Towards Better Illness Perception in Advanced Chronic Kidney Disease: Clinical, Psychological and Cognitive Factors to Address

Towards Better Illness Perception in Advanced Chronic Kidney Disease: Clinical, Psychological and Cognitive Factors to Address | 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 Article Towards Better Illness Perception in Advanced Chronic Kidney Disease: Clinical, Psychological and Cognitive Factors to Address Alicia Tamarit, Laura Lacomba-Trejo, Eva Carbajo, Antonio Galán This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7048081/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Oct, 2025 Read the published version in Scientific Reports → Version 1 posted 10 You are reading this latest preprint version Abstract People with advanced chronic kidney disease (ACKD) frequently experience psychological distress due to the progressive nature of the illness and the burden of long-term treatment. Illness perception plays a critical role in emotional adjustment and health behaviors, yet the psychosocial and clinical variables shaping these perceptions are not fully understood. This study aimed to identify combinations of psychological, behavioral, and clinical factors that predict how individuals with ACKD perceive their illness, using a Qualitative Comparative Analysis (QCA) approach. The sample included 69 participants with ACKD. Illness perception was assessed via the Brief Illness Perception Questionnaire (B-IPQ). Predictive conditions included: anxiety (HADS-A), coping styles (Brief COPE), kidney disease knowledge (KiKS), emotional social support (MOS-SSS), neuroticism (NEO-FFI), and CKD stage. QCA results revealed multiple pathways to high illness threat perception. Configurations characterized by high anxiety, elevated neuroticism, and low active coping were consistently associated with negative illness representations. Conversely, combinations including greater disease knowledge and active coping predicted more adaptive perceptions. These findings underscore the relevance of addressing both emotional and cognitive variables when designing psychosocial interventions for people with ACKD, supporting a multidimensional approach to improving patient adjustment and health outcomes. Health sciences/Diseases Health sciences/Health care Biological sciences/Psychology Social science/Psychology Chronic Kidney Disease Illness Perception CKD stage Coping Strategies Health Knowledge Neuroticism Anxiety Introduction Chronic kidney disease (CKD) is a highly prevalent, progressive condition affecting approximately 10% of adults worldwide, between 500 and 800 million people across the globe [ 1 , 2 ]. CKD is classified according to stages of severity, ranging from Stage 1, which indicates mild kidney damage, to Stage 5, representing the most severe cases of kidney damage and almost complete failure [ 3 ]. People with advanced chronic kidney disease (ACKD) are in stages 4 and 5 of this classification, which prevalence studies give an estimate to be around 0,5% of the general population, amounting to over 26 million adults worldwide [ 2 ]. These advanced stages entail significant physical, social and psychological challenges: patients face not only the decreased renal function and its consequences, but also the reality of long-term treatment and its profound impact in their lives [ 4 ]. Along the psychological factors that play a role in adjustment to ACKD, illness perception is one of the most significant, shaping the entire experience of patients in these advanced stages [ 5 , 6 ]. Perception of ACKD, encompassing awareness of the condition and subjective threat assessment, has been identified as one of the most relevant factors in adherence to treatment, adaptation, self-regulation and overall well-being in patients living with chronic kidney conditions [ 7 ]. Illness perception includes a wide variety of psychological processes, from consequences of the disease to timeline, personal control, or treatment control, as well as how symptoms affect identity, concerns about the process, emotional response to the condition, and illness understanding [ 8 ]. This study focuses on the processes of consequences, concern, emotional response and overall threat perception as, according to the Common-Sense Model of Self-Regulation (CSM), these dimensions best capture the emotional and subjective components of illness representation and are particularly relevant for predicting psychological distress [ 9 ]. The CSM is a widely used theoretical framework that describes how individuals detect and interpret health threats, regulate emotional responses, generate cognitive representations of the illness and develop coping strategies and action plans based on these perceptions [ 10 ]. According to this theoretical model, consequences would refer to the perceived impact of illness on daily life; concern, on the other hand, describes worries related to the health condition, with components of anticipation and rumination; and emotional response would address the intensity of negative affective reactions, such as anger, sadness or fear, in response to illness [ 7 ]. Due to the intersectional, multidimensional nature of this process, the literature is still exploring the multiple agents conditioning illness perception in ACKD; from purely clinical such as biological indicators of kidney function (usually measured through glomerular filtration rate or eGFR) [ 3 ] to psychological and social factors [ 11 ]. These latter ones often refer to personality traits like emotional instability, manifested through neuroticism, which is associated with anxiety or stress when dealing with highly demanding, life-threatening situations like chronic disease [ 12 ]. Neuroticism is a widely researched personality dimension, most often assessed through the Big-Five model of personality, which explores five general dimensions of personality through the NEO-PI-R: extraversion, neuroticism, agreeableness, conscientiousness and openness to experience [ 13 , 14 ]. This trait has been observed to be associated with feelings of uncertainty and lack of control, and reporting of abnormal symptoms, which can easily lead to an increase in anxiety during treatment [ 15 ]. This is key to adherence and coping, as the literature indicates a consistent increase in anxiety levels for patients with kidney disease, especially those in advanced stages [ 16 , 17 ]. Similarly, research has observed an association between these factors and illness perception: higher scores in neuroticism and increased anxiety have been linked to more negative perceptions of illness in chronic patients [ 18 ]. However, protective cognitive factors such as disease-specific knowledge can reduce anxiety and lead to adaptive illness perceptions, counteracting misinformation and increasing motivation and engagement with care [ 19 , 20 ]. Disease knowledge can look different for every patient: although it usually alleviates distress, in some cases the desire to stay informed could lead to increased health-related internet use or other maladaptive behaviors, especially when co-occurring with emotional instability and anxiety [ 21 , 22 ]. While increased knowledge has been associated with more positive – or less harmful – perceptions of illness, more research is needed to explore non-linear associations between these factors [ 23 ]. Coping mechanisms can also become protective in the face of chronic illness – particularly when individuals are confronted with situation that are largely uncontrollable, such as the progression of ACKD [ 24 ]. In these situations, emotion-focused coping strategies can help patients regulate emotional distress and process the psychological impact of illness; however, this kind of coping is not inherently adaptive or maladaptive: its effectiveness depends on the strategy used, the context in which it is put into practice, and the psychological profile of the patient [ 25 , 26 ]. In controllable situations, problem-focused strategies could lead to better outcomes over emotion-focused coping, as it tackles the root of the problem; this could lead to the assumption that the latter would be more adaptive in incontrollable situations such as chronic disease [ 8 , 27 ]. Nevertheless, it is essential to distinguish between adaptive regulation strategies, such as seeking support, finding communities or constructive emotional processing, and more dysfunctional patterns, such as excessive venting or rumination [ 11 ]. Thus, emotion-focused coping could improve the perception of illness or reduce threat when adaptive strategies are aligned with adequate context and a less anxiety-prone psychological profile of patients, although more research is needed on this area to further explore this connection [ 28 ]. Closely related to emotional coping, the social aspect of patient support is crucial in ACKD: not only is the presence of social support a common moderator of chronic disease and well-being, but its absence is often linked to increased anxiety and depression, and worsened health outcomes [ 29 , 30 ]. Moreover, social support could lead to a reduced illness threat perception, if this support is adequate, relies on affection and contributes to emotional regulation and instrumental and logistic care [ 31 ]. Despite a growing number of studies linking single predictors – such as anxiety, coping mechanisms or eGFR – to illness threat perception in ACKD, most of this work has relied on linear, variable-centered statistics [ 6 , 12 , 16 ]. There is yet a need for research that looks at these factors through interactive, non-linear pathways, and allows to understand the combinations of these variables instead of analyzing their separate contribution to illness threat perception. Qualitative Comparative Analysis (QCA) is a statistical method that provides casual reasoning by examining how different factors (in this case, psychological, behavioral and clinical) jointly contribute to an outcome [ 32 ]. In the context of research on ACKD, this method could help shed light on the multiple pathways that shape patients’ illness threat perception, serving as a blueprint for tailored interventions designed for this vulnerable population [ 4 , 33 ]. Thus, this study aims to identify combinations of psychological, behavioral, and clinical factors that predict how individuals with ACKD perceive their illness. Firstly, we hypothesize that neuroticism and anxiety will predict the presence of the patients’ illness threat perception. Secondly, we hypothesize that renal function, emotion-focused coping, social support and knowledge of the illness will predict the absence of the patients’ illness threat perception. Method Procedures Data collection took place between 2018 and 2024, during a single session carried out by two licensed health psychologists trained in clinical assessment. Participants were recruited through referrals from the Nephrology Unit to the Clinical and Health Psychology Unit, within the framework of the Kidney Patient School Project at the Hospital General Universitario Consortium of Valencia. Consequently, the sampling strategy was non-probabilistic and based on availability. To be eligible for inclusion, participants were required to have a confirmed diagnosis of advanced chronic kidney disease (ACKD), stage 3b or higher. Individuals presenting with diagnosed psychological disorders or cognitive impairments were excluded based on information obtained from their medical records ( n = 10). Prior to data collection, all participants received verbal and written information about the study objectives and procedures, including confidentiality safeguards and data handling protocols. Informed consent was obtained in writing from all participants. The self-report instruments were then administered in a structured format during the same session. The study strictly followed the ethical principles of the Declaration of Helsinki [ 34 ] and was approved by the Clinical Research Ethics Committee of the Hospital General Universitario Consortium of Valencia (Reference: 2019/9). Participants The study included 69 individuals diagnosed with chronic kidney disease (CKD), aged between 38 and 88 years ( M = 69.44, SD = 10.04), all of whom were under follow-up at the Nephrology Unit of the Hospital General Universitario Consortium of Valencia. The majority were men (78.5%, n = 51). In terms of clinical characteristics, hypertension was present in 93.3% of participants, 45% had type 2 diabetes mellitus, and 38.3% reported a heart condition. Regarding mental health, 16.7% had a history of psychological problems, although none were currently experiencing a diagnosed mental health condition. With respect to hospitalizations in the past year, 70.4% had not been hospitalized, while 16.7% had been hospitalized once. Smaller percentages reported being hospitalized twice (5.6%), three times (1.9%), or four times (5.6%). In terms of disease stage, 64.6% were in stage 4, 21.4% in stage 5, and 13.8% in stage 3b of CKD. As for sociodemographic variables, 86.9% lived with a companion, and most participants were married or in a relationship (71.7%), followed by widowed (11.7%) and separated or divorced (8.3%). Educational levels were generally low: 31.7% had incomplete primary education, 28.3% completed secondary education, 25% completed primary education, and 15% had higher education. Regarding employment status, 80% were retired, while others were on disability leave (11.7%), unemployed (5%), or actively working (3.3%). Data Collection The following variables were analyzed: (a) Sociodemographic and Clinical Variables An ad hoc questionnaire was developed to collect sociodemographic and clinical variables. Regarding the clinical variables, medical history was also consulted in order to check the blood tests that had been carried out on the day of the psychological assessment. From it, we extracted the value of estimated glomerular filtration rate (eGFR). Renal function was assessed through the eGFR, calculated by nephrology professionals using standardized clinical formulas (CKD-EPI). The eGFR is expressed in ml/min/1.73m² and reflects the level of kidney function. For descriptive purposes, patients were categorized according to these clinical stages. However, for predictive analyses, the eGFR value was included as a continuous variable, representing the degree of renal deterioration (lower values indicating more advanced disease). (b) Psychological Variables - Illness Threat Perception : Perceived illness threat was assessed using the Spanish adaptation of the Brief Illness Perception Questionnaire (B-IPQ) [ 35 , 36 ]. The B-IPQ consists of eight Likert-scale items (0–10) that assess various dimensions of illness perception, including consequences, timeline, personal control, treatment control, symptoms (identity), concern, emotional response, and illness understanding. A total illness threat score is computed by summing the item scores, after reversing the positively worded items: personal control, treatment control, and understanding. In this study, the following subscales from the questionnaire were used as outcome variables: perceived consequences, concern, emotional response, personal control, and overall illness threat perception. Participants were instructed to respond with a focus on their experience of advanced chronic kidney disease (ACKD). The B-IPQ has demonstrated adequate internal consistency in previous studies (α = .67–.89) [ 37 ], and reliability in the current sample was acceptable (α = .50) - Neuroticism : Neuroticism was measured using the Neuroticism subscale of the NEO Five-Factor Inventory (NEO-FFI) short version [ 38 ], adapted to Spanish [ 39 , 40 ]. The full inventory includes 60 Likert-scale items distributed across five dimensions: neuroticism, extraversion, openness, agreeableness, and conscientiousness. For the purposes of this study, only the neuroticism