Xu WL, Wang Y, Zhu L, Zhang X, Tan YS, Peng PP, Yang XJ. Impact of narrative support on stigma, anxiety, and depression in young and middle-aged patients undergoing maintenance hemodialysis. World J Psychiatry 2026; 16(9): 119511 [DOI: 10.5498/wjp.119511]
Corresponding Author of This Article
Xing-Ju Yang, Chief Nurse, Department of Nursing, People’s Hospital Affiliated to Shandong First Medical University, No. 001 Xuehu Street, Laiwu District, Jinan 271100, Shandong Province, China. doc_yangxingjv@163.com
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Xu WL, Wang Y, Zhu L, Zhang X, Tan YS, Peng PP, Yang XJ. Impact of narrative support on stigma, anxiety, and depression in young and middle-aged patients undergoing maintenance hemodialysis. World J Psychiatry 2026; 16(9): 119511 [DOI: 10.5498/wjp.119511]
Wen-Li Xu, Yue Wang, Xing-Ju Yang, Department of Nursing, People’s Hospital Affiliated to Shandong First Medical University, Jinan 271100, Shandong Province, China
Lin Zhu, Xin Zhang, Yong-Shun Tan, Hemodialysis Room, People’s Hospital Affiliated to Shandong First Medical University, Jinan 271100, Shandong Province, China
Pei-Pei Peng, Department of Psychiatry, Laiwu Central Hospital of Shandong Yiyang Health Group, Jinan 250013, Shandong Province, China
Author contributions: Xu WL was responsible for writing the paper; Wang Y was responsible for analyzing the statistical data; Zhu L and Zhang X collected materials; Tan YS and Peng PP were responsible for providing clinical advice; Yang XJ was responsible for researching, designing, and developing the intervention plans; and all the authors have approved the manuscript.
Supported by Jinan Municipal Health Commission’s 2024 Science and Technology Development Plan Development Project, No. 2024305010.
Institutional review board statement: This study was approved by the Medical Ethics Committee of the Jinan City People’s Hospital, approval No. 2024yxkt-6.
Informed consent statement: The informed consent was waived by the Institutional Review Board.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: The data used in this study can be obtained from the corresponding author upon request.
Corresponding author: Xing-Ju Yang, Chief Nurse, Department of Nursing, People’s Hospital Affiliated to Shandong First Medical University, No. 001 Xuehu Street, Laiwu District, Jinan 271100, Shandong Province, China. doc_yangxingjv@163.com
Received: March 25, 2026 Revised: April 28, 2026 Accepted: June 3, 2026 Published online: September 19, 2026 Processing time: 151 Days and 20.4 Hours
Abstract
BACKGROUND
End-stage renal disease requires maintenance hemodialysis (MHD), which imposes a huge psychological and social burden on young and middle-aged patients. This group often needs to balance professional and social roles, and is therefore highly vulnerable to stigma, anxiety and depression. These conditions can severely undermine treatment adherence and the quality of life. Although narrative support has shown benefits in other chronic illnesses, its structured application in young and middle-aged MHD populations remains underexplored.
AIM
To assess the effects of narrative support on stigma, adherence, sleep, and quality of life in patients undergoing MHD.
METHODS
This retrospective study included 158 patients who received MHD treatment. The control group (n = 73) received standard treatment, while the observation group (n = 85) received additional narrative support. The Social Impact Scale (SIS), Self-rating Anxiety Scale, Pittsburgh Sleep Quality Index, Self-rating Depression Scale, short form-36 health survey health questionnaire and end-stage renal disease compliance questionnaire were used to evaluate before and after intervention.
RESULTS
Compared to the control group, patients receiving narrative support showed a significantly greater reduction in perceived stigma, anxiety, and depression. In addition, the intervention group performed better in treatment compliance and sleep quality, and scored significantly higher in all eight dimensions of the short form-36 health survey scale, indicating that their physical and mental health had improved. After applying Bonferroni correction, all significant differences remained robust.
