The most notable event in today's societies is the prevalence of chronic diseases. Chronic renal failure is one of the most common chronic diseases [1]. It is estimated that 8% of the global population is diagnosed with renal failure annually [2]. The prevalence of Chronic Kidney Disease (CKD) and End-Stage Renal Disease (ESRD) in Iran has been reported to be relatively high, with estimates approaching approximately 15-20% in some populations [3]. According to the announcement of the head of the Transplant and Special Diseases of the Ministry of Health, the growth rate of patients with kidney disease in Iran over the past 10 years was14%, and the growth rate of dialysis patients was 12% [1]. Patients undergoing dialysis face medical, psychological, and therapeutic complications, leading to restrictions in their physical, social, and psychological function. Psychological problems of these patients can be manifested as an increased level of stress [4]. Chronic stress has been shown to adversely affect multiple physiological and psychological systems in patients with chronic diseases, including those undergoing hemodialysis [5]. Lazarus and Folkman believe that stress stems proportionally from a complex and dynamic interaction between the individual and their surroundings [6]. The Lazarus and Folkman’s transactional model is one of the models that organizes the ways people employ to adapt to a chronic disease [7]. The main assumption of the model is that primary evaluation, secondary evaluation, and coping strategies mediate between stressors and stress outcomes in people, such that people choose and apply appropriate coping styles based on their interaction with others and their living environment [8]. Based on this model, there are three coping: problem-oriented, emotion-oriented, and meaning-oriented [9]. Meaning-oriented style instills positive emotions to maintain the coping process [6]. Meaning-based coping includes the aspects of positive reappraisal, revision of goals, spiritual beliefs and positive thinking. In all these cases, some kind of interpretation of stressful situations is performed in a meaningful way [8]. The results of the study conducted by Mafi et al. showed that most hemodialysis patients have moderate to severe stress [1]. Another study showed that hemodialysis patients employ various coping strategies that can improve their quality of life and their mood [10]. The beneficial effect of coping strategies on reducing stress has also been indicated in other studies [5]. Interestingly, another study found that people use religious and spiritual practices as coping mechanisms to overcome their depression, anxiety, and stress [4].

Coping with stress in patients with chronic diseases is a very important issue that demands further attention from researchers and community health planners in this area. According to the literature review, the focus of most articles that have investigated stress levels in hemodialysis patients has been mainly on emotion-focused and problem-focused coping styles. A thorough review of the literature revealed that no studies to date have specifically assessed stress levels using meaning-based coping styles in these patients.

Meaning-based coping style can serve as an effective framework for stress level interventions in hemodialysis patients. To further alleviate stress, policies and programs should be developed to strengthen the components of this coping style. Additional research is needed to evaluate the effectiveness of educational programs that employ appropriate theoretical models. Such models, emphasizing mental relaxation and rational behavior, may assist hemodialysis patients in coping with disease-related stressors and ultimately promote their overall health. Accordingly, this study aimed to examine the relationship between stress level and meaning-based coping style, grounded in Lazarus and Folkman’s transactional model, among hemodialysis patients in Kerman.

This descriptive-analytical, cross-sectional study was conducted between July and September 2023 in four major hemodialysis centers in Kerman: Shafa Hospital, Javad Al-Aemeh Clinic, Afzalipour Hospital, and Basat Hospital. The study population consisted of patients with End-Stage Renal Disease (ESRD) undergoing maintenance hemodialysis. Inclusion criteria were as follows: age 18 years or older; history of hemodialysis treatment for at least three months; ability to communicate verbally and understand the Persian language; Patients with no documented history of severe psychiatric disorders (e.g., psychosis) were included, as confirmed through patient interviews and review of medical records; absence of major visual or auditory impairments as reported by the patients or their families; and provision of written informed consent. Patients who were unwilling to participate were excluded from the study.

Given that one of the main objectives of the study was to determine the relationship between stress and spiritual beliefs in hemodialysis patients in Kerman, using the same study [11] and based on the sample size formula shown below, the calculated minimum sample size was 164 patients. To enhance the generalizability and sufficient statistical power of the study findings, a total of 334 patients were enrolled in the study. The subjects, using a convenience sampling method, were selected from hemodialysis patients in Kerman. Then, the data was analyzed by SPSS 20 software using descriptive and inferential statistics. A p-value below 0.05 was considered significant.

In this formula, the significance level is considered 5%, the power 90%, and r=0.25.

To conduct the study, ethical approval was first obtained from the Research Information System (Pazhoohan), and official authorization was granted by Kerman University of Medical Sciences. The researcher was permitted to collect data in the dialysis departments of Shafa Hospital, Javad Al-Aemeh Clinic, Afzalipour Hospital, and Basat Hospital. Following these approvals, the researcher attended the dialysis units across the four centers, introduced himself to the patients, explained the study objectives, and initiated data collection.

Questionnaires were administered approximately one hour after the start of dialysis, when patients’ conditions had stabilized, to provide uniform conditions for answering. The researcher approached each patient at the bedside, obtained written informed consent, and carefully observed all ethical principles throughout the process.

A total of 334 hemodialysis patients participated in the study, of whom 158 (47.3%) were female, and 176 (52.7%) were male. The mean age of participants was 54.8 ± 15.4 years, ranging from 18 to 85 years. The average duration of dialysis treatment was 61.2 ± 52.8 months (minimum 3 months, maximum 360 months).

This study aimed to determine the relationship between stress level and meaning-based coping style in hemodialysis patients. The present study showed that the level of stress in most patients was moderate. In agreement with the present study, Dhungana et al. showed that hemodialysis patients experience moderate levels of stress [13]. It appears that previous experience of hemodialysis and exchanging experiences with fellow patients may be associated with moderate stress levels in this population. The present study showed that there is a significant relationship between gender and stress level. The study by Tu et al. demonstrated that overall stress levels and coping strategies did not differ significantly by gender; however, female patients tended to experience higher levels of psychosocial stress compared with their male counterparts [14]. However, another study showed no substantial relationship between stress and gender in hemodialysis patients, which was inconsistent with the results of the present study [15]. Women with a genetic background, a history of fear and phobias, environmental incidents, and low self-esteem tended to report higher stress levels. Furthermore, hemodialysis women reported higher perceived demands due to multiple roles and responsibilities, including being a wife, motherