Assessing Fear of Progression, Stigma, and Psychological Detachment in Hemodialysis Patients: A Structural Equation Modeling Study

Assessing Fear of Progression, Stigma, and Psychological Detachment in Hemodialysis Patients: A Structural Equation Modeling Study | 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 Assessing Fear of Progression, Stigma, and Psychological Detachment in Hemodialysis Patients: A Structural Equation Modeling Study Liu Cong¹, Wu Jianyi¹, Lyu Xiaoran¹, Wang Qin¹, Liu Nian¹, Li Xianglin¹, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7545852/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Apr, 2026 Read the published version in BMC Nephrology → Version 1 posted 10 You are reading this latest preprint version Abstract Aims: To explore the mediating effects of fear of disease progression (FoP) and stigma on the relationship between the level of family caregiving and psychological disengagement in maintenance hemodialysis (MHD) patients. Methods: A cross-sectional study was conducted including 320 MHD patients from a hemodialysis center in China. Data were collected using the Fear of Progression Questionnaire-Short Form (FoP-Q-SF), Social Impact Scale (SIS), Family APGAR Index, and Psychological Disengagement Scale. Structural equation modeling was performed via AMOS 26.0. Results: The total score for psychological disengagement was 193.10±24.37, indicating a moderate level. Family caring degree had a positive correlation with FoP (r=0.157, P<0.05) and negative correlations with stigma (r=-0.205, P<0.01) and psychological disengagement (r=-0.218, P<0.01). The fear of disease progression partially mediated the relationship between stigma and psychological disengagement (mediation effect=0.112, 16.20% of total effect). Conclusion: Psychological disengagement among MHD patients is influenced by stigma, FoP, and family support. Interventions targeting family-centered care and stigma reduction may enhance psychological disengagement. Maintenance hemodialysis Psychological disengagement Stigma Family caring degree Mediating effect Figures Figure 1 1. Introduction Maintenance hemodialysis (MHD) is the most prevalent renal replacement therapy for patients with end-stage renal disease (ESRD). By the end of 2022, the population of MHD patients in mainland China exceeded 840,000, ranking first worldwide [ 1 ] . Although long-term MHD treatment alleviates symptoms of ESRD, the irreversible deterioration of residual renal function, along with increased complications such as calcium-phosphorus metabolism disorders, cardiovascular diseases, and microinflammatory responses, results in many patients suffering from physical symptoms like restless legs syndrome, fatigue, and sleep disorders. These patients may also face psychological challenges, including restlessness, depression, and anxiety, which serve as stressors. They may also experience varied degrees of psychological distress such as tension, depression, and anxiety, which serve as symptomatic stressors for patients. The stress process theory [ 2 ] posits that when individuals encounter stressors, a series of physiological, psychological, and behavioral responses arises, influenced by the interaction, feedback regulation, and control of internal and external factors, encompassing cognitive appraisal, social support, coping styles, and personality traits, further influencing their health or disease status. Psychological detachment, within the framework of positive psychology, generally refers to individuals' disengagement from stressful environments or events. The effort-recovery theory [ 3 ] suggests that psychological detachment is essential for recovery experiences, and an appropriate level of psychological detachment enables individuals to effectively replenish the physical and mental resources exhausted by work-related stress. Psychological detachment, closely associated with positive outcomes and manifested by dual physical and psychological disengagement, facilitates stress reduction, the restoration of positive emotions, and the replenishment of exhausted physical and mental resources. Fear of disease progression (FoP) denotes individuals' apprehension regarding all facets related to their current diseases. Prolonged FoP easily induces depressive emotions in patients [ 4 ] . Stigma, also known as the social impact of disease, primarily signifies patients' internalized shame experienced by patients about their illnesses. In the dialysis patient population, stigma triggers emotional fluctuations, psychological disorders, weakened self-care ability, reduced treatment adherence, and avoidance of normal social interactions. Stigma is also a high-risk factor for depression [ 5 ] . Theoretically, stigma among patients should promote psychological detachment; however, no studies have confirmed the relationship between stigma and psychological detachment, and the potential existence of individual-level mediating variables necessitates urgent investigation. Research indicates [ 6 ] that family structure and function are intricately associated with the quality of life in hemodialysis patients, with robust family support significantly improving patients' quality of life. Based on the above theories, external environments and internal factors interact to shape individual behavior. Stigma, as the primary emotional response to psychological detachment, reflects patients' positive emotion towards stigma and their authentic experiences of the external environment, affecting their level of psychological detachment. The psychological detachment level of MHD patients directly impacts their quality of life and social functions. However, existing studies mainly focus on single psychological factors, neglecting the exploration of the interaction mechanisms among multiple variables. Additionally, the empirical investigation of how family support affects psychological detachment through stigma and FoP remains unexamined. Consequently, it is crucial to examine and systematically analyze this mechanism and evaluate whether FoP and stigma mediate the relationship between family support and psychological detachment in MHD patients. Therefore, this study aims to explore the mediating effects of FoP and stigma on the link between family support and psychological detachment among MHD patients, providing references for improving their psychological detachment levels. 2. Methods 2.1 Participant Selection We used convenience sampling to recruit maintenance hemodialysis (MHD) patients from the Blood Purification Center of Yichang Central People's Hospital, Hubei Province, in November 5, 2024. Inclusion criteria: MHD treatment duration ≥ 3 months; age > 18 years; clear consciousness, normal intelligence and hearing, able to correctly complete the questionnaire. Exclusion criteria: ① Complicated by severe organ dysfunction such as NYHA Class IV cardiac function or Child-Pugh Class C liver function; ② Experienced major negative life events, such as bereavement and unemployment, within the past 3 months; ③ Diagnosed with mental illnesses such as schizophrenia or bipolar disorder; ④ Non-local permanent or temporary dialysis patients; ⑤ Planned to receive kidney transplantation or transition to peritoneal dialysis within 3 months. ④ Non-local permanent or temporary dialysis patients; ⑤ Scheduled to undergo kidney transplantation or transition to peritoneal dialysis within three months. We calculated the sample size using the cross-sectional linear correlation formula: n = 4[(µα + µβ)/ln((1 + r)/(1 - r))]² + 3, with α = 0.05 and β = 0.1. A pilot study indicated that a minimum correlation coefficient (r = 0.269) among FoP, stigma, family caring degree, and psychological detachment yielded a minimum sample size of 142. After accounting for a 20% invalid response rate, the final sample size was 178. 2.2 Survey Instruments 2.2.1 Demographic Questionnaire The researchers designed the demographic questionnaire in accordance with the research's objectives and relevance, including age, gender, marital status, educational level, employment status, family monthly per capita income, dialysis duration, and medical payment method. The Demographic Questionnaire was self-designed for this study, and its English version is available in Supplementary File S2. 2.2.2 Fear of Progression Questionnaire-Short Form The Fear of Progression Questionnaire-Short Form (FoP-Q-SF)was originally developed by Mehnert et al. [ 7 ] in 2006 through the simplification of the Fear of Progression Scale, was translated into Chinese and adapted by Wu Qiyun et al. [ 8 ] in 2015, was used in this study, with written permission obtained from the original developers (Mehnert team) via email [see 2.5 Ethics considerations]. It consists of 12 items across two dimensions: Physical Health and Social-Family. The total scores, derived on a 5-point Likert scale (1 = "never," 5 = "always"), range from 12 to 60, with higher scores indicating an increased fear of progression. The Cronbach’s α coefficient is 0.883. The total Cronbach's α coefficient of this scale in the study was 0.888. 2.2.3 Stigma Scale We used the Social Impact Scale (SIS) developed by Fife et al. [ 9 ] to measure the social and psychological impact of the disease, specifically stigma. Revised and translated by Pan et al. [ 10 ] in 2007.Authorization for using the Chinese version was confirmed by Prof. Fife’s team via email [see 2.5 Ethics considerations].The scale includes four dimensions: Social Rejection (9 items), Economic Discrimination (3 items), Internal Shame (5 items), and Social Isolation (7 items), amounting to a total of 24 items. The 4-point Likert scale (1 = "strongly disagree," 2 = "disagree," 3 = "agree," 4 = "strongly agree") yields total scores between 24 to 96, where higher scores signify greater stigma. The Cronbach's α coefficient is 0.85–0.90 [ 11 ] . The total Cronbach's α coefficient of this scale in the study was 0.951. 2.2.4 Family APGAR Index Designed by American physician Smilkstein [ 12 ] and introduced to China by Chinese scholars LYU Fan et al. [ 13 ] in 1995, is a public-domain instrument requiring no specific authorizationthis. The scale assesses patients' satisfaction with family function by evaluating their perception of family care level. The scale, exhibiting a Cronbach's α coefficient of 0.83, comprises five items: Adaptation, Partnership, Growth, Affection, and Resolve. Utilizing a 3-point Likert scale (2 = "often," 1 = "sometimes," 0 = "almost never"), total scores range from 0 to 10. Tota scores of 0–3 indicate severe family dysfunction, 4–6 denote moderate dysfunction, and 7–10 reflect healthy family function. The total Cronbach's α coefficient of this scale in the study was 0.895. 2.2.5 Psychological Detachment Scale for MHD Patients Tian Chunying [ 14 ] meticulously developed this scale and constructed an item pool to assess psychological detachment levels in MHD patients, drawing from qualitative research findings on psychological detachment in MHD patients and referencing research on hemodialysis complications [ 6 , 15 , 16 ], employment status, [ 17 ], marital quality, and positive disease perceptions. Its English version is provided in Supplementary File S3.The scale includes 55 items across five dimensions: Physical, Psychological, Social, Environmental, and Positive Feelings–Gains. Total scores, utilizing a 5-point Likert scale (1–5), can reach a maximum of 275. Higher scores indicate higher levels of positive factors influencing psychological detachment. The overall Cronbach's α coefficient is 0.949. The total Cronbach's α coefficient of this scale in the study was 0.921. 2.3 Data Collection Data were collected from November 5, 2024, to January 30, 2025, marking the duration of data collection. The detectives preemptively reached out to the medical personnel of the blood purification center. Subsequently, with the aid of the medical personnel at the blood purifying center, the investigators enlisted patients to partake in this survey. The researchers presented the objective and details of the study to the participants. After obtaining the patient's electronic informed consent form the investigators disseminated the questionnaires and apprised them of the pertinent considerations for completion. Demographic data was self-reported by the patients, whereas disease-related information was obtained by the investigator from the patients' medical records. For patients unable to independently complete the questionnaire, the investigator read the items aloud and recorded the responses accordingly. Upon completion of the questionnaire, a token of appreciation was bestowed upon the patient. After collection, a researcher verified completeness, excluding obviously erroneous responses, such as work experience listed for age. Invalid questionnaires were identified based on specific criteria: ① Response time below the theoretical minimum (30 minutes); ② Regular responses (e.g., 10 consecutive items with the same option); ③ Logical contradictions (e.g., age < 18 years but dialysis duration ≥ 5 years). Two researchers independently determined invalidity, while a third researcher mediated the disputes. We distributed a total of 250 questionnaires, yielding 232 valid responses (valid return rate: 92.8%). 