To the best of our knowledge, this is the first study that investigated the chain mediating effects of anxiety and depression in the relationship between family function and hope in MHD patients. The hope of MHD patients was found to be moderate in this study, which was consistent with a previous study (Du, Yan, Ma, & Xie, 2017). The reasons may be as follows: On the one hand, the patients in this study had been on dialysis for more than 3 months. Their health status was stable, and they were physically and psychologically better accustomed and accepted to hemodialysis. Meanwhile, 78.0% (177 cases) of MHD patients in this study were married and had stable family relationships, which contributes to the maintenance of their hope level. On the other hand, due to the complexity and specialization of the disease, MHD patients may have psychological fear and worry about the further deterioration of the condition and poor prognosis, resulting in low level of hope.
The family function of MHD patients was found to be moderately impaired in our study, which was similar to the findings of the previous study (Liu, Zhao, Wang, Song, & Wang, 2019). The reasons may be as follows: First, due to disease and self-avoidance, patients may be prone to role change and status adjustment in the family, which will increase their own psychological pressure and thus impair emotional communication between family members. Second, MHD patients require long-term dialysis and have relatively low self-care ability, which means that family caregivers need to bear long-term medical expenses and daily care of patients. The heavy care work has a great impact on the physical and mental health of caregivers, thus reducing the intimacy between family members. However, family caregivers are not always negative in the process of care, but experience more positive feelings. The family members usually give patients more care, help and spiritual support, increasing the patients' hope for life and actively dealing with the negative impact of the disease, according to a two-factor model (Lawton, Moss, Kleban, Glicksman, & Rovine, 1991).
The prevalence of anxiety was 22.03 percent (50 cases) and the prevalence of depression was 35.24 percent (80 cases) in our study, which was similar to the results from Al Naamani, Gormley, Noble, Santin, & Al Maqbali (2021). The reasons may be as follows: First, it's possible that MHD treatment causes mental deterioration in patients, which has a negative impact on their mental health. Second, the high prevalence of new coronaviruses, as well as their concerning implications, would exacerbate anxiety and depression symptoms in MHD patients (Al Naamani, Gormley, Noble, Santin, & Al Maqbali, 2021). Third, ERSD patients have long-term urotoxin deposition, renal anemia, calcium and phosphorus metabolism disorder, hyperparathyroidism and other factors that damage brain nerve cells, and then show varying degrees of cognition impairment, according to the hypothesis of "kidney-brain axis" neurodegeneration (Bugnicourt, Godefroy, Chillon, Choukroun, & Massy, 2013). However, regular hemodialysis treatment can remove urotoxin from the body and improve anemia symptoms, thus improving cognition impairment. Previous studies have shown that better cognitive function can improve patients' negative emotions, which is conducive to the construction of patients' confidence in overcoming the disease (Feng, Lu, Wang, & Li, 2021).
The findings of this study demonstrated that family function was linked to hope, which was consistent with earlier research (Wang et al., 2017). According to the positive psychology theory (Wang et al., 2021). Hope is a positive cognitive process that people have toward the future, which indicates that people have optimistic wishes and expectations for life and the future while not knowing what will happen in the future. Patients with MHD have to deal with unpredictability in disease development as well as the financial burden of long-term dialysis treatment. Family support can help patients to gain knowledge of the disease, treat it more optimistically, and adopt positive coping mechanisms, increasing their hope level.
Depression was found to have a substantial negative relationship with family function and hope. According to the social support buffer model (Boumans & Landeweerd, 1992), when people are in danger, family support can assist to buffer the negative consequences of stress and thereby reduce depression. Positive emotions have been proven to help patients gain confidence in their ability to overcome disease and hence boost their degree of hope (Wang et al., 2017). As a result, MHD patients who have better family function have better mental health, fewer depressive symptoms, and are more likely to use appropriate and positive coping strategies, thus they may have a higher sense of hope, while patients who do not have the company and support of family members must confront the pressures of disease and life alone, which can lead to depression, as well as a loss of motivation and confidence in the future and life, and a low level of hope. Thus, family function has an impact on MHD patients' hope via depression.
Anxiety and depression were found to be a chain mediating effect in the relationship between family function and hope in the outcomes of the mediating effect. It is in line with the interpersonal relationship theoretical model (Chang, Zhu, Zhang, & Li, 2021), which states that good family function can alleviate depressive symptoms by reducing anxiety. At the same time, depression acted as a mediator between anxiety and hope, implying that anxiety's effect on hope can be fulfilled through depression. As a result, depression had a stronger impact on hope than anxiety. The better MHD patients' family function, the less anxiety experience, which lessens depressive symptoms and, as a result, enhances their degree of hope.
This is the first study to use the SEM method to investigate the chain mediating effect of anxiety and depression in the relationships between family function and hope. Our findings suggest that family function influences hope in MHD patients through a psychological mechanism. Therefore, interventions can be provided from the following aspects to improve the level of hope of patients. First, to improve family function. Based on the family system therapy (Skinner, Steinhauer, & Sitarenios, 2000), medical staff can help family members build a supportive relationship with the patient, aiding family members in assisting the patient in focusing on current life, reassessing perceived problems or pressures, and setting appropriate expectations and goals. Second, to improve anxiety and depression symptoms. Medical staff can use cognitive behavioral therapy, mindfulness therapy, sensory art therapies and other psychotherapeutic methods (Bosman et al., 2021; Newland & Bettencourt, 2020; Thoma, Pilecki, & McKay, 2015). With the development of computer networks, computerized cognitive behavioral therapy (CCBT) has been helpful in improving anxiety and depression in MHD patients. CCBT is psychotherapy that changes patients' thinking or behavior through computer interactive interface, combined with web pages, cartoons, animations, videos, sound and other highly structured media interactions (Liu et al., 2021). Compared with other methods, CCBT has the advantages of simple operation, intervention at any time, saving manpower and cost, and can assist nurses to carry out psychological intervention for patients with anxiety and depression. In addition, traditional Chinese medicine (TCM) can also be used for treatment, such as the five-element music therapy of TCM (Wu & Yang, 2021), baduanjin exercise (Fu, Wang, Zhou, Lin, & Li, 2021 ) and so on. Finally, as family function improves, symptoms of anxiety and depression decrease, leading to increased levels of hope.
The study has some limitations. First, the data were collected from two hospitals in one province, which might not be representative of all MHD patients in China. Second, the subjective nature of self-report questionnaires may not reflect the actual situation of the patients. Third, this is a descriptive cross-section. It is difficult to assess the change of study variables over time, and no causal inference could be made. Thus, the following points can be considered for future research: First, future research should include a larger sample size using tertiary hospitals in multiple regions. Second, the combination of subjective and objective measurement tools to evaluate study variables, such as adding patients' clinical examination and medical records to the subjective assessment of anxiety or depression, can better and more accurate assessment of anxiety or depression. Third, longitudinal study can be carried out and more hope-related variables can be added to further enrich the theoretical framework of this study. Finally, the results of the mediation analysis in this study can be used to tailor interventions for MHD patients to improve their level of hope.
It should be noted that there are differences between Chinese and Western family cultures. Thus, it should be cautious to extend our results to MHD populations in other countries after fully understanding the culture between Chinese and Western families and seeking common ground while reserving differences. It will be interesting to validate the results of this study in a culturally diverse MHD population in the future.