subscale was used (e.g., “I often feel tense or nervous”). The Spanish versions have shown adequate psychometric properties, which were supported in this sample as well (α = .68). - Emotion-Focused Coping : This variable was assessed using the emotion-focused coping subscale of the COPE Inventory [ 41 ], in its Spanish adaptation by [ 42 ]. The COPE consists of 24 items with four response options, grouped into twelve first-order factors that form two second-order dimensions: problem-focused coping and emotion-focused coping. Problem-focused strategies (e.g., active coping, planning) are generally considered adaptive when stressors are controllable, while emotion-focused strategies (e.g., seeking emotional support, expressing emotions) help regulate emotional responses and may be adaptive in uncontrollable contexts. For this study, only the emotion-focused coping subscale was used (e.g., “I try to get comfort and understanding from someone”). Internal consistency for the Spanish version has been reported as acceptable (α = .70–.80), and reliability in the present sample was also satisfactory (α = .61). - Social Support : Perceived social support was evaluated using the Spanish version [ 43 ] of the Medical Outcomes Study–Social Support Survey (MOS-SSS) [ 44 ]. This 20-item instrument includes 19 Likert-type items (5-point scale) and 1 open-ended item assessing the estimated size of the respondent’s social network. The scale was developed for use with individuals suffering from chronic illnesses. It yields four subscales—emotional/informational support, instrumental support, positive social interaction, and affective support—which can be summed to obtain a total social support score, used in the present study. Internal consistency for the Spanish version is considered excellent (α > .90) [ 43 ] (α = .79). - Kidney Disease Knowledge : Knowledge about kidney disease was assessed using the Kidney Disease Knowledge Survey (KiKS) [ 45 ], adapted to Spanish [ 46 ]. The questionnaire includes 28 items, of which five are multiple choice and the rest are yes/no questions. Items assess knowledge about kidney function, treatment options for kidney failure, symptoms and progression of the disease, nephrotoxic medications, blood pressure goals, and other key topics for renal health. A total score is calculated based on the number of correct answers. The Spanish version has demonstrated adequate internal consistency (α = .71) [ 46 ]. - Anxiety : Anxiety symptoms were measured using the Anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A) developed by Zigmond and Snaith [ 47 ], in its Spanish version [ 48 ]. The HADS was specifically designed for individuals with physical health problems, excluding somatic items to reduce confounding. It consists of 14 items, split equally into two subscales: anxiety and depression. Previous studies have reported good psychometric properties for this scale [ 49 ]. In the current study, reliability for the anxiety subscale was modest (HADS-A: α = .50). Data Analysis Descriptive statistics were computed using SPSS version 29 (IBM Corporation, Armonk, NY, USA) to obtain calibration values for the variables. Subsequently, analyses were conducted using fsQCA 2.5 [ 50 ] to identify necessary and sufficient conditions for predicting high levels of illness threat perception. Prior to analysis, the variables were recalibrated based on established guidelines in the literature [ 51 ], using three qualitative anchors: a value of 0 was assigned to cases completely outside the 10th percentile, 0.5 to the median (50th percentile), and 1 to cases entirely within the 90th percentile. Following calibration, an analysis of necessary conditions was performed. Conditions with consistency values above 0.90 were considered necessary for the outcome [ 51 ]. Next, sufficiency analyses were carried out. Models were retained when they met the conventional threshold of consistency > 0.74, indicating a satisfactory level of empirical relevance. Three types of solutions were generated—parsimonious, complex, and intermediate—based on standard QCA procedures. The intermediate solution was selected for interpretation, as it incorporates both theoretical knowledge and empirical evidence. Within this solution, conditions also present in the parsimonious solution were identified as core conditions, while those appearing only in the intermediate solution were classified as peripheral. In the truth table and solution chart, core conditions are typically presented in bold or larger symbols to reflect their greater explanatory weight [ 32 ]. Results Descriptive and calibration values Participants reported moderate levels of illness threat perception, neuroticism, and emotion-focused coping, alongside high levels of perceived social support, moderate knowledge about kidney disease, and low levels of anxiety. Detailed descriptive statistics are presented in Table 1 . Table 1 Descriptive statistics, calibration values and associations between variables Neuroticism Emotion-Focused Coping Social support Kidney disease knowledge Anxiety Consequences Concern Emotional response Threat perception M 15.02 1.82 85.10 16.26 6.22 5.10 6.41 4.44 39.67 SD 7.52 0.44 13.88 4.28 2.80 2.76 3.27 2.91 9.34 Min. 0 1 40 5 2 0 0 0 16 Max. 32 3.08 95 24 15 10 10 9 62 P10 5.20 1.25 66.10 10.00 3.00 0 0 0 27.10 P50 14.00 1.75 91.00 16.50 6.00 5.00 7.00 5.00 39.50 P90 26.60 2.48 95.00 21.00 10.00 8.80 10.00 8.00 51.00 Note. M = Mean; SD = Standard Deviation; Min = Minimum; Max = Maximum; P10 = 10th Percentile; P50 = 50th Percentile; P90 = 90th Percentile. Fuzzy-set Qualitative Comparative Analysis (fsQCA) Necessity analysis In line with previous literature, analyses of necessary conditions were conducted first, followed by sufficiency analyses (Table 2 ). Table 2 Summary of the main conditions sufficient for the intermediate solution of consequences, concern, emotional response and threat perception Consequences Concern Emotional response Threat perception Frequency cut-off 1 High levels of Consequences Consistency cut-off .85 Low levels of Consequences Consistency cut-off .86 High levels of Concern Consistency cut-off .86 Low levels of Concern Consistency cut-off .84 High levels of Emotional response Consistency cut-off .85 Low levels of Emotional response Consistency cut-off .86 High levels of Threat perception Consistency cut-off .85 Low levels of Threat perception Consistency cut-off .85 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 eGFR ○ ○ ○ ○ ● ● ● ● ○ ○ ○ ● ○ ○ ● Neuroticism ● ○ ○ ● ● ● ○ ● ○ ● ● ● ● ○ ○ Emotion-Focused Coping ● ● ○ ○ ● ● ● ● ● ● ○ Social support ○ ● ○ ○ ○ ○ ● ○ ● ● ○ ● ● ● Kidney disease knowledge ● ○ ○ ● ○ ● ● ○ ● ● ○ ● Anxiety ○ ● ○ ○ ● ○ ○ ● ● ○ ○ ● ● ○ ○ ○ Raw Coverage .43 .40 .37 .35 .35 .22 .44 .29 .30 .30 .30 .25 .32 .30 .29 .57 .31 .23 .42 .36 .25 .42 .30 .31 Unique Coverage .08 .05 .05 .05 .06 .02 .03 .01 0 0 0 .06 .02 .04 .02 .15 .06 .02 .03 .03 .02 .05 0 0 Consistency .82 .84 .87 .83 .89 .84 .86 .83 .86 .88 .88 .87 .83 .91 .89 .90 .87 .81 .86 .85 .86 .89 .82 .85 Overall Consistency .76 .78 .77 .78 .82 .82 .77 .83 Overall Coverage .84 .81 .78 .66 .79 .79 .80 .75 Note. Expected vector for high levels of quality of consequences, concern, emotional response and threat perception: 1,1,0,0,0,1 [ 32 ]. ● indicates presence of core conditions; ○ indicates absence of core conditions; There were no peripheral conditions. No condition met the threshold for necessity (consistency ≥ 0.90) for predicting either high or low levels of illness threat perception or any of its subdimensions among individuals with ACKD. Sufficiency analysis Regarding the perception of high consequences associated with illness , three causal pathways were identified, explaining 84% of cases. The most relevant configuration involved the combination of low eGFR and low social support. The second pathway, explaining 40% of cases, combined high emotion-focused coping, high disease knowledge and low anxiety. A third solution, accounting for 37% of cases, involved low eGFR combined with high neuroticism and high anxiety. As for the low perception of illness consequences , seven distinct pathways explained 81% of cases. The most relevant combination, explaining 35%, involved high emotion-focused coping, low disease knowledge, and low anxiety. The second pathway, also explaining 35%, was defined by low neuroticism, low emotion-focused coping, high social support, and adequate disease knowledge. A third solution, accounting for 22%, included low neuroticism, emotion-focused coping, social support, low anxiety, and high disease knowledge. With respect to high concern , fourteen configurations explained 78% of cases. The most prominent path combined low eGFR and high anxiety; and the second combined low eGFR, high neuroticism and low social support. In contrast, low concern was predicted by seven pathways explaining 66% of cases, the most relevant being the combination of high eGFR, emotion-focused coping, high disease knowledge, and low social support. Another key solution involved high eGFR, neuroticism, high disease knowledge, and low social support, while a third included high eGFR, emotion-focused coping, low neuroticism, low anxiety, and adequate knowledge. For high levels of emotional response , six pathways explained 73% of cases. The most relevant involved high eGFR, high neuroticism, emotion-focused coping, and low anxiety. The second solution included low eGFR, low neuroticism, high disease knowledge, and high anxiety. The third pathway featured low eGFR, high neuroticism, high anxiety, and high social support. As for low emotional response , five configurations explained 79% of cases, the most relevant being the combination of low disease knowledge and low anxiety. Another involved high eGFR and high disease knowledge, despite low social support, and a third featured low eGFR, low anxiety, high neuroticism, and social support. Finally, for high levels of illness threat perception , eleven distinct pathways explained 80% of cases. The most prominent path involved high neuroticism, emotion-focused coping, and social support. The second most relevant, explaining 37% of cases, combined low eGFR, emotion-focused coping, and anxiety. A third pathway, explaining 25%, featured high neuroticism and high anxiety, alongside low social support and low disease knowledge. Conversely, low threat perception was explained by seven configurations, accounting for 83% of cases. The most important, explaining 42%, combined high eGFR, social support, and low anxiety. Another relevant path explained 31% of cases via low neuroticism, low anxiety, high social support, and high disease knowledge. A third solution also accounted for 31% and included low neuroticism, low anxiety, low emotion-focused coping, and high social support. Discussion This research aimed to identify combinations of psychological, behavioral, and clinical factors that predict how individuals with ACKD perceive their illness. Results show that distinct combinations of these factors shape how patients perceive their kidney conditions. Specifically, configurations involving low renal function, high anxiety and low social support consistently predicted heightened perceptions of illness threat. Additionally, profiles marked by emotional stability, strong social support and low anxiety were associated with more adaptive illness perceptions. Notably, the role of knowledge and emotion-focused coping varied depending on the emotional and interpersonal context, highlighting the non-linear and interactive nature of these influences. Firstly, we hypothesized that neuroticism and anxiety would predict the presence of the patients’ illness threat perception. Results are in line with our hypothesis, supporting previous research highlighting the negative impact of neuroticism and anxiety in patients’ illness perceptions, especially in the context of kidney disease [ 15 , 16 ]. Both of these factors were present in the most important combinations explaining all dimensions of illness threat perception: high perception of consequences, concern, emotional response and overall threat perception. This indicates that emotional instability or negative affectivity manifested through neurotic personality traits usually coexists with anxiety when explaining concerned, alarmed or fearful attitudes of patients towards their kidney conditions in ACKD, more so when indicators of low renal function are present. Moreover, the absence of these traits is often found in configurations explaining the absence of all threat perceptions, notably linked to reduced concern, fear of consequences or anticipation of threat. This might indicate that neuroticism and anxiety might be buffering the clinical information they are receiving (interestingly reflected by high knowledge of the disease), for example, when renal function drops, worsening the perception they have of their kidney condition. These results point to the importance of looking at the emotional background of patients, their personality traits and ability to handle and regulate emotions, both when providing clinical information and in the overall progression of their treatment. Secondly, we hypothesized that renal function, emotion-focused coping, social support and knowledge of the illness would predict the absence of the patients’ illness threat perception. Our results partially support this hypothesis, giving crucial nuance on how to interpret the effect of these variables on threat perception in ACKD. Renal function, specifically low levels of eGFR as an indicator of kidney failure, featured in the leading paths to all threat dimensions; similarly, and as hypothesized, high levels of eGFR indicating increased renal function appeared consistently in paths explaining the absence of threat perception. These results support extend previous evidence pointing at biological factors and their impact on patients’ illness perception, adding information about their joint effect when paired with psychological risk factors such as anxiety and neuroticism [ 3 , 33 ]. Regarding social support, its presence is overall consistent in pathways explaining the absence of threat perceptions, namely of perception of consequences, emotional response and overall threat perception. Similarly, lower social support appears in pathways explaining high perception of consequences, concern and overall threat perception. This supports our hypothesis and adds to previous research observing the protective role of social support and the risk entailed by the lack of a protective network for patients with ACKD, which emphasizes the need for actions that create, support and spread community [ 29 ]. In fact, social support has been shown to play such a crucial role in illness progression that it has even been associated with reduced mortality in patients with chronic conditions, highlighting the significant protective value of social and affective networks [ 52 , 53 ]. This is particularly true for specific populations: men and older people (notably the main demography in our sample) may have a harder time seeking support; therefore, these actions could have a greater potential for those with less access or abilities to create social and affective networks [ 11 , 54 ]. Nevertheless, our non-linear analyses provide important nuance on this variable and the different interpretations we could extract from the results obtained. Social support has also featured in the configuration of emotional response to illness, specifically when paired with high-risk factors – neuroticism, anxiety and low eGFR. This could indicate that well-intended carers might inadvertently reinforce worry or possibly add to fears already present in anxious or emotionally unstable patients. Interventions focusing on patient wellbeing in ACKD often counteract this phenomenon: e.g., the Kidney Patient School works to generate support groups that