CONCLUSION
Narrative support can help to reduce the psychological burden of young and middle-aged patients undergoing hemodialysis, improve treatment compliance, and improve their quality of life.
Core Tip: Structured narrative support significantly reduces stigma, anxiety, and depression in young and middle-aged hemodialysis patients. It also improves treatment adherence, sleep quality, and health-related quality of life. This patient-centered approach helps patients reframe their illness experiences through guided storytelling, offering an effective strategy to address the psychosocial challenges of long-term dialysis. Narrative support is a valuable complement to the standard clinical care.
Citation: Xu WL, Wang Y, Zhu L, Zhang X, Tan YS, Peng PP, Yang XJ. Impact of narrative support on stigma, anxiety, and depression in young and middle-aged patients undergoing maintenance hemodialysis. World J Psychiatry 2026; 16(9): 119511
Maintenance hemodialysis (MHD) is the main renal replacement therapy for patients with end-stage renal disease (ESRD), which can significantly improve the survival rate. However, it brings huge physical and psychological burden to patients[1]. With the increasing prevalence of chronic kidney disease in the world, the demand for dialysis continues to grow. By 2021, the number of people receiving dialysis treatment worldwide has exceeded 3.8 million, with hemodialysis accounting for more than 70% of all treatment methods[2]. It is predicted that the global number of dialysis patients may exceed 5.4 million by 2030, and the proportion of young patients will continue to rise[3]. Young and middle-aged individuals undergoing MHD often face unique challenges as they are in life stages that are heavily defined by occupational, familial, and social responsibilities. The long-term nature of dialysis treatment can lead to physical fatigue, work obstruction, family role imbalance and social function decline, all of which can aggravate psychological stress[4]. This group is particularly vulnerable to negative emotions such as stigma, anxiety and depression, which may weaken their treatment compliance and reduce their overall quality of life[5].
Although previous studies have focused on symptom management and overall quality of life in dialysis populations, systematic studies on the specific psychosocial adaptation problems and targeted interventions for young patients undergoing MHD are significantly scarce[6]. In this study, we aim to address this research gap by specifically examining the effectiveness of structured narrative support interventions for this underserved population. Research indicates that there is a significant association between psychological distress and poor treatment adherence, an increased risk of complications, and higher mortality rates among patients with mental health conditions[7]. Additionally, stigma is a significant psychosocial factor, reinforcing self-stigmatization and social withdrawal, potentially weakening a patient’s motivation and engagement with treatment[8]. As a patient-centered psychosocial intervention model, narrative support has received increasing attention in the field of chronic disease care. By promoting empathetic dialogue and structured narrative reconstruction, patients can reinterpret their own disease experience, enhance self-identity, alleviate emotional distress, and improve treatment compliance[9]. Studies have reported beneficial outcomes of narrative support in patients with cancer, diabetes, and chronic heart failure[10-12]. However, the application of this method in young and middle-aged patients undergoing MHD treatment has not been fully studied; most of the existing literature focuses on elderly patients, while the data on the individualized psychosocial needs of young people are limited[13].
In view of the significant stigma and emotional burden of young and middle-aged patients undergoing MHD, this study aimed to assess the impact of narrative support on multiple psychosocial outcomes. This study focuses on a structured, phased narrative intervention tailored to the specific psychosocial challenges of young and middle-aged dialysis patients. This field has rarely been studied before, so it has contributed to the relevant literature. We hypothesized that the intervention would reduce illness-related stigma, alleviate anxiety and depression, and improve treatment adherence and quality of life. We expect that by fostering a more integrated and meaningful understanding of illness through a guided narrative, patients will experience better engagement in care. By using the mechanism of empathy listening and meaning construction, the intervention aims to provide this group with a tailored and clinically significant psychological support strategy.
