Spiritual Well-Being and Quality of Life in Maintenance Hemodialysis Patients: A Latent Profile Analysis and Serial Mediation Model

Spiritual Well-Being and Quality of Life in Maintenance Hemodialysis Patients: A Latent Profile Analysis and Serial Mediation Model | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Spiritual Well-Being and Quality of Life in Maintenance Hemodialysis Patients: A Latent Profile Analysis and Serial Mediation Model BiXia Yuan, QingHua Lai, Jing Wu, RongRong Wang, YongMei Lu, Meng Wu, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6726006/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Spiritual health and psychosocial factors are critical yet underexplored determinants of health-related quality of life (HRQoL) in patients undergoing maintenance hemodialysis (MHD). This study examines the heterogeneous patterns of spiritual health and its sequential mediating pathways (via family care and spiritual coping) in shaping HRQoL among MHD patients, addressing a gap in chronic disease management research. Methods A cross-sectional design was employed with 220 MHD patients recruited from two tertiary hospitals in Guangdong, China (August 2023–January 2024). Validated instruments—the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-SP-12), Family Care Index, Spiritual Coping Questionnaire (SCQ), and Short Form-12 (SF-12)—were administered. Latent profile analysis (LPA) categorized spiritual health subgroups, while chain mediation models (PROCESS macro, 5,000 bootstraps) tested hypothesized pathways. Results HRQoL scores averaged 56.50±22.29. Significant correlations emerged: spiritual health ( r =0.557, P <0.001), family care ( r =0.426, P <0.001), and positive spiritual coping (r =0.565, P <0.001) positively predicted HRQoL, whereas negative coping correlated inversely ( r =−0.343, P <0.001). LPA identified four distinct profiles: Low Spiritual Health (36.8%), Moderate Spiritual Health (20.0%), Peaceful Mindset with Low Belief (13.6%), and High Spiritual Health (29.5%). The mediation analysis revealed that family support and spiritual coping partially mediated the relationship between spiritual well-being and HRQoL (effect sizes: 0.074–0.175, 95% CI excluding 0). The chain mediation pathway "spiritual well-being → family support → spiritual coping → HRQoL" was statistically significant, with total indirect effects of 0.268 and 0.114 (95% CIs excluding 0). Conclusions This study highlights the cascading mechanism by which spiritual health enhances HRQoL through family support and adaptive coping strategies. The heterogeneity of spiritual health profiles underscores the need for tailored interventions, particularly for subgroups like Peaceful Mindset with Low Belief. Clinicians should integrate spiritual assessments and family-centered care into routine MHD management to optimize long-term outcomes. Maintenance hemodialysis Spiritual well-being Quality of life Latent profile analysis Psychosocial mediation Family support Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction The rising prevalence of diabetes and population aging has contributed to a rapid increase in the incidence of chronic kidney disease (CKD) globally. In China, the prevalence of CKD among adults is reported to be 8.2%, with a marked upward trend in older age groups [ 1 ]. End-stage renal disease (ESRD), the terminal phase of CKD progression, affects approximately 2% of CKD patients annually in China [ 2 ]. Maintenance hemodialysis (MHD) remains the most widely used renal replacement therapy, with 89.5% of ESRD patients in China undergoing MHD [ 3 ]. While advancements in medical care have improved the 5-year survival rate of MHD patients to 20–70% [ 4 ], long-term dialysis imposes significant burdens, including physical discomfort, complications, financial strain, and psychological distress, which severely compromise patients’ quality of life. A recent analysis of health-related quality of life (HRQoL) in Chinese MHD patients revealed suboptimal HRQoL levels [ 5 ]. Notably, studies such as that by Mantzouka et al. [ 6 ] have identified impaired HRQoL as a critical predictor of adverse clinical outcomes in MHD populations. These findings underscore the urgent need to investigate modifiable determinants of HRQoL in MHD patients, providing evidence-based insights for tailored interventions to optimize patient-centered care. Health-Related Quality of Life (HRQoL) refers to an individual’s perception of their position in life, influenced by cultural context, values, goals, expectations, and concerns, reflecting the impact of disease on health and daily living [ 7 ]. Impaired HRQoL is highly prevalent among dialysis patients, with MHD patients experiencing multidimensional has implications on physical, psychological, and social functioning [ 8 ]. Physical HRQoL decline manifests as functional limitations (e.g., restricted mobility), role constraints due to poor health, and sleep disturbances such as obstructive sleep apnea, restless legs syndrome, and fatigue. Psychological HRQoL impairment is characterized by depressive cognition, diminished positive affect, anxiety, and social isolation [ 9 ]. Notably, psychosocial and biological changes associated with dialysis treatment exacerbate the risk of depression in CKD patients, further deteriorating HRQoL [ 10 ]. Addressing psychological distress and enhancing HRQoL during MHD treatment is critical to promoting social reintegration and optimizing patient outcomes. Spiritual well-being is a state in which individuals affirm their life’s meaning, recognize their interconnectedness with others and the environment, and harness inner strength to transcend limitations [ 11 ]. As an internal adaptive resource, spirituality plays a vital role in helping patients cope with illness [ 12 ]. Patel et al. [ 13 ] demonstrated a significant association between spirituality and health outcomes, highlighting its positive influence on health perceptions and resilience in severe disease management. Patients with life-threatening conditions who exhibit higher spiritual well-being often report enhanced quality of life [ 14 ]. However, compared to the general population, MHD patients experience marked impairments in physical, social, and psychological well-being [ 15 ]. Fradelos et al. [ 16 ] further revealed that MHD patients generally exhibit lower levels of spiritual well-being, which significantly correlates with poorer quality of life. Despite growing evidence on factors influencing HRQoL in MHD patients, the pathways linking spiritual well-being to HRQoL remain poorly understood. Family care, a critical component of social support systems [ 17 ], provides both practical assistance and emotional sustenance to MHD patients, fostering health improvement and quality of life. Yet, limited studies have explored the interplay between spiritual well-being, family care, and HRQoL in this population. Existing literature suggests a positive correlation between spiritual well-being and family care [ 18 ], and studies in cardiac populations indicate that family care significantly enhances quality of life [ 19 ]. These findings underscore the need to investigate tailored interventions integrating spiritual and family-centered support for MHD patients. Spiritual well-being significantly influences the selection of spiritual coping strategies, which are cognitive-behavioral approaches through which patients utilize spiritual resources to manage illness-related stressors [ 20 ]. Spirituality, as an intrinsic resource, permeates all aspects of life and is accessible regardless of religious affiliation. Spiritual coping strategies generally fall into two categories: religious (e.g., prayer, rituals) and non-religious (e.g., connecting with family, nature, or personal values) [ 21 ]. Influenced by cultural traditions, Chinese MHD patients predominantly adopt non-religious coping strategies, emphasizing familial and social bonds. Grounded in Gall’s [ 22 ] framework of spiritual coping, this study conceptualizes spirituality as a dynamic process where individuals employ faith- and value-based resources—including spiritual appraisal, coping strategies, spiritual connections, and meaning-making—to achieve holistic well-being (physical, psychological, social, and spiritual). Guided by this framework, we position spiritual connection (operationalized as family care) and spiritual coping (positive and negative strategies) as mediators to explore the relationship between spiritual appraisal (spiritual well-being) and health outcomes (HRQoL). Additionally, latent profile analysis (LPA) is used to examine heterogeneity in spiritual well-being among MHD patients. This approach aims to inform tailored spiritual and quality-of-life interventions for clinical practice. We propose the following hypotheses:(see Fig. 1 for details) H1: Spiritual well-being, family care, spiritual coping, and HRQoL are significantly correlated. H2: Heterogeneity in spiritual well-being can be identified through latent profile analysis (LPA). H3: Spiritual well-being influences HRQoL through the mediating roles of family care and spiritual coping. H4: Family care and spiritual coping sequentially mediate the relationship between spiritual well-being and HRQoL (chain mediation). Methods Participants A convenience sampling method was used to recruit patients from the hemodialysis centers of two tertiary hospitals in Guangdong Province, China, between August 2023 and January 2024. Inclusion criteria: (1) age ≥18 years; (2) diagnosed with chronic renal failure according to clinical criteria; (3) receiving regular hemodialysis 2–3 times weekly for ≥3 months with stable condition; (4) ability to communicate and complete questionnaires independently; (5) voluntary participation. Exclusion criteria: (1) history of mental illness or intellectual disability; (2) acute critical comorbidities. A total of 228 questionnaires were distributed, with 220 valid responses retained (valid response rate: 96.5%). Data Collection Procedure This study was approved by the ethics committee of The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Grant number: YM2023-219). Two trained investigators administered the questionnaires using standardized instructions. Participants were informed of the study’s purpose, confidentiality, and their right to withdraw at any time. Questionnaires were completed independently by patients before dialysis sessions to avoid interference with treatment. For participants unable to self-complete, investigators verbally administered items and recorded responses. The survey process lasted 15–20 minutes, and questionnaires were reviewed immediately for completeness, with missing items addressed promptly. Measures Demographic and Clinical Characteristics Data included gender, age, religious affiliation, marital status, education level, employment status, household monthly income per capita, medical payment method, dialysis vintage, and number of chronic comorbidities. Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-SP-12) [ 23 ] The Chinese version of the FACIT-SP-12 was used to assess spiritual well-being. This 12-item scale comprises three dimensions ( peace , meaning , and faith ) rated on a 5-point Likert scale (0 = "not at all" to 4 = "very much"). Items 4 and 8 were reverse-scored. Total scores range from 0 to 48, categorized as low (0–23), moderate (24–35), or high (≥36) spiritual well-being. Cronbach’s α coefficient for this scale was 0.950 in the current study. Family Care Index The Family Care Index, originally developed by Smilkstein et al. and adapted into Chinese by Lü et al. [24], comprises five dimensions: family adaptation, partnership, growth, affection, and resolve. Each item is rated on a 3-point Likert scale (0 = "rarely," 2 = "often"), with total scores ranging from 0 to 10. Higher scores indicate better family functioning. In this study, the scale demonstrated excellent internal consistency (Cronbach’s α =0.873). Chinese Version of the Spiritual Coping Questionnaire (SCQ) The SCQ, developed by Charzynska et al. [25] based on a multidimensional conceptualization of spirituality, was translated into Chinese to assess both religious and non-religious spiritual coping strategies. It includes two subscales: positive spiritual coping (personal, social, environmental, and transcendental dimensions) and negative spiritual coping (personal, social, and transcendental dimensions), totaling 26 items across seven dimensions. Items are rated on a 5-point Likert scale (1 = "very inaccurate" to 5 = "very accurate"). Subscale scores are calculated as the mean of item responses, with higher scores indicating greater reliance on specific coping strategies. Internal consistency was high for both subscales (positive coping: α =0.884; negative coping: α =0.908). Short Form-12 Health Survey (SF-12) The SF-12, derived from the SF-36 by Ware et al. [26], assesses HRQoL across eight domains grouped into two summary scores: Physical Component Summary (PCS; includes general health [GH], physical functioning [PF], role limitations due to physical health [RP], and bodily pain [BP]) and Mental Component Summary (MCS; includes role limitations due to emotional problems [RE], mental health [MH], vitality [VT], and social functioning [SF]). The total score is standardized to a 0–100 scale, with higher scores reflecting better quality of life. The scale showed strong reliability in this study (Cronbach’s α =0.913). Statistical Analysis All statistical analyses were performed using IBM SPSS 25.0, the SPSS PROCESS macro v4.1, and Mplus 8.3. First, demographic and clinical variables were described using means ± standard deviations (SD) or frequencies (percentages). Pearson correlation analysis was conducted to examine associations among spiritual well-being, family care, spiritual coping, and HRQoL. Subsequently, latent profile analysis (LPA) was employed to identify subgroups of spiritual well-being. Model fit indices included the Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC), sample-size-adjusted BIC (aBIC), entropy, Lo-Mendell-Rubin likelihood ratio test (LMR-LRT), and bootstrap likelihood ratio test (BLRT). Lower values of AIC, BIC, and aBIC indicated better model fit, while entropy ≥0.8 suggested classification accuracy >90%. A significant P -value (<0.05) for LMR-LRT or BLRT indicated adequate model fit. Finally, mediation effects of family care and spiritual coping between spiritual well-being (categorical latent classes) and HRQoL were tested using Model 4 of the PROCESS macro. Chain mediation pathways (spiritual well-being → family care → spiritual coping → HRQoL) were examined using Model 6. Bias-corrected percentile bootstrap methods (5,000 resamples, 95% confidence interval [CI]) were applied to assess total, direct, and indirect effects. Mediation effects were considered statistically significant if the 95% CI excluded zero [27]. Results Descriptive Statistics Among the 220 MHD patients (130 males, 90 females), the majority were aged ≤ 60 years (109, 49.5%), had no religious affiliation (180, 81.8%), were married (172, 78.2%), had a middle school education (75, 34.0%), and were unemployed (169, 76.8%). Most patients had medical insurance (214, 97.3%), a household monthly income > 5,000 CNY (86, 39.1%), a dialysis duration of 12–60 months (97, 44.1%), and 3–4 chronic comorbidities (114, 51.8%). The mean HRQoL score was 56.50 ± 22.29. Significant differences in HRQoL were observed across age ( P = 0.004), religious status ( P = 0.003), education level ( P = 0.013), employment status ( P = 0.005), and number of comorbidities ( P = 0.003) (see Table 1 ). Table 1 Demographic and Clinical Characteristics of MHD Patients (N = 220) Variable n (%) HRQoL(Mean ± SD) t/F P Gender 1.02 0.309 Male 130(59.1) 57.77 ± 21.63 Female 90(40.9) 54.66 ± 23.21 Age (years) 5.81 0.004 45 42(19.1) 62.01 ± 18.73 45 ~ 60 79(35.9) 60.47 ± 20.79 >60 99(45.0) 50.99 ± 23.73 Religious Affiliation 3.02 0.003 Yes 40(18.2) 65.96 ± 19.94 No 180(81.8) 54.40 ± 22.29 Marital Status 2.04 0.133 Unmarried 19(8.6) 63.51 ± 19.26 Married 172(78.2) 56.75 ± 22.18 Divorced/Widowed 29(13.2) 50.44 ± 23.88 Education Level 3.23 0.013 Primary school or below 55(25.0) 50.21 ± 22.18 Middle school 75(34.1) 54.62 ± 20.10 High school/Technical 50(22.7) 59.38 ± 23.77 College 19(8.6) 61.88 ± 21.87 Bachelor’s or above 21(9.5) 67.95 ± 22.25 Employment Status 2.84 0.005 Employed 51 64.13 ± 19.40 Unemployed 169 54.20 ± 22.64 Household Income (CNY) 1.30 0.277 5000 86(39.1) 58.58 ± 21.67 Medical Payment 1.13 0.34 Medical Insurance 178(80.9) 57.33 ± 22.03 New Rural Cooperative 27(12.3) 51.59 ± 20.64 Public Funding 9(4.1) 61.68 ± 30.07 Self-payment 6(2.7) 46.03 ± 24.26 Dialysis Vintage 1.14 0.332 10 years 18(8.2) 57.47 ± 26.81 Chronic Comorbidities 5.99 0.003 4 16(7.3) 51.22 ± 22.49 Common Method Bias Test As self-administered questionnaires may introduce common method bias, Harman’s single-factor test [ 28 ] was conducted to assess potential bias. Exploratory factor analysis (EFA) of all study variables revealed 12 factors with eigenvalues > 1. The first factor accounted for 32.65% of the variance (below the 40% threshold), indicating no significant common method bias or multicollinearity. Multivariate Linear Regression Analysis of Factors Influencing HRQoL in MHD Patients This study explored the determinants of health-related quality of life (HRQoL) in maintenance hemodialysis (MHD) patients through hierarchical multivariate linear regression analysis (see Table 2 ). After sequentially incorporating demographic characteristics, spiritual well-being, family support, and spiritual coping strategies into the models, the adjusted R ² increased significantly from 0.11 (Model 1) to 0.42 (Model 4). The results identified spiritual well-being ( β = 0.51, p < 0.01) as the strongest predictor of HRQoL, with its effects partially mediated through family support ( β = 0.30, p < 0.01) and positive spiritual coping strategies ( β = 0.28, p < 0.01). In contrast, age ( β = -0.10, p < 0.01) and number of chronic comorbidities ( β = -0.15, p 0.05). These findings suggest that interventions aimed at enhancing spiritual well-being, strengthening family support systems, and fostering adaptive coping strategies may improve long-term quality of life in MHD patients. Table 2 Multivariate linear regression analysis of factors influencing HRQoL in MHD patients ( n = 220) Model Variable β SE Standardized β F R² Model 1 Age -2.8 2.15 -0.10 6.52** 0.11 Religious affiliation 10.18** 3.69 0.18 Education level 2.79* 1.31 0.15 Employment status 2.44 3.90 0.05 Number of comorbidities -5.45* 2.42 -0.15 Model 2 Age -0.17 1.94 -0.01 16.55** 0.30 Religious affiliation 2.05 3.45 0.04 Education level 0.61 1.20 0.03 Employment status 0.50 3.47 0.01 Number of comorbidities -2.68 2.18 -0.07 Spiritual well-being 0.93** 0.12 0.51 Model 3 Age -2.08 1.88 -0.07 19.25** 0.37 Religious affiliation 4.07 3.30 0.07 Education level 0.12 1.14 0.01 Employment status 0.85 3.29 0.02 Number of comorbidities -3.70 2.08 -0.10 Spiritual well-being 0.68** 0.13 0.37 Family care 2.49** 0.50 0.30 Model 4 Age -2.151 1.83 -0.07 18.29** 0.42 Religious affiliation 2.547 3.23 0.04 Education level 0.343 1.11 0.02 Employment status 1.354 3.17 0.03 Number of comorbidities -3.744 2.03 -0.10 Spiritual well-being 0.33** 0.15 0.18 Family care 1.72** 0.52 0.20 Positive spiritual coping 0.47** 0.13 0.28 Negative spiritual coping -0.37 0.20 -0.11 * P <0.05, ** P <0.01 Latent Profile Analysis of Spiritual Well-Being in MHD Patients As shown in Table 2 , implementing latent profile modeling using MHD patients' dimensional scores of peace, meaning, and faith from spiritual well-being assessments as manifest observed variables, the entropy values for 1–5 latent profile models were all above 0.80. With an increasing number of classes, the AIC, BIC, and adjusted BIC (aBIC) gradually decreased, indicating better model fit for higher class numbers. The Lo-Mendell-Rubin adjusted likelihood ratio test (LMR) suggested that the 4-profile model provided a significantly better fit than the 3-profile model ( P 0.05). Based on model fit indices and practical interpretability, the 4-profile model was selected as optimal. The four latent classes C1 ~ C4 are named as: Low Spiritual Health (36.8%), Moderate Spiritual Health (20.0%), Peaceful Mindset with Low Belief (13.6%), and High Spiritual Health (29.5%), (see Fig. 2 for details). Table 3 Fit indices of latent profile models for spiritual well-being in MHD patients (n = 220) Model 1 2 3 4 5 6 LL -1936.717 -1785.774 -1750.936 -1724.862 -1709.438 -1701.974 AIC 3885.433 3591.548 3529.871 3485.724 3462.876 3455.948 BIC 3905.795 3625.484 3577.382 3546.81 3537.536 3544.182 aBIC 3886.781 3593.794 3533.016 3489.768 3467.818 3461.788 Entropy — 0.884 0.816 0.849 0.827 0.844 LMR(P) — <0.0001 0.0428 0.0057 0.1869 0.3938 BLRT(P) — <0.001 <0.001 <0.001 <0.001 0.0500 Group sizes(%) C1 220(100%) 115(52.3%) 84(38.2%) 81(36.8%) 46(20.9%) 62(28.2%) C2 — 105(47.7%) 73(33.2%) 44(20.0%) 70(31.8%) 52(23.6%) C3 — — 63(28.6%) 30(13.6%) 36(16.4%) 24(10.9%) C4 — — — 65(29.5%) 30(13.6%) 26(11.8%) C5 — — — — 38(17.3%) 21(9.5%) C6 — — — — — 35(15.9%) Validation of the Mediation Models Involving Family Support and Spiritual Coping The results revealed significant correlations among quality of life, spiritual well-being, family support, positive spiritual coping, and negative spiritual coping ( P < 0.01 for all). Detailed Analysis of Table 4 . Using the low spiritual well-being group (as a reference category in the latent profile analysis of spiritual health), Detailed Analysis of Table 5 , the mediation effects of family support were estimated as 0.122, 0.217, and 0.227. The 95% Bootstrap confidence intervals were (0.258, 0.873), (0.170, 0.885), and (0.732, 1.301), which did not contain “0”, demonstrating a significant mediating effect. Similarly, the mediation effects of spiritual coping were 0.186, 0.0895, and 0.248. The 95% Bootstrap confidence intervals were (0.026, 0.330), (0.009, 0.186), and(0.035, 0.439), which did not contain “0”, demonstrating a significant mediating effect. Detailed pathways are illustrated in Fig. 3 . Table 4 Correlation analysis among spiritual well-being, family support, spiritual coping, and health-related quality of life (HR-QOL) in MHD patients (n = 220) Variable Correlation Mean SD 1 2 3 4 5 6 1. HRQoL 56.5 22.29 1 2. Spiritual Well-Being 21.77 12.2 0.557** 1 3. Family Support 7.63 2.65 0.426** 0.360** 1 4. Spiritual Coping 72.51 13.14 0.403** 0.552** 0.209** 1 5. Positive Spiritual Coping 55.8 13.43 0.565** 0.685** 0.408** 0.874** 1 6. Negative Spiritual Coping 16.72 6.68 -0.343** -0.292** -0.408** 0.210** -0.292** 1 ** P <0.01 Table 5 Mediation effects of spiritual well-being latent classes (categorical variable) on health-related quality of life (HRQoL) Mediation Pathway Effect(95%CI)1VS.2 Effect(95%CI)1VS.3 Effect(95%CI)1VS.4 Model 1 Direct effect: Spiritual well-being →HRQoL 0.566(0.258,0.873) 0.528(0.170,0.885) 1.016(0.732,1.301) Indirect effect: Spiritual well-being → Family support →HRQoL 0.122(0.019,0.250) 0.217(0.087,0.369) 0.227(0.111,0.371) Model 2 Direct effect: Spiritual well-being →HRQoL 0.501(0.158,0.845) 0.655(0.290,1.021) 0.995(0.662,1.329) Indirect effect: Spiritual well-being → Spiritual coping →HRQoL 0.186(0.026,0.330) 0.0895(0.009,0.186) 0.248(0.035,0.439) Chain Mediation Effect Analysis Two chain mediation models were constructed with spiritual well-being (continuous variable) as the independent variable, family support and positive/negative spiritual coping as mediators, and quality of life as the dependent variable, as illustrated in Figs. 3 and 4 . The bias-corrected percentile bootstrap method (5,000 resamples) was used to validate the chain mediation effects of family support and spiritual coping on spiritual well-being and quality of life, with 95% confidence intervals (CIs). The results, detailed in Table 3 , demonstrated that the total, direct, and indirect effects of spiritual well-being on quality of life were all statistically significant (95% CIs excluded zero). Specifically, spiritual well-being indirectly influenced quality of life through family support (effect sizes: 0.074 and 0.077; 95% CIs: [0.032, 0.126] and [0.031, 0.132]) and through spiritual coping (effect sizes: 0.175 and 0.021; 95% CIs: [0.074, 0.264] and [0.001, 0.051]). Furthermore, the chain mediation pathway via both family support and spiritual coping significantly impacted quality of life (effect sizes: 0.019 and 0.016; 95% CIs: [0.004, 0.040] and [0.001, 0.051]). Comprehensive results are provided in Table 6 . Table 6 Chain Mediation Effects of Family Support and Spiritual Coping on Spiritual Well-Being and Health-Related Quality of Life (HRQoL) Path Effect SE LLCI ULCI Model 1 Total Effect 0.557 0.056 0.446 0.668 Direct Effect 0.289 0.072 0.146 0.432 Ind1: Spiritual Well-Being → Family Support → HRQoL 0.074 0.024 0.032 0.126 Ind2: Spiritual Well-Being → Positive Spiritual Coping →HRQoL 0.175 0.048 0.074 0.264 Ind3: Spiritual Well-Being → Family Support → Positive Spiritual Coping →HRQoL 0.019 0.009 0.004 0.040 Total Indirect Effect 0.268 0.053 0.155 0.366 Model 2 Total Effect 0.557 0.056 0.446 0.668 Direct Effect 0.443 0.058 0.328 0.558 Ind1: Spiritual Well-Being → Family Support →HRQoL 0.077 0.026 0.031 0.132 Ind2: Spiritual Well-Being → Negative Spiritual Coping →HRQoL 0.021 0.013 0.001 0.051 Ind3: Spiritual Well-Being → Family Support → Negative Spiritual Coping →HRQoL 0.016 0.008 0.002 0.033 