provide accurate information about their illness process, looking at improving their quality of life and reducing the possible psychological and physiological impact of their kidney conditions [ 55 ]. Community actions such as the ERC are crucial to ensure that social support is consistently and effectively protective when dealing with chronic kidney disease, especially in its more advanced stages. Results on emotion-focused coping and disease knowledge are also nuanced, providing useful insights into the mechanisms in which they operate to prevent negative perceptions of illness by ACKD patients. Regarding emotion-focused coping, it was present on the most frequent conditions on both adaptive and maladaptive illness perception configurations, showcasing the heterogeneity of pathways in which it can impact patients’ experiences of their kidney conditions. On one hand, when present in pathways explaining the absence of illness threat perceptions, emotion-focused coping worked in combination with lower anxiety and improved renal function. This could suggest that patients with higher emotional regulation skills – possibly reflected in lower anxiety – prefer this coping mechanism, especially when renal indicators are favorable. On the other hand, emotion-focused coping is observed to be present in configurations showing higher threat perceptions and absent in pathways showcasing lower threat perceptions. This could suggest that emotion-focused coping could prove maladaptive when paired with specific factors, namely neuroticism and lower eGFR. In these cases, emotion-focused coping could entail rumination or emotional venting without regulation, which could lead to a worsened perception of their condition and increased concerns about the threats involved. Another key fact could be the characteristics of the sample: as it is composed by a majority of men, this could have influenced the direction of the data. The literature indicates that men tend to use maladaptive coping strategies more frequently than women, specifically in the context of chronic disease [ 24 ], which provides another interpretation to our results. Although emotion-focused coping and its benefits have been widely researched on other areas, such as coping strategies in sports [ 56 ], the literature is still scarce regarding the impact of this mechanism in ACKD patients. This population faces a high emotional burden and uncertainty and is therefore at a higher risk of psychological distress and in critical need of effective coping strategies to support adjustment and treatment adherence. Regarding disease knowledge, results partially support our hypothesis, suggesting a double-edged nature of this factor. Previous research has observed the benefits of competent, consistent care towards patients through the provision of accurate information about their disease and its process [ 19 , 20 ]. In these studies, disease knowledge has been observed to foster treatment adherence, realistic expectations and greater self-efficacy, particularly when patients are required to engage in complex decision-making regarding dialysis or transplantation. Our results are consistent with this perspective when paired with low anxiety, low neuroticism, high emotion-focused coping and higher social support. These combinations likely reflect emotionally stable patients who are able to process medical information through effective regulation and reliance on their affective and social networks, for whom disease knowledge has a positive impact in the perception of their kidney condition. Conversely, our results also highlight configurations where high knowledge appeared in pathways explaining perceptions of high threat and consequences, particularly in combination with anxiety and emotion-focused coping. This could suggest that in emotionally vulnerable profiles, or those who focus on their emotional state when coping with long-term treatment, detailed illness knowledge could intensify the awareness of the disease’s irreversibility, progression and the potential risk of mortality, possibly increasing distress. This double-edged effect of disease knowledge could suggest that access to information has a nuanced impact on the patients’ well-being: the source of this information and the patient’s psychological profile shape the effect this knowledge will have on the threat perception they develop of their health condition. This has been observed in the literature on the COVID-19 pandemic and the management of information about the disease: whether the patients accessed this knowledge through competent healthcare professionals or health-related internet use widely vary the mental health outcomes for individuals suffering from illness [ 21 ]. While the former provides reassurance and care that caters to patients individually, the latter could add to the anxiety and distress they could already be experiencing. Similarly, a more anxious profile of patients could interpret accurate, careful information through a maladaptive lens, reinforcing the idea that the provision of information should adapt to each patient and their psychological and social context to prevent negative outcomes to this process. These findings suggest the importance of tailoring psychological interventions to individual profiles prior to implementing group-based educational programs. Specifically, patients suffering from anxiety, high emotional reactivity, or maladaptive coping styles may benefit from individualized psychological support focused on emotional regulation and distress reduction. Once emotional vulnerability is addressed, these patients could more effectively engage in group interventions designed to enhance disease knowledge and reduce perceived threat. Thus, a preliminary psychological screening assessing anxiety, coping strategies, and emotional reactivity could inform the decision on the best pathway for every patient – individual versus group intervention. In summary, emotion-focused coping and disease knowledge have proved to not be intrinsically positive or negative, but rather dependent on the influence of other factors and the complex pathways in which they jointly operate [ 26 ]. Together with the other factors analyzed, these dimensions create unique profiles that provide valuable context to understand illness threat perception. Strengths, limitations and future research directions This study offers significant contributions to the existing literature on ACKD and patients living with chronic illness. By applying QCA, this research moves beyond traditional linear approaches and provides multiple, context-dependent pathways that lead to different illness perceptions in patients with ACKD, highlighting the many ways in which psychological processes operate that could be overlooked in regression-based models. Moreover, these findings challenge the assumption that emotion-focused coping and disease knowledge are unequivocally positive; rather, they showcase how these factors can combine with anxiety and either buffer or amplify threat perceptions of their kidney condition. This could contribute to a more context-sensitive view of psychological adjustment in patients of ACKD. Finally, these results may inform tailored intervention design by identifying psychological profiles most at risk of maladaptive illness perceptions [ 4 ]. Emotion regulation training, kidney disease psychoeducation and peer-based social support are key in intervention programs when designed to decrease the intensity of the threat perception in patients with ACKD, potentially increasing their well-being and quality of life associated with health [ 57 ]. Despite these contributions, this study is not without limitations. First, the B-IPQ subscales showed acceptable but not optimal psychometrics, which could have influenced results obtained. Second, subtle neurocognitive deficits – highly relevant in ACKD patients – were not accounted for in the battery provided, although it is important to note that they were indicated to be an exclusion criterion through contact with patients. Third, participation through the EPR may have selected more engaged, socially connected patients, limiting generalizability of results and underrepresenting those with more limited access to support and care. Patients generally disclosed higher social support through the MOS-SSS, which is theoretically inconsistent with the characteristics of the sample (typically older and male), which could indicate that this questionnaire did not accurately discriminate between patients regarding the strength and quality of the support they were receiving. Another explanation for these results could be social desirability, which may have skewed the responses – a common occurrence with in-person data gathering. Finally, these results were obtained through a cross-sectional design, therefore longitudinal research is recommended to test whether the observed configurations prospectively predict changes in illness perception of kidney disease. Despite these limitations, this study focuses on a complex and hard-to-reach sample, consisting of patients in advanced stages of CKD. Moreover, the inclusion of both biological and psychological measures strengthens the robustness of the findings and enhances clinical relevance, entailing a significant contribution to research and medical practice. Ultimately, this study aims to emphasize that the different ways a person lives with chronic illness are shaped not only by the progression of their condition, but also by the intricate web of emotions, beliefs and relationships surrounding them. For people with ACKD – who often navigate fear, uncertainty and physical decline – coping is not a single act but a continuous process. Furthermore, these findings provide valuable insights into psychological intervention by highlighting the importance of tailoring support to individual psychological profiles. Implementing prior psychological assessments could help identify specific needs and guide whether patients might benefit more from individual or group-based interventions, thus increasing the likelihood of therapeutic success. Recognizing the nuanced ways in which psychological and social factors combine can bring us closer to designing care that is not only clinically effective, but also emotionally significant, and treats each person with utmost care and respect. Declarations Conflict of Interest The authors declare no conflicts of interest. Funding Declaration The authors did not receive any specific funding for this research. Author Contribution LLT: Responsible for research design, data collection through interviews, data processing, analysis, and interpretation. Drafted the initial version of the manuscript and conducted subsequent revisions; AT: Drafted the initial version of the manuscript and contributed to its subsequent revisions; EC: Contributed to research design, data collection through interviews, and served as project coordinator. Reviewed and provided critical revisions to the manuscript; AG: Contributed to research design, facilitated referrals to the psychology service for patients meeting the inclusion criteria, and reviewed the manuscript. All authors revised the manuscript. Acknowledgement The authors wish to express their sincere gratitude to the individuals with advanced chronic kidney disease who generously participated in this study. We also thank the colleagues involved in the Kidney patient School project, whose collaboration made this work possible. Data Availability The data that support the findings of this study belong to a larger research project involving multiple authors and collaborators. Due to this, the data are not publicly available. However, they can be made available upon reasonable request to the corresponding author, with permission from all contributors. References Kovesdy, C. P. Epidemiology of chronic kidney disease: an update 2022. Kidney Int Suppl [Internet]. 2022 [cited 2025 Jul 2];12(1):7. (2011). Shrestha, S. et al. Care of Adults with Advanced Chronic Kidney Disease. J. Clin. Med. [Internet] 2024 [cited 2025 Jul 2]; 13 (15):4378 . Levey, A. S. & Defining, A. K. D. The Spectrum of AKI, AKD, and CKD. Nephron [Internet]. [cited 2025 Jul 1];146(3):302–305. (2022). Jenkins, Z. M. et al. A psychosocial intervention for individuals with advanced chronic kidney disease: A feasibility randomized controlled trial. Nephrol. [Internet] . 26 (5), 442–453 (2021). [cited 2025 Jul 1];. Vélez-Vélez, E. & Bosch, R. J. Illness perception, coping and adherence to treatment among patients with chronic kidney disease. J. Adv. Nurs. [Internet] . 72 (4), 849–863 (2016). [cited 2025 Jul 2];. Sitjar-Suñer, M. et al. The Perception of Illness in People with Advanced Chronic Kidney Disease. J. Personalized Med. 2025 , 15 , Page 120 [Internet]. 2025 [cited 2025 Jul 2];15(3):120 . Meuleman, Y. et al. Exploring Patients’ Perceptions About Chronic Kidney Disease and Their Treatment: A Qualitative Study. Int. J. Behav. Med. [Internet] . 31 (2), 263–275 (2023). [cited 2025 Jul 2];. Muscat, P. et al. Illness perceptions predict distress in patients with chronic kidney disease. BMC Psychol [Internet]. [cited 2025 Jul 4];9(1):1–13. (2021). Leventhal, E. A. Aging and the Perception of Illness. Res Aging [Internet]. 1984 [cited 2025 Jul 4];6(1):119–135. Leventhal, H., Phillips, L. A. & Burns, E. The Common-Sense Model of Self-Regulation (CSM): a dynamic framework for understanding illness self-management. J. Behav. Med. [Internet] . 39 (6), 935–946 (2016). [cited 2025 Jul 4];. Cusolito, P. D. Coping With Kidney Disease: The Role of Age, Stage of Disease, Years of Education, and Endorsed Gender Stereotypes in Predicting Depression, Anxiety, and Coping Behavior (Fielding Graduate University, 2023). Guerra, F. et al. Chronic Kidney Disease and Its Relationship with Mental Health: Allostatic Load Perspective for Integrated Care. J. Personalized Med. 2021 , 11 , Page 1367 [Internet]. 2021 [cited 2025 Jul 1];11(12):1367 . McCrae, R. R. & Costa, P. T. A contemplated revision of the NEO Five-Factor Inventory. Pers Individ Dif [Internet]. (2004). [cited 2017 Oct 10]; 36 :587–596 . McCrae, R. R. & Costa, P. T. Jr. Brief Versions of the NEO-PI-3. J. Individ Differ. [Internet] . 28 (3), 116–128 (2007). Lech, M. et al. Influence of the Expression of Personality Traits on Growing Intensity of Interdialytic Disorders and Change of Pro-Health Behaviors in Patients with Chronic Kidney Disease. Med. Sci. Monit. [Internet] . 27 , e930151–e930151 (2021). [cited 2025 Jul 2];. Yarlioglu, A. M. et al. The relationship between depression, anxiety, quality of life levels, and the chronic kidney disease stage in the autosomal dominant polycystic kidney disease. Int. Urol. Nephrol. [Internet] . 55 (4), 983–992 (2023). [cited 2025 Jul 1];. Huang, J. et al. Association of anxiety, depression symptoms and sleep quality with chronic kidney disease among older Chinese. Medicine (United States) [Internet]. (2023). [cited 2025 Jul 1]; 102 (43):E35812 . Li, Q. F. et al. Neuroticism and patients’ depressive symptoms: a moderated mediation model of illness perception and patient-physician trust. Curr. Psychol. [Internet] . 42 (8), 6877–6885 (2023). [cited 2025 Jul 4];. Wu, S. F. V. et al. Differences in self-care knowledge, self-efficacy, psychological distress and self-management between patients with early- and end-stage chronic kidney disease. J. Clin. Nurs. [Internet] . 31 (15–16), 2287–2295 (2022). [cited 2025 Jul 1];. Molnar, A. O., Akbari, A. & Brimble, K. S. Perceived and Objective Kidney Disease Knowledge in Patients With Advanced CKD Followed in a Multidisciplinary CKD Clinic. Can. J. Kidney Health Dis. [Internet] (2020). [cited 2025 Jul 1];7. Schenkel, S. K. et al. Conceptualizations of cyberchondria and relations to the anxiety spectrum: Systematic review and meta-analysis. J. Med. Internet Res. [Internet] . 