MATERIALS AND METHODS
Patients and setting
In this retrospective study, we analyzed the data of 158 young and middle-aged patients who underwent MHD at the Jinan City People’s Hospital between January 2022 and January 2024. Because this study is a retrospective study, patients were not randomly divided. The control group (n = 73) consisted of patients who received early standard dialysis treatment, while the observation group (n = 85) consisted of patients who subsequently received systematic narrative support. Data collection and result analysis were performed by different personnel to minimize potential evaluator bias. The study was approved by the Ethics Committee of the Jinan City People’s Hospital (No. 2024yxkt-6), which waived the requirement for written informed consent.
The inclusion criteria: (1) Age between 18 years and 60 years; (2) Receiving regular MHD treatment for at least one year; and (3) Intact cognitive function and normal communication ability.
The exclusion criteria: (1) Diagnosis of severe psychiatric or neurological disorders; (2) Concurrent malignancies, acute infections, or sequelae of major cardiovascular or cerebrovascular events; and (3) Significant cardiac or hepatic dysfunction.
According to the preliminary data and clinical experience, and based on conventional effect size estimates in similar psychosocial interventions, it was estimated that at least 60 participants per group would be required to detect significant differences in primary psychosocial outcomes (such as stigma, anxiety, and depression scores) between the two groups under a significance level of α = 0.05 and a statistical power of 1-β = 0.80. In order to improve the robustness and universality of the research results, it was finally determined that at least 70 participants were needed in each group. In the final sample, the control group included 73 patients and the intervention group included 85 patients. Both groups exceeded the minimum requirements.
Methods
Patients in the control group received standard hemodialysis care, including monitoring of vital signs during dialysis, prevention of dialysis-related complications, health education, and dietary and medication guidance. On the basis of routine care, the observation group also received structured narrative support.
Formation of a narrative support team
A multidisciplinary nursing support team has been set up, consisting of a nurse-in-charge, six registered nurses, a psychological consultant and a nephrologist. The team is led by a head nurse who is responsible for coordinating work and quality assurance. All team members received unified pre-intervention training, covering key topics such as narrative nursing concepts, open questions, emotional recognition, non-critical responses, and empathy listening skills. The training emphasized the specific psychosocial challenges faced by young and middle-aged patients undergoing MHD, including occupational disruption, family role strain, and identity shifts, to improve the nurses’ capacity to provide individualized and emotionally attuned interventions.
Development of the narrative support protocol
Based on literature review and preliminary interviews, an intervention program was developed to clarify the objectives, content, frequency, and evaluation framework. This approach emphasises a patient-centred narrative process, aiming to explore an individual’s subjective experience of illness, emotional coping strategies and life transitions. The study employed a structured framework incorporating strategies such as “participation, guidance, emotional expression, deconstruction and reconstruction” to facilitate emotional release, cognitive restructuring and identity reconstruction, with the ultimate aim of alleviating the stigma and negative emotions experienced by patients receiving inpatient psychiatric care. Narrative support interventions are tailored specifically for young and middle-aged patients, focusing on common sources of stress in this age group, such as job disruption, parenting challenges, social role stress, and concerns about stigma and loss of identity. These factors provide a basis for the content and implementation of intervention measures.
Implementation of the narrative intervention
The 12-week intervention program consisted of one-on-one interviews (30 minutes to 45 minutes each time) by designated nurses once a week before or during dialysis to maintain continuity and enhance doctor-patient trust. The intervention program includes the following four stages.
Trust building and initial listening (weeks 1 and 2): Nurses established a rapport with patients through non-judgmental and empathetic communication, and encouraged patients to talk about their initial reactions to dialysis, lifestyle changes, and perceptions of social stigma. By proposing “How do you feel at the first dialysis?” Open questions, such as guiding patients to talk about their own dialysis process, focusing on changes in life roles, such as unemployment or changes in family relationships, thus creating a psychologically safe expression space.