2.4 Statistical Analysis We exported data from Wenjuanxing as .sav files and performed statistical analysis using SPSS 26.0 and AMOS 26.0. We employed frequencies, percentages, means, and standard deviations for statistical description, executed Pearson linear correlation analysis, performed mediation analysis via AMOS 26.0, and established structural equation models, with statistical significance defined at P < 0.05. 2.5 Ethics considerations Fear of Progression Questionnaire-Short Form (FoP-Q-SF): The Chinese version translated by Wu Qiyun et al. (2015) was employed, with written permission obtained from the original developers (Mehnert team) via email.Social Impact Scale (SIS): The Chinese version revised by Pan Aimei et al. (2007) was used, and authorization was confirmed by Prof. Fife’s team via email.Family APGAR Index: As a public-domain instrument, the Chinese version introduced by Lü Fan et al. (1995) requires no specific authorization.Self-designed scales (Demographic Questionnaire, Psychological Detachment Scale) were approved by the Ethics Committee. All scale applications complied with the Declaration of Helsinki. This study strictly adhered to the ethical guidelines of the Declaration of Helsinki and was approved by the Ethics Review Committee of Yichang Central People's Hospital (Approval Number: 2024-456-01). All research subjects provided electronic informed consent forms to comply with the ethical norms for human subject research. All research data are strictly confidential and will only be used for this study, which does not involve minors.Clinical trial number: not applicable. 3. Results 3.1 Demographic Characteristics of Participants We enrolled 232 MHD patients, including 125 males and 107 females. The participants included 140 individuals under 60 years and 92 individuals aged 61 and above, with a mean age of 56.12 years. Other demographic data are presented in Table 1 . 3.2 Comparison of Psychological Detachment Scores Among MHD Patients with Different Characteristics Univariate analysis revealed statistically significant differences in psychological detachment scores across age, family income, and long-term residence (P < 0.05). Items with no significant differences are listed in Table 1 . Table 1 Comparison of Psychological Detachment Scores Among MHD Patients with Different Characteristics (n = 232) Item Number (Percentage, %) Psychological Detachment Score (± S) t/F value P value Sex Male 125 (53.8) 194.45 ± 24.30 0.910 0.364 Female 107 (46.2) 191.53 ± 24.47 Age < 60 years 140 (60.3) 189.87 ± 26.04 -2.524 0.012 ≥ 61 years 92 (39.7) 198.03 ± 20.76 Educational Level Primary school or below 22 (9.5) 187.04 ± 23.85 1.850 0.120 Junior high school 58 (25) 188.43 ± 21.03 Senior high school 89 (38.3) 193.64 ± 24.95 Junior college 41 (17.7) 200.09 ± 25.97 Undergraduate 22 (9.5) 196.31 ± 25.73 Marital Status Married 199 (85.7) 194.04 ± 23.74 1.163 0.325 Unmarried 21 (9.1) 186.19 ± 26.70 Divorced 7 (3.0) 183.00 ± 26.36 Widowed 5 (2.2) 199.00 ± 35.42 Caregiver Self 107(46.1) 193.46 ± 25.87 1.216 0.305 Spouse 91 (39.2) 195.46 ± 23.50 Children 16 (6.9) 189.12 ± 21.11 Parents 16 (6.9) 181.68 ± 21.53 Nanny or care worker 2 (0.9) 190.00 ± 4.24 Employment Employed 53 (22.8) 193.39 ± 26.57 0.098 0.922 Non-employed 179 (77.2) 193.02 ± 23.75 Dialysis Duration ≤ 2 83 (35.8) 195.72 ± 23.02 0.530 0.662 2–5 51 (22) 192.00 ± 24.95 5–9 47 (20.2) 190.68 ± 24.65 ≥ 9 51 (22) 192.19 ± 25.96 Household Income ≤ 3000 84 (36.2) 186.64 ± 23.97 4.104 0.007 3000–6000 105 (45.3) 196.88 ± 24.19 6000–10000 32 (13.8) 200.00 ± 22.21 > 1,000 11 (4.7) 186.36 ± 24.37 Long-term Residence Urban 187 (80.6) 195.03 ± 23.80 4.085 0.018 County 26 (11.2) 189.38 ± 23.40 Rural 19 (8.2) 179.21 ± 27.25 3.3 Scores of Family Caring Degree, FoP, Social Impact, and Psychological Detachment Among Hemodialysis Patients The survey showed that the total score of family caring degree among MHD patients was 6.46 ± 2.20, FoP was 29.58 ± 8.61, social impact was 62.06 ± 11.12, and psychological detachment was 193.10 ± 24.37. The subscale scores for psychological detachment were: Physical (52.85 ± 6.09), Psychological (36.41 ± 5.70), Social (51.33 ± 9.12), Environmental (16.96 ± 2.17), and Positive Feelings–Gains (32.18 ± 7.22). The Physical dimension received the highest score, while the Environmental dimension had the lowest score. Other data are shown in Table 2 . Table 2 Scores of Family Caring Degree, FoP, Social Impact, and Psychological Detachment Among MHD Patients (n = 232) Item Item Count Total Score Mean Score per Item Family Caring Degree 5 6.46 ± 2.20 1.29 ± 0.44 Adaptation 1 1.23 ± 0.48 1.23 ± 0.48 Partnership 1 1.38 ± 0.59 1.38 ± 0.59 Growth 1 1.30 ± 0.51 1.30 ± 0.51 Affection 1 1.32 ± 0.54 1.32 ± 0.54 Resolve 1 1.20 ± 0.48 1.20 ± 0.48 Fear of Disease Progression 12 29.58 ± 8.61 2.46 ± 0.71 Physical Health 6 15.81 ± 4.33 2.63 ± 0.72 Social-Family 6 13.77 ± 5.09 2.29 ± 0.84 Social Impact 24 62.06 ± 11.12 2.58 ± 0.46 Social Rejection 9 24.3 ± 4.55 2.70 ± 0.50 Economic Discrimination 3 7.12 ± 1.81 2.37 ± 0.60 Internal Shame 5 12.76 ± 2.69 2.55 ± 0.53 Social Isolation 7 17.87 ± 3.42 2.55 ± 0.48 Psychological Detachment 55 193.10 ± 24.37 3.57 ± 0.45 Physical 16 52.85 ± 6.09 3.30 ± 0.38 Psychological 10 36.41 ± 5.70 3.64 ± 0.57 Society 15 51.33 ± 9.12 3.64 ± 0.66 Environmental 4 16.96 ± 2.17 4.24 ± 0.54 Positive Feelings–Gains 10 32.18 ± 7.22 3.21 ± 0.72 3.4 Correlation Analysis Among Family Caring Degree, FoP, Social Impact, and Psychological Detachment in MHD Patients Pearson correlation analysis showed that family care was positively correlated with fear of disease progression (r = 0.157, P < 0.001), negatively correlated with social impact (r = -0.205, P < 0.001), and negatively correlated with psychological disengagement (r = -0.218, P < 0.001). Fear of disease progression was negatively correlated with social impact (r = -0.412, P < 0.001) and negatively correlated with psychological disengagement (r = -0.336, P < 0.001). Social impact was positively correlated with psychological disengagement (r = 0.587, P < 0.001).Other data are shown in Table 3 . Table 3 Correlation Coefficients (r) Among Family Caring Degree, FoP, Social Impact, and Psychological Detachment in MHD Patients Family Support FoP Social Impact Psychological Detachment Family Support 1 FoP 0.157* 1 Social Impact -0.205** -0.412** 1 Psychological Detachment -0.218** -0.336** 0.587** 1 Note: * means P < 0.01, and ** means P < 0.05. 3.5 Mediating Effect Analysis of Family Caring Degree, FoP, Social Impact, and Psychological Detachment in MHD Patients Taking fear of disease progression as the mediating variable, stigma as the independent variable, and psychological detachment as the dependent variable, we constructed a structural equation model using AMOS 26.0, as illustrated in Fig. 1 . The model fit indices were as follows: χ²/df = 1.893, root mean square error of approximation (RMSEA) = 0.062 (excellent fit), goodness-of-fit index (GFI) = 0.939, adjusted goodness-of-fit index (AGFI) = 0.885, and comparative fit index (CFI) = 0.874 (good fit). Bootstrap test results indicated that the direct effect of stigma on psychological detachment was 0.63, accounting for 67.02% of the overall effect. The fear of disease progression played a partial mediating role between stigma and psychological detachment, with a mediating effect of 0.47 × 0.16 = 0.08, accounting for 8.51% of the total effect. The direct effect of family caring degree on stigma was 0.23. The total effect was 0.08 + 0.63 + 0.23 = 0.94. 4. Discussion 4.1 Psychological Detachment in MHD Patients Is at a Moderate Level and Needs Further Improvement This study found that the total score of psychological detachment in MHD patients was (193.10 ± 24.37), with a mean score per item of (3.57 ± 0.45), surpassing the findings of Wang Fang [ 18 ] . The Physical dimension recorded the highest total score (52.85 ± 6.09), while the Environmental dimension had the lowest (16.96 ± 2.17). Fatigue is common among MHD patients after dialysis, and multiple studies indicate that the duration of recovery from post-dialysis fatigue correlates with its severity—the longer the recovery period, the more severe the fatigue [ 19 ] . Studies have demonstrated that fatigue, pruritus, edema, and other symptoms are prevalent in MHD patients and serve as important predictors of quality of life [ 20 , 21 ] . Additionally, due to the long-term nature of dialysis treatment, patients must persist in long-term treatment to maintain physiological stability. During this process, patients encounter not only economic difficulties from escalating medical expenses but also bear pressures such as increased care burdens and family role changes. Patients with MHD are more vulnerable to mental health issues, including anxiety, inferiority, and depression, due to variables such as prolonged illness, limited physical function, and apprehensions of future uncertainties [ 22 ] .These negative emotions diminish social motivation and self-efficacy, leading patients to actively or passively curtail social participation, manifesting as social withdrawal behaviors such as avoiding social events and minimizing interpersonal interactions, which detrimentally impact social functions [ 23 ] . Univariate analysis showed that older patients and those living in urban areas had higher levels of psychological detachment. As age and dialysis duration increase, the physiological function of elderly MHD patients gradually declines, leading to a marked rise in the prevalence of frailty and sarcopenia, as evidenced by prior research indicating a significant escalation in these conditions within this demographic [ 24 ] . Meanwhile, decreased physical function reduces social interaction frequency, narrows social circles, and leads to social isolation—either through deliberate withdrawal from social engagement or passive disengagement from existing relationships—thereby impacting mental health and overall quality of life. Therefore, healthcare providers should prioritize elderly MHD patients characterized by older age, longer dialysis duration, and poor health status. We must customize comprehensive interventions through multidisciplinary collaboration, incorporating psychological support, social skills training, and community linkage, based on detailed assessments of social needs, to effectively enhance social status, address social demands, and improve overall quality of life and rehabilitation outcomes, thus offering scientific evidence and practical guidance for the long-term care of elderly MHD patients. MHD patients face numerous challenges. For example, those who are family breadwinners struggle to fulfill family responsibilities due to prolonged illness and recurrent dialysis, leading to heavy economic and care burdens. Negative psychological states such as inferiority, depression, and stigma persistently afflict patients [ 25 ] , diminishing their perceived control in disease management, daily life, and social interactions, thus greatly affecting physical-mental health and quality of life. Notably, patients with poor economic status frequently prioritize survival over social engagement, rendering social interactions a luxury and driving them toward social isolation due to immense financial pressure. Additionally, retired patients, a group that warrants attention, have sudden deteriorations in social roles, income, relationships, and lifestyle after falling ill [ 26 ], resulting in adjustment disorders and an escalating sensation of psychological detachment. Problems among patient populations interweave and compound difficulties for MHD patients during treatment and rehabilitation. During non-dialysis periods, patients physically detach from the dialysis environment and mentally disengage from dialysis-related concerns, temporarily freeing themselves from treatment-related cognitive patterns to relax and regain their pre-illness life states as much as possible [ 27 ] . Extensive study on disease benefit perception has revealed positive psychological experiences in hemodialysis patients, such as recognition of personal growth and advantages derived from illness [ 28 , 29 ] . Tian Chunying's [ 26 ] interview study showed that some MHD patients experienced more rest time, acquisition of abundant health knowledge, formation of new friendships, development of completely new life perspectives, and enjoyment derived from sharing and helping others following their illness. When patients' positive feelings and sense of gain exceed disease-related negative emotions, their psychological detachment increases, allowing them to fully escape dialysis-related distress. Therefore, clinicians should focus on MHD patients with low economic status, while governments should consistently optimize social security systems within feasible ranges—such as expanding dialysis medical insurance reimbursement ratios—to alleviate economic burdens, reduce social isolation risks, and foster physical-mental rehabilitation and social integration. 