Total Indirect Effect 0.114 0.029 0.063 0.174 Discussion Spirituality, as a critical component of holistic health, has been recognized as a universal trait through which individuals seek meaning in life and has been consistently linked to improved quality of life [ 29 ]. In this study, we identified heterogeneity in spiritual well-being among MHD patients, with spiritual well-being directly influencing health-related quality of life (HRQoL). Family support and spiritual coping strategies partially mediated this relationship. Furthermore, the established chain mediation models demonstrated that family support and spiritual coping sequentially mediate the pathway between spiritual well-being and HRQoL. Correlations Among Spiritual Well-Being, Family Support, Spiritual Coping, and HRQoL in MHD Patients The findings revealed a positive correlation between spiritual well-being and HRQoL in MHD patients, suggesting that inner peace, a sense of purpose, and spiritual beliefs contribute to better health outcomes [ 30 ]. Family support, a key element of social support systems, not only directly enhanced HRQoL but also partially mediated the relationship between spiritual well-being and HRQoL, underscoring its role in fostering adaptive spiritual health and coping strategies [ 31 ]. Higher levels of family support provided patients with greater resources to mitigate disease-related distress, promote positive health behaviors, and reframe their perspectives on illness, thereby improving quality of life [ 32 ]. Spiritual coping influenced HRQoL through dual pathways of psychological adaptation and behavioral modification [ 33 ]. Specifically, positive spiritual coping strengthened adaptive behaviors to enhance HRQoL, whereas negative spiritual coping exacerbated feelings of helplessness, further deteriorating HRQoL. Latent Class Analysis of Spiritual Well-Being in MHD Patients Previous studies have predominantly assessed spiritual well-being using total scores, neglecting population heterogeneity [ 34 ]. This study employed latent profile analysis (LPA) to classify MHD patients into four distinct spiritual well-being profiles: low spiritual well-being (36.8%), moderate spiritual well-being (20.0%), peaceful mindset-low spiritual belief (13.6%), and high spiritual well-being (29.5%). Notably, over 50% of patients fell into the low or moderate spiritual well-being categories. The peaceful mindset-low spiritual belief group exhibited high scores in inner peace but low scores in spiritual conviction, indicating that some patients maintain emotional calmness yet lack spiritual beliefs or faith-based support. This phenomenon may relate to the relatively low prevalence of religious affiliation in China. However, spirituality is culturally specific, and religion represents only one facet of spiritual resources [ 35 ]. Traditional Chinese philosophies, such as Confucianism and Taoism, can serve as intrinsic spiritual resources, providing psychological resilience and support [ 36 ]. Clinicians should tailor spiritual care interventions to patients’ latent class characteristics and cultural contexts to enhance spiritual well-being. Mediating Roles of Family Support and Spiritual Coping Family support mediated the relationship between spiritual well-being and HRQoL, indicating that spiritual well-being indirectly improves quality of life through enhanced family support. Family functioning—defined as the capacity to provide emotional, practical, and financial support—strengthens individual and collective resilience to life stressors, playing a pivotal role in health outcomes [ 37 ]. MHD imposes significant lifestyle disruptions, including dietary restrictions and occupational limitations. Family support acts as a protective factor, offering critical assistance and emotional reinforcement to help patients adapt to new routines, alleviate stress, and foster proactive disease management [ 38 ]. The findings further revealed that spiritual well-being influenced HRQoL through positive spiritual coping (e.g., seeking meaning, social connectedness), with higher spiritual well-being associated with greater use of adaptive coping strategies. Conversely, negative spiritual coping (e.g., spiritual discontent, passive resignation) mediated the detrimental effects of low spiritual well-being on HRQoL. Spiritual well-being serves as an internal resource for stress management; individuals with lower spiritual well-being possess fewer coping resources, perceive higher stress levels, and are more prone to maladaptive coping [ 39 ]. Chain Mediation Effects of Family Support and Spiritual Coping Between Spiritual Well-Being and Quality of Life in MHD Patients The findings of this study demonstrate that spiritual well-being influences quality of life through a chain mediation pathway involving family support and spiritual coping. This aligns with the spiritual coping process model , which posits that individuals under stress navigate challenges through sequential mechanisms of spiritual appraisal, spiritual connection, and spiritual coping, ultimately manifesting in psychophysiological outcomes. For MHD patients, spiritual well-being reflects their cognitive appraisal of spirituality, family support represents an external spiritual connection, and spiritual coping signifies their adaptive or maladaptive strategies. These factors collectively determine stress-related health outcomes, such as HRQoL. Notably, individuals with low spiritual well-being struggle to mobilize internal coping resources, leading to biased cognitive processing of emotional stimuli and heightened vulnerability to negative affective states, thereby exacerbating poor mental health outcomes [ 40 ]. In contrast, family support serves as a critical protective factor for psychological well-being. Enhancing family support mitigates negative emotions and improves HRQoL by fostering resilience and adaptive coping. Evidence further suggests that higher spiritual well-being predicts better prognoses and quality of life in chronic disease populations [ 41 ]. Limitations This study has several limitations. First, the sample comprised only Chinese MHD patients, and the findings may not generalize to other populations due to cultural and healthcare system differences. Second, the cross-sectional design precludes causal inferences; future research should adopt longitudinal designs to establish temporal relationships. Third, data were collected from two tertiary hospitals in China via convenience sampling, which may introduce selection bias and limit external validity. Fourth, self-report questionnaires were used to measure spiritual well-being, family support, spiritual coping, and HRQoL, potentially inflating results due to social desirability bias or subjective interpretation. Finally, while focusing on spirituality-related factors, this study did not account for other potential determinants of HRQoL (e.g., socioeconomic status, psychological comorbidities), which should be explored in future work. Declarations Acknowledgements The authors are grateful to all the participants in the study. Author contributions BiXia Yuan 1245, QingHua Lai 1235, Jing Wu 123, RongRong Wang 156, YongMei Lu 156, Meng Wu 156, Yun Chen 156, JieQian Wu 156. 1 Conceptualization; 2 Methodology; 3 Data curation; 4 Writing Original Draft; 5 Writing - Review & Editing; 6 Funding acquisition. Funding Not applicable. Data availability Due to the privacy of the research participants, the data generated during the current study are not publicly available but are available from the corresponding author upon reasonable request. Ethics approval and consent to participate This study was approved by the ethics committee of The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Grant number: YM2023-219). And informed consent was obtained from the participants and their guardians before starting the program. We confirm that all the experiment is in accordance with the relevant guidelines and regulations such as the declaration of Helsinki. Consent for publication Not applicable. Clinical trial number Not applicable. Competing interests The authors declare no competing interests. References Zhao ZP, Wang LM. [Challenges and suggestions for the prevention and control of chronic kidney disease in China]. Zhonghua Liu Xing Bing Xue Za Zhi. 2025;46:9–17. Zhang L, Zhao M-H, Zuo L, Wang Y, Yu F, Zhang H, et al. China Kidney Disease Network (CK-NET) 2016 Annual Data Report. Kidney Int Suppl (2011). 2020;10:e97–185. Zhang Q, Cao H. 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Wang A, Wu C, Tang D, Zhao J, Yang S, Fang HQ, et al. Associations among health-related quality of life, mental resilience and social support in patients early after surgery for osteoporotic vertebral compression fractures: a longitudinal study. BMJ Open. 2025;15:e084781. Zhi M, Zeng Y, Chen C, Deng S, Liu Y, Huang Y, et al. The relationship between intradialytic hypotension and health-related quality of life in patients undergoing hemodialysis: a cross-sectional study. Sci Rep. 2025;15:11532. Lopes MB, Karaboyas A, Sukul N, Tsuruya K, Al Salmi I, Asgari E, et al. Utility of a Single Itch-Related Question and the Skindex-10 Questionnaire for Assessing Pruritus and Predicting Health-Related Quality of Life in Patients Receiving Hemodialysis. Kidney Med. 2022;4:100476. Pretto CR, Winkelmann ER, Hildebrandt LM, Barbosa DA, Colet C de F, Stumm EMF. Quality of life of chronic kidney patients on hemodialysis and related factors. Rev Lat Am Enfermagem. 2020;28:e3327. Xiao Q, Xu Y, Hu X. Confirmation and Validation of a Chinese version of the Equanimity Scale. Mindfulness. 2025;16:289–99. Gholami M, Tafazoli M, Mohebbi-Dehnavi Z, Kamali Z. Effect of spiritual care education on the spiritual health of preeclamptic women with postpartum stress disorder. Journal of Education and Health Promotion. 2021;10:443. Patel SS, Shah VS, Peterson RA, Kimmel PL. Psychosocial variables, quality of life, and religious beliefs in ESRD patients treated with hemodialysis. Am J Kidney Dis. 2002;40:1013–22. Wachelder EM, Moulaert VRMP, van Heugten C, Gorgels T, Wade DT, Verbunt JA. Dealing with a life changing event: The influence of spirituality and coping style on quality of life after survival of a cardiac arrest or myocardial infarction. Resuscitation. 2016;109:81–6. Joshi U, Subedi R, Poudel P, Ghimire PR, Panta S, Sigdel MR. Assessment of quality of life in patients undergoing hemodialysis using WHOQOL-BREF questionnaire: a multicenter study. 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[In Chinese] Liu X, Chen FY, Guo W, Zhang Y, Cui J. A qualitative study on spiritual coping experiences of advanced cancer patients and family caregivers from a dyadic perspective. Journal of Nursing Science. 2023;38:91–5, 104. [In Chinese] Saffari M, Chen H. Mediating effect of spiritual coping strategies on caregiving burden and mental health in caregivers of Iranian patients with dementia. Asian Journal of Social Health and Behavior. 2019;2:117–26. Gall, Terry, Lynn, Charbonneau, Claire, Clarke, et al. Understanding the Nature and Role of Spirituality in Relation to Coping and Health: A Conceptual Framework. Canadian Psychology. 2005. Bredle JM, Salsman JM, Debb SM, Arnold BJ, Cella D. Spiritual Well-Being as a Component of Health-Related Quality of Life: The Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being Scale (FACIT-Sp). Religions. 2011;2:77–94. Lv F, Gu Y. The Family APGAR Questionnaire and its clinical applications. Foreign Medical Sciences (Hospital Management Edition) . 1995. [In Chinese] Charzyńska E. Multidimensional Approach Toward Spiritual Coping: Construction and Validation of the Spiritual Coping Questionnaire (SCQ). J Relig Health. 2015;54:1629–46. Ware J, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34:220–33. Berkovits I, Hancock GR, Nevitt J. Bootstrap Resampling Approaches for Repeated Measure Designs: Relative Robustness to Sphericity and Normality Violations. Educational and Psychological Measurement. 2000;60:877–92. Tang DD, Wen ZL. Common method bias testing: Issues and recommendations. Psychological Science . 2020;43:215–23. [In Chinese] Nair T, Kumar GP. Correlation Between Spirituality and Quality of Life in People With Musculoskeletal Disorders: A Cross-Sectional Study. Cureus. 2025. https://doi.org/10.7759/cureus.80055. Batra M, Gallagher C, Yuen E, White VM, Erbas B, Wilson C. Comparing spiritual wellbeing and illness perceptions between cancer patients from culturally and linguistically diverse and those from mainstream backgrounds in Australia. Support Care Cancer. 2024;32:823. Zhou J-J, Zhang Y, Ren Q-Z, Li T, Lin G-D, Liao M-Y, et al. Mediating effects of meaning in life on the relationship between family care, depression, and quality of life in Chinese older adults. Front Public Health. 