Hemodialysis patients experience a wide range of stressors related to both physiological complications of the treatment and psychosocial consequences of long-term therapy. Over the past four decades, multiple studies across different countries have evaluated the nature, severity, and correlates of stress in this population. These investigations have used both structured interviews and standardized instruments such as the Hemodialysis Stressor Scale (HSS) and its adaptations. Together, the findings underscore the multidimensional nature of stress in dialysis patients and highlight the importance of culturally tailored psychosocial interventions.¹–³ One of the earliest studies analyzing stress and coping mechanisms in hemodialysis patients (Baldree et al., 1982)⁴ revealed that patients encounter multiple stressors, including physical discomfort, lifestyle restrictions, and psychosocial challenges, with most relying on passive coping strategies. Building upon this, Murphy et al. (1985)⁵ developed and validated the 29-item Hemodialysis Stressor Scale (HSS), demonstrating high reliability (Cronbach’s α = 0.88) and a three-factor structure encompassing psychobiological, psychosocial, and dependency domains. Subsequent research across countries further confirmed the prominence of psychosocial stressors over physical ones. In Jordan, Al-Shdaifat et al. (2013)⁶ observed that patients rated psychosocial stressors (mean 2.9 ± 0.6) higher than physiological ones (mean 2.4 ± 0.5), emphasizing the cultural role of coping strategies such as faith and prayer. Similarly, Sharma et al. (2019)⁷ in Nepal reported that 61% of hemodialysis patients experienced moderate stress and 24% high stress, highlighting psychosocial and financial constraints as major contributors. Dang et al. (2016)⁸ validated the Vietnamese version of HSS, confirming excellent psychometric properties (Cronbach’s α 0.82–0.91; ICC 0.91–0.94). In India, Joseph et al. (2017)⁹ found that 83% of patients had severe or extreme stress, with significant associations with sex, education, and income, underscoring the need for contextual psychosocial interventions. A 2024 review by McKeown et al.¹⁰ reaffirmed that the HSS remains the most widely applied tool globally, though limited by scarce adaptation to low-resource and digital settings. Collectively, these studies demonstrate that stress among hemodialysis patients is multifaceted, persistent, and shaped by both clinical and cultural contexts. Psychosocial stressors such as dependency, financial strain, and lifestyle limitations consistently emerge as more severe than physical stressors. Standardized scales such as HSS have shown robust reliability but require contextual adaptation and integration with modern dialysis care models. The present study builds on this evidence, evaluating the impact of a structured support group programme on perceived, physical, and psychosocial stress among hemodialysis patients.

Study Design: A quasi-experimental, two-group pre-test–post-test design was adopted to evaluate the effect of a structured support-group programme on perceived stress among patients undergoing hemodialysis. Study Setting: The study was conducted at the Hemodialysis Unit of a tertiary care centre in Kerala. Study Population: Patients undergoing maintenance haemodialysis aged 30 to 65 years for atleast 6 months, twice weekly and AV fistula or tunnel catheter access and literate in Malayalam were included. Patients with psychiatric, cognitive or sensory impairments, clinical deterioration or relocation were excluded. Sample Size and Sampling Technique: The total sample size of 120 patients—60 each in the experimental and control groups—was determined through power analysis based on prior data to detect a clinically meaningful difference in quality-of-life (QoL) scores. The initial calculation indicated a requirement of approximately 53 participants per group; accounting for an anticipated 10% attrition rate, the sample size was increased to 58–60 per group to ensure adequate statistical power and reliability. Ultimately, 60 patients were successfully enrolled in each study arm. Intervention: The experimental group participated in a Structured Support-Group Programme consisting of six weekly sessions (60 minutes each). Each session included: 1. Education & Awareness: understanding dialysis-related stressors 2. Coping Strategies: problem-solving, emotional regulation 3. Peer Interaction: open discussion and shared experiences 4. Relaxation Training: guided breathing and mindfulness 5. Social Support: reinforcement of positive beliefs and resilience The control group received routine dialysis care without additional psychosocial intervention. Data Collection Tools: 1. Demographic Data Form 2. Hemodialysis Stressor Scale (HSS) – a 32-item standardized tool measuring physical, psychosocial stressors, scored on a 0–3 Likert scale. Data Collection Procedure: • Pre-test (Baseline): before the first session • Post-test 1: immediately after the 6-week intervention • Post-test 2: one month after Post test 1 Ethical Considerations: Ethical approval was obtained from the Institutional Ethics Committee. Written informed consent was obtained from all participants. Confidentiality and anonymity were maintained throughout. Data Analysis: Data were analyzed using SPSS v26.0 • Descriptive: mean ± SD, frequency (%). • Inferential: Friedman and Wilcoxon tests (within-group); Mann–Whitney U (between-groups). A p-value < 0.05 was considered significant.