Deep narrative and identity reconstruction (weeks 3-8): Nurses guide patients in exploring topics such as “What is my life like now?” and “How do others perceive me?” in order to identify internalised stigma or negative self-label. By listening to feedback and advantage-based responses, nurses help patients confront hidden emotions (such as shame and helplessness) and reshape their dialysis identity with positive life experiences (such as caring for others and continuing employment), thereby reinforcing personal values and resisting social stigma.
Emotional support and resource integration (weeks 9 and 10): During this phase, the focus is on recurring feelings of anxiety and depression through cognitive restructuring. Nurses will ask targeted questions, such as: “Does your sense of frustration stem more from the illness itself, or from the disruption to your daily life?”, to help patients better understand the triggers of their emotions. In addition, external resources such as counselling services, peer support groups and vocational rehabilitation are provided to strengthen patients’ psychosocial support networks.
Reflection and future orientation (weeks 11 and 12): In the final stage, patients reviewed the emotional and cognitive changes experienced throughout the intervention. They are encouraged to write to their “future selves”, or set short-term goals, to establish new perceptions of disease, build resilience, and reinforce their sense of meaning and control in life.
Quality control procedures
In order to ensure the consistency of intervention among different nurses, the team leader and the psychological counselor used the standardized compliance checklist to conduct a random sampling review of 20% of the conversation recordings. Any deviation from the plan is discussed and corrected at a biweekly supervision meeting. All interviews were documented by the nursing staff to record key content, and when necessary, technical guidance was provided by a psychological counsellor to help optimize communication skills and interview strategies. To ensure adherence to the intervention protocol, the team leader regularly conducted spot checks of the interview records based on a standardized checklist. At the same time, team leaders and psychological counselors jointly supervise the consistency of interventions to ensure that different service providers follow a standardized process.
Baseline data collection
Before the intervention, the researchers used standardized questionnaires to collect demographic and socio-economic data of patients, including gender, age, family per capita monthly income, body mass index, education level, employment status, marital status, and payment methods. Clinical information such as primary disease and dialysis vintage was also recorded. Laboratory data, including the levels of hemoglobin, serum albumin, serum calcium, and serum phosphorus, as well as the urea reduction ratio and urea clearance index, were extracted from the hospital’s electronic medical records.
Observation indicators
Key psychosocial and clinical indicators were assessed before and after the 12-week treatment in both groups.
Stigma: Stigma was evaluated using the Social Impact Scale, a 24-item instrument developed by Wu et al[14]. These items are classified into four different dimensions: Internalized shame, economic insecurity, social exclusion and social isolation. Answers were recorded using a 4-point Likert scale of 1 point to 4 points. The total score ranged from 24 points to 96 points. The higher the score, the higher the degree of stigmatization perceived by individuals[14]. In an initial validation study, the scale demonstrated excellent internal consistency with a Cronbach’s alpha of 0.96[15]. In our study, Cronbach’s alpha was 0.89, which also reflects good reliability and supports the instrument’s internal consistency within our sample.
Negative emotional state: The degree of anxiety was measured by Self-rating Anxiety Scale (SAS) and converted to a standard score of 100 points. Score ≥ 70 indicates severe anxiety, 60-69 indicates moderate anxiety, and 50-59 indicates mild anxiety[16]. The degree of depression was assessed using the Self-rating Depression Scale (SDS), which consisted of 20 items. The scores were divided into three categories: Mild (53-62), moderate (63-72) and severe (≥ 73)[17]. In the original studies, Cronbach’s alpha for the SAS and SDS was 0.75 and 0.78, respectively[18]. In the current study, these values were 0.73 and 0.76, respectively, suggesting that both scales demonstrated good internal consistency.