4.2 Mediating Effect Analysis 4.2.1 Relationship Between Stigma and Psychological Detachment in MHD Patients The results indicated that stigma affects patients' psychological detachment levels through family support, with a direct effect size of 0.23 and a mediating effect accounting for 24.46% of the total effect. Family function encompasses multidimensional interactions among members, manifested as effective communication, accurate role performance, collaborative coping with and flexible adaptation to family stress, and the preservation of appropriate mutual relationships [ 27 ] . From the psychosocial impact perspective, a positive and harmonious family atmosphere is crucial for patients, facilitating the construction of secure attachment relationships with family members [ 28 ], This enables individuals to acutely perceive environmental support, embrace self-acceptance, cultivate positive self-evaluations, and thereby stabilize and enhance emotional security. Conversely, in contexts of imbalanced family support, individuals' psychological needs remain unmet, prone to triggering self-doubt, distrust, anxiety, and potentially negative behavioral patterns like avoidance and withdrawal. These hinder the construction of healthy interpersonal relationships and the socialization process [ 29 ] , ultimately trapping individuals in loneliness and impeding the improvement of psychological detachment. Li Xue et al. [ 30 ] demonstrated that patients with higher family support can promptly obtain assistance and care from family members, effectively alleviating self-burden perception and psychological stress. The family's social system, characterized by inherent complexity and diversity, along with life events and the prevailing public opinion, impacts the efficacy of family function [ 31 ] . A good family support can alleviate patients' stigma toward dialysis and improve psychological detachment levels. Therefore, it is advisable for healthcare providers to pay attention to patients' family support, promptly assess their family caring status, and encourage family members to exert the supportive role of the family system, providing patients with more emotional support and value affirmation. Meanwhile, patients can regularly participate in exchange activities and public welfare mutual assistance activities among fellow patients to enhance their psychological detachment. The study revealed a direct effect value of 0.63 between stigma and psychological detachment. Research indicates that stigma, as a negative psychological experience, adversely affects patients' physical and mental health [ 32 ] . Despite being a crucial treatment modality, hemodialysis exerts detrimental psychological effects on patients for the following reasons: After treatment, patients experience substantial lifestyle alterations, including a restricted diet, limited water intake, and regular medical visits, which considerably diminish their autonomy; physical changes such as pruritus and complexion changes caused by dialysis contribute to a distorted self-image; if healthcare providers lack patience and care in communication and treatment, it is easy to make patients generate stigma. Multiple factors interact to aggravate patients' psychological burden, making them susceptible to negative emotions such as depression, anxiety, loss of morale, and despair [ 33 ] . Alleviating stigma experience can strengthen patients' understanding of the disease, facilitate adaptation to family role transition, and establish new models of labor division and responsibility-sharing, thereby bolstering family support; it can also elevate social participation levels, enhance social adaptability, and reduce loneliness [ 34 ] and psychological detachment. Therefore, it is imperative to call on all sectors of society to pay attention to the vulnerable group of MHD patients and build a continuous support mechanism involving hospitals, families, and the society. We urge patients to open their hearts, engage socially, and have the courage to self-disclose [35] , thereby accessing additional support, fostering a sense of security and belonging, enhancing emotional self-regulation, and mitigating stigma while promoting psychological detachment. 4.2.2 Mediating Effect of Fear of Disease Progression Between Stigma and Psychological Detachment in MHD Patients Structural equation modeling showed that FoP partially mediates the relationship between stigma and psychological detachment, indicating that stigma directly affects psychological detachment and indirectly predicts it through fear of disease progression, with the mediating effect accounting for 8.51% of the total effect. In MHD patients, stigma influences psychological detachment through both direct prediction and indirect effects via FoP [ 36 ] . Possible reasons include: First, stigma stemming from a sense of guilt arises from disease itself, physical changes, economic factors, emotional experiences, and role transitions. MHD patients with low self-esteem and strong inferiority related to their condition demonstrate high concern regarding health and future uncertainties, which affects FoP scores and thus their psychological detachment. Second, patients experiencing strong stigma often internalize unfavorable occurrences, perceiving their illness as a source of economic and caregiving responsibilities on their family members [ 37 ] , aggravating fear of disease progression. This manifests as excessive worry, hyperfocus on physical ailments, and withdrawal from familial and social interactions to avert more burdens, culminating in psychological detachment. Therefore, stronger stigma correlates with more intense FoP and lower psychological detachment. Intervening from the perspective of FoP holds value for improving patients' psychological detachment and social function recovery. Haack et al. [ 38 ] identified a significant association between FoP and quality of life, indicating that higher FoP levels correlate with lower quality of life. Moderate FoP can moderately and positively enhance patients' preventive health awareness and treatment adherence [ 39 , 40 ] . However, when fear reaches clinically significant levels (score ≥ 34), chronic intrusive thoughts about disease progression emerge, substantially aggravating psychological burden and triggering negative emotions like anxiety and depression, which impair quality of life. From the neuroendocrine-immune mechanism perspective, psychological responses regulate this complex mechanism to impact cancer patients' immune systems [ 41 ] . Patients apprehensive about disease progression or recurrence frequently employ maladaptive coping mechanisms, which diminish treatment adherence, impair immune function, intensify unpleasant effects such as nausea, vomiting, and radiation enteritis, and substantially degrade quality of life. Healthcare providers can use aromatherapy to alleviate anxiety, depression, and symptoms like insomnia or nausea, while implementing positive psychological interventions to harness patients' potential, eliminate fear, facilitate correct disease cognition, and assist them in adopting a constructive mindset to restore life confidence, thereby improving psychological detachment. 4.3 Limitations and recommendations This study initially explored the associations and functioning processes among familial caregiving, stigma, fear of disease progression, and psychological detachment, yet it has several limitations. The sample was solely drawn from the blood purification center of Yichang Central People's Hospital, resulting in limited regional representativeness; differences across regions in economic status, medical resources, cultural customs, and social security regulations may affect patients' psychosocial experiences, warranting caution regarding the generalizability of findings. Though the sample size calculation is reasonable, convenience sampling may introduce selection bias—patients with more severe conditions, poor psychological status, or limited communication skills may have low participation willingness or difficulty participating, potentially underestimating the problem's severity. Additionally, the extremely low proportion of rural household patients (8.2%) restricts the generalizability of results to rural maintenance hemodialysis patients.​ Moreover, the psychological detachment scale compiled by Tian Chunying, despite good reliability and validity, requires more evidence for its theoretical basis, dimensional structure, and verification in mental illness populations, especially when compared with more mature and widely validated "psychological detachment" measurement tools (e.g., the psychological detachment subscale in the Work-domain Recovery Experience Questionnaire). The reasons for the lowest scores in the "environment" dimension also demand in-depth exploration. Furthermore, the research model showing partial mediation may have omitted other important mediating or moderating variables, such as patients' coping styles. To enhance the representativeness and generalizability of findings, future research should conduct multicenter collaborative studies involving diverse regions and hospital tiers nationwide, with a focus on increasing the proportion of rural patients. This approach will allow for a broader and more representative sample, enabling exploration of similarities and differences in influencing mechanisms across various geographical, economic, and cultural contexts. Additionally, future research ought to systematically incorporate and examine more potential mediating variables (e.g., coping styles, self-efficacy, social support networks) and moderating variables (e.g., personality traits, disease stage, socio-demographic characteristics) to develop a more comprehensive theoretical model that accounts for greater variance—specifically, investigating alternative mechanisms through which familial caregiving affects psychological disengagement. Furthermore, efforts should be made to further validate and refine psychological disengagement assessment instruments for MHD patients, or to introduce more sophisticated concepts (e.g., recovery experiences within the work-family interface) into MHD research for cross-cultural adaptation and validation. 5. Conclusion This cross-sectional study explored the relationships among family caring degree, stigma, fear of disease progression, and psychological detachment in MHD patients, verifying that fear of disease progression plays a partial mediating role. Stigma and fear of disease progression positively influence psychological detachment. Nurses should prioritize the importance of family support in MHD patients' rehabilitation, bolster family resilience by augmenting internal resources, and mitigate stigma and fear of disease progression to improve psychological detachment. Declarations 6.1 Ethics Approval and Consent to Participate This study strictly adhered to the ethical guidelines of the Declaration of Helsinki and was approved by the Ethics Review Committee of Yichang Central People's Hospital (Approval Number: 2024-456-01). All participants provided electronic informed consent prior to enrollment, in compliance with human subject research ethical norms. The study did not involve minors, and all research data are strictly confidential and used exclusively for this study. 