2023;11:1079593. Iida H, Hayashi S, Yasunaka M, Tsugihashi Y, Hirose M, Shirahige Y, et al. Patient-centred care and quality of life and hope among Japanese patients receiving home medical care: a multicentre, cross-sectional study. BMJ Open. 2025;15:e089639. Bonilla Sierra P, Pérez-Jiménez JM, Espinoza Quezada DP, Lucchetti G, De-Diego-Cordero R. Association between religious/spiritual coping and quality of life among hemodialysis patients in Ecuador. Front Public Health. 2025;13:1510329. Babamohamadi H, Kadkhodaei-Elyaderani H, Ebrahimian A, Ghorbani R. The Effect of Spiritual Care Based on the Sound Heart Model on the Spiritual Health of Patients with Acute Myocardial Infarction. J Relig Health. 2020;59:2638–53. Xu SL, Yuan ZM, Cheng XM, Xu Y, Li X. Revision of the Chinese version of the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale and its application in maintenance hemodialysis patients. Nursing Research. 2023;37:2001–5. [In Chinese] Wang K. On Wu Jingxiong’s integration of Confucianism, Buddhism, Taoism, and Christianity. Religious Studies. 2024;[Volume]:173–9. [In Chinese] Gallardo-Peralta LP, Sanchez-Moreno E, Herrera S. Aging and Family Relationships among Aymara, Mapuche and Non-Indigenous People: Exploring How Social Support, Family Functioning, and Self-Perceived Health Are Related to Quality of Life. Int J Environ Res Public Health. 2022;19:9247. Mohammadi R, Varjoshani NJ, Bousari MP, Ghahremani Z. The Association of Family Function with Anxiety and Depression among Patients Undergoing Hemodialysis: a Cross-Sectional Study in Iran. Maedica. 2024;19. Xia S. The Effects of Cognitive Behavioral Stress Management on Loneliness, Spiritual Well-Being, Anxiety, and Depression in Patients with Unresectable Advanced Gastric Carcinoma: A Randomized, Controlled Study. Tohoku J Exp Med. 2025. https://doi.org/10.1620/tjem.2025.J025. Hu X, Gao J, Liang S, Yue Z, Zheng R. Status and influential factors of spiritual well-being in cancer patients with drug clinical trials: a cross-sectional study. Support Care Cancer. 2023;31:646. Agglopoulou O, Gkrinia E, Bizaki-Vallaskangas A, Hajiioannou J, Bizakis I. Quality of Life in Patients With Well-Differentiated Thyroid Carcinoma After Total Thyroidectomy in Greece. Cureus. 2024;16:e53304. 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-6726006","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":489569448,"identity":"3b7a12b7-61e3-4040-9d7e-be88a13402f2","order_by":0,"name":"BiXia Yuan","email":"","orcid":"","institution":"Shenzhen Hospital (Fu Tian) of Guangzhou University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"BiXia","middleName":"","lastName":"Yuan","suffix":""},{"id":489569450,"identity":"895871ac-b6a7-4b76-9732-a28132b406b0","order_by":1,"name":"QingHua Lai","email":"","orcid":"","institution":"Shenzhen Hospital (Fu Tian) 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10:24:18","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":22179,"visible":true,"origin":"","legend":"\u003cp\u003eThe conceptual model\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6726006/v1/cce03445770658e027882359.jpg"},{"id":87724499,"identity":"f5af7416-6c22-4687-a0ab-ab7a9ad86677","added_by":"auto","created_at":"2025-07-28 10:24:21","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":42888,"visible":true,"origin":"","legend":"\u003cp\u003eScore Probabilities of Four Latent Profiles of Spiritual Well-Being in Maintenance Hemodialysis (MHD) Patients\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6726006/v1/fb579089ff212be235cf1c38.jpg"},{"id":87724459,"identity":"f5a811d6-eb07-44d5-a221-b1089029affc","added_by":"auto","created_at":"2025-07-28 10:24:18","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":33820,"visible":true,"origin":"","legend":"\u003cp\u003eChain Mediation Effect of Family Support and Positive Spiritual Coping on Health-Related Quality of Life (HRQoL)\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6726006/v1/f46ed751ca2a6a2b54cce7c3.jpg"},{"id":87724920,"identity":"c25a54c4-e09a-4748-9d98-aa6bafbe10d5","added_by":"auto","created_at":"2025-07-28 10:32:19","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":32403,"visible":true,"origin":"","legend":"\u003cp\u003eChain Mediation Effect of Family Support and Negative Spiritual Coping on Health-Related Quality of Life (HRQoL)\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6726006/v1/f7e3818b107cbe66c5b2fa4b.jpg"},{"id":100237222,"identity":"c0f04572-529e-41ea-adb6-f55435d22d36","added_by":"auto","created_at":"2026-01-14 12:41:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1612521,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6726006/v1/5089687e-7675-40e8-b841-150294b3def4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eSpiritual Well-Being and Quality of Life in Maintenance Hemodialysis Patients: A Latent Profile Analysis and Serial Mediation Model\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe rising prevalence of diabetes and population aging has contributed to a rapid increase in the incidence of chronic kidney disease (CKD) globally. In China, the prevalence of CKD among adults is reported to be 8.2%, with a marked upward trend in older age groups [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. End-stage renal disease (ESRD), the terminal phase of CKD progression, affects approximately 2% of CKD patients annually in China [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Maintenance hemodialysis (MHD) remains the most widely used renal replacement therapy, with 89.5% of ESRD patients in China undergoing MHD [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. While advancements in medical care have improved the 5-year survival rate of MHD patients to 20\u0026ndash;70% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], long-term dialysis imposes significant burdens, including physical discomfort, complications, financial strain, and psychological distress, which severely compromise patients\u0026rsquo; quality of life. A recent analysis of health-related quality of life (HRQoL) in Chinese MHD patients revealed suboptimal HRQoL levels [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Notably, studies such as that by Mantzouka et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] have identified impaired HRQoL as a critical predictor of adverse clinical outcomes in MHD populations. These findings underscore the urgent need to investigate modifiable determinants of HRQoL in MHD patients, providing evidence-based insights for tailored interventions to optimize patient-centered care.\u003c/p\u003e\u003cp\u003eHealth-Related Quality of Life (HRQoL) refers to an individual\u0026rsquo;s perception of their position in life, influenced by cultural context, values, goals, expectations, and concerns, reflecting the impact of disease on health and daily living [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Impaired HRQoL is highly prevalent among dialysis patients, with MHD patients experiencing multidimensional has implications on physical, psychological, and social functioning [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Physical HRQoL decline manifests as functional limitations (e.g., restricted mobility), role constraints due to poor health, and sleep disturbances such as obstructive sleep apnea, restless legs syndrome, and fatigue. Psychological HRQoL impairment is characterized by depressive cognition, diminished positive affect, anxiety, and social isolation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Notably, psychosocial and biological changes associated with dialysis treatment exacerbate the risk of depression in CKD patients, further deteriorating HRQoL [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Addressing psychological distress and enhancing HRQoL during MHD treatment is critical to promoting social reintegration and optimizing patient outcomes.\u003c/p\u003e\u003cp\u003eSpiritual well-being is a state in which individuals affirm their life\u0026rsquo;s meaning, recognize their interconnectedness with others and the environment, and harness inner strength to transcend limitations [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. As an internal adaptive resource, spirituality plays a vital role in helping patients cope with illness [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Patel et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] demonstrated a significant association between spirituality and health outcomes, highlighting its positive influence on health perceptions and resilience in severe disease management. Patients with life-threatening conditions who exhibit higher spiritual well-being often report enhanced quality of life [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, compared to the general population, MHD patients experience marked impairments in physical, social, and psychological well-being [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Fradelos et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] further revealed that MHD patients generally exhibit lower levels of spiritual well-being, which significantly correlates with poorer quality of life. Despite growing evidence on factors influencing HRQoL in MHD patients, the pathways linking spiritual well-being to HRQoL remain poorly understood.\u003c/p\u003e\u003cp\u003eFamily care, a critical component of social support systems [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], provides both practical assistance and emotional sustenance to MHD patients, fostering health improvement and quality of life. Yet, limited studies have explored the interplay between spiritual well-being, family care, and HRQoL in this population. Existing literature suggests a positive correlation between spiritual well-being and family care [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], and studies in cardiac populations indicate that family care significantly enhances quality of life [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. These findings underscore the need to investigate tailored interventions integrating spiritual and family-centered support for MHD patients.\u003c/p\u003e\u003cp\u003eSpiritual well-being significantly influences the selection of spiritual coping strategies, which are cognitive-behavioral approaches through which patients utilize spiritual resources to manage illness-related stressors [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Spirituality, as an intrinsic resource, permeates all aspects of life and is accessible regardless of religious affiliation. Spiritual coping strategies generally fall into two categories: \u003cem\u003ereligious\u003c/em\u003e (e.g., prayer, rituals) and \u003cem\u003enon-religious\u003c/em\u003e (e.g., connecting with family, nature, or personal values) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Influenced by cultural traditions, Chinese MHD patients predominantly adopt non-religious coping strategies, emphasizing familial and social bonds. Grounded in Gall\u0026rsquo;s [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] framework of spiritual coping, this study conceptualizes spirituality as a dynamic process where individuals employ faith- and value-based resources\u0026mdash;including spiritual appraisal, coping strategies, spiritual connections, and meaning-making\u0026mdash;to achieve holistic well-being (physical, psychological, social, and spiritual). Guided by this framework, we position \u003cem\u003espiritual connection\u003c/em\u003e (operationalized as family care) and \u003cem\u003espiritual coping\u003c/em\u003e (positive and negative strategies) as mediators to explore the relationship between \u003cem\u003espiritual appraisal\u003c/em\u003e (spiritual well-being) and health outcomes (HRQoL). Additionally, latent profile analysis (LPA) is used to examine heterogeneity in spiritual well-being among MHD patients. This approach aims to inform tailored spiritual and quality-of-life interventions for clinical practice. We propose the following hypotheses:(see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for details)\u003c/p\u003e\u003cp\u003eH1: Spiritual well-being, family care, spiritual coping, and HRQoL are significantly correlated.\u003c/p\u003e\u003cp\u003eH2: Heterogeneity in spiritual well-being can be identified through latent profile analysis (LPA).\u003c/p\u003e\u003cp\u003eH3: Spiritual well-being influences HRQoL through the mediating roles of family care and spiritual coping.\u003c/p\u003e\u003cp\u003eH4: Family care and spiritual coping sequentially mediate the relationship between spiritual well-being and HRQoL (chain mediation).