Treatment adherence: In this study, the ESRD compliance questionnaire (ESRD-AQ) was used to assess the compliance of patients receiving MHD in multiple treatment areas. The scale consisted of 46 items: 5 demographic questions and 4 compliance subscales: Drug compliance (9 items), treatment compliance (14 items), fluid intake restriction (10 items) and dietary advice (8 items). A mix of Likert scales, multiple-choice items, and dichotomous items were used. The total scores ranged from 0 to 1200: < 700 indicated poor adherence, 700-999 indicated moderate adherence, and 1000-1200 good adherence[19]. The original study reported a Cronbach’s α of 0.83 for the ESRD-AQ[20]. In our sample, the reliability coefficient was 0.85, indicating good internal consistency.
Sleep quality: The Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality. This scale consists of seven dimensions: Latency to fall asleep, habitual sleep efficiency, subjective sleep quality, sleep duration, use of sleeping pills, sleep disorders, and daytime dysfunction. The score of each sub-item ranged from 0 points to 3 points, and the total score ranged from 0 points to 21 points. A total score of ≥ 7 points indicates poor sleep quality[21]. The Cronbach’s α coefficient of PSQI in the original validation study was 0.83[22], which was 0.86 in this study, indicating that its reliability was acceptable.
Quality of life: Quality of life was assessed using the short form-36 health survey (SF-36), covering eight domains: Role-emotional, role-physical, vitality, bodily pain, general health, social functioning, physical functioning, and mental health. Each domain was scored from 0 to 100, with higher scores indicating a better state. These scores contributed to the Mental Component Summary and Physical Component Summary[23]. The original study reported a Cronbach’s α of 0.78 for the SF-36[24]. In our sample, Cronbach’s alpha was 0.74.
Statistical analysis
Statistical analyses were performed using IBM SPSS Statistics for Windows, version 22.0 (IBM Corp., Armonk, NY, United States). The Kolmogorov-Smirnov test was used to assess the normality of the data distribution. For continuous data that follow a normal distribution, the results are presented as mean ± SD and were compared using the independent-samples t-test or paired t-test; for continuous data that do not follow a normal distribution, results are presented as median (interquartile range) and were compared using the Mann-Whitney U test or Wilcoxon signed-rank test. Categorical variables are expressed as proportions and were compared using the χ2 test. Bonferroni correction was applied for multiple comparisons to adjust the significance level. Statistical significance was set at P < 0.01 (adjusted for multiple testing).
RESULTS
Clinical characteristics of patients undergoing MHD
As shown in Table 1, no statistically significant differences were observed between the two groups in terms of the baseline characteristics, including age, sex, body mass index, dialysis duration, employment status, household income, payment type, marital status, education level, or primary disease (P > 0.05). Similarly, no significant intergroup differences were observed in key laboratory parameters, such as the levels of hemoglobin, serum albumin, serum calcium, serum phosphorus, urea clearance index, or urea reduction ratio (P > 0.05), indicating good baseline comparability.
Table 1 Clinical characteristics of patients undergoing maintenance hemodialysis, n (%)/mean ± SD.
Post-intervention SIS total scores were significantly lower in the observation group (51.06 ± 9.08) than in the control group (63.62 ± 8.31) (P < 0.001). The scores in all four subdomains (social exclusion, financial insecurity, internalized shame, and social isolation) were significantly lower in the observation group (P < 0.05) (Table 2). These findings suggest that narrative support relates to reduced stigma in patients undergoing MHD.
Following the intervention, anxiety (SAS) and depression (SDS) scores in the observation group (40.76 ± 7.19 and 38.98 ± 6.36, respectively) were significantly lower than those in the control group (48.58 ± 9.11 and 43.18 ± 8.71, respectively) (P < 0.001) (Table 3), demonstrating favorable changes in negative emotional states.
Table 3 Comparison of negative emotions, mean ± SD.
The observation group exhibited a significantly higher ESRD-AQ total score (835.07 ± 64.06) than the control group (656.41 ± 67.28) (P < 0.001). These included significantly improved scores for treatment adherence, medication adherence, fluid restriction, and dietary compliance (P < 0.001) (Table 4). Our results indicated that narrative support was associated with enhanced treatment adherence.