6.2 Funding The authors declare that no specific external funding was received for this study from any public, commercial, or not-for-profit funding agencies. All study processes—including participant recruitment, administration of assessment scales (Fear of Progression Questionnaire-Short Form, Social Impact Scale, Family APGAR Index, and Psychological Detachment Scale), data collection and statistical analysis (via SPSS 26.0 and AMOS 26.0), and manuscript drafting and revision—were completed using internal resources of the research team from the Blood Purification Center and Nursing Department of Yichang Central People’s Hospital Affiliated to China Three Gorges University. The funding status had no impact on study design, data interpretation, result reporting, or the decision to submit the manuscript for publication. 6.3 Conflict of Interest All authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. 6.4 Availability of Data and Materials The dataset used in this study is available as Supplementary File S1 (XLSX). The English versions of the self-designed questionnaires (Demographic Questionnaire and Psychological Detachment Scale for MHD Patients) are provided in Supplementary Files S2 (DOCX) and S3 (DOCX), respectively. All other scales used in the study are publicly available or have obtained necessary authorization from the original developers [see 2.5 Ethics considerations and relevant sections in 2.2 Survey Instruments]. 6.5 Authors' Contributions Conceptualization: LIU Cong, WEI Yongting Data curation: LYU Xiaoran, WANG Qin, LIU Nian, LI Xianglin, YOU Lang, ZOU Li Formal analysis: LIU Cong Investigation: XI Zuyang Methodology: LIU Cong, WEI Yongting Project administration: WU Jianyi Software: Randah Barakat Supervision: XI Zuyang Validation: WEI Yongting Writing – original draft: LIU Cong Writing – review & editing: LIU Cong, XI Zuyang Clinical Trial Registration This study is a cross-sectional observational study, and clinical trial registration is not applicable. 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Supplementary Files S2File.EnglishVersionofDemographicQuestionnaire.docx S3File.EnglishVersionofPsychologicalDetachmentScaleforMHDPatients.docx Cite Share Download PDF Status: Published Journal Publication published 10 Apr, 2026 Read the published version in BMC Nephrology → Version 1 posted Editorial decision: Revision requested 05 Jan, 2026 Reviews received at journal 03 Dec, 2025 Reviewers agreed at journal 27 Oct, 2025 Reviews received at journal 12 Oct, 2025 Reviewers agreed at journal 12 Oct, 2025 Reviewers invited by journal 26 Sep, 2025 Editor assigned by journal 26 Sep, 2025 Editor invited by journal 15 Sep, 2025 Submission checks completed at journal 11 Sep, 2025 First submitted to journal 11 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Introduction","content":"\u003cp\u003eMaintenance hemodialysis (MHD) is the most prevalent renal replacement therapy for patients with end-stage renal disease (ESRD). By the end of 2022, the population of MHD patients in mainland China exceeded 840,000, ranking first worldwide \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Although long-term MHD treatment alleviates symptoms of ESRD, the irreversible deterioration of residual renal function, along with increased complications such as calcium-phosphorus metabolism disorders, cardiovascular diseases, and microinflammatory responses, results in many patients suffering from physical symptoms like restless legs syndrome, fatigue, and sleep disorders.\u003c/p\u003e\u003cp\u003eThese patients may also face psychological challenges, including restlessness, depression, and anxiety, which serve as stressors. They may also experience varied degrees of psychological distress such as tension, depression, and anxiety, which serve as symptomatic stressors for patients. The stress process theory \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e posits that when individuals encounter stressors, a series of physiological, psychological, and behavioral responses arises, influenced by the interaction, feedback regulation, and control of internal and external factors, encompassing cognitive appraisal, social support, coping styles, and personality traits, further influencing their health or disease status.\u003c/p\u003e\u003cp\u003ePsychological detachment, within the framework of positive psychology, generally refers to individuals' disengagement from stressful environments or events. The effort-recovery theory \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e suggests that psychological detachment is essential for recovery experiences, and an appropriate level of psychological detachment enables individuals to effectively replenish the physical and mental resources exhausted by work-related stress. Psychological detachment, closely associated with positive outcomes and manifested by dual physical and psychological disengagement, facilitates stress reduction, the restoration of positive emotions, and the replenishment of exhausted physical and mental resources. Fear of disease progression (FoP) denotes individuals' apprehension regarding all facets related to their current diseases. Prolonged FoP easily induces depressive emotions in patients \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Stigma, also known as the social impact of disease, primarily signifies patients' internalized shame experienced by patients about their illnesses. In the dialysis patient population, stigma triggers emotional fluctuations, psychological disorders, weakened self-care ability, reduced treatment adherence, and avoidance of normal social interactions. Stigma is also a high-risk factor for depression \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Theoretically, stigma among patients should promote psychological detachment; however, no studies have confirmed the relationship between stigma and psychological detachment, and the potential existence of individual-level mediating variables necessitates urgent investigation.\u003c/p\u003e\u003cp\u003eResearch indicates \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e that family structure and function are intricately associated with the quality of life in hemodialysis patients, with robust family support significantly improving patients' quality of life. Based on the above theories, external environments and internal factors interact to shape individual behavior. Stigma, as the primary emotional response to psychological detachment, reflects patients' positive emotion towards stigma and their authentic experiences of the external environment, affecting their level of psychological detachment. The psychological detachment level of MHD patients directly impacts their quality of life and social functions.\u003c/p\u003e\u003cp\u003eHowever, existing studies mainly focus on single psychological factors, neglecting the exploration of the interaction mechanisms among multiple variables. Additionally, the empirical investigation of how family support affects psychological detachment through stigma and FoP remains unexamined. Consequently, it is crucial to examine and systematically analyze this mechanism and evaluate whether FoP and stigma mediate the relationship between family support and psychological detachment in MHD patients. Therefore, this study aims to explore the mediating effects of FoP and stigma on the link between family support and psychological detachment among MHD patients, providing references for improving their psychological detachment levels.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Participant Selection\u003c/h2\u003e\u003cp\u003eWe used convenience sampling to recruit maintenance hemodialysis (MHD) patients from the Blood Purification Center of Yichang Central People's Hospital, Hubei Province, in November 5, 2024. Inclusion criteria: MHD treatment duration\u0026thinsp;\u0026ge;\u0026thinsp;3 months; age\u0026thinsp;\u0026gt;\u0026thinsp;18 years; clear consciousness, normal intelligence and hearing, able to correctly complete the questionnaire. Exclusion criteria: ① Complicated by severe organ dysfunction such as NYHA Class IV cardiac function or Child-Pugh Class C liver function; ② Experienced major negative life events, such as bereavement and unemployment, within the past 3 months; ③ Diagnosed with mental illnesses such as schizophrenia or bipolar disorder; ④ Non-local permanent or temporary dialysis patients; ⑤ Planned to receive kidney transplantation or transition to peritoneal dialysis within 3 months. ④ Non-local permanent or temporary dialysis patients; ⑤ Scheduled to undergo kidney transplantation or transition to peritoneal dialysis within three months. We calculated the sample size using the cross-sectional linear correlation formula: n\u0026thinsp;=\u0026thinsp;4[(\u0026micro;α\u0026thinsp;+\u0026thinsp;\u0026micro;β)/ln((1\u0026thinsp;+\u0026thinsp;r)/(1 - r))]\u0026sup2; + 3, with α\u0026thinsp;=\u0026thinsp;0.05 and β\u0026thinsp;=\u0026thinsp;0.1. A pilot study indicated that a minimum correlation coefficient (r\u0026thinsp;=\u0026thinsp;0.269) among FoP, stigma, family caring degree, and psychological detachment yielded a minimum sample size of 142. After accounting for a 20% invalid response rate, the final sample size was 178.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Survey Instruments\u003c/h2\u003e\u003cdiv id=\"Sec5\" class=\"Section3\"\u003e\u003ch2\u003e2.2.1 Demographic Questionnaire\u003c/h2\u003e\u003cp\u003eThe researchers designed the demographic questionnaire in accordance with the research's objectives and relevance, including age, gender, marital status, educational level, employment status, family monthly per capita income, dialysis duration, and medical payment method. The Demographic Questionnaire was self-designed for this study, and its English version is available in Supplementary File S2.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\u003ch2\u003e2.2.2 Fear of Progression Questionnaire-Short Form\u003c/h2\u003e\u003cp\u003eThe Fear of Progression Questionnaire-Short Form (FoP-Q-SF)was originally developed by Mehnert et al. \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e in 2006 through the simplification of the Fear of Progression Scale, was translated into Chinese and adapted by Wu Qiyun et al. \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e in 2015, was used in this study, with written permission obtained from the original developers (Mehnert team) via email [see 2.5 Ethics considerations]. It consists of 12 items across two dimensions: Physical Health and Social-Family. The total scores, derived on a 5-point Likert scale (1 = \"never,\" 5 = \"always\"), range from 12 to 60, with higher scores indicating an increased fear of progression. The Cronbach\u0026rsquo;s α coefficient is 0.883. The total Cronbach's α coefficient of this scale in the study was 0.888.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\u003ch2\u003e2.2.3 Stigma Scale\u003c/h2\u003e\u003cp\u003eWe used the Social Impact Scale (SIS) developed by Fife et al. \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e to measure the social and psychological impact of the disease, specifically stigma. Revised and translated by Pan et al. \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e in 2007.Authorization for using the Chinese version was confirmed by Prof. Fife\u0026rsquo;s team via email [see 2.5 Ethics considerations].The scale includes four dimensions: Social Rejection (9 items), Economic Discrimination (3 items), Internal Shame (5 items), and Social Isolation (7 items), amounting to a total of 24 items. The 4-point Likert scale (1 = \"strongly disagree,\" 2 = \"disagree,\" 3 = \"agree,\" 4 = \"strongly agree\") yields total scores between 24 to 96, where higher scores signify greater stigma. The Cronbach's α coefficient is 0.85\u0026ndash;0.90 \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. The total Cronbach's α coefficient of this scale in the study was 0.951.