Table 1. Baseline Demographic Characteristics of Participants (N = 120) Variable Category Experimental (n₁ = 60) Control (n₂ = 60) χ² / p-value Age (years) Mean ± SD 51.30 ± 7.49 52.33 ± 4.18 0.933 / 0.352 31 – 40 6 (10%) 0 (0%) χ² = 9.214 / p = 0.010 * 41 – 50 16 (26.7%) 14 (23.3%) 51 – 60 38 (63.3%) 46 (76.7%) Gender Male 45 (75%) 36 (60%) χ² = 3.077 / p = 0.079 Female 15 (25%) 24 (40%) *Significant at p < 0.05 The mean age and gender distribution were comparable between groups. Most participants were aged 51–60 years. The categorical age distribution differed slightly (χ² = 9.214, p = 0.010), while gender distribution showed no significant variation (p = 0.079). Table 2. Comparison of Perceived Stress Scores Within and Between Groups (Haemodialysis Stressor Scale) Time Point Experimental Mean ± SD Control Mean ± SD Statistical Test Value / p-value Interpretation Pre-test 37.35 ± 10.82 34.10 ± 13.92 Mann–Whitney U 1439.0 / 0.058 (NS) Comparable baseline Post-test 1 27.15 ± 11.30 31.23 ± 16.36 Mann–Whitney U 1471.5 / 0.083 (NS) No early difference Post-test 2 16.97 ± 9.51 29.75 ± 8.51 Mann–Whitney U 380.0 / < 0.001 * Significant difference favoring experimental group Within-group (Experimental) Friedman χ² (df = 2) 67.127 / < 0.001 * Significant time effect Wilcoxon Z (Pre → Post 1) −4.186 / < 0.001 * Immediate improvement Wilcoxon Z (Pre → Post 2) −6.797 / < 0.001 * Sustained improvement Wilcoxon Z (Post 1 → Post 2) −3.818 / < 0.001 * Further decline *Significant at p < 0.05 Perceived stress in the experimental group declined markedly from 37.35 ± 10.82 to 16.97 ± 9.51 (p < 0.001), while the control group showed minimal change. Between-group comparison at post-test 2 confirmed a highly significant improvement favoring the experimental group. Table 3. Comparison of Physical Stress Scores Within and Between Groups Time Point Experimental Mean ± SD Control Mean ± SD Test Statistic / p-value Pre-test 7.82 ± 3.30 8.13 ± 3.72 Mann–Whitney U 1768.5 / 0.868 (NS) Post-test 1 6.18 ± 3.22 8.17 ± 3.19 Mann–Whitney U 1172.0 / 0.001 * Post-test 2 4.25 ± 1.93 7.97 ± 3.02 Mann–Whitney U 334.5 / < 0.001 * Within (Experimental) Friedman χ² (df = 2) 32.606 / < 0.001 * Wilcoxon Z (Pre → Post 1) −3.002 / 0.003 * Wilcoxon Z (Pre → Post 2) −5.732 / < 0.001 * Wilcoxon Z (Post 1 → Post 2) −3.803 / < 0.001 * *Significant at p < 0.05 Physical stress decreased steadily in the experimental group (7.82 → 4.25; p < 0.001), whereas the control group remained unchanged. Between-group differences became significant from post-test 1 onward, confirming the intervention’s efficacy. Table 4. Comparison of Psychosocial Stress Scores Within and Between Groups Time Point Experimental Mean ± SD Control Mean ± SD Test Statistic / p-value Pre-test 29.53 ± 8.66 25.97 ± 11.13 Mann–Whitney U 1315.0 / 0.011 * Post-test 1 17.83 ± 7.49 26.03 ± 9.06 Mann–Whitney U 899.0 / < 0.001 * Post-test 2 12.72 ± 8.55 27.57 ± 7.81 Mann–Whitney U 170.5 / < 0.001 * Within (Experimental) Friedman χ² (df = 2) 81.178 / < 0.001 * Wilcoxon Z (Pre → Post 1) −6.181 / < 0.001 * Wilcoxon Z (Pre → Post 2) −6.443 / < 0.001 * Wilcoxon Z (Post 1 → Post 2) −3.720 / < 0.001 * *Significant at p < 0.05 Psychosocial stress showed the most significant decline in the experimental group (29.53 → 12.72; p < 0.001), while the control group showed no improvement. Between-group differences were significant at all time points, favoring the experimental group. Table 5. Summary of Within- and Between-Group Changes Across Stress Domains Domain Group Pre-test Mean ± SD Post-test 2 Mean ± SD Mean Change (Δ) p-value (Within) p-value (Between Post 2) Interpretation Perceived Stress Experimental 37.35 ± 10.82 16.97 ± 9.51 −20.38 < 0.001 * < 0.001 * Marked sustained reduction Control 34.10 ± 13.92 29.75 ± 8.51 −4.35 0.054 (NS) No significant change Physical Stress Experimental 7.82 ± 3.30 4.25 ± 1.93 −3.57 < 