Table 4 Comparison of treatment adherence rates, mean ± SD.
The observation group had a significantly lower total PSQI score (6.60 ± 1.94) than the control group (8.11 ± 2.14) (P < 0.001), indicating better sleep quality. Significant improvements were observed in many aspects, including daytime dysfunction, habitual sleep efficiency, sleep latency, sleep disorders, and sleep duration. No significant difference was found in subjective sleep quality or use of sleeping medications (P > 0.05) (Table 5).
Post-intervention, the observation group showed significantly higher SF-36 scores across all eight dimensions (P < 0.05). Significant improvements were observed in all indicators related to physical and mental health, including physical functioning, bodily pain, role-emotional, vitality, general health, mental health, and social functioning (Table 6). These results underscore the potential benefits of narrative support in promoting physical rehabilitation and psychosocial well-being in patients undergoing MHD.
Comparison of changes in pre- and post-treatment indicators
Finally, we compared the differences between the pre- and post-treatment scores for each indicator across the two patient groups. We found significant differences in the changes between the pre- and post-treatment scores for all indicators, except for “Use of sleep medications” and “Subjective sleep quality” (P < 0.05) (Table 7).
Table 7 Comparison of changes in indicators (pre- vs post-treatment).
Although MHD can prolong the survival of patients with ESRD, it is often accompanied by a considerable burden of symptoms[25]. Young and middle-aged patients undergoing MHD not only face physical stress, but also face a series of psychosocial challenges, including work interruptions, family role conflicts, and decreased social function, which can trigger significant negative emotional responses[26]. Compared with other psychosocial interventions such as cognitive behavioral therapy or mindfulness therapy, narrative support focuses more on constructing meaning in the patient’s own language and life context through storytelling and emotional processing. cognitive behavioral therapy focuses on cognitive reconstruction and behavioral activation, while mindfulness emphasizes current awareness and non-judgmental acceptance, and narrative support provides patients with a personalized and interpersonally connected way to help them reconstruct the disease narrative, which may be particularly important for young patients facing identity disruption and role conflict[27,28]. In this study, we evaluated the role of narrative support in reducing stigma, anxiety and depression in this population, and further explored its association with treatment compliance, overall quality of life and sleep quality. Our findings suggest that younger dialysis patients receiving narrative support experienced greater improvements across multiple dimensions, underscoring the adaptability and clinical utility of narrative support. Different from most previous studies that focused on the physiological results of the elderly mental health patients or a single psychological scale, this study adopted a comprehensive framework based on psychosocial adaptation, behavioral change and functional recovery to evaluate the multiple benefits of narrative support.
Stigma is particularly prevalent among younger patients undergoing MHD, often prompting them to hide their dialysis status in social or professional settings[8]. Evidence indicates that stigma diminishes patient initiative by reducing social engagement and help-seeking behaviors[29]. Our results confirm that narrative support helps patients reconstruct their dialysis identity in a more positive way, thereby reducing stigma. Through a structured narrative process, patients are encouraged to express their dialysis experience, gradually get rid of stigmatized labels, and establish a healthier self-cognition[30]. Similarly, studies on patients with post-traumatic stress disorder have shown that narrative reconstruction can not only reduce the sense of shame and isolation, but also enhance resilience and promote emotional adaptation[31]. As a central mechanism of narrative intervention, the reconstruction of meaning helps patients to interpret their illness as part of their lives rather than as a burden or a label. Consequently, narrative support serves not only as a means of emotional catharsis, but is also a cognitive reconstruction process with long-term therapeutic potential. Although no formal qualitative data were collected, the nursing staff’s consultation records show that many patients reported changes in their self-perception of their own accord, for example, the transition from a feeling of discrimination to a feeling of greater acceptance. Future research should employ systematic qualitative research methods to directly capture this process of identity reconstruction.