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\u003ch2\u003e2.2.4 Family APGAR Index\u003c/h2\u003e\u003cp\u003eDesigned by American physician Smilkstein \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e and introduced to China by Chinese scholars LYU Fan et al. \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e in 1995, is a public-domain instrument requiring no specific authorizationthis. The scale assesses patients' satisfaction with family function by evaluating their perception of family care level. The scale, exhibiting a Cronbach's α coefficient of 0.83, comprises five items: Adaptation, Partnership, Growth, Affection, and Resolve. Utilizing a 3-point Likert scale (2 = \"often,\" 1 = \"sometimes,\" 0 = \"almost never\"), total scores range from 0 to 10. Tota scores of 0\u0026ndash;3 indicate severe family dysfunction, 4\u0026ndash;6 denote moderate dysfunction, and 7\u0026ndash;10 reflect healthy family function. The total Cronbach's α coefficient of this scale in the study was 0.895.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003e2.2.5 Psychological Detachment Scale for MHD Patients\u003c/h2\u003e\u003cp\u003eTian Chunying \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e meticulously developed this scale and constructed an item pool to assess psychological detachment levels in MHD patients, drawing from qualitative research findings on psychological detachment in MHD patients and referencing research on hemodialysis complications \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e],\u003c/sup\u003e employment status, \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e],\u003c/sup\u003e marital quality, and positive disease perceptions. Its English version is provided in Supplementary File S3.The scale includes 55 items across five dimensions: Physical, Psychological, Social, Environmental, and Positive Feelings\u0026ndash;Gains. Total scores, utilizing a 5-point Likert scale (1\u0026ndash;5), can reach a maximum of 275. Higher scores indicate higher levels of positive factors influencing psychological detachment. The overall Cronbach's α coefficient is 0.949. The total Cronbach's α coefficient of this scale in the study was 0.921.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Data Collection\u003c/h2\u003e\u003cp\u003eData were collected from November 5, 2024, to January 30, 2025, marking the duration of data collection. The detectives preemptively reached out to the medical personnel of the blood purification center. Subsequently, with the aid of the medical personnel at the blood purifying center, the investigators enlisted patients to partake in this survey. The researchers presented the objective and details of the study to the participants. After obtaining the patient's electronic informed consent form the investigators disseminated the questionnaires and apprised them of the pertinent considerations for completion. Demographic data was self-reported by the patients, whereas disease-related information was obtained by the investigator from the patients' medical records. For patients unable to independently complete the questionnaire, the investigator read the items aloud and recorded the responses accordingly. Upon completion of the questionnaire, a token of appreciation was bestowed upon the patient. After collection, a researcher verified completeness, excluding obviously erroneous responses, such as work experience listed for age. Invalid questionnaires were identified based on specific criteria: ① Response time below the theoretical minimum (30 minutes); ② Regular responses (e.g., 10 consecutive items with the same option); ③ Logical contradictions (e.g., age\u0026thinsp;\u0026lt;\u0026thinsp;18 years but dialysis duration\u0026thinsp;\u0026ge;\u0026thinsp;5 years). Two researchers independently determined invalidity, while a third researcher mediated the disputes. We distributed a total of 250 questionnaires, yielding 232 valid responses (valid return rate: 92.8%).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Statistical Analysis\u003c/h2\u003e\u003cp\u003eWe exported data from Wenjuanxing as .sav files and performed statistical analysis using SPSS 26.0 and AMOS 26.0. We employed frequencies, percentages, means, and standard deviations for statistical description, executed Pearson linear correlation analysis, performed mediation analysis via AMOS 26.0, and established structural equation models, with statistical significance defined at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Ethics considerations\u003c/h2\u003e\u003cp\u003eFear of Progression Questionnaire-Short Form (FoP-Q-SF): The Chinese version translated by Wu Qiyun et al. (2015) was employed, with written permission obtained from the original developers (Mehnert team) via email.Social Impact Scale (SIS): The Chinese version revised by Pan Aimei et al. (2007) was used, and authorization was confirmed by Prof. Fife\u0026rsquo;s team via email.Family APGAR Index: As a public-domain instrument, the Chinese version introduced by L\u0026uuml; Fan et al. (1995) requires no specific authorization.Self-designed scales (Demographic Questionnaire, Psychological Detachment Scale) were approved by the Ethics Committee. All scale applications complied with the Declaration of Helsinki.\u003c/p\u003e\u003cp\u003e This study strictly adhered to the ethical guidelines of the Declaration of Helsinki and was approved by the Ethics Review Committee of Yichang Central People's Hospital (Approval Number: 2024-456-01). All research subjects provided electronic informed consent forms to comply with the ethical norms for human subject research. All research data are strictly confidential and will only be used for this study, which does not involve minors.Clinical trial number: not applicable.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Demographic Characteristics of Participants\u003c/h2\u003e\u003cp\u003eWe enrolled 232 MHD patients, including 125 males and 107 females. The participants included 140 individuals under 60 years and 92 individuals aged 61 and above, with a mean age of 56.12 years. Other demographic data are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Comparison of Psychological Detachment Scores Among MHD Patients with Different Characteristics\u003c/h2\u003e\u003cp\u003eUnivariate analysis revealed statistically significant differences in psychological detachment scores across age, family income, and long-term residence (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Items with no significant differences are listed in 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\u003eComparison of Psychological Detachment Scores Among MHD Patients with Different Characteristics (n\u0026thinsp;=\u0026thinsp;232)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNumber (Percentage, %)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003ePsychological Detachment\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eScore (\u0026plusmn;\u0026thinsp;S) \u003cspan class=\"InlineEquation\"\u003e\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003et/F value\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eP value\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\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e125 (53.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e194.45\u0026thinsp;\u0026plusmn;\u0026thinsp;24.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.910\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.364\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e107 (46.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e191.53\u0026thinsp;\u0026plusmn;\u0026thinsp;24.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;60 years\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e140 (60.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e189.87\u0026thinsp;\u0026plusmn;\u0026thinsp;26.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-2.524\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.012\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\u003e\u0026ge;\u0026thinsp;61 years\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e92 (39.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e198.03\u0026thinsp;\u0026plusmn;\u0026thinsp;20.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducational Level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary school or below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (9.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e187.04\u0026thinsp;\u0026plusmn;\u0026thinsp;23.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.850\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.120\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\u003eJunior high school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58 (25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e188.43\u0026thinsp;\u0026plusmn;\u0026thinsp;21.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSenior high school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e89 (38.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e193.64\u0026thinsp;\u0026plusmn;\u0026thinsp;24.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eJunior college\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41 (17.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e200.09\u0026thinsp;\u0026plusmn;\u0026thinsp;25.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUndergraduate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (9.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e196.31\u0026thinsp;\u0026plusmn;\u0026thinsp;25.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarital Status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e199 (85.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e194.04\u0026thinsp;\u0026plusmn;\u0026thinsp;23.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.163\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.325\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\u003eUnmarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (9.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e186.19\u0026thinsp;\u0026plusmn;\u0026thinsp;26.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDivorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e183.00\u0026thinsp;\u0026plusmn;\u0026thinsp;26.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWidowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (2.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e199.00\u0026thinsp;\u0026plusmn;\u0026thinsp;35.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCaregiver\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSelf\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e107(46.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e193.46\u0026thinsp;\u0026plusmn;\u0026thinsp;25.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.216\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.305\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\u003eSpouse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e91 (39.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e195.46\u0026thinsp;\u0026plusmn;\u0026thinsp;23.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChildren\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (6.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e189.12\u0026thinsp;\u0026plusmn;\u0026thinsp;21.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eParents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (6.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e181.68\u0026thinsp;\u0026plusmn;\u0026thinsp;21.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNanny or care worker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (0.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e190.00\u0026thinsp;\u0026plusmn;\u0026thinsp;4.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmployment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53 (22.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e193.39\u0026thinsp;\u0026plusmn;\u0026thinsp;26.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.098\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.922\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\u003eNon-employed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e179 (77.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e193.02\u0026thinsp;\u0026plusmn;\u0026thinsp;23.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDialysis Duration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e83 (35.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e195.72\u0026thinsp;\u0026plusmn;\u0026thinsp;23.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.530\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.662\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\u003e2\u0026ndash;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51 (22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e192.00\u0026thinsp;\u0026plusmn;\u0026thinsp;24.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u0026ndash;9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47 (20.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e190.68\u0026thinsp;\u0026plusmn;\u0026thinsp;24.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;9\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51 (22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e192.19\u0026thinsp;\u0026plusmn;\u0026thinsp;25.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHousehold Income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;3000\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e84 (36.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e186.64\u0026thinsp;\u0026plusmn;\u0026thinsp;23.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.104\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.007\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\u003e3000\u0026ndash;6000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e105 (45.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e196.88\u0026thinsp;\u0026plusmn;\u0026thinsp;24.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6000\u0026ndash;10000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32 (13.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e200.00\u0026thinsp;\u0026plusmn;\u0026thinsp;22.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;1,000\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (4.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e186.36\u0026thinsp;\u0026plusmn;\u0026thinsp;24.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLong-term Residence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e187 (80.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e195.03\u0026thinsp;\u0026plusmn;\u0026thinsp;23.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.085\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.018\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\u003eCounty\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (11.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e189.38\u0026thinsp;\u0026plusmn;\u0026thinsp;23.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (8.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e179.21\u0026thinsp;\u0026plusmn;\u0026thinsp;27.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Scores of Family Caring Degree, FoP, Social Impact, and Psychological Detachment Among Hemodialysis Patients\u003c/h2\u003e\u003cp\u003eThe survey showed that the total score of family caring degree among MHD patients was 6.46\u0026thinsp;\u0026plusmn;\u0026thinsp;2.20, FoP was 29.58\u0026thinsp;\u0026plusmn;\u0026thinsp;8.61, social impact was 62.06\u0026thinsp;\u0026plusmn;\u0026thinsp;11.12, and psychological detachment was 193.10\u0026thinsp;\u0026plusmn;\u0026thinsp;24.37. The subscale scores for psychological detachment were: Physical (52.85\u0026thinsp;\u0026plusmn;\u0026thinsp;6.09), Psychological (36.41\u0026thinsp;\u0026plusmn;\u0026thinsp;5.70), Social (51.33\u0026thinsp;\u0026plusmn;\u0026thinsp;9.12), Environmental (16.96\u0026thinsp;\u0026plusmn;\u0026thinsp;2.17), and Positive Feelings\u0026ndash;Gains (32.18\u0026thinsp;\u0026plusmn;\u0026thinsp;7.22). The Physical dimension received the highest score, while the Environmental dimension had the lowest score. Other data are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\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\u003eScores of Family Caring Degree, FoP, Social Impact, and Psychological Detachment Among MHD Patients (n\u0026thinsp;=\u0026thinsp;232)\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=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eItem Count\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal Score\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean Score per Item\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily Caring Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e6.46\u0026thinsp;\u0026plusmn;\u0026thinsp;2.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e1.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdaptation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e1.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePartnership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e1.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrowth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e1.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAffection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.32\u0026thinsp;\u0026plusmn;\u0026thinsp;0.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e1.32\u0026thinsp;\u0026plusmn;\u0026thinsp;0.54\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResolve\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e1.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFear of Disease Progression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e29.58\u0026thinsp;\u0026plusmn;\u0026thinsp;8.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e2.46\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical Health\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e15.81\u0026thinsp;\u0026plusmn;\u0026thinsp;4.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e2.63\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial-Family\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e13.77\u0026thinsp;\u0026plusmn;\u0026thinsp;5.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e2.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.84\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial Impact\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e62.06\u0026thinsp;\u0026plusmn;\u0026thinsp;11.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e2.58\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial Rejection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e24.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e2.70\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEconomic Discrimination\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e7.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e2.37\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInternal Shame\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e12.76\u0026thinsp;\u0026plusmn;\u0026thinsp;2.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e2.55\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial Isolation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e17.87\u0026thinsp;\u0026plusmn;\u0026thinsp;3.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e2.55\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychological Detachment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e193.10\u0026thinsp;\u0026plusmn;\u0026thinsp;24.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e3.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e52.85\u0026thinsp;\u0026plusmn;\u0026thinsp;6.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e3.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychological\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e36.41\u0026thinsp;\u0026plusmn;\u0026thinsp;5.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e3.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSociety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e51.33\u0026thinsp;\u0026plusmn;\u0026thinsp;9.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e3.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEnvironmental\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e16.96\u0026thinsp;\u0026plusmn;\u0026thinsp;2.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e4.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.54\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePositive Feelings\u0026ndash;Gains\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e32.18\u0026thinsp;\u0026plusmn;\u0026thinsp;7.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e3.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72\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=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Correlation Analysis Among Family Caring Degree, FoP, Social Impact, and Psychological Detachment in MHD Patients\u003c/h2\u003e\u003cp\u003ePearson correlation analysis showed that family care was positively correlated with fear of disease progression (r\u0026thinsp;=\u0026thinsp;0.157, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), negatively correlated with social impact (r = -0.205, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and negatively correlated with psychological disengagement (r = -0.218, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Fear of disease progression was negatively correlated with social impact (r = -0.412, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and negatively correlated with psychological disengagement (r = -0.336, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Social impact was positively correlated with psychological disengagement (r\u0026thinsp;=\u0026thinsp;0.587, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).Other data are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\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\u003eCorrelation Coefficients (r) Among Family Caring Degree, FoP, Social Impact, and Psychological Detachment in MHD Patients\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=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFamily Support\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFoP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSocial Impact\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePsychological Detachment\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\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\u003eFoP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.157*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\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\u003eSocial Impact\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.205**\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.412**\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychological Detachment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.218**\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.336**\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.587**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote: * means P\u0026thinsp;\u0026lt;\u0026thinsp;0.01, and ** means P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e3.5 Mediating Effect Analysis of Family Caring Degree, FoP, Social Impact, and Psychological Detachment in MHD Patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTaking fear of disease progression as the mediating variable, stigma as the independent variable, and psychological detachment as the dependent variable, we constructed a structural equation model using AMOS 26.0, as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The model fit indices were as follows: χ\u0026sup2;/df\u0026thinsp;=\u0026thinsp;1.893, root mean square error of approximation (RMSEA)\u0026thinsp;=\u0026thinsp;0.062 (excellent fit), goodness-of-fit index (GFI)\u0026thinsp;=\u0026thinsp;0.939, adjusted goodness-of-fit index (AGFI)\u0026thinsp;=\u0026thinsp;0.885, and comparative fit index (CFI)\u0026thinsp;=\u0026thinsp;0.874 (good fit).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eBootstrap test results indicated that the direct effect of stigma on psychological detachment was 0.63, accounting for 67.02% of the overall effect. The fear of disease progression played a partial mediating role between stigma and psychological detachment, with a mediating effect of 0.47 \u0026times; 0.16\u0026thinsp;=\u0026thinsp;0.08, accounting for 8.51% of the total effect. The direct effect of family caring degree on stigma was 0.23. The total effect was 0.08\u0026thinsp;+\u0026thinsp;0.63\u0026thinsp;+\u0026thinsp;0.23\u0026thinsp;=\u0026thinsp;0.94.\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Psychological Detachment in MHD Patients Is at a Moderate Level and Needs Further Improvement\u003c/h2\u003e\u003cp\u003eThis study found that the total score of psychological detachment in MHD patients was (193.10\u0026thinsp;\u0026plusmn;\u0026thinsp;24.37), with a mean score per item of (3.