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA convenience sampling method was used to recruit patients from the hemodialysis centers of two tertiary hospitals in Guangdong Province, China, between August 2023 and January 2024. Inclusion criteria: (1) age \u0026ge;18 years; (2) diagnosed with chronic renal failure according to clinical criteria; (3) receiving regular hemodialysis 2\u0026ndash;3 times weekly for \u0026ge;3 months with stable condition; (4) ability to communicate and complete questionnaires independently; (5) voluntary participation. Exclusion criteria: (1) history of mental illness or intellectual disability; (2) acute critical comorbidities. A total of 228 questionnaires were distributed, with 220 valid responses retained (valid response rate: 96.5%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the ethics committee of The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Grant number: YM2023-219). Two trained investigators administered the questionnaires using standardized instructions. Participants were informed of the study\u0026rsquo;s purpose, confidentiality, and their right to withdraw at any time. Questionnaires were completed independently by patients before dialysis sessions to avoid interference with treatment. For participants unable to self-complete, investigators verbally administered items and recorded responses. The survey process lasted 15\u0026ndash;20 minutes, and questionnaires were reviewed immediately for completeness, with missing items addressed promptly.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic and Clinical Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData included gender, age, religious affiliation, marital status, education level, employment status, household monthly income per capita, medical payment method, dialysis vintage, and number of chronic comorbidities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunctional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-SP-12) [\u003c/strong\u003e\u003cstrong\u003e23\u003c/strong\u003e\u003cstrong\u003e]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Chinese version of the FACIT-SP-12 was used to assess spiritual well-being. This 12-item scale comprises three dimensions (\u003cem\u003epeace\u003c/em\u003e, \u003cem\u003emeaning\u003c/em\u003e, and \u003cem\u003efaith\u003c/em\u003e) rated on a 5-point Likert scale (0 = \u0026quot;not at all\u0026quot; to 4 = \u0026quot;very much\u0026quot;). Items 4 and 8 were reverse-scored. Total scores range from 0 to 48, categorized as \u003cem\u003elow\u003c/em\u003e (0\u0026ndash;23), \u003cem\u003emoderate\u003c/em\u003e (24\u0026ndash;35), or \u003cem\u003ehigh\u003c/em\u003e (\u0026ge;36) spiritual well-being. Cronbach\u0026rsquo;s \u003cem\u003e\u0026alpha;\u003c/em\u003e coefficient for this scale was 0.950 in the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFamily Care Index\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Family Care Index, originally developed by Smilkstein et al. and adapted into Chinese by L\u0026uuml; et al. [24], comprises five dimensions: family adaptation, partnership, growth, affection, and resolve. Each item is rated on a 3-point Likert scale (0 = \u0026quot;rarely,\u0026quot; 2 = \u0026quot;often\u0026quot;), with total scores ranging from 0 to 10. Higher scores indicate better family functioning. In this study, the scale demonstrated excellent internal consistency (Cronbach\u0026rsquo;s \u003cem\u003e\u0026alpha;\u003c/em\u003e=0.873).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChinese Version of the Spiritual Coping Questionnaire (SCQ)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe SCQ, developed by Charzynska et al. [25] based on a multidimensional conceptualization of spirituality, was translated into Chinese to assess both religious and non-religious spiritual coping strategies. It includes two subscales: positive spiritual coping (personal, social, environmental, and transcendental dimensions) and negative spiritual coping (personal, social, and transcendental dimensions), totaling 26 items across seven dimensions. Items are rated on a 5-point Likert scale (1 = \u0026quot;very inaccurate\u0026quot; to 5 = \u0026quot;very accurate\u0026quot;). Subscale scores are calculated as the mean of item responses, with higher scores indicating greater reliance on specific coping strategies. Internal consistency was high for both subscales (positive coping: \u003cem\u003e\u0026alpha;\u003c/em\u003e=0.884; negative coping: \u003cem\u003e\u0026alpha;\u003c/em\u003e=0.908).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eShort Form-12 Health Survey (SF-12)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe SF-12, derived from the SF-36 by Ware et al. [26], assesses HRQoL across eight domains grouped into two summary scores: \u003cem\u003ePhysical Component Summary\u003c/em\u003e (PCS; includes general health [GH], physical functioning [PF], role limitations due to physical health [RP], and bodily pain [BP]) and \u003cem\u003eMental Component Summary\u003c/em\u003e (MCS; includes role limitations due to emotional problems [RE], mental health [MH], vitality [VT], and social functioning [SF]). The total score is standardized to a 0\u0026ndash;100 scale, with higher scores reflecting better quality of life. The scale showed strong reliability in this study (Cronbach\u0026rsquo;s \u003cem\u003e\u0026alpha;\u003c/em\u003e=0.913).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll statistical analyses were performed using IBM SPSS 25.0, the SPSS PROCESS macro v4.1, and Mplus 8.3. First, demographic and clinical variables were described using means \u0026plusmn; standard deviations (SD) or frequencies (percentages). Pearson correlation analysis was conducted to examine associations among spiritual well-being, family care, spiritual coping, and HRQoL. Subsequently, latent profile analysis (LPA) was employed to identify subgroups of spiritual well-being. Model fit indices included the Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC), sample-size-adjusted BIC (aBIC), entropy, Lo-Mendell-Rubin likelihood ratio test (LMR-LRT), and bootstrap likelihood ratio test (BLRT). Lower values of AIC, BIC, and aBIC indicated better model fit, while entropy \u0026ge;0.8 suggested classification accuracy \u0026gt;90%. A significant \u003cem\u003eP\u003c/em\u003e-value (\u0026lt;0.05) for LMR-LRT or BLRT indicated adequate model fit.\u003c/p\u003e\n\u003cp\u003eFinally, mediation effects of family care and spiritual coping between spiritual well-being (categorical latent classes) and HRQoL were tested using Model 4 of the PROCESS macro. Chain mediation pathways (spiritual well-being \u0026rarr; family care \u0026rarr; spiritual coping \u0026rarr; HRQoL) were examined using Model 6. Bias-corrected percentile bootstrap methods (5,000 resamples, 95% confidence interval [CI]) were applied to assess total, direct, and indirect effects. Mediation effects were considered statistically significant if the 95% CI excluded zero [27].\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eDescriptive Statistics\u003c/h2\u003e\u003cp\u003eAmong the 220 MHD patients (130 males, 90 females), the majority were aged\u0026thinsp;\u0026le;\u0026thinsp;60 years (109, 49.5%), had no religious affiliation (180, 81.8%), were married (172, 78.2%), had a middle school education (75, 34.0%), and were unemployed (169, 76.8%). Most patients had medical insurance (214, 97.3%), a household monthly income\u0026thinsp;\u0026gt;\u0026thinsp;5,000 CNY (86, 39.1%), a dialysis duration of 12\u0026ndash;60 months (97, 44.1%), and 3\u0026ndash;4 chronic comorbidities (114, 51.8%). The mean HRQoL score was 56.50\u0026thinsp;\u0026plusmn;\u0026thinsp;22.29. Significant differences in HRQoL were observed across age (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004), religious status (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003), education level (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.013), employment status (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005), and number of comorbidities (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003) (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic and Clinical Characteristics of MHD Patients (N\u0026thinsp;=\u0026thinsp;220)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHRQoL(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et/F\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.309\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e130(59.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e57.77\u0026thinsp;\u0026plusmn;\u0026thinsp;21.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90(40.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e54.66\u0026thinsp;\u0026plusmn;\u0026thinsp;23.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42(19.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e62.01\u0026thinsp;\u0026plusmn;\u0026thinsp;18.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e45\u0026thinsp;~\u0026thinsp;60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e79(35.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e60.47\u0026thinsp;\u0026plusmn;\u0026thinsp;20.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e99(45.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e50.99\u0026thinsp;\u0026plusmn;\u0026thinsp;23.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReligious Affiliation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40(18.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e65.96\u0026thinsp;\u0026plusmn;\u0026thinsp;19.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e180(81.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e54.40\u0026thinsp;\u0026plusmn;\u0026thinsp;22.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.133\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnmarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19(8.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e63.51\u0026thinsp;\u0026plusmn;\u0026thinsp;19.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e172(78.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e56.75\u0026thinsp;\u0026plusmn;\u0026thinsp;22.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDivorced/Widowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29(13.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e50.44\u0026thinsp;\u0026plusmn;\u0026thinsp;23.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducation Level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.013\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary school or below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e55(25.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e50.21\u0026thinsp;\u0026plusmn;\u0026thinsp;22.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e75(34.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e54.62\u0026thinsp;\u0026plusmn;\u0026thinsp;20.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh school/Technical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50(22.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e59.38\u0026thinsp;\u0026plusmn;\u0026thinsp;23.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCollege\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19(8.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e61.88\u0026thinsp;\u0026plusmn;\u0026thinsp;21.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBachelor\u0026rsquo;s or above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21(9.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e67.95\u0026thinsp;\u0026plusmn;\u0026thinsp;22.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEmployment Status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e64.13\u0026thinsp;\u0026plusmn;\u0026thinsp;19.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e169\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e54.20\u0026thinsp;\u0026plusmn;\u0026thinsp;22.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHousehold Income (CNY)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.277\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;1000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26(11.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e50.18\u0026thinsp;\u0026plusmn;\u0026thinsp;16.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1001\u0026thinsp;~\u0026thinsp;3000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39(17.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e59.26\u0026thinsp;\u0026plusmn;\u0026thinsp;18.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3001\u0026thinsp;~\u0026thinsp;5000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e69(31.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e54.73\u0026thinsp;\u0026plusmn;\u0026thinsp;26.