23 (11), e27835 (2021). [cited 2025 Jul 2];. Nadeem, F. et al. Relationship between Health-Anxiety and Cyberchondria: Role of Metacognitive Beliefs. J. Clin. Med. 2022 , 11 , Page 2590 [Internet]. 2022 [cited 2025 Jul 2];11(9):2590 . Shah, S. A. et al. Poor perception of chronic kidney diseases and its influencing factors among diabetics patients. Sci Rep [Internet]. [cited 2025 Jul 4];12(1):1–13. (2022). Gemmell, L. A. et al. Gender and Racial Differences in Stress, Coping, and Health-Related Quality of Life in Chronic Kidney Disease. J. Pain Symptom Manage. [Internet] . 52 (6), 806–812 (2016). [cited 2025 Jul 2];. Matthews, M. et al. Knowledge Requirements and Unmet Needs of Informal Caregivers of Patients with End-Stage Kidney Disease (ESKD) Receiving Haemodialysis: A Narrative Review. Healthcare (Switzerland) [Internet]. (2022). [cited 2025 Jul 4]; 10 (1):57 . Gomis-Pomares, A., Lacomba-Trejo, L. & Villanueva, L. Using Avoidant Emotion-Focused Coping and being a Woman with Adverse Childhood Experiences as the Worst-Case Scenario for Internalising Problems. J. Child. Adolesc. Trauma. [Internet] . 18 (2), 319–329 (2025). [cited 2025 Jul 4];. Kalantar-Zadeh, K. et al. Patient-centred approaches for the management of unpleasant symptoms in kidney disease. Nat. Reviews Nephrol. 2022 . 18 (3), 185–198 (2022). [cited 2025 Jul 4];:3 [Internet]. Torres, L. A. et al. Higher Perceived Stress as an Independent Predictor for Lower Use of Emotion-Focused Coping Strategies in Hypertensive Individuals. Front. Psychol. [Internet] . 13 , 872852 (2022). [cited 2025 Jul 4];. Arenas, M. D. et al. Social determinants of health influencing the choice of dialysis modality in advanced chronic kidney disease: Need of an interdisciplinary approach. Nefrología (English Edition) [Internet]. (2024). [cited 2025 Jul 1]; 44 (4):560–567 . Nair, D. et al. Psychological Adaptation to Serious Illness: A Qualitative Study of Culturally Diverse Patients With Advanced Chronic Kidney Disease. J Pain Symptom Manage [Internet]. [cited 2025 Jul 1];61(1):32–41.e2. (2021). Hu, N., Wang, A. & Chang, T. Social support mediates the relationship between illness perception and psychosocial adaptation among young and middle-aged kidney transplant recipients in China. Front. Psychol. 14 , 1062337 (2023). Pappas, I. O. & Woodside, A. G. Fuzzy-set Qualitative Comparative Analysis (fsQCA): Guidelines for research practice in Information Systems and marketing. Int. J. Inf. Manage. 58 , 102310 (2021). Neyra, J. A. & Chawla, L. S. Acute Kidney Disease to Chronic Kidney Disease. Crit. Care Clin. [Internet] . 37 (2), 453–474 (2021). [cited 2025 Jul 1];. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. J. Am. Med. Association (JAMA) . 310 (20), 2191–2194 (2013). Weinman, J. et al. The illness perception questionnaire: A new method for assessing the cognitive representation of illness. Psychol. Health . 11 (3), 431–445 (1996). Pacheco-Huergo, V. et al. Percepción en enfermedades crónicas: validación lingüística del Illness Perception Questionnaire Revised y del Brief Illness Perception Questionnaire para la población española. Aten Primaria [Internet] . 44 (5), 280–287 (2012). [cited 2025 Jul 1];. Valero-Moreno, S. et al. Psychometric properties of the questionnaire on threat perception of chronic illnesses in pediatric patients. Rev. Lat Am. Enfermagem [Internet] (2020). [cited 2025 Jul 1];28. Körner, A. et al. Personality assessment with the NEO-Five-Factor Inventory: The 30-item-short-version (NEO-FFI-30). PPmP Psychother. Psychosom. Medizinische Psychologie . 58 (6), 238–245 (2008). Cordero, A., Pamos, A. & Seisdedos, N. Inventario de personalidad NEO Revisado (NEO PI-R) e Inventario NEO Reducido de cinco factores (NEO-FFI). Madrid; (1999). Fumero, A. & De Miguel, A. Validación de la versión española del NEO-FFI-30. Análisis y Modificación. de Conducta ; 49 (179). (2023). Carver, C. S., Scheier, M. F. & Weintraub, J. K. Assessing coping strategies: A theoretically based approach. J Pers Soc Psychol [Internet]. [cited 2025 Jul 1];56(2):267–283. (1989). Morán, C., Autónoma, U. & León, N. COPE-28: A Psychometric Analysis of the Spanish Version of the Brief COPE. Universitas Physiol. 9 (2), 1657–9267 (2010). Requena, G. C., Salamero, M. & Gil, F. Validación del cuestionario MOS-SSS de apoyo social en pacientes con cáncer. Med Clin (Barc) [Internet]. 2007 [cited 2025 Jul 1];128(18):687–691. Sherbourne, C. D. & Stewart, A. L. The MOS social support survey. Soc. Sci. Med. 32 (6), 705–714 (1991). Wright, J. A. et al. Development and results of a kidney disease knowledge survey given to patients with CKD. Am. J. Kidney Dis. [Internet] . 57 (3), 387–395 (2011). [cited 2025 Jul 1];. Mota-Anaya, E. et al. Spanish version of the Kidney Disease Knowledge Survey (KiKS) in Peru: cross-cultural adaptation and validation. Medwave 16 (7), e6510 (2016). Zigmond, A. S. & Snaith, R. P. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. [Internet] . 67 (6), 361–370 (1983). [cited 2025 Jul 1];. De Las, C. et al. Hosp. Anxiety Depress. Scale y Psicopatología Afectiva ; 11 :126–130. (1995). Lacomba-Trejo, L. et al. Enfermedad renal crónica avanzada. Asociación entre ansiedad, depresión y resiliencia. Revista Colombiana de Nefrología [Internet]. [cited 2025 Jul 1];6(2):103–111. (2019). Claude, R. & Christopher, R. Acq [computer Programme] [Internet]. University of Houston-Downtown. 2014 [cited 2024 Dec 17]. Available from: https://sites.socsci.uci.edu/~cragin/fsQCA/software.shtml Ragin, C. C. Redesigning Social Inquiry. Fuzzy sets and beyond (University of Chicago Press, 2008). Christiansen, J. et al. Loneliness, Social Isolation, and Chronic Disease Outcomes. Annals Behav. Med. [Internet] . 55 (3), 203–215 (2021). [cited 2025 Jul 4];. Vila, J. Social Support and Longevity: Meta-Analysis-Based Evidence and Psychobiological Mechanisms. Front Psychol [Internet]. [cited 2025 Jul 4];12:717164. (2021). Kneavel, M. Relationship Between Gender, Stress, and Quality of Social Support. Psychol Rep [Internet]. (2021). [cited 2025 Jul 2]; 124 (4):1481–1501 . Cerón-Erazo, M. L. & Sánchez-Juan, C. Valoración de un programa de educación alimentaria en pacientes con insuficiencia renal crónica en prediálisis. Revista San Gregorio [Internet] 2019 [cited 2025 Jul 2]; 1 (33):77–87 . Robazza, C. et al. Basic psychological needs satisfaction, coping functions, and emotional experiences in competitive athletes: a multi-states theory perspective. Sci. Rep. [Internet] . 15 (1), 1854 (2025). [cited 2025 Jul 2];. Zhang, L., Zou, L. & Zhou, L. Effectiveness of psychoeducational interventions on psychological distress and health-related quality of life among patients with maintenance hemodialysis: a systematic review and meta-analysis. Ren. Fail. [Internet] . 46 (1), 2331613 (2024). [cited 2025 Jul 2];. Additional Declarations No competing interests reported. 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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-7048081","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":494878608,"identity":"43bf1e08-1e83-4a7b-8ce7-c2e79d334c08","order_by":0,"name":"Alicia Tamarit","email":"","orcid":"","institution":"University of Valencia","correspondingAuthor":false,"prefix":"","firstName":"Alicia","middleName":"","lastName":"Tamarit","suffix":""},{"id":494878609,"identity":"6c0fb3bc-7b9b-4b0d-9bd0-a92448eeab13","order_by":1,"name":"Laura Lacomba-Trejo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYBACPghlASLYGBgqiNDCBqEkoOwzJGthbCNGC/sZsw8/GCTk+du70x78nHc4sYG9/QF+LTw5xjN7GCQMZ5w5u92wdxtQC88ZAwIOyzFm4GGQYNwgkbtNgnfbYWMGiRwCDuN/Y8z4h0HCHqRF8u8coBb55wQcJpFjzAy0JRGkRZq34bAcMCgIOEziWTGzjIFEMsgvxjLH0uWAvsOvhZ8/eTPjmwob2/723m0P39RY8/CzH8fvMAhANpaNCPWjYBSMglEwCggAAJOlOjCnAjyyAAAAAElFTkSuQmCC","orcid":"","institution":"University of Valencia","correspondingAuthor":true,"prefix":"","firstName":"Laura","middleName":"","lastName":"Lacomba-Trejo","suffix":""},{"id":494878610,"identity":"65380a7c-b06e-4e52-89ea-426d3e36de7f","order_by":2,"name":"Eva Carbajo","email":"","orcid":"","institution":"Hospital General Universitario De Valencia","correspondingAuthor":false,"prefix":"","firstName":"Eva","middleName":"","lastName":"Carbajo","suffix":""},{"id":494878611,"identity":"437d55eb-cdee-4937-a81e-426ad5c7b744","order_by":3,"name":"Antonio Galán","email":"","orcid":"","institution":"Hospital General Universitario De Valencia","correspondingAuthor":false,"prefix":"","firstName":"Antonio","middleName":"","lastName":"Galán","suffix":""}],"badges":[],"createdAt":"2025-07-04 15:23:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7048081/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7048081/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-19881-z","type":"published","date":"2025-10-14T15:57:39+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":93956110,"identity":"ac2740c5-3232-45ad-9b27-0bacd036c1a3","added_by":"auto","created_at":"2025-10-20 16:10:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1077366,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7048081/v1/d8b18478-e9b9-4637-a053-278eea0a9865.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Towards Better Illness Perception in Advanced Chronic Kidney Disease: Clinical, Psychological and Cognitive Factors to Address","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic kidney disease (CKD) is a highly prevalent, progressive condition affecting approximately 10% of adults worldwide, between 500 and 800\u0026nbsp;million people across the globe [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. CKD is classified according to stages of severity, ranging from Stage 1, which indicates mild kidney damage, to Stage 5, representing the most severe cases of kidney damage and almost complete failure [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. People with advanced chronic kidney disease (ACKD) are in stages 4 and 5 of this classification, which prevalence studies give an estimate to be around 0,5% of the general population, amounting to over 26\u0026nbsp;million adults worldwide [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These advanced stages entail significant physical, social and psychological challenges: patients face not only the decreased renal function and its consequences, but also the reality of long-term treatment and its profound impact in their lives [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Along the psychological factors that play a role in adjustment to ACKD, illness perception is one of the most significant, shaping the entire experience of patients in these advanced stages [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePerception of ACKD, encompassing awareness of the condition and subjective threat assessment, has been identified as one of the most relevant factors in adherence to treatment, adaptation, self-regulation and overall well-being in patients living with chronic kidney conditions [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Illness perception includes a wide variety of psychological processes, from consequences of the disease to timeline, personal control, or treatment control, as well as how symptoms affect identity, concerns about the process, emotional response to the condition, and illness understanding [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This study focuses on the processes of consequences, concern, emotional response and overall threat perception as, according to the Common-Sense Model of Self-Regulation (CSM), these dimensions best capture the emotional and subjective components of illness representation and are particularly relevant for predicting psychological distress [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The CSM is a widely used theoretical framework that describes how individuals detect and interpret health threats, regulate emotional responses, generate cognitive representations of the illness and develop coping strategies and action plans based on these perceptions [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. According to this theoretical model, consequences would refer to the perceived impact of illness on daily life; concern, on the other hand, describes worries related to the health condition, with components of anticipation and rumination; and emotional response would address the intensity of negative affective reactions, such as anger, sadness or fear, in response to illness [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDue to the intersectional, multidimensional nature of this process, the literature is still exploring the multiple agents conditioning illness perception in ACKD; from purely clinical such as biological indicators of kidney function (usually measured through glomerular filtration rate or eGFR) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] to psychological and social factors [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These latter ones often refer to personality traits like emotional instability, manifested through neuroticism, which is associated with anxiety or stress when dealing with highly demanding, life-threatening situations like chronic disease [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Neuroticism is a widely researched personality dimension, most often assessed through the Big-Five model of personality, which explores five general dimensions of personality through the NEO-PI-R: extraversion, neuroticism, agreeableness, conscientiousness and openness to experience [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This trait has been observed to be associated with feelings of uncertainty and lack of control, and reporting of abnormal symptoms, which can easily lead to an increase in anxiety during treatment [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This is key to adherence and coping, as the literature indicates a consistent increase in anxiety levels for patients with kidney disease, especially those in advanced stages [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Similarly, research has observed an association between these factors and illness perception: higher scores in neuroticism and increased anxiety have been linked to more negative perceptions of illness in chronic patients [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, protective cognitive factors such as disease-specific knowledge can reduce anxiety and lead to adaptive illness perceptions, counteracting misinformation and increasing motivation and engagement with care [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Disease knowledge can look different for every patient: although it usually alleviates distress, in some cases the desire to stay informed could lead to increased health-related internet use or other maladaptive behaviors, especially when co-occurring with emotional instability and anxiety [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. While increased knowledge has been associated with more positive – or less harmful – perceptions of illness, more research is needed to explore non-linear associations between these factors [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Coping mechanisms can also become protective in the face of chronic illness – particularly when individuals are confronted with situation that are largely uncontrollable, such as the progression of ACKD [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In these situations, emotion-focused coping strategies can help patients regulate emotional distress and process the psychological impact of illness; however, this kind of coping is not inherently adaptive or maladaptive: its effectiveness depends on the strategy used, the context in which it is put into practice, and the psychological profile of the patient [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In controllable situations, problem-focused strategies could lead to better outcomes over emotion-focused coping, as it tackles the root of the problem; this could lead to