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45), surpassing the findings of Wang Fang \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. The Physical dimension recorded the highest total score (52.85\u0026thinsp;\u0026plusmn;\u0026thinsp;6.09), while the Environmental dimension had the lowest (16.96\u0026thinsp;\u0026plusmn;\u0026thinsp;2.17). Fatigue is common among MHD patients after dialysis, and multiple studies indicate that the duration of recovery from post-dialysis fatigue correlates with its severity\u0026mdash;the longer the recovery period, the more severe the fatigue \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Studies have demonstrated that fatigue, pruritus, edema, and other symptoms are prevalent in MHD patients and serve as important predictors of quality of life \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. Additionally, due to the long-term nature of dialysis treatment, patients must persist in long-term treatment to maintain physiological stability. During this process, patients encounter not only economic difficulties from escalating medical expenses but also bear pressures such as increased care burdens and family role changes. Patients with MHD are more vulnerable to mental health issues, including anxiety, inferiority, and depression, due to variables such as prolonged illness, limited physical function, and apprehensions of future uncertainties \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e .These negative emotions diminish social motivation and self-efficacy, leading patients to actively or passively curtail social participation, manifesting as social withdrawal behaviors such as avoiding social events and minimizing interpersonal interactions, which detrimentally impact social functions \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e .\u003c/p\u003e\u003cp\u003eUnivariate analysis showed that older patients and those living in urban areas had higher levels of psychological detachment. As age and dialysis duration increase, the physiological function of elderly MHD patients gradually declines, leading to a marked rise in the prevalence of frailty and sarcopenia, as evidenced by prior research indicating a significant escalation in these conditions within this demographic\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. Meanwhile, decreased physical function reduces social interaction frequency, narrows social circles, and leads to social isolation\u0026mdash;either through deliberate withdrawal from social engagement or passive disengagement from existing relationships\u0026mdash;thereby impacting mental health and overall quality of life. Therefore, healthcare providers should prioritize elderly MHD patients characterized by older age, longer dialysis duration, and poor health status. We must customize comprehensive interventions through multidisciplinary collaboration, incorporating psychological support, social skills training, and community linkage, based on detailed assessments of social needs, to effectively enhance social status, address social demands, and improve overall quality of life and rehabilitation outcomes, thus offering scientific evidence and practical guidance for the long-term care of elderly MHD patients.\u003c/p\u003e\u003cp\u003eMHD patients face numerous challenges. For example, those who are family breadwinners struggle to fulfill family responsibilities due to prolonged illness and recurrent dialysis, leading to heavy economic and care burdens. Negative psychological states such as inferiority, depression, and stigma persistently afflict patients \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e, diminishing their perceived control in disease management, daily life, and social interactions, thus greatly affecting physical-mental health and quality of life. Notably, patients with poor economic status frequently prioritize survival over social engagement, rendering social interactions a luxury and driving them toward social isolation due to immense financial pressure. Additionally, retired patients, a group that warrants attention, have sudden deteriorations in social roles, income, relationships, and lifestyle after falling ill \u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e],\u003c/sup\u003e resulting in adjustment disorders and an escalating sensation of psychological detachment. Problems among patient populations interweave and compound difficulties for MHD patients during treatment and rehabilitation. During non-dialysis periods, patients physically detach from the dialysis environment and mentally disengage from dialysis-related concerns, temporarily freeing themselves from treatment-related cognitive patterns to relax and regain their pre-illness life states as much as possible \u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. Extensive study on disease benefit perception has revealed positive psychological experiences in hemodialysis patients, such as recognition of personal growth and advantages derived from illness \u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. Tian Chunying's \u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e interview study showed that some MHD patients experienced more rest time, acquisition of abundant health knowledge, formation of new friendships, development of completely new life perspectives, and enjoyment derived from sharing and helping others following their illness. When patients' positive feelings and sense of gain exceed disease-related negative emotions, their psychological detachment increases, allowing them to fully escape dialysis-related distress. Therefore, clinicians should focus on MHD patients with low economic status, while governments should consistently optimize social security systems within feasible ranges\u0026mdash;such as expanding dialysis medical insurance reimbursement ratios\u0026mdash;to alleviate economic burdens, reduce social isolation risks, and foster physical-mental rehabilitation and social integration.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Mediating Effect Analysis\u003c/h2\u003e\u003cdiv id=\"Sec21\" class=\"Section3\"\u003e\u003ch2\u003e4.2.1 Relationship Between Stigma and Psychological Detachment in MHD Patients\u003c/h2\u003e\u003cp\u003eThe results indicated that stigma affects patients' psychological detachment levels through family support, with a direct effect size of 0.23 and a mediating effect accounting for 24.46% of the total effect. Family function encompasses multidimensional interactions among members, manifested as effective communication, accurate role performance, collaborative coping with and flexible adaptation to family stress, and the preservation of appropriate mutual relationships \u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. From the psychosocial impact perspective, a positive and harmonious family atmosphere is crucial for patients, facilitating the construction of secure attachment relationships with family members \u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e],\u003c/sup\u003e This enables individuals to acutely perceive environmental support, embrace self-acceptance, cultivate positive self-evaluations, and thereby stabilize and enhance emotional security. Conversely, in contexts of imbalanced family support, individuals' psychological needs remain unmet, prone to triggering self-doubt, distrust, anxiety, and potentially negative behavioral patterns like avoidance and withdrawal. These hinder the construction of healthy interpersonal relationships and the socialization process \u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e, ultimately trapping individuals in loneliness and impeding the improvement of psychological detachment. Li Xue et al. \u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e demonstrated that patients with higher family support can promptly obtain assistance and care from family members, effectively alleviating self-burden perception and psychological stress. The family's social system, characterized by inherent complexity and diversity, along with life events and the prevailing public opinion, impacts the efficacy of family function \u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e. A good family support can alleviate patients' stigma toward dialysis and improve psychological detachment levels. Therefore, it is advisable for healthcare providers to pay attention to patients' family support, promptly assess their family caring status, and encourage family members to exert the supportive role of the family system, providing patients with more emotional support and value affirmation. Meanwhile, patients can regularly participate in exchange activities and public welfare mutual assistance activities among fellow patients to enhance their psychological detachment.\u003c/p\u003e\u003cp\u003eThe study revealed a direct effect value of 0.63 between stigma and psychological detachment. Research indicates that stigma, as a negative psychological experience, adversely affects patients' physical and mental health \u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e. Despite being a crucial treatment modality, hemodialysis exerts detrimental psychological effects on patients for the following reasons: After treatment, patients experience substantial lifestyle alterations, including a restricted diet, limited water intake, and regular medical visits, which considerably diminish their autonomy; physical changes such as pruritus and complexion changes caused by dialysis contribute to a distorted self-image; if healthcare providers lack patience and care in communication and treatment, it is easy to make patients generate stigma. Multiple factors interact to aggravate patients' psychological burden, making them susceptible to negative emotions such as depression, anxiety, loss of morale, and despair \u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e. Alleviating stigma experience can strengthen patients' understanding of the disease, facilitate adaptation to family role transition, and establish new models of labor division and responsibility-sharing, thereby bolstering family support; it can also elevate social participation levels, enhance social adaptability, and reduce loneliness \u003csup\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e and psychological detachment. Therefore, it is imperative to call on all sectors of society to pay attention to the vulnerable group of MHD patients and build a continuous support mechanism involving hospitals, families, and the society. We urge patients to open their hearts, engage socially, and have the courage to self-disclose \u003csup\u003e[35]\u003c/sup\u003e, thereby accessing additional support, fostering a sense of security and belonging, enhancing emotional self-regulation, and mitigating stigma while promoting psychological detachment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section3\"\u003e\u003ch2\u003e4.2.2 Mediating Effect of Fear of Disease Progression Between Stigma and Psychological Detachment in MHD Patients\u003c/h2\u003e\u003cp\u003eStructural equation modeling showed that FoP partially mediates the relationship between stigma and psychological detachment, indicating that stigma directly affects psychological detachment and indirectly predicts it through fear of disease progression, with the mediating effect accounting for 8.51% of the total effect. In MHD patients, stigma influences psychological detachment through both direct prediction and indirect effects via FoP \u003csup\u003e[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/sup\u003e. Possible reasons include: First, stigma stemming from a sense of guilt arises from disease itself, physical changes, economic factors, emotional experiences, and role transitions. MHD patients with low self-esteem and strong inferiority related to their condition demonstrate high concern regarding health and future uncertainties, which affects FoP scores and thus their psychological detachment. Second, patients experiencing strong stigma often internalize unfavorable occurrences, perceiving their illness as a source of economic and caregiving responsibilities on their family members \u003csup\u003e[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/sup\u003e, aggravating fear of disease progression. This manifests as excessive worry, hyperfocus on physical ailments, and withdrawal from familial and social interactions to avert more burdens, culminating in psychological detachment. Therefore, stronger stigma correlates with more intense FoP and lower psychological detachment. Intervening from the perspective of FoP holds value for improving patients' psychological detachment and social function recovery.