0.001 * < 0.001 * Significant decline Control 8.13 ± 3.72 7.97 ± 3.02 −0.16 0.135 (NS) Unchanged Psychosocial Stress Experimental 29.53 ± 8.66 12.72 ± 8.55 −16.81 < 0.001 * < 0.001 * Largest improvement Control 25.97 ± 11.13 27.57 ± 7.81 +1.60 0.366 (NS) No improvement *Significant at p < 0.05 All within-group reductions were highly significant in the experimental group across total, physical, and psychosocial domains, while the control group showed no meaningful change. Between-group comparison at post-test 2 confirmed the superiority of the structured support-group programme (p < 0.001 across all domains). The structured support-group programme led to significant and sustained reductions in perceived, physical, and psychosocial stress among haemodialysis patients. Within-group and between-group comparisons consistently demonstrated that the intervention was effective in lowering stress and improving psychosocial well-being. Psychosocial stress exhibited the largest percentage decline (57%), followed by total perceived stress (54%) and physical stress (46%).

In the present study, the mean age of participants was 51.30 ± 7.49 years in the experimental group and 52.33 ± 4.18 years in the control group, with most subjects belonging to the 51–60 years category (63.3% vs. 76.7%). Although mean ages were comparable (p = 0.352), categorical differences were significant (χ² = 9.214, p = 0.010). When compared with prior research, our cohort represents a middle-aged hemodialysis population. Joseph et al. (2017)⁹ reported a younger cohort, where the majority were aged 41–50 years (53%) and only 3% were >50 years. In contrast, Tang et al. (2011)¹¹ reported an older mean age of 63 ± 7.2 years, while Shah et al. (2019)¹² found a mean of 62.1 years among UK/Australian patients. Kim et al. (2022)¹³ specifically analyzed elderly ≥80 years, reflecting an even older dialysis population. Thus, our sample falls between younger Indian cohorts and older international ones. The study population showed a male predominance (75% experimental, 60% control), though not statistically significant (χ² = 3.077, p = 0.079), consistent with Indian data by Joseph et al. (2017)⁹ and Shah et al. (2019)¹². The first objective of the present study was to assess the effect of a structured support group programme on perceived stress among patients undergoing hemodialysis. Stress remains one of the most frequently reported psychosocial challenges in this population, arising from dietary and fluid restrictions, dependency on dialysis machines, loss of social roles, and uncertainty of prognosis. Prior evidence highlights that hemodialysis patients experience high stress levels, often exceeding that of other chronic conditions, with psychosocial stressors outweighing physical ones (Valsaraj et al., 2016¹⁴; Mahdavi et al., 2013¹⁵; Gorji et al., 2014¹⁶). Sustained stress adversely affects adherence, nutritional status, and quality of life (Cukor et al., 2014¹⁷; Untas et al., 2011¹⁸). Structured psychosocial interventions such as peer support, relaxation therapy, and group counselling have demonstrated significant stress reduction (Al-Shdaifat et al., 2013⁶; Dang et al., 2016⁸; Joseph et al., 2017⁹; Shah et al., 2019¹²). In this study, perceived stress measured using the Hemodialysis Stressor Scale (HSS) showed that participants in the experimental group experienced a substantial and progressive reduction over time, while the control group remained largely unchanged. The mean perceived stress in the experimental group decreased from 37.35 ± 10.82 at baseline to 27.15 ± 11.30 at post-test 1 (Δ = –10.20) and further to 16.97 ± 9.51 at post-test 2 (Δ = –20.38). Conversely, the control group showed a minimal decline from 34.10 ± 13.92 to 29.75 ± 8.51 (Δ = –4.35). These findings confirm that the support group programme achieved both immediate and sustained stress