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;5000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e86(39.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e58.58\u0026thinsp;\u0026plusmn;\u0026thinsp;21.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMedical Payment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedical Insurance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e178(80.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e57.33\u0026thinsp;\u0026plusmn;\u0026thinsp;22.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNew Rural Cooperative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27(12.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e51.59\u0026thinsp;\u0026plusmn;\u0026thinsp;20.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePublic Funding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9(4.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e61.68\u0026thinsp;\u0026plusmn;\u0026thinsp;30.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-payment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(2.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e46.03\u0026thinsp;\u0026plusmn;\u0026thinsp;24.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDialysis Vintage\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.332\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;1 year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e68(30.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e54.34\u0026thinsp;\u0026plusmn;\u0026thinsp;22.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u0026ndash;5 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e97(44.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e55.59\u0026thinsp;\u0026plusmn;\u0026thinsp;21.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u0026ndash;10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37(16.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e62.39\u0026thinsp;\u0026plusmn;\u0026thinsp;20.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18(8.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e57.47\u0026thinsp;\u0026plusmn;\u0026thinsp;26.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eChronic Comorbidities\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90(40.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e62.60\u0026thinsp;\u0026plusmn;\u0026thinsp;21.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u0026thinsp;~\u0026thinsp;4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e114(51.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e52.42\u0026thinsp;\u0026plusmn;\u0026thinsp;21.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16(7.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e51.22\u0026thinsp;\u0026plusmn;\u0026thinsp;22.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eCommon Method Bias Test\u003c/h2\u003e\u003cp\u003eAs self-administered questionnaires may introduce common method bias, Harman\u0026rsquo;s single-factor test [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] was conducted to assess potential bias. Exploratory factor analysis (EFA) of all study variables revealed 12 factors with eigenvalues\u0026thinsp;\u0026gt;\u0026thinsp;1. The first factor accounted for 32.65% of the variance (below the 40% threshold), indicating no significant common method bias or multicollinearity.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eMultivariate Linear Regression Analysis of Factors Influencing HRQoL in MHD Patients\u003c/h2\u003e\u003cp\u003eThis study explored the determinants of health-related quality of life (HRQoL) in maintenance hemodialysis (MHD) patients through hierarchical multivariate linear regression analysis (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). After sequentially incorporating demographic characteristics, spiritual well-being, family support, and spiritual coping strategies into the models, the adjusted \u003cem\u003eR\u003c/em\u003e\u0026sup2; increased significantly from 0.11 (Model 1) to 0.42 (Model 4). The results identified spiritual well-being (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.51, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) as the strongest predictor of HRQoL, with its effects partially mediated through family support (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.30, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and positive spiritual coping strategies (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.28, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). In contrast, age (\u003cem\u003eβ\u003c/em\u003e = -0.10, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and number of chronic comorbidities (\u003cem\u003eβ\u003c/em\u003e = -0.15, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) were negatively associated with HR-QOL, while negative spiritual coping did not reach statistical significance (\u003cem\u003eβ\u003c/em\u003e = -0.11, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). These findings suggest that interventions aimed at enhancing spiritual well-being, strengthening family support systems, and fostering adaptive coping strategies may improve long-term quality of life in MHD patients.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMultivariate linear regression analysis of factors influencing HRQoL in MHD patients (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;220)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModel\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSE\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eStandardized β\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eR\u0026sup2;\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eModel 1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-2.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e6.52**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReligious affiliation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.18**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEducation level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.79*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmployment status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of comorbidities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-5.45*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eModel 2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e16.55**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReligious affiliation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEducation level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmployment status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of comorbidities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-2.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSpiritual well-being\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.93**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eModel 3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-2.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e19.25**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReligious affiliation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEducation level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmployment status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of comorbidities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-3.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSpiritual well-being\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.68**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFamily care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.49**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eModel 4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-2.151\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e18.29**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReligious affiliation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.547\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEducation level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.343\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmployment status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.354\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of comorbidities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-3.744\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSpiritual well-being\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.33**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFamily care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.72**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePositive spiritual coping\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.47**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNegative spiritual coping\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e*\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05, **\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eLatent Profile Analysis of Spiritual Well-Being in MHD Patients\u003c/h2\u003e\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, implementing latent profile modeling using MHD patients' dimensional scores of peace, meaning, and faith from spiritual well-being assessments as manifest observed variables, the entropy values for 1\u0026ndash;5 latent profile models were all above 0.80. With an increasing number of classes, the AIC, BIC, and adjusted BIC (aBIC) gradually decreased, indicating better model fit for higher class numbers. The Lo-Mendell-Rubin adjusted likelihood ratio test (LMR) suggested that the 4-profile model provided a significantly better fit than the 3-profile model (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, when retaining 4 or 5 classes, the LMR test results were non-significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Based on model fit indices and practical interpretability, the 4-profile model was selected as optimal. The four latent classes C1\u0026thinsp;~\u0026thinsp;C4 are named as: Low Spiritual Health (36.8%), Moderate Spiritual Health (20.0%), Peaceful Mindset with Low Belief (13.6%), and High Spiritual Health (29.5%), (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e for details).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFit indices of latent profile models for spiritual well-being in MHD patients (n\u0026thinsp;=\u0026thinsp;220)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModel\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-1936.717\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-1785.774\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-1750.936\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-1724.862\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-1709.438\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e-1701.974\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAIC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3885.433\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3591.548\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3529.871\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3485.724\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3462.876\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e3455.948\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBIC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3905.795\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3625.484\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3577.382\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3546.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3537.536\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e3544.182\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eaBIC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3886.781\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3593.794\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3533.016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3489.768\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3467.818\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e3461.788\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEntropy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.884\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.816\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.849\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.827\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.844\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLMR(P)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0428\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.0057\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.1869\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.3938\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBLRT(P)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.0500\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGroup sizes(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e220(100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e115(52.