the assumption that the latter would be more adaptive in incontrollable situations such as chronic disease [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Nevertheless, it is essential to distinguish between adaptive regulation strategies, such as seeking support, finding communities or constructive emotional processing, and more dysfunctional patterns, such as excessive venting or rumination [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Thus, emotion-focused coping could improve the perception of illness or reduce threat when adaptive strategies are aligned with adequate context and a less anxiety-prone psychological profile of patients, although more research is needed on this area to further explore this connection [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Closely related to emotional coping, the social aspect of patient support is crucial in ACKD: not only is the presence of social support a common moderator of chronic disease and well-being, but its absence is often linked to increased anxiety and depression, and worsened health outcomes [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Moreover, social support could lead to a reduced illness threat perception, if this support is adequate, relies on affection and contributes to emotional regulation and instrumental and logistic care [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite a growing number of studies linking single predictors – such as anxiety, coping mechanisms or eGFR – to illness threat perception in ACKD, most of this work has relied on linear, variable-centered statistics [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. There is yet a need for research that looks at these factors through interactive, non-linear pathways, and allows to understand the combinations of these variables instead of analyzing their separate contribution to illness threat perception. Qualitative Comparative Analysis (QCA) is a statistical method that provides casual reasoning by examining how different factors (in this case, psychological, behavioral and clinical) jointly contribute to an outcome [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In the context of research on ACKD, this method could help shed light on the multiple pathways that shape patients’ illness threat perception, serving as a blueprint for tailored interventions designed for this vulnerable population [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThus, this study aims to identify combinations of psychological, behavioral, and clinical factors that predict how individuals with ACKD perceive their illness. Firstly, we hypothesize that neuroticism and anxiety will predict the presence of the patients’ illness threat perception. Secondly, we hypothesize that renal function, emotion-focused coping, social support and knowledge of the illness will predict the absence of the patients’ illness threat perception.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003e\u003cstrong\u003eProcedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection took place between 2018 and 2024, during a single session carried out by two licensed health psychologists trained in clinical assessment. Participants were recruited through referrals from the Nephrology Unit to the Clinical and Health Psychology Unit, within the framework of the Kidney Patient School Project at the Hospital General Universitario Consortium of Valencia. Consequently, the sampling strategy was non-probabilistic and based on availability.\u003c/p\u003e\n\u003cp\u003eTo be eligible for inclusion, participants were required to have a confirmed diagnosis of advanced chronic kidney disease (ACKD), stage 3b or higher. Individuals presenting with diagnosed psychological disorders or cognitive impairments were excluded based on information obtained from their medical records (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10).\u003c/p\u003e\n\u003cp\u003ePrior to data collection, all participants received verbal and written information about the study objectives and procedures, including confidentiality safeguards and data handling protocols. Informed consent was obtained in writing from all participants. The self-report instruments were then administered in a structured format during the same session.\u003c/p\u003e\n\u003cp\u003eThe study strictly followed the ethical principles of the Declaration of Helsinki [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e] and was approved by the Clinical Research Ethics Committee of the Hospital General Universitario Consortium of Valencia (Reference: 2019/9).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study included 69 individuals diagnosed with chronic kidney disease (CKD), aged between 38 and 88 years (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;69.44, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10.04), all of whom were under follow-up at the Nephrology Unit of the Hospital General Universitario Consortium of Valencia.\u003c/p\u003e\n\u003cp\u003eThe majority were men (78.5%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;51). In terms of clinical characteristics, hypertension was present in 93.3% of participants, 45% had type 2 diabetes mellitus, and 38.3% reported a heart condition. Regarding mental health, 16.7% had a history of psychological problems, although none were currently experiencing a diagnosed mental health condition.\u003c/p\u003e\n\u003cp\u003eWith respect to hospitalizations in the past year, 70.4% had not been hospitalized, while 16.7% had been hospitalized once. Smaller percentages reported being hospitalized twice (5.6%), three times (1.9%), or four times (5.6%). In terms of disease stage, 64.6% were in stage 4, 21.4% in stage 5, and 13.8% in stage 3b of CKD.\u003c/p\u003e\n\u003cp\u003eAs for sociodemographic variables, 86.9% lived with a companion, and most participants were married or in a relationship (71.7%), followed by widowed (11.7%) and separated or divorced (8.3%). Educational levels were generally low: 31.7% had incomplete primary education, 28.3% completed secondary education, 25% completed primary education, and 15% had higher education. Regarding employment status, 80% were retired, while others were on disability leave (11.7%), unemployed (5%), or actively working (3.3%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe following variables were analyzed:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(a) Sociodemographic and Clinical Variables\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn ad hoc questionnaire was developed to collect sociodemographic and clinical variables. Regarding the clinical variables, medical history was also consulted in order to check the blood tests that had been carried out on the day of the psychological assessment. From it, we extracted the value of estimated glomerular filtration rate (eGFR). Renal function was assessed through the eGFR, calculated by nephrology professionals using standardized clinical formulas (CKD-EPI). The eGFR is expressed in ml/min/1.73m\u0026sup2; and reflects the level of kidney function. For descriptive purposes, patients were categorized according to these clinical stages. However, for predictive analyses, the eGFR value was included as a continuous variable, representing the degree of renal deterioration (lower values indicating more advanced disease).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(b) Psychological Variables\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003eIllness Threat Perception\u003c/em\u003e: Perceived illness threat was assessed using the Spanish adaptation of the Brief Illness Perception Questionnaire (B-IPQ) [\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e]. The B-IPQ consists of eight Likert-scale items (0\u0026ndash;10) that assess various dimensions of illness perception, including consequences, timeline, personal control, treatment control, symptoms (identity), concern, emotional response, and illness understanding. A total illness threat score is computed by summing the item scores, after reversing the positively worded items: personal control, treatment control, and understanding. In this study, the following subscales from the questionnaire were used as outcome variables: perceived consequences, concern, emotional response, personal control, and overall illness threat perception. Participants were instructed to respond with a focus on their experience of advanced chronic kidney disease (ACKD). The B-IPQ has demonstrated adequate internal consistency in previous studies (\u0026alpha;\u0026thinsp;=\u0026thinsp;.67\u0026ndash;.89) [\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e], and reliability in the current sample was acceptable (\u0026alpha;\u0026thinsp;=\u0026thinsp;.50)\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003eNeuroticism\u003c/em\u003e: Neuroticism was measured using the Neuroticism subscale of the NEO Five-Factor Inventory (NEO-FFI) short version [\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e], adapted to Spanish [\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e]. The full inventory includes 60 Likert-scale items distributed across five dimensions: neuroticism, extraversion, openness, agreeableness, and conscientiousness. For the purposes of this study, only the neuroticism subscale was used (e.g., \u0026ldquo;I often feel tense or nervous\u0026rdquo;). The Spanish versions have shown adequate psychometric properties, which were supported in this sample as well (\u0026alpha;\u0026thinsp;=\u0026thinsp;.68).\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003eEmotion-Focused Coping\u003c/em\u003e: This variable was assessed using the emotion-focused coping subscale of the COPE Inventory [\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e], in its Spanish adaptation by [\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e]. The COPE consists of 24 items with four response options, grouped into twelve first-order factors that form two second-order dimensions: problem-focused coping and emotion-focused coping. Problem-focused strategies (e.g., active coping, planning) are generally considered adaptive when stressors are controllable, while emotion-focused strategies (e.g., seeking emotional support, expressing emotions) help regulate emotional responses and may be adaptive in uncontrollable contexts. For this study, only the emotion-focused coping subscale was used (e.g., \u0026ldquo;I try to get comfort and understanding from someone\u0026rdquo;). Internal consistency for the Spanish version has been reported as acceptable (\u0026alpha;\u0026thinsp;=\u0026thinsp;.70\u0026ndash;.80), and reliability in the present sample was also satisfactory (\u0026alpha;\u0026thinsp;=\u0026thinsp;.61).\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003eSocial Support\u003c/em\u003e: Perceived social support was evaluated using the Spanish version [\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e] of the Medical Outcomes Study\u0026ndash;Social Support Survey (MOS-SSS) [\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e]. This 20-item instrument includes 19 Likert-type items (5-point scale) and 1 open-ended item assessing the estimated size of the respondent\u0026rsquo;s social network. The scale was developed for use with individuals suffering from chronic illnesses. It yields four subscales\u0026mdash;emotional/informational support, instrumental support, positive social interaction, and affective support\u0026mdash;which can be summed to obtain a total social support score, used in the present study. Internal consistency for the Spanish version is considered excellent (\u0026alpha;\u0026thinsp;\u0026gt;\u0026thinsp;.90) [\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e] (\u0026alpha;\u0026thinsp;=\u0026thinsp;.79).\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003eKidney Disease Knowledge\u003c/em\u003e: Knowledge about kidney disease was assessed using the Kidney Disease Knowledge Survey (KiKS) [\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e], adapted to Spanish [\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e]. The questionnaire includes 28 items, of which five are multiple choice and the rest are yes/no questions. Items assess knowledge about kidney function, treatment options for kidney failure, symptoms and progression of the disease, nephrotoxic medications, blood pressure goals, and other key topics for renal health. A total score is calculated based on the number of correct answers. The Spanish version has demonstrated adequate internal consistency (\u0026alpha;\u0026thinsp;=\u0026thinsp;.71) [\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003eAnxiety\u003c/em\u003e: Anxiety symptoms were measured using the Anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A) developed by Zigmond and Snaith [\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e], in its Spanish version [\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e]. The HADS was specifically designed for individuals with physical health problems, excluding somatic items to reduce confounding. It consists of 14 items, split equally into two subscales: anxiety and depression. Previous studies have reported good psychometric properties for this scale [\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e]. In the current study, reliability for the anxiety subscale was modest (HADS-A: \u0026alpha;\u0026thinsp;=\u0026thinsp;.50).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData Analysis\u003c/h2\u003e\n\u003cp\u003eDescriptive statistics were computed using SPSS version 29 (IBM Corporation, Armonk, NY, USA) to obtain calibration values for the variables. Subsequently, analyses were conducted using fsQCA 2.5 [\u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e] to identify necessary and sufficient conditions for predicting high levels of illness threat perception.\u003c/p\u003e\n\u003cp\u003ePrior to analysis, the variables were recalibrated based on established guidelines in the literature [\u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e], using three qualitative anchors: a value of 0 was assigned to cases completely outside the 10th percentile, 0.5 to the median (50th percentile), and 1 to cases entirely within the 90th percentile.\u003c/p\u003e\n\u003cp\u003eFollowing calibration, an analysis of necessary conditions was performed. Conditions with consistency values above 0.90 were considered necessary for the outcome [\u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e]. Next, sufficiency analyses were carried out. Models were retained when they met the conventional threshold of consistency\u0026thinsp;\u0026gt;\u0026thinsp;0.74, indicating a satisfactory level of empirical relevance.\u003c/p\u003e\n\u003cp\u003eThree types of solutions were generated\u0026mdash;parsimonious, complex, and intermediate\u0026mdash;based on standard QCA procedures. The intermediate solution was selected for interpretation, as it incorporates both theoretical knowledge and empirical evidence. Within this solution, conditions also present in the parsimonious solution were identified as core conditions, while those appearing only in the intermediate solution were classified as peripheral. In the truth table and solution chart, core conditions are typically presented in bold or larger symbols to reflect their greater explanatory weight [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDescriptive and calibration values\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants reported moderate levels of illness threat perception, neuroticism, and emotion-focused coping, alongside high levels of perceived social support, moderate knowledge about kidney disease, and low levels of anxiety. Detailed descriptive statistics are presented in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cem\u003eDescriptive statistics, calibration values and associations between variables\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNeuroticism\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEmotion-Focused Coping\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSocial support\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eKidney disease knowledge\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eConsequences\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eConcern\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEmotional response\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eThreat perception\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e85.