,2018,8(10).\u003c/li\u003e\n\u003cli\u003eRayner M , Muscara F , Dimovski A , et al. Take A Breath: study protocol for a randomized controlled trial of an online group intervention to reduce traumatic stress in parents of children with a life threatening illness or injury[J]. Bmc Psychiatry, 2016, 16(1):1-12.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Acceptance and commitment therapy, Colorectal cancer, Disease acceptance, Intestinal function, Quality of life, Psychological flexibility, Oncology, Stigma","lastPublishedDoi":"10.21203/rs.3.rs-8768115/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8768115/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study evaluated a four-session acceptance and commitment therapy (ACT) intervention targeting the effects on health outcomes of postoperative patients with colorectal cancer.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eParticipants were 100 adults (56% male; M\u0026thinsp;=\u0026thinsp;59.3 years, SD\u0026thinsp;=\u0026thinsp;8.7) with colorectal cancer who were randomized to the ACT intervention group or the usual care group. Psychological flexibility, stigma, disease acceptance, intestinal function, and quality of life were assessed at baseline and at 3 months and 6 months after the intervention.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 100 participants who started the intervention, 95% completed it and reported high satisfaction. Participants were randomized to four weekly sessions of acceptance and commitment therapy or routine nursing mode. Lost to follow-up cases were performed using a propensity score matching analysis. There was no significant difference at baseline between the intervention and control groups in terms of general information and various test indicators. Compared with the control group, the ACT group had a significant effect on psychological flexibility, stigma, disease acceptability, intestinal function, and quality of life.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eACT can improve the psychological flexibility and disease acceptance of postoperative patients with colorectal cancer, reduce stigma levels, improve intestinal function and quality of life.\u003c/p\u003e","manuscriptTitle":"Effects of Acceptance and Commitment Therapy on Postoperative Patients with Colorectal Cancer: A randomized controlled trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-10 00:44:25","doi":"10.21203/rs.3.rs-8768115/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"232882312796807086903328822107311089200","date":"2026-05-10T04:59:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-03T19:53:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-03T19:50:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-06T03:41:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2026-02-02T18:08:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f692787a-801c-4456-bdea-1153fc6740ea","owner":[],"postedDate":"March 10th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"232882312796807086903328822107311089200","date":"2026-05-10T04:59:25+00:00","index":30,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-10T00:44:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-10 00:44:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8768115","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8768115","identity":"rs-8768115","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}