The degree of anxiety and depression in the observation group was also lower. In this population, the pressure of taking into account family, work and medical roles, coupled with the long-term interference caused by dialysis, often leads to emotional exhaustion, helplessness and economic pressure[32]. Narrative support provides a safe space for the expression of emotions and is complemented by reflective feedback and the redefinition of roles to help patients develop adaptive cognitive frameworks[33,34]. For patients who suffer from high social expectations, open and empathetic communication facilitated by narrative support may be particularly beneficial[35].
At the behavioral level, the significant enhancement in treatment adherence supports the notion that emotional improvement may contribute to behavioral transformation. This finding suggests that narrative support helps patients gain a deeper understanding of and responsibility for their treatment processes. Evidence indicates that when individuals feel emotionally understood and accepted, they are more likely to actively engage in the treatment and establish a sense of trust[36]. Gariani et al[37] reported in their study on diabetic patients that structured emotional support improved patients’ identification with disease management behaviors, thereby enhancing the consistency of their adherence. Moreover, doctor–patient trust developed through narrative support intervention serves as a critical foundation for improved adherence[38]. In addition, patients in the observation group demonstrated better overall sleep quality. However, no statistically significant differences were observed in subjective sleep quality or the use of sleep medications. This may be attributed to the fact that narrative support, as a non-pharmacological psychosocial intervention, mainly improves objective sleep structure (such as sleep latency, sleep efficiency, and sleep duration) rather than subjective sleep perception; sleep medication use is affected by physician advice, psychological dependence, and long-term habits, which are less responsive to short-term psychosocial interventions[39]. In addition, subjective sleep perception is often influenced by mood swings and cognitive expectations, and therefore may not be immediately consistent with objective improvements. This highlights the need for future follow-up studies to monitor long-term trends in sleep-related outcomes[40].
It is worth noting that narrative support is also positively correlated with the improvement of quality of life in physical and psychosocial aspects. Compared with traditional health education, this method pays more attention to the narrative and emotional expression of patients, which helps to promote more in-depth participation, cognitive reconstruction and improvement of coping ability[41,42]. For younger patients with complex social roles, improvements in social reintegration and family functioning are key indicators of perceived well-being[43,44].
This study has some limitations. First, as a single-center retrospective analysis using non-randomized, consecutive sampling, the sample source and design inherently limit its generalizability and preclude causal inference. The lack of randomization increases the risk of selection bias; for instance, patients who received narrative support might have differed systematically from those who did not in terms of motivation or psychological resilience. Additionally, using a historical control group introduces the possibility for a time trend, where improvements in general care quality over the study period could be misinterpreted for an intervention effect. Although data collection and outcome assessments were conducted independently to minimize bias, a formal blinding procedure was not used. In addition, no subgroup analysis was performed in this study, which may limit our ability to find differences in efficacy between different patient characteristics. Thus, the external validity of the findings warrants further confirmation through multicenter prospective studies. Second, all outcome indicators rely on self-reported scales without objective biochemical or dialysis adequacy indicators as secondary outcomes, which limits the clinical persuasiveness of conclusions. Third, the outcomes were primarily assessed using self-reported questionnaires, and the absence of follow-up data over extended periods limited our ability to assess the sustainability of behavioral and emotional changes over time. Future research should adopt a multi-center, prospective, randomized controlled study design, combined with longitudinal tracking, objective outcome indicators and qualitative research methods to better clarify the long-term effects and potential mechanisms of narrative support in chronic disease management.
CONCLUSION
In summary, this study established a structured narrative support intervention associated with emotional regulation, behavioral transformation, functional recovery, and improved quality of life in patients undergoing MHD. Although these findings support the feasibility and potential clinical application value of narrative support, strict prospective randomized controlled trials are still needed to confirm its efficacy and establish a causal relationship.
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