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMin.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMax.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e91.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\"\u003e\u003cem\u003eNote. M\u0026thinsp;=\u0026thinsp;Mean; SD\u0026thinsp;=\u0026thinsp;Standard Deviation; Min\u0026thinsp;=\u0026thinsp;Minimum; Max\u0026thinsp;=\u0026thinsp;Maximum; P10\u0026thinsp;=\u0026thinsp;10th Percentile; P50\u0026thinsp;=\u0026thinsp;50th Percentile; P90\u0026thinsp;=\u0026thinsp;90th Percentile.\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eFuzzy-set Qualitative Comparative Analysis (fsQCA)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNecessity analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn line with previous literature, analyses of necessary conditions were conducted first, followed by sufficiency analyses (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cem\u003eSummary of the main conditions sufficient for the intermediate solution of consequences, concern, emotional response and threat perception\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth colspan=\"6\" align=\"left\"\u003e\n \u003cp\u003eConsequences\u003c/p\u003e\n \u003c/th\u003e\n \u003cth colspan=\"6\" align=\"left\"\u003e\n \u003cp\u003eConcern\u003c/p\u003e\n \u003c/th\u003e\n \u003cth colspan=\"6\" align=\"left\"\u003e\n \u003cp\u003eEmotional response\u003c/p\u003e\n \u003c/th\u003e\n \u003cth colspan=\"6\" align=\"left\"\u003e\n \u003cp\u003eThreat perception\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFrequency cut-off 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh levels of Consequences\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eConsistency cut-off .85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow levels of Consequences\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eConsistency cut-off .86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh levels of Concern\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eConsistency cut-off .86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow levels of Concern\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eConsistency cut-off .84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh levels of Emotional response\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eConsistency cut-off .85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow levels of Emotional response\u003c/strong\u003e Consistency cut-off .86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh levels of Threat perception\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eConsistency cut-off .85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow levels of Threat perception\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eConsistency cut-off .85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eeGFR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeuroticism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmotion-Focused Coping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSocial support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKidney disease knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e●\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e○\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRaw Coverage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnique Coverage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConsistency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall Consistency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall Coverage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"25\"\u003e\u003cem\u003eNote. Expected vector for high levels of quality of consequences, concern, emotional response and threat perception: 1,1,0,0,0,1\u003c/em\u003e[\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e]. \u003cem\u003e● indicates presence of core conditions; ○ indicates absence of core conditions; There were no peripheral conditions.\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNo condition met the threshold for necessity (consistency\u0026thinsp;\u0026ge;\u0026thinsp;0.90) for predicting either high or low levels of illness threat perception or any of its subdimensions among individuals with ACKD.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSufficiency analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRegarding the perception of \u003cstrong\u003ehigh consequences associated with illness\u003c/strong\u003e, three causal pathways were identified, explaining 84% of cases. The most relevant configuration involved the combination of low eGFR and low social support. The second pathway, explaining 40% of cases, combined high emotion-focused coping, high disease knowledge and low anxiety. A third solution, accounting for 37% of cases, involved low eGFR combined with high neuroticism and high anxiety.\u003c/p\u003e\n\u003cp\u003eAs for the \u003cstrong\u003elow perception of illness consequences\u003c/strong\u003e, seven distinct pathways explained 81% of cases. The most relevant combination, explaining 35%, involved high emotion-focused coping, low disease knowledge, and low anxiety. The second pathway, also explaining 35%, was defined by low neuroticism, low emotion-focused coping, high social support, and adequate disease knowledge. A third solution, accounting for 22%, included low neuroticism, emotion-focused coping, social support, low anxiety, and high disease knowledge.\u003c/p\u003e\n\u003cp\u003eWith respect to \u003cstrong\u003ehigh concern\u003c/strong\u003e, fourteen configurations explained 78% of cases. The most prominent path combined low eGFR and high anxiety; and the second combined low eGFR, high neuroticism and low social support. In contrast, \u003cstrong\u003elow concern\u003c/strong\u003e was predicted by seven pathways explaining 66% of cases, the most relevant being the combination of high eGFR, emotion-focused coping, high disease knowledge, and low social support. Another key solution involved high eGFR, neuroticism, high disease knowledge, and low social support, while a third included high eGFR, emotion-focused coping, low neuroticism, low anxiety, and adequate knowledge.\u003c/p\u003e\n\u003cp\u003eFor \u003cstrong\u003ehigh levels of emotional response\u003c/strong\u003e, six pathways explained 73% of cases. The most relevant involved high eGFR, high neuroticism, emotion-focused coping, and low anxiety. The second solution included low eGFR, low neuroticism, high disease knowledge, and high anxiety. The third pathway featured low eGFR, high neuroticism, high anxiety, and high social support. As for \u003cstrong\u003elow emotional response\u003c/strong\u003e, five configurations explained 79% of cases, the most relevant being the combination of low disease knowledge and low anxiety. Another involved high eGFR and high disease knowledge, despite low social support, and a third featured low eGFR, low anxiety, high neuroticism, and social support.\u003c/p\u003e\n\u003cp\u003eFinally, for \u003cstrong\u003ehigh levels of illness threat perception\u003c/strong\u003e, eleven distinct pathways explained 80% of cases. The most prominent path involved high neuroticism, emotion-focused coping, and social support. The second most relevant, explaining 37% of cases, combined low eGFR, emotion-focused coping, and anxiety. A third pathway, explaining 25%, featured high neuroticism and high anxiety, alongside low social support and low disease knowledge.\u003c/p\u003e\n\u003cp\u003eConversely, \u003cstrong\u003elow threat perception\u003c/strong\u003e was explained by seven configurations, accounting for 83% of cases. The most important, explaining 42%, combined high eGFR, social support, and low anxiety. Another relevant path explained 31% of cases via low neuroticism, low anxiety, high social support, and high disease knowledge. A third solution also accounted for 31% and included low neuroticism, low anxiety, low emotion-focused coping, and high social support.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis research aimed to identify combinations of psychological, behavioral, and clinical factors that predict how individuals with ACKD perceive their illness. Results show that distinct combinations of these factors shape how patients perceive their kidney conditions. Specifically, configurations involving low renal function, high anxiety and low social support consistently predicted heightened perceptions of illness threat. Additionally, profiles marked by emotional stability, strong social support and low anxiety were associated with more adaptive illness perceptions. Notably, the role of knowledge and emotion-focused coping varied depending on the emotional and interpersonal context, highlighting the non-linear and interactive nature of these influences.\u003c/p\u003e\u003cp\u003eFirstly, we hypothesized that neuroticism and anxiety would predict the presence of the patients\u0026rsquo; illness threat perception. Results are in line with our hypothesis, supporting previous research highlighting the negative impact of neuroticism and anxiety in patients\u0026rsquo; illness perceptions, especially in the context of kidney disease [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Both of these factors were present in the most important combinations explaining all dimensions of illness threat perception: high perception of consequences, concern, emotional response and overall threat perception. This indicates that emotional instability or negative affectivity manifested through neurotic personality traits usually coexists with anxiety when explaining concerned, alarmed or fearful attitudes of patients towards their kidney conditions in ACKD, more so when indicators of low renal function are present. Moreover, the absence of these traits is often found in configurations explaining the absence of all threat perceptions, notably linked to reduced concern, fear of consequences or anticipation of threat. This might indicate that neuroticism and anxiety might be buffering the clinical information they are receiving (interestingly reflected by high knowledge of the disease), for example, when renal function drops, worsening the perception they have of their kidney condition. These results point to the importance of looking at the emotional background of patients, their personality traits and ability to handle and regulate emotions, both when providing clinical information and in the overall progression of their treatment.\u003c/p\u003e\u003cp\u003eSecondly, we hypothesized that renal function, emotion-focused coping, social support and knowledge of the illness would predict the absence of the patients\u0026rsquo; illness threat perception. Our results partially support this hypothesis, giving crucial nuance on how to interpret the effect of these variables on threat perception in ACKD. Renal function, specifically low levels of eGFR as an indicator of kidney failure, featured in the leading paths to all threat dimensions; similarly, and as hypothesized, high levels of eGFR indicating increased renal function appeared consistently in paths explaining the absence of threat perception. These results support extend previous evidence pointing at biological factors and their impact on patients\u0026rsquo; illness perception, adding information about their joint effect when paired with psychological risk factors such as anxiety and neuroticism [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRegarding social support, its presence is overall consistent in pathways explaining the absence of threat perceptions, namely of perception of consequences, emotional response and overall threat perception. Similarly, lower social support appears in pathways explaining high perception of consequences, concern and overall threat perception. This supports our hypothesis and adds to previous research observing the protective role of social support and the risk entailed by the lack of a protective network for patients with ACKD, which emphasizes the need for actions that create, support and spread community [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In fact, social support has been shown to play such a crucial role in illness progression that it has even been associated with reduced mortality in patients with chronic conditions, highlighting the significant protective value of social and affective networks [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. This is particularly true for specific populations: men and older people (notably the main demography in our sample) may have a harder time seeking support; therefore, these actions could have a greater potential for those with less access or abilities to create social and affective networks [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Nevertheless, our non-linear analyses provide important nuance on this variable and the different interpretations we could extract from the results obtained. Social support has also featured in the configuration of emotional response to illness, specifically when paired with high-risk factors \u0026ndash; neuroticism, anxiety and low eGFR. This could indicate that well-intended carers might inadvertently reinforce worry or possibly add to fears already present in anxious or emotionally unstable patients. Interventions focusing on patient wellbeing in ACKD often counteract this phenomenon: e.g., the Kidney Patient School works to generate support groups that provide accurate information about their illness process, looking at improving their quality of life and reducing the possible psychological and physiological impact of their kidney conditions [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Community actions such as the ERC are crucial to ensure that social support is consistently and effectively protective when dealing with chronic kidney disease, especially in its more advanced stages.\u003c/p\u003e\u003cp\u003eResults on emotion-focused coping and disease knowledge are also nuanced, providing useful insights into the mechanisms in which they operate to prevent negative perceptions of illness by ACKD patients. Regarding emotion-focused coping, it was present on the most frequent conditions on both adaptive and maladaptive illness perception configurations, showcasing the heterogeneity of pathways in which it can impact patients\u0026rsquo; experiences of their kidney conditions. On one hand, when present in pathways explaining the absence of illness threat perceptions, emotion-focused coping worked in combination with lower anxiety and improved renal function. This could suggest that patients with higher emotional regulation skills \u0026ndash; possibly reflected in lower anxiety \u0026ndash; prefer this coping mechanism, especially when renal indicators are favorable. On the other hand, emotion-focused coping is observed to be present in configurations showing higher threat perceptions and absent in pathways showcasing lower threat perceptions. This could suggest that emotion-focused coping could prove maladaptive when paired with specific factors, namely neuroticism and lower eGFR. In these cases, emotion-focused coping could entail rumination or emotional venting without regulation, which could lead to a worsened perception of their condition and increased concerns about the threats involved. Another key fact could be the characteristics of the sample: as it is composed by a majority of men, this could have influenced the direction of the data. The literature indicates that men tend to use maladaptive coping strategies more frequently than women, specifically in the context of chronic disease [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], which provides another interpretation to our results. Although emotion-focused coping and its benefits have been widely researched on other areas, such as coping strategies in sports [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e], the literature is still scarce regarding the impact of this mechanism in ACKD patients. This population faces a high emotional burden and uncertainty and is therefore at a higher risk of psychological distress and in critical need of effective coping strategies to support adjustment and treatment adherence.