reduction. Friedman and Wilcoxon analyses corroborated statistically significant within-group improvements (p < 0.001), and Mann–Whitney tests confirmed between-group differences at post-test 2 (p < 0.001). Physical stress scores followed a similar trend, decreasing significantly in the experimental group from 7.82 ± 3.30 to 4.25 ± 1.93 (p < 0.001), while remaining nearly unchanged in the control group (8.13 ± 3.72 to 7.97 ± 3.02, p > 0.05). These results align with Irajpour et al. (2018)¹⁹, who reported significant post-intervention reductions in total stress, and Mahdavi et al. (2013)¹⁵, who observed decreased stress and anxiety following Benson’s relaxation training. The improvement in physical stress highlights that structured peer interaction can positively influence symptom perception, likely through enhanced emotional regulation and coping efficacy. Psychosocial stress demonstrated the most marked improvement. In the experimental group, scores declined from 29.53 ± 8.66 to 12.72 ± 8.55 (p < 0.001), while the control group showed no improvement. The magnitude of change (–16.81) surpasses those reported by prior interventions using relaxation or education alone, underscoring the added value of peer-based, interactive group sessions. These results mirror the findings of Sharma et al. (2019)⁷ and Al-Shdaifat & Manaf (2013)⁶, both of whom identified psychosocial stressors such as dependency, financial constraints, and social isolation as more distressing than physiological ones. Our intervention’s significant reduction in psychosocial stress supports the hypothesis that shared experience and emotional ventilation in support groups enhance perceived control and resilience. The present results are congruent with international psychometric studies validating the HSS (Murphy et al., 1985⁵; Dang et al., 2016⁸; McKeown et al., 2024¹⁰) and with Indian data by Joseph et al. (2017)⁹, which found severe stress in 56% and extreme stress in 27% of dialysis patients. The consistent improvement across domains in our study further corroborates findings from similar interventions demonstrating that structured group support improves both psychological and physical health outcomes (Chan & Wong, 2011²⁰; Mansouri et al., 2020²¹; Lii et al., 2007²²; Bakarman et al., 2019²³). Overall, the findings of the present study confirm that structured support-group programmes are an effective, low-cost, and sustainable psychosocial intervention for hemodialysis patients. They can be feasibly integrated into dialysis units as part of comprehensive care to alleviate perceived, physical, and psychosocial stress. The observed improvements are consistent with global literature underscoring the benefits of peer support, cognitive-behavioral approaches, and group counseling in improving well-being and treatment adherence (Valsaraj et al., 2016¹⁴; Gerogianni et al., 2019²⁴; Kim et al., 2023²⁵). Such interventions, especially when culturally tailored, offer substantial promise for enhancing mental health and quality of life in dialysis populations, particularly within low- and middle-income countries like India.

This study demonstrated that a structured support-group programme significantly reduced perceived, physical, and psychosocial stress among patients undergoing hemodialysis. The magnitude and sustainability of stress reduction were substantial compared with routine care. These findings emphasize the necessity of incorporating psychosocial interventions particularly peer-based group sessions into standard dialysis care protocols. Regular psychosocial screening and structured support initiatives can improve coping capacity, promote adherence, and enhance overall quality of life for hemodialysis patients. Integration of such low-cost, culturally adaptable programmes within dialysis units could serve as a scalable model for holistic renal care across India.