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e84(38.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e81(36.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e46(20.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e62(28.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e105(47.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e73(33.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e44(20.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e70(31.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e52(23.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e63(28.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30(13.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e36(16.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e24(10.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e65(29.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e30(13.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e26(11.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e38(17.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e21(9.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e35(15.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eValidation of the Mediation Models Involving Family Support and Spiritual Coping\u003c/h2\u003e\u003cp\u003eThe results revealed significant correlations among quality of life, spiritual well-being, family support, positive spiritual coping, and negative spiritual coping (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01 for all). Detailed Analysis of Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Using the low spiritual well-being group (as a reference category in the latent profile analysis of spiritual health), Detailed Analysis of Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, the mediation effects of family support were estimated as 0.122, 0.217, and 0.227. The 95% Bootstrap confidence intervals were (0.258, 0.873), (0.170, 0.885), and (0.732, 1.301), which did not contain \u0026ldquo;0\u0026rdquo;, demonstrating a significant mediating effect. Similarly, the mediation effects of spiritual coping were 0.186, 0.0895, and 0.248. The 95% Bootstrap confidence intervals were (0.026, 0.330), (0.009, 0.186), and(0.035, 0.439), which did not contain \u0026ldquo;0\u0026rdquo;, demonstrating a significant mediating effect. Detailed pathways are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCorrelation analysis among spiritual well-being, family support, spiritual coping, and health-related quality of life (HR-QOL) in MHD patients (n\u0026thinsp;=\u0026thinsp;220)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eCorrelation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. HRQoL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e56.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. Spiritual Well-Being\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e21.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.557**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. Family Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.426**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.360**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. Spiritual Coping\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e72.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.403**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.552**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.209**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. Positive Spiritual Coping\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e55.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.565**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.685**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.408**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.874**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6. Negative Spiritual Coping\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.343**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.292**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.408**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.210**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.292**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003e**\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMediation effects of spiritual well-being latent classes (categorical variable) on health-related quality of life (HRQoL)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMediation Pathway\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEffect(95%CI)1VS.2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEffect(95%CI)1VS.3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEffect(95%CI)1VS.4\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModel 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDirect effect: Spiritual well-being \u0026rarr;HRQoL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.566(0.258,0.873)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.528(0.170,0.885)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.016(0.732,1.301)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndirect effect: Spiritual well-being \u0026rarr; Family support \u0026rarr;HRQoL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.122(0.019,0.250)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.217(0.087,0.369)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.227(0.111,0.371)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eModel 2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDirect effect: Spiritual well-being \u0026rarr;HRQoL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.501(0.158,0.845)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.655(0.290,1.021)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.995(0.662,1.329)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndirect effect: Spiritual well-being \u0026rarr; Spiritual coping \u0026rarr;HRQoL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.186(0.026,0.330)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.0895(0.009,0.186)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.248(0.035,0.439)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eChain Mediation Effect Analysis\u003c/h2\u003e\u003cp\u003eTwo chain mediation models were constructed with spiritual well-being (continuous variable) as the independent variable, family support and positive/negative spiritual coping as mediators, and quality of life as the dependent variable, as illustrated in Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The bias-corrected percentile bootstrap method (5,000 resamples) was used to validate the chain mediation effects of family support and spiritual coping on spiritual well-being and quality of life, with 95% confidence intervals (CIs). The results, detailed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, demonstrated that the total, direct, and indirect effects of spiritual well-being on quality of life were all statistically significant (95% CIs excluded zero). Specifically, spiritual well-being indirectly influenced quality of life through family support (effect sizes: 0.074 and 0.077; 95% CIs: [0.032, 0.126] and [0.031, 0.132]) and through spiritual coping (effect sizes: 0.175 and 0.021; 95% CIs: [0.074, 0.264] and [0.001, 0.051]). Furthermore, the chain mediation pathway via both family support and spiritual coping significantly impacted quality of life (effect sizes: 0.019 and 0.016; 95% CIs: [0.004, 0.040] and [0.001, 0.051]). Comprehensive results are provided in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eChain Mediation Effects of Family Support and Spiritual Coping on Spiritual Well-Being and Health-Related Quality of Life (HRQoL)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePath\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEffect\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eSE\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLLCI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eULCI\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModel 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Effect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.557\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.056\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.446\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.668\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDirect Effect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.289\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.072\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.432\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInd1: Spiritual Well-Being \u0026rarr; Family Support \u0026rarr; HRQoL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.074\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.032\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.126\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInd2: Spiritual Well-Being \u0026rarr; Positive Spiritual Coping \u0026rarr;HRQoL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.175\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.048\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.074\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.264\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInd3: Spiritual Well-Being \u0026rarr; Family Support \u0026rarr; Positive Spiritual Coping \u0026rarr;HRQoL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.009\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.040\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Indirect Effect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.268\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.053\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.155\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.366\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eModel 2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Effect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.557\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.056\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.446\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.668\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDirect Effect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.443\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.058\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.328\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.558\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInd1: Spiritual Well-Being \u0026rarr; Family Support \u0026rarr;HRQoL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.077\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.026\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.031\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.132\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInd2: Spiritual Well-Being \u0026rarr; Negative Spiritual Coping \u0026rarr;HRQoL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.051\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInd3: Spiritual Well-Being \u0026rarr; Family Support \u0026rarr; Negative Spiritual Coping \u0026rarr;HRQoL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.033\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Indirect Effect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.029\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.063\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.174\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eSpirituality, as a critical component of holistic health, has been recognized as a universal trait through which individuals seek meaning in life and has been consistently linked to improved quality of life [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In this study, we identified heterogeneity in spiritual well-being among MHD patients, with spiritual well-being directly influencing health-related quality of life (HRQoL). Family support and spiritual coping strategies partially mediated this relationship. Furthermore, the established chain mediation models demonstrated that family support and spiritual coping sequentially mediate the pathway between spiritual well-being and HRQoL.