\u003c/p\u003e\u003cp\u003eRegarding disease knowledge, results partially support our hypothesis, suggesting a double-edged nature of this factor. Previous research has observed the benefits of competent, consistent care towards patients through the provision of accurate information about their disease and its process [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In these studies, disease knowledge has been observed to foster treatment adherence, realistic expectations and greater self-efficacy, particularly when patients are required to engage in complex decision-making regarding dialysis or transplantation. Our results are consistent with this perspective when paired with low anxiety, low neuroticism, high emotion-focused coping and higher social support. These combinations likely reflect emotionally stable patients who are able to process medical information through effective regulation and reliance on their affective and social networks, for whom disease knowledge has a positive impact in the perception of their kidney condition. Conversely, our results also highlight configurations where high knowledge appeared in pathways explaining perceptions of high threat and consequences, particularly in combination with anxiety and emotion-focused coping. This could suggest that in emotionally vulnerable profiles, or those who focus on their emotional state when coping with long-term treatment, detailed illness knowledge could intensify the awareness of the disease\u0026rsquo;s irreversibility, progression and the potential risk of mortality, possibly increasing distress. This double-edged effect of disease knowledge could suggest that access to information has a nuanced impact on the patients\u0026rsquo; well-being: the source of this information and the patient\u0026rsquo;s psychological profile shape the effect this knowledge will have on the threat perception they develop of their health condition. This has been observed in the literature on the COVID-19 pandemic and the management of information about the disease: whether the patients accessed this knowledge through competent healthcare professionals or health-related internet use widely vary the mental health outcomes for individuals suffering from illness [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. While the former provides reassurance and care that caters to patients individually, the latter could add to the anxiety and distress they could already be experiencing. Similarly, a more anxious profile of patients could interpret accurate, careful information through a maladaptive lens, reinforcing the idea that the provision of information should adapt to each patient and their psychological and social context to prevent negative outcomes to this process. These findings suggest the importance of tailoring psychological interventions to individual profiles prior to implementing group-based educational programs. Specifically, patients suffering from anxiety, high emotional reactivity, or maladaptive coping styles may benefit from individualized psychological support focused on emotional regulation and distress reduction. Once emotional vulnerability is addressed, these patients could more effectively engage in group interventions designed to enhance disease knowledge and reduce perceived threat. Thus, a preliminary psychological screening assessing anxiety, coping strategies, and emotional reactivity could inform the decision on the best pathway for every patient \u0026ndash; individual versus group intervention.\u003c/p\u003e\u003cp\u003eIn summary, emotion-focused coping and disease knowledge have proved to not be intrinsically positive or negative, but rather dependent on the influence of other factors and the complex pathways in which they jointly operate [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Together with the other factors analyzed, these dimensions create unique profiles that provide valuable context to understand illness threat perception.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths, limitations and future research directions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study offers significant contributions to the existing literature on ACKD and patients living with chronic illness. By applying QCA, this research moves beyond traditional linear approaches and provides multiple, context-dependent pathways that lead to different illness perceptions in patients with ACKD, highlighting the many ways in which psychological processes operate that could be overlooked in regression-based models. Moreover, these findings challenge the assumption that emotion-focused coping and disease knowledge are unequivocally positive; rather, they showcase how these factors can combine with anxiety and either buffer or amplify threat perceptions of their kidney condition. This could contribute to a more context-sensitive view of psychological adjustment in patients of ACKD. Finally, these results may inform tailored intervention design by identifying psychological profiles most at risk of maladaptive illness perceptions [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Emotion regulation training, kidney disease psychoeducation and peer-based social support are key in intervention programs when designed to decrease the intensity of the threat perception in patients with ACKD, potentially increasing their well-being and quality of life associated with health [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite these contributions, this study is not without limitations. First, the B-IPQ subscales showed acceptable but not optimal psychometrics, which could have influenced results obtained. Second, subtle neurocognitive deficits \u0026ndash; highly relevant in ACKD patients \u0026ndash; were not accounted for in the battery provided, although it is important to note that they were indicated to be an exclusion criterion through contact with patients. Third, participation through the EPR may have selected more engaged, socially connected patients, limiting generalizability of results and underrepresenting those with more limited access to support and care. Patients generally disclosed higher social support through the MOS-SSS, which is theoretically inconsistent with the characteristics of the sample (typically older and male), which could indicate that this questionnaire did not accurately discriminate between patients regarding the strength and quality of the support they were receiving. Another explanation for these results could be social desirability, which may have skewed the responses \u0026ndash; a common occurrence with in-person data gathering. Finally, these results were obtained through a cross-sectional design, therefore longitudinal research is recommended to test whether the observed configurations prospectively predict changes in illness perception of kidney disease. Despite these limitations, this study focuses on a complex and hard-to-reach sample, consisting of patients in advanced stages of CKD. Moreover, the inclusion of both biological and psychological measures strengthens the robustness of the findings and enhances clinical relevance, entailing a significant contribution to research and medical practice.\u003c/p\u003e\u003cp\u003eUltimately, this study aims to emphasize that the different ways a person lives with chronic illness are shaped not only by the progression of their condition, but also by the intricate web of emotions, beliefs and relationships surrounding them. For people with ACKD \u0026ndash; who often navigate fear, uncertainty and physical decline \u0026ndash; coping is not a single act but a continuous process. Furthermore, these findings provide valuable insights into psychological intervention by highlighting the importance of tailoring support to individual psychological profiles. Implementing prior psychological assessments could help identify specific needs and guide whether patients might benefit more from individual or group-based interventions, thus increasing the likelihood of therapeutic success. Recognizing the nuanced ways in which psychological and social factors combine can bring us closer to designing care that is not only clinically effective, but also emotionally significant, and treats each person with utmost care and respect.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConflict of Interest\u003c/h2\u003e\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eDeclaration\u003c/p\u003e\u003cp\u003eThe authors did not receive any specific funding for this research.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eLLT: Responsible for research design, data collection through interviews, data processing, analysis, and interpretation. Drafted the initial version of the manuscript and conducted subsequent revisions; AT: Drafted the initial version of the manuscript and contributed to its subsequent revisions; EC: Contributed to research design, data collection through interviews, and served as project coordinator. Reviewed and provided critical revisions to the manuscript; AG: Contributed to research design, facilitated referrals to the psychology service for patients meeting the inclusion criteria, and reviewed the manuscript. All authors revised the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors wish to express their sincere gratitude to the individuals with advanced chronic kidney disease who generously participated in this study. We also thank the colleagues involved in the Kidney patient School project, whose collaboration made this work possible.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study belong to a larger research project involving multiple authors and collaborators. Due to this, the data are not publicly available. However, they can be made available upon reasonable request to the corresponding author, with permission from all contributors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKovesdy, C. P. Epidemiology of chronic kidney disease: an update 2022. Kidney Int Suppl [Internet]. 2022 [cited 2025 Jul 2];12(1):7. (2011).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShrestha, S. et al. Care of Adults with Advanced Chronic Kidney Disease. \u003cem\u003eJ. Clin. Med. [Internet]\u003c/em\u003e 2024 [cited 2025 Jul 2];\u003cb\u003e13\u003c/b\u003e(15):4378 .\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLevey, A. S. \u0026amp; Defining, A. K. D. The Spectrum of AKI, AKD, and CKD. Nephron [Internet]. [cited 2025 Jul 1];146(3):302\u0026ndash;305. (2022).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJenkins, Z. M. et al. A psychosocial intervention for individuals with advanced chronic kidney disease: A feasibility randomized controlled trial. \u003cem\u003eNephrol. [Internet]\u003c/em\u003e. \u003cb\u003e26\u003c/b\u003e (5), 442\u0026ndash;453 (2021). [cited 2025 Jul 1];.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eV\u0026eacute;lez-V\u0026eacute;lez, E. \u0026amp; Bosch, R. J. Illness perception, coping and adherence to treatment among patients with chronic kidney disease. \u003cem\u003eJ. Adv. Nurs. [Internet]\u003c/em\u003e. \u003cb\u003e72\u003c/b\u003e (4), 849\u0026ndash;863 (2016). [cited 2025 Jul 2];.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSitjar-Su\u0026ntilde;er, M. et al. The Perception of Illness in People with Advanced Chronic Kidney Disease. \u003cem\u003eJ. Personalized Med. 2025\u003c/em\u003e, \u003cb\u003e15\u003c/b\u003e, Page 120 [Internet]. 2025 [cited 2025 Jul 2];15(3):120 .\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMeuleman, Y. et al. Exploring Patients\u0026rsquo; Perceptions About Chronic Kidney Disease and Their Treatment: A Qualitative Study. \u003cem\u003eInt. J. Behav. Med. [Internet]\u003c/em\u003e. \u003cb\u003e31\u003c/b\u003e (2), 263\u0026ndash;275 (2023). [cited 2025 Jul 2];.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMuscat, P. et al. Illness perceptions predict distress in patients with chronic kidney disease. BMC Psychol [Internet]. [cited 2025 Jul 4];9(1):1\u0026ndash;13. (2021).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLeventhal, E. A. Aging and the Perception of Illness. Res Aging [Internet]. 1984 [cited 2025 Jul 4];6(1):119\u0026ndash;135.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLeventhal, H., Phillips, L. A. \u0026amp; Burns, E. The Common-Sense Model of Self-Regulation (CSM): a dynamic framework for understanding illness self-management. \u003cem\u003eJ. Behav. Med. [Internet]\u003c/em\u003e. \u003cb\u003e39\u003c/b\u003e (6), 935\u0026ndash;946 (2016). [cited 2025 Jul 4];.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCusolito, P. D. \u003cem\u003eCoping With Kidney Disease: The Role of Age, Stage of Disease, Years of Education, and Endorsed Gender Stereotypes in Predicting Depression, Anxiety, and Coping Behavior\u003c/em\u003e (Fielding Graduate University, 2023).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuerra, F. et al. Chronic Kidney Disease and Its Relationship with Mental Health: Allostatic Load Perspective for Integrated Care. \u003cem\u003eJ. Personalized Med. 2021\u003c/em\u003e, \u003cb\u003e11\u003c/b\u003e, Page 1367 [Internet]. 2021 [cited 2025 Jul 1];11(12):1367 .\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcCrae, R. R. \u0026amp; Costa, P. T. A contemplated revision of the NEO Five-Factor Inventory. Pers Individ Dif [Internet]. (2004). [cited 2017 Oct 10];\u003cb\u003e36\u003c/b\u003e:587\u0026ndash;596 .\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcCrae, R. R. \u0026amp; Costa, P. T. Jr. Brief Versions of the NEO-PI-3. \u003cem\u003eJ. Individ Differ. [Internet]\u003c/em\u003e. \u003cb\u003e28\u003c/b\u003e (3), 116\u0026ndash;128 (2007).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLech, M. et al. Influence of the Expression of Personality Traits on Growing Intensity of Interdialytic Disorders and Change of Pro-Health Behaviors in Patients with Chronic Kidney Disease. \u003cem\u003eMed. Sci. Monit. [Internet]\u003c/em\u003e. \u003cb\u003e27\u003c/b\u003e, e930151\u0026ndash;e930151 (2021). [cited 2025 Jul 2];.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYarlioglu, A. M. et al. The relationship between depression, anxiety, quality of life levels, and the chronic kidney disease stage in the autosomal dominant polycystic kidney disease. \u003cem\u003eInt. Urol. Nephrol. [Internet]\u003c/em\u003e. \u003cb\u003e55\u003c/b\u003e (4), 983\u0026ndash;992 (2023). [cited 2025 Jul 1];.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHuang, J. et al. Association of anxiety, depression symptoms and sleep quality with chronic kidney disease among older Chinese. Medicine (United States) [Internet]. (2023). [cited 2025 Jul 1];\u003cb\u003e102\u003c/b\u003e(43):E35812 .\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi, Q. F. et al. Neuroticism and patients\u0026rsquo; depressive symptoms: a moderated mediation model of illness perception and patient-physician trust. \u003cem\u003eCurr. Psychol. [Internet]\u003c/em\u003e. \u003cb\u003e42\u003c/b\u003e (8), 6877\u0026ndash;6885 (2023). [cited 2025 Jul 4];.