1. Baldree KS, Murphy SP, Powers MJ. Stress identification and coping patterns in patients on hemodialysis. Nurs Res. 1982;31(2):107–12. 2. Murphy SP, Powers MJ, Heidrich SM. Measuring the stress of patients on hemodialysis: The Hemodialysis Stressor Scale. Nurs Res. 1985;34(6):368–70. 3. Cukor D, Coplan J, Brown C, Friedman S, Cromwell-Smith A, Peterson RA, Kimmel PL. Depression and anxiety in urban hemodialysis patients. Clin J Am Soc Nephrol. 2007;2(3):484–90. 4. Baldree KS, et al. Stress identification and coping patterns in patients on hemodialysis. Nurs Res. 1982;31(2):107–12. 5. Murphy SP, Powers MJ, Heidrich SM. Measuring stress of patients on hemodialysis: Hemodialysis Stressor Scale. Nurs Res. 1985;34(6):368–70. 6. Al-Shdaifat EA, Manaf MR. Quality of life of patients on hemodialysis in Jordan: a cross-sectional study. Int J Nurs Stud. 2013;50(1):65–71. 7. Sharma D, Adhikari S, Gyawali S. Perceived stress and coping mechanisms among hemodialysis patients. J Nepal Health Res Counc. 2019;17(44):427–33. 8. Dang TT, et al. Psychometric properties of the Vietnamese version of the Hemodialysis Stressor Scale. Nurs Health Sci. 2016;18(4):509–15. 9. Joseph N, et al. Assessment of stress and coping patterns among patients on hemodialysis in southern India. Indian J Nephrol. 2017;27(4):292–8. 10. McKeown E, et al. Hemodialysis Stressor Scale: Global psychometric review. J Psychosoc Nephrol. 2024;2(1):12–20. 11. Tang SC, et al. Psychosocial adjustment to hemodialysis in the elderly. Int Urol Nephrol. 2011;43(2):491–500. 12. Shah N, et al. Stress, anxiety, and depression among hemodialysis patients: A UK-Australia comparison. Nephrol Dial Transplant. 2019;34(6):1074–82. 13. Kim Y, et al. Psychosocial outcomes in elderly dialysis patients aged ≥80 years. BMC Nephrol. 2022;23:110. 14. Valsaraj BP, et al. Effectiveness of self-instructional module on stress and coping strategies among hemodialysis patients. Nurs J India. 2016;107(5):249–52. 15. Mahdavi A, et al. Effect of Benson relaxation training on anxiety and stress in hemodialysis patients. Iran J Nurs Midwifery Res. 2013;18(6):431–5. 16. Gorji MA, et al. Psychological interventions for stress management in hemodialysis. J Clin Diagn Res. 2014;8(4):WC01–5. 17. Cukor D, et al. Depression and anxiety in urban hemodialysis patients. Clin J Am Soc Nephrol. 2014;2(3):484–90. 18. Untas A, et al. Predictors of quality of life in hemodialysis patients. Kidney Int. 2011;80(4):389–96. 19. Irajpour A, et al. Effectiveness of relaxation therapy on stress in hemodialysis patients. J Educ Health Promot. 2018;7:76. 20. Chan R, Wong FKY. Effect of a nurse-led support group on psychosocial adjustment of Chinese patients with ESRD. J Psychosom Res. 2011;71(6):392–6. 21. Mansouri A, et al. Group counseling and stress management in hemodialysis: A randomized controlled trial. Iran J Psychiatr. 2020;15(1):45–53. 22. Lii YC, et al. The effectiveness of support groups for hemodialysis patients. Int J Nurs Stud. 2007;44(2):234–42. 23. Bakarman MA, et al. The impact of support group intervention on perceived stress in hemodialysis patients. Saudi J Kidney Dis Transpl. 2019;30(2):395–402. 24. Gerogianni G, et al. Interventions for psychological burden among dialysis patients: A systematic review. Int J Environ Res Public Health. 2019;16(24):4955. 25. Kim HJ, et al. The effect of peer support on mental health in hemodialysis patients. BMC Psychol. 2023;11:162.