\u003c/p\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eCorrelations Among Spiritual Well-Being, Family Support, Spiritual Coping, and HRQoL in MHD Patients\u003c/h2\u003e\u003cp\u003eThe findings revealed a positive correlation between spiritual well-being and HRQoL in MHD patients, suggesting that inner peace, a sense of purpose, and spiritual beliefs contribute to better health outcomes [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Family support, a key element of social support systems, not only directly enhanced HRQoL but also partially mediated the relationship between spiritual well-being and HRQoL, underscoring its role in fostering adaptive spiritual health and coping strategies [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Higher levels of family support provided patients with greater resources to mitigate disease-related distress, promote positive health behaviors, and reframe their perspectives on illness, thereby improving quality of life [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Spiritual coping influenced HRQoL through dual pathways of psychological adaptation and behavioral modification [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Specifically, positive spiritual coping strengthened adaptive behaviors to enhance HRQoL, whereas negative spiritual coping exacerbated feelings of helplessness, further deteriorating HRQoL.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eLatent Class Analysis of Spiritual Well-Being in MHD Patients\u003c/h2\u003e\u003cp\u003ePrevious studies have predominantly assessed spiritual well-being using total scores, neglecting population heterogeneity [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. This study employed latent profile analysis (LPA) to classify MHD patients into four distinct spiritual well-being profiles: low spiritual well-being (36.8%), moderate spiritual well-being (20.0%), peaceful mindset-low spiritual belief (13.6%), and high spiritual well-being (29.5%). Notably, over 50% of patients fell into the low or moderate spiritual well-being categories. The peaceful mindset-low spiritual belief group exhibited high scores in inner peace but low scores in spiritual conviction, indicating that some patients maintain emotional calmness yet lack spiritual beliefs or faith-based support. This phenomenon may relate to the relatively low prevalence of religious affiliation in China. However, spirituality is culturally specific, and religion represents only one facet of spiritual resources [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Traditional Chinese philosophies, such as Confucianism and Taoism, can serve as intrinsic spiritual resources, providing psychological resilience and support [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Clinicians should tailor spiritual care interventions to patients\u0026rsquo; latent class characteristics and cultural contexts to enhance spiritual well-being.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eMediating Roles of Family Support and Spiritual Coping\u003c/h2\u003e\u003cp\u003eFamily support mediated the relationship between spiritual well-being and HRQoL, indicating that spiritual well-being indirectly improves quality of life through enhanced family support. Family functioning\u0026mdash;defined as the capacity to provide emotional, practical, and financial support\u0026mdash;strengthens individual and collective resilience to life stressors, playing a pivotal role in health outcomes [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. MHD imposes significant lifestyle disruptions, including dietary restrictions and occupational limitations. Family support acts as a protective factor, offering critical assistance and emotional reinforcement to help patients adapt to new routines, alleviate stress, and foster proactive disease management [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The findings further revealed that spiritual well-being influenced HRQoL through positive spiritual coping (e.g., seeking meaning, social connectedness), with higher spiritual well-being associated with greater use of adaptive coping strategies. Conversely, negative spiritual coping (e.g., spiritual discontent, passive resignation) mediated the detrimental effects of low spiritual well-being on HRQoL. Spiritual well-being serves as an internal resource for stress management; individuals with lower spiritual well-being possess fewer coping resources, perceive higher stress levels, and are more prone to maladaptive coping [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eChain Mediation Effects of Family Support and Spiritual Coping Between Spiritual Well-Being and Quality of Life in MHD Patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe findings of this study demonstrate that spiritual well-being influences quality of life through a chain mediation pathway involving family support and spiritual coping. This aligns with the \u003cem\u003espiritual coping process model\u003c/em\u003e, which posits that individuals under stress navigate challenges through sequential mechanisms of spiritual appraisal, spiritual connection, and spiritual coping, ultimately manifesting in psychophysiological outcomes. For MHD patients, spiritual well-being reflects their cognitive appraisal of spirituality, family support represents an external spiritual connection, and spiritual coping signifies their adaptive or maladaptive strategies. These factors collectively determine stress-related health outcomes, such as HRQoL. Notably, individuals with low spiritual well-being struggle to mobilize internal coping resources, leading to biased cognitive processing of emotional stimuli and heightened vulnerability to negative affective states, thereby exacerbating poor mental health outcomes [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. In contrast, family support serves as a critical protective factor for psychological well-being. Enhancing family support mitigates negative emotions and improves HRQoL by fostering resilience and adaptive coping. Evidence further suggests that higher spiritual well-being predicts better prognoses and quality of life in chronic disease populations [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis study has several limitations. First, the sample comprised only Chinese MHD patients, and the findings may not generalize to other populations due to cultural and healthcare system differences. Second, the cross-sectional design precludes causal inferences; future research should adopt longitudinal designs to establish temporal relationships. Third, data were collected from two tertiary hospitals in China via convenience sampling, which may introduce selection bias and limit external validity. Fourth, self-report questionnaires were used to measure spiritual well-being, family support, spiritual coping, and HRQoL, potentially inflating results due to social desirability bias or subjective interpretation. Finally, while focusing on spirituality-related factors, this study did not account for other potential determinants of HRQoL (e.g., socioeconomic status, psychological comorbidities), which should be explored in future work.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are grateful to all the participants in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBiXia Yuan 1245, QingHua Lai 1235, Jing Wu 123, RongRong Wang 156, YongMei Lu 156, Meng Wu 156, Yun Chen 156, JieQian Wu 156. 1 Conceptualization; 2 Methodology; 3 Data curation; 4 Writing Original Draft; 5 Writing - Review \u0026amp; Editing; 6 Funding acquisition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to the privacy of the research participants, the data generated during the current study are not publicly available but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the ethics committee of\u0026nbsp;The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Grant number: YM2023-219). And informed consent was obtained from the participants and their guardians before starting the program. We confirm that all the experiment is in accordance with the relevant guidelines and regulations such as the declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eZhao ZP, Wang LM. [Challenges and suggestions for the prevention and control of chronic kidney disease in China]. Zhonghua Liu Xing Bing Xue Za Zhi. 2025;46:9\u0026ndash;17.\u003c/li\u003e\n\u003cli\u003eZhang L, Zhao M-H, Zuo L, Wang Y, Yu F, Zhang H, et al. China Kidney Disease Network (CK-NET) 2016 Annual Data Report. Kidney Int Suppl (2011). 2020;10:e97\u0026ndash;185.\u003c/li\u003e\n\u003cli\u003eZhang Q, Cao H. Relationships between dyadic coping, marital adjustment, and post-traumatic growth in patients with maintenance hemodialysis patients and their spouses. Front Psychol. 2024;15:1487355.\u003c/li\u003e\n\u003cli\u003eZhou D, Ye YY, Yang FH, Yang J, Qian Q, Huang Y, et al. Predictive value of eosinophil percentage, platelet/lymphocyte ratio, and albumin/C-reactive protein ratio for prognosis in end-stage renal disease patients undergoing maintenance hemodialysis.\u003cem\u003e \u003c/em\u003eClinical Journal of Medical Officers. 2023;51:810\u0026ndash;3. [In Chinese]\u003c/li\u003e\n\u003cli\u003eMai Q, Xu S, Hu J, Sun X, Chen G, Ma Z, et al. 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Cureus. 2024;16:e53304.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Maintenance hemodialysis, Spiritual well-being, Quality of life, Latent profile analysis, Psychosocial mediation, Family support","lastPublishedDoi":"10.21203/rs.3.rs-6726006/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6726006/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpiritual health and psychosocial factors are critical yet underexplored determinants of health-related quality of life (HRQoL) in patients undergoing maintenance hemodialysis (MHD). This study examines the heterogeneous patterns of spiritual health and its sequential mediating pathways (via family care and spiritual coping) in shaping HRQoL among MHD patients, addressing a gap in chronic disease management research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional design was employed with 220 MHD patients recruited from two tertiary hospitals in Guangdong, China (August 2023–January 2024). Validated instruments—the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-SP-12), Family Care Index, Spiritual Coping Questionnaire (SCQ), and Short Form-12 (SF-12)—were administered. Latent profile analysis (LPA) categorized spiritual health subgroups, while chain mediation models (PROCESS macro, 5,000 bootstraps) tested hypothesized pathways.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHRQoL scores averaged 56.50±22.29. Significant correlations emerged: spiritual health (\u003cem\u003er\u003c/em\u003e=0.557,\u003cem\u003e P\u003c/em\u003e\u0026lt;0.001), family care (\u003cem\u003er\u003c/em\u003e=0.426, \u0026nbsp;\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001), and positive spiritual coping \u003cem\u003e(r\u003c/em\u003e=0.565, \u003cem\u003e\u0026nbsp;P\u003c/em\u003e\u0026lt;0.001) positively predicted HRQoL, whereas negative coping correlated inversely (\u003cem\u003er\u003c/em\u003e=−0.343, \u0026nbsp;\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). LPA identified four distinct profiles: Low Spiritual Health (36.8%), Moderate Spiritual Health (20.0%), Peaceful Mindset with Low Belief (13.6%), and High Spiritual Health (29.5%). The mediation analysis revealed that family support and spiritual coping partially mediated the relationship between spiritual well-being and HRQoL (effect sizes: 0.074–0.175, 95% CI excluding 0). The chain mediation pathway \"spiritual well-being → family support → spiritual coping → HRQoL\" was statistically significant, with total indirect effects of 0.268 and 0.114 (95% CIs excluding 0).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study highlights the cascading mechanism by which spiritual health enhances HRQoL through family support and adaptive coping strategies. The heterogeneity of spiritual health profiles underscores the need for tailored interventions, particularly for subgroups like Peaceful Mindset with Low Belief. Clinicians should integrate spiritual assessments and family-centered care into routine MHD management to optimize long-term outcomes.\u003c/p\u003e","manuscriptTitle":"Spiritual Well-Being and Quality of Life in Maintenance Hemodialysis Patients: A Latent Profile Analysis and Serial Mediation Model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-28 10:23:44","doi":"10.21203/rs.3.rs-6726006/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4aa0b404-4eb0-4848-b869-553468a168f9","owner":[],"postedDate":"July 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-14T12:39:25+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-28 10:23:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6726006","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6726006","identity":"rs-6726006","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}