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWu, S. F. V. et al. Differences in self-care knowledge, self-efficacy, psychological distress and self-management between patients with early- and end-stage chronic kidney disease. \u003cem\u003eJ. Clin. Nurs. [Internet]\u003c/em\u003e. \u003cb\u003e31\u003c/b\u003e (15\u0026ndash;16), 2287\u0026ndash;2295 (2022). [cited 2025 Jul 1];.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMolnar, A. O., Akbari, A. \u0026amp; Brimble, K. S. Perceived and Objective Kidney Disease Knowledge in Patients With Advanced CKD Followed in a Multidisciplinary CKD Clinic. \u003cem\u003eCan. J. Kidney Health Dis. [Internet]\u003c/em\u003e (2020). [cited 2025 Jul 1];7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchenkel, S. K. et al. Conceptualizations of cyberchondria and relations to the anxiety spectrum: Systematic review and meta-analysis. \u003cem\u003eJ. Med. Internet Res. [Internet]\u003c/em\u003e. \u003cb\u003e23\u003c/b\u003e (11), e27835 (2021). [cited 2025 Jul 2];.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNadeem, F. et al. Relationship between Health-Anxiety and Cyberchondria: Role of Metacognitive Beliefs. \u003cem\u003eJ. Clin. Med. 2022\u003c/em\u003e, \u003cb\u003e11\u003c/b\u003e, Page 2590 [Internet]. 2022 [cited 2025 Jul 2];11(9):2590 .\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShah, S. A. et al. Poor perception of chronic kidney diseases and its influencing factors among diabetics patients. Sci Rep [Internet]. [cited 2025 Jul 4];12(1):1\u0026ndash;13. (2022).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGemmell, L. A. et al. Gender and Racial Differences in Stress, Coping, and Health-Related Quality of Life in Chronic Kidney Disease. \u003cem\u003eJ. Pain Symptom Manage. [Internet]\u003c/em\u003e. \u003cb\u003e52\u003c/b\u003e (6), 806\u0026ndash;812 (2016). [cited 2025 Jul 2];.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMatthews, M. et al. Knowledge Requirements and Unmet Needs of Informal Caregivers of Patients with End-Stage Kidney Disease (ESKD) Receiving Haemodialysis: A Narrative Review. Healthcare (Switzerland) [Internet]. (2022). [cited 2025 Jul 4];\u003cb\u003e10\u003c/b\u003e(1):57 .\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGomis-Pomares, A., Lacomba-Trejo, L. \u0026amp; Villanueva, L. Using Avoidant Emotion-Focused Coping and being a Woman with Adverse Childhood Experiences as the Worst-Case Scenario for Internalising Problems. \u003cem\u003eJ. Child. Adolesc. Trauma. [Internet]\u003c/em\u003e. \u003cb\u003e18\u003c/b\u003e (2), 319\u0026ndash;329 (2025). [cited 2025 Jul 4];.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKalantar-Zadeh, K. et al. Patient-centred approaches for the management of unpleasant symptoms in kidney disease. \u003cem\u003eNat. Reviews Nephrol. 2022\u003c/em\u003e. \u003cb\u003e18\u003c/b\u003e (3), 185\u0026ndash;198 (2022). [cited 2025 Jul 4];:3 [Internet].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTorres, L. A. et al. Higher Perceived Stress as an Independent Predictor for Lower Use of Emotion-Focused Coping Strategies in Hypertensive Individuals. \u003cem\u003eFront. Psychol. [Internet]\u003c/em\u003e. \u003cb\u003e13\u003c/b\u003e, 872852 (2022). [cited 2025 Jul 4];.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eArenas, M. D. et al. Social determinants of health influencing the choice of dialysis modality in advanced chronic kidney disease: Need of an interdisciplinary approach. Nefrolog\u0026iacute;a (English Edition) [Internet]. (2024). [cited 2025 Jul 1];\u003cb\u003e44\u003c/b\u003e(4):560\u0026ndash;567 .\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNair, D. et al. Psychological Adaptation to Serious Illness: A Qualitative Study of Culturally Diverse Patients With Advanced Chronic Kidney Disease. J Pain Symptom Manage [Internet]. [cited 2025 Jul 1];61(1):32\u0026ndash;41.e2. (2021).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHu, N., Wang, A. \u0026amp; Chang, T. Social support mediates the relationship between illness perception and psychosocial adaptation among young and middle-aged kidney transplant recipients in China. \u003cem\u003eFront. Psychol.\u003c/em\u003e \u003cb\u003e14\u003c/b\u003e, 1062337 (2023).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePappas, I. O. \u0026amp; Woodside, A. G. Fuzzy-set Qualitative Comparative Analysis (fsQCA): Guidelines for research practice in Information Systems and marketing. \u003cem\u003eInt. J. Inf. Manage.\u003c/em\u003e \u003cb\u003e58\u003c/b\u003e, 102310 (2021).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNeyra, J. A. \u0026amp; Chawla, L. S. Acute Kidney Disease to Chronic Kidney Disease. \u003cem\u003eCrit. Care Clin. [Internet]\u003c/em\u003e. \u003cb\u003e37\u003c/b\u003e (2), 453\u0026ndash;474 (2021). [cited 2025 Jul 1];.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. \u003cem\u003eJ. Am. Med. Association (JAMA)\u003c/em\u003e. \u003cb\u003e310\u003c/b\u003e (20), 2191\u0026ndash;2194 (2013).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWeinman, J. et al. The illness perception questionnaire: A new method for assessing the cognitive representation of illness. \u003cem\u003ePsychol. Health\u003c/em\u003e. \u003cb\u003e11\u003c/b\u003e (3), 431\u0026ndash;445 (1996).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePacheco-Huergo, V. et al. Percepci\u0026oacute;n en enfermedades cr\u0026oacute;nicas: validaci\u0026oacute;n ling\u0026uuml;\u0026iacute;stica del Illness Perception Questionnaire Revised y del Brief Illness Perception Questionnaire para la poblaci\u0026oacute;n espa\u0026ntilde;ola. \u003cem\u003eAten Primaria [Internet]\u003c/em\u003e. \u003cb\u003e44\u003c/b\u003e (5), 280\u0026ndash;287 (2012). [cited 2025 Jul 1];.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eValero-Moreno, S. et al. Psychometric properties of the questionnaire on threat perception of chronic illnesses in pediatric patients. \u003cem\u003eRev. Lat Am. Enfermagem [Internet]\u003c/em\u003e (2020). [cited 2025 Jul 1];28.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eK\u0026ouml;rner, A. et al. Personality assessment with the NEO-Five-Factor Inventory: The 30-item-short-version (NEO-FFI-30). \u003cem\u003ePPmP Psychother. Psychosom. Medizinische Psychologie\u003c/em\u003e. \u003cb\u003e58\u003c/b\u003e (6), 238\u0026ndash;245 (2008).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCordero, A., Pamos, A. \u0026amp; Seisdedos, N. Inventario de personalidad NEO Revisado (NEO PI-R) e Inventario NEO Reducido de cinco factores (NEO-FFI). Madrid; (1999).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFumero, A. \u0026amp; De Miguel, A. Validaci\u0026oacute;n de la versi\u0026oacute;n espa\u0026ntilde;ola del NEO-FFI-30. An\u0026aacute;lisis y Modificaci\u0026oacute;n. \u003cem\u003ede Conducta\u003c/em\u003e ;\u003cb\u003e49\u003c/b\u003e(179). (2023).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCarver, C. S., Scheier, M. F. \u0026amp; Weintraub, J. K. Assessing coping strategies: A theoretically based approach. J Pers Soc Psychol [Internet]. [cited 2025 Jul 1];56(2):267\u0026ndash;283. (1989).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMor\u0026aacute;n, C., Aut\u0026oacute;noma, U. \u0026amp; Le\u0026oacute;n, N. COPE-28: A Psychometric Analysis of the Spanish Version of the Brief COPE. \u003cem\u003eUniversitas Physiol.\u003c/em\u003e \u003cb\u003e9\u003c/b\u003e (2), 1657\u0026ndash;9267 (2010).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRequena, G. C., Salamero, M. \u0026amp; Gil, F. Validaci\u0026oacute;n del cuestionario MOS-SSS de apoyo social en pacientes con c\u0026aacute;ncer. Med Clin (Barc) [Internet]. 2007 [cited 2025 Jul 1];128(18):687\u0026ndash;691.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSherbourne, C. D. \u0026amp; Stewart, A. L. The MOS social support survey. \u003cem\u003eSoc. Sci. Med.\u003c/em\u003e \u003cb\u003e32\u003c/b\u003e (6), 705\u0026ndash;714 (1991).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWright, J. A. et al. Development and results of a kidney disease knowledge survey given to patients with CKD. \u003cem\u003eAm. J. Kidney Dis. [Internet]\u003c/em\u003e. \u003cb\u003e57\u003c/b\u003e (3), 387\u0026ndash;395 (2011). [cited 2025 Jul 1];.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMota-Anaya, E. et al. Spanish version of the Kidney Disease Knowledge Survey (KiKS) in Peru: cross-cultural adaptation and validation. \u003cem\u003eMedwave\u003c/em\u003e \u003cb\u003e16\u003c/b\u003e (7), e6510 (2016).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZigmond, A. S. \u0026amp; Snaith, R. P. The Hospital Anxiety and Depression Scale. \u003cem\u003eActa Psychiatr Scand. [Internet]\u003c/em\u003e. \u003cb\u003e67\u003c/b\u003e (6), 361\u0026ndash;370 (1983). [cited 2025 Jul 1];.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDe Las, C. et al. \u003cem\u003eHosp. Anxiety Depress. Scale y Psicopatolog\u0026iacute;a Afectiva\u003c/em\u003e ;\u003cb\u003e11\u003c/b\u003e:126\u0026ndash;130. (1995).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLacomba-Trejo, L. et al. Enfermedad renal cr\u0026oacute;nica avanzada. Asociaci\u0026oacute;n entre ansiedad, depresi\u0026oacute;n y resiliencia. Revista Colombiana de Nefrolog\u0026iacute;a [Internet]. [cited 2025 Jul 1];6(2):103\u0026ndash;111. (2019).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eClaude, R. \u0026amp; Christopher, R. Acq [computer Programme] [Internet]. University of Houston-Downtown. 2014 [cited 2024 Dec 17]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://sites.socsci.uci.edu/~cragin/fsQCA/software.shtml\u003c/span\u003e\u003cspan address=\"https://sites.socsci.uci.edu/~cragin/fsQCA/software.shtml\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRagin, C. C. \u003cem\u003eRedesigning Social Inquiry. Fuzzy sets and beyond\u003c/em\u003e (University of Chicago Press, 2008).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChristiansen, J. et al. Loneliness, Social Isolation, and Chronic Disease Outcomes. \u003cem\u003eAnnals Behav. Med. [Internet]\u003c/em\u003e. \u003cb\u003e55\u003c/b\u003e (3), 203\u0026ndash;215 (2021). [cited 2025 Jul 4];.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVila, J. Social Support and Longevity: Meta-Analysis-Based Evidence and Psychobiological Mechanisms. Front Psychol [Internet]. [cited 2025 Jul 4];12:717164. (2021).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKneavel, M. Relationship Between Gender, Stress, and Quality of Social Support. Psychol Rep [Internet]. (2021). [cited 2025 Jul 2];\u003cb\u003e124\u003c/b\u003e(4):1481\u0026ndash;1501 .\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCer\u0026oacute;n-Erazo, M. L. \u0026amp; S\u0026aacute;nchez-Juan, C. Valoraci\u0026oacute;n de un programa de educaci\u0026oacute;n alimentaria en pacientes con insuficiencia renal cr\u0026oacute;nica en predi\u0026aacute;lisis. \u003cem\u003eRevista San Gregorio [Internet]\u003c/em\u003e 2019 [cited 2025 Jul 2];\u003cb\u003e1\u003c/b\u003e(33):77\u0026ndash;87 .\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRobazza, C. et al. Basic psychological needs satisfaction, coping functions, and emotional experiences in competitive athletes: a multi-states theory perspective. \u003cem\u003eSci. Rep. [Internet]\u003c/em\u003e. \u003cb\u003e15\u003c/b\u003e (1), 1854 (2025). [cited 2025 Jul 2];.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang, L., Zou, L. \u0026amp; Zhou, L. Effectiveness of psychoeducational interventions on psychological distress and health-related quality of life among patients with maintenance hemodialysis: a systematic review and meta-analysis. \u003cem\u003eRen. Fail. [Internet]\u003c/em\u003e. \u003cb\u003e46\u003c/b\u003e (1), 2331613 (2024). [cited 2025 Jul 2];.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Chronic Kidney Disease, Illness Perception, CKD stage, Coping Strategies, Health Knowledge, Neuroticism, Anxiety","lastPublishedDoi":"10.21203/rs.3.rs-7048081/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7048081/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePeople with advanced chronic kidney disease (ACKD) frequently experience psychological distress due to the progressive nature of the illness and the burden of long-term treatment. Illness perception plays a critical role in emotional adjustment and health behaviors, yet the psychosocial and clinical variables shaping these perceptions are not fully understood.\u003c/p\u003e\u003cp\u003eThis study aimed to identify combinations of psychological, behavioral, and clinical factors that predict how individuals with ACKD perceive their illness, using a Qualitative Comparative Analysis (QCA) approach. The sample included 69 participants with ACKD. Illness perception was assessed via the Brief Illness Perception Questionnaire (B-IPQ). Predictive conditions included: anxiety (HADS-A), coping styles (Brief COPE), kidney disease knowledge (KiKS), emotional social support (MOS-SSS), neuroticism (NEO-FFI), and CKD stage.\u003c/p\u003e\u003cp\u003eQCA results revealed multiple pathways to high illness threat perception. Configurations characterized by high anxiety, elevated neuroticism, and low active coping were consistently associated with negative illness representations. Conversely, combinations including greater disease knowledge and active coping predicted more adaptive perceptions.\u003c/p\u003e\u003cp\u003eThese findings underscore the relevance of addressing both emotional and cognitive variables when designing psychosocial interventions for people with ACKD, supporting a multidimensional approach to improving patient adjustment and health outcomes.\u003c/p\u003e","manuscriptTitle":"Towards Better Illness Perception in Advanced Chronic Kidney Disease: Clinical, Psychological and Cognitive Factors to Address","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-04 14:52:16","doi":"10.21203/rs.3.rs-7048081/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-19T12:21:14+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-18T18:25:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"286508682864282537042246409334496428041","date":"2025-08-12T07:33:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-05T06:11:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58331071383459310376260109384170148749","date":"2025-08-01T14:23:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"139912574221159012495455029830520913385","date":"2025-07-30T14:08:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-30T13:45:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-25T13:16:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-16T16:57:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-07-09T08:36:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7bd01133-178a-42d8-af77-251a0424e58f","owner":[],"postedDate":"August 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":52556278,"name":"Health sciences/Diseases"},{"id":52556279,"name":"Health sciences/Health care"},{"id":52556280,"name":"Biological sciences/Psychology"},{"id":52556281,"name":"Social science/Psychology"}],"tags":[],"updatedAt":"2025-10-20T16:06:16+00:00","versionOfRecord":{"articleIdentity":"rs-7048081","link":"https://doi.org/10.1038/s41598-025-19881-z","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-10-14 15:57:39","publishedOnDateReadable":"October 14th, 2025"},"versionCreatedAt":"2025-08-04 14:52:16","video":"","vorDoi":"10.1038/s41598-025-19881-z","vorDoiUrl":"https://doi.org/10.1038/s41598-025-19881-z","workflowStages":[]},"version":"v1","identity":"rs-7048081","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7048081","identity":"rs-7048081","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}