\u003c/p\u003e\u003cp\u003eHaack et al. \u003csup\u003e[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/sup\u003e identified a significant association between FoP and quality of life, indicating that higher FoP levels correlate with lower quality of life. Moderate FoP can moderately and positively enhance patients' preventive health awareness and treatment adherence \u003csup\u003e[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eHowever, when fear reaches clinically significant levels (score\u0026thinsp;\u0026ge;\u0026thinsp;34), chronic intrusive thoughts about disease progression emerge, substantially aggravating psychological burden and triggering negative emotions like anxiety and depression, which impair quality of life.\u003c/p\u003e\u003cp\u003eFrom the neuroendocrine-immune mechanism perspective, psychological responses regulate this complex mechanism to impact cancer patients' immune systems \u003csup\u003e[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e41\u003c/span\u003e]\u003c/sup\u003e. Patients apprehensive about disease progression or recurrence frequently employ maladaptive coping mechanisms, which diminish treatment adherence, impair immune function, intensify unpleasant effects such as nausea, vomiting, and radiation enteritis, and substantially degrade quality of life. Healthcare providers can use aromatherapy to alleviate anxiety, depression, and symptoms like insomnia or nausea, while implementing positive psychological interventions to harness patients' potential, eliminate fear, facilitate correct disease cognition, and assist them in adopting a constructive mindset to restore life confidence, thereby improving psychological detachment.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Limitations and recommendations\u003c/h2\u003e\u003cp\u003eThis study initially explored the associations and functioning processes among familial caregiving, stigma, fear of disease progression, and psychological detachment, yet it has several limitations. The sample was solely drawn from the blood purification center of Yichang Central People's Hospital, resulting in limited regional representativeness; differences across regions in economic status, medical resources, cultural customs, and social security regulations may affect patients' psychosocial experiences, warranting caution regarding the generalizability of findings. Though the sample size calculation is reasonable, convenience sampling may introduce selection bias\u0026mdash;patients with more severe conditions, poor psychological status, or limited communication skills may have low participation willingness or difficulty participating, potentially underestimating the problem's severity. Additionally, the extremely low proportion of rural household patients (8.2%) restricts the generalizability of results to rural maintenance hemodialysis patients.​\u003c/p\u003e\u003cp\u003eMoreover, the psychological detachment scale compiled by Tian Chunying, despite good reliability and validity, requires more evidence for its theoretical basis, dimensional structure, and verification in mental illness populations, especially when compared with more mature and widely validated \"psychological detachment\" measurement tools (e.g., the psychological detachment subscale in the Work-domain Recovery Experience Questionnaire). The reasons for the lowest scores in the \"environment\" dimension also demand in-depth exploration. Furthermore, the research model showing partial mediation may have omitted other important mediating or moderating variables, such as patients' coping styles.\u003c/p\u003e\u003cp\u003eTo enhance the representativeness and generalizability of findings, future research should conduct multicenter collaborative studies involving diverse regions and hospital tiers nationwide, with a focus on increasing the proportion of rural patients. This approach will allow for a broader and more representative sample, enabling exploration of similarities and differences in influencing mechanisms across various geographical, economic, and cultural contexts.\u003c/p\u003e\u003cp\u003eAdditionally, future research ought to systematically incorporate and examine more potential mediating variables (e.g., coping styles, self-efficacy, social support networks) and moderating variables (e.g., personality traits, disease stage, socio-demographic characteristics) to develop a more comprehensive theoretical model that accounts for greater variance\u0026mdash;specifically, investigating alternative mechanisms through which familial caregiving affects psychological disengagement. Furthermore, efforts should be made to further validate and refine psychological disengagement assessment instruments for MHD patients, or to introduce more sophisticated concepts (e.g., recovery experiences within the work-family interface) into MHD research for cross-cultural adaptation and validation.\u003c/p\u003e\u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis cross-sectional study explored the relationships among family caring degree, stigma, fear of disease progression, and psychological detachment in MHD patients, verifying that fear of disease progression plays a partial mediating role. Stigma and fear of disease progression positively influence psychological detachment. Nurses should prioritize the importance of family support in MHD patients' rehabilitation, bolster family resilience by augmenting internal resources, and mitigate stigma and fear of disease progression to improve psychological detachment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e6.1 Ethics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study strictly adhered to the ethical guidelines of the Declaration of Helsinki and was approved by the Ethics Review Committee of Yichang Central People's Hospital (Approval Number: 2024-456-01). All participants provided electronic informed consent prior to enrollment, in compliance with human subject research ethical norms. The study did not involve minors, and all research data are strictly confidential and used exclusively for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.2 Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no specific external funding was received for this study from any public, commercial, or not-for-profit funding agencies. All study processes—including participant recruitment, administration of assessment scales (Fear of Progression Questionnaire-Short Form, Social Impact Scale, Family APGAR Index, and Psychological Detachment Scale), data collection and statistical analysis (via SPSS 26.0 and AMOS 26.0), and manuscript drafting and revision—were completed using internal resources of the research team from the Blood Purification Center and Nursing Department of Yichang Central People’s Hospital Affiliated to China Three Gorges University. The funding status had no impact on study design, data interpretation, result reporting, or the decision to submit the manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.3 Conflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.4 Availability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset used in this study is available as Supplementary File S1 (XLSX). The English versions of the self-designed questionnaires (Demographic Questionnaire and Psychological Detachment Scale for MHD Patients) are provided in Supplementary Files S2 (DOCX) and S3 (DOCX), respectively. All other scales used in the study are publicly available or have obtained necessary authorization from the original developers [see 2.5 Ethics considerations and relevant sections in 2.2 Survey Instruments].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.5 Authors' Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: LIU Cong, WEI Yongting\u003c/p\u003e\n\u003cp\u003eData curation: LYU Xiaoran, WANG Qin, LIU Nian, LI Xianglin, YOU Lang, ZOU Li\u003c/p\u003e\n\u003cp\u003eFormal analysis: LIU Cong\u003c/p\u003e\n\u003cp\u003eInvestigation: XI Zuyang\u003c/p\u003e\n\u003cp\u003eMethodology: LIU Cong, WEI Yongting\u003c/p\u003e\n\u003cp\u003eProject administration: WU Jianyi\u003c/p\u003e\n\u003cp\u003eSoftware: Randah Barakat\u003c/p\u003e\n\u003cp\u003eSupervision: XI Zuyang\u003c/p\u003e\n\u003cp\u003eValidation: WEI Yongting\u003c/p\u003e\n\u003cp\u003eWriting\u0026nbsp;–\u0026nbsp;original draft: LIU Cong\u003c/p\u003e\n\u003cp\u003eWriting\u0026nbsp;–\u0026nbsp;review \u0026amp; editing: LIU Cong, XI Zuyang\u003c/p\u003e\n\u003cp\u003eClinical Trial Registration\u003c/p\u003e\n\u003cp\u003eThis study is a cross-sectional observational study, and clinical trial registration is not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLiu P et al. 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PMID: 30334417.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Maintenance hemodialysis, Psychological disengagement, Stigma, Family caring degree, Mediating effect","lastPublishedDoi":"10.21203/rs.3.rs-7545852/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7545852/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eAims: \u003c/strong\u003eTo explore the mediating effects of fear of disease progression (FoP) and stigma on the relationship between the level of family caregiving and psychological disengagement in maintenance hemodialysis (MHD) patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A cross-sectional study was conducted including 320 MHD patients from a hemodialysis center in China. Data were collected using the Fear of Progression Questionnaire-Short Form (FoP-Q-SF), Social Impact Scale (SIS), Family APGAR Index, and Psychological Disengagement Scale. Structural equation modeling was performed via AMOS 26.0.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe total score for psychological disengagement was 193.10±24.37, indicating a moderate level. Family caring degree had a positive correlation with FoP (r=0.157, P\u0026lt;0.05) and negative correlations with stigma (r=-0.205, P\u0026lt;0.01) and psychological disengagement (r=-0.218, P\u0026lt;0.01). The fear of disease progression partially mediated the relationship between stigma and psychological disengagement (mediation effect=0.112, 16.20% of total effect).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Psychological disengagement among MHD patients is influenced by stigma, FoP, and family support. Interventions targeting family-centered care and stigma reduction may enhance psychological disengagement.\u003c/p\u003e","manuscriptTitle":"Assessing Fear of Progression, Stigma, and Psychological Detachment in Hemodialysis Patients: A Structural Equation Modeling Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-10 14:46:52","doi":"10.21203/rs.3.rs-7545852/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-05T09:09:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-03T16:16:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9129080172962031706940739150804182924","date":"2025-10-27T18:55:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-12T06:03:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"133782130669485713644587445705570101483","date":"2025-10-12T05:10:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-26T10:55:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-26T10:50:43+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-15T08:53:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-11T16:54:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nephrology","date":"2025-09-11T16:51:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8afd5038-4ebd-4d93-8863-5e5cd014d128","owner":[],"postedDate":"October 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T16:03:28+00:00","versionOfRecord":{"articleIdentity":"rs-7545852","link":"https://doi.org/10.1186/s12882-026-04953-7","journal":{"identity":"bmc-nephrology","isVorOnly":false,"title":"BMC Nephrology"},"publishedOn":"2026-04-10 15:57:41","publishedOnDateReadable":"April 10th, 2026"},"versionCreatedAt":"2025-10-10 14:46:52","video":"","vorDoi":"10.1186/s12882-026-04953-7","vorDoiUrl":"https://doi.org/10.1186/s12882-026-04953-7","workflowStages":[]},"version":"v1","identity":"rs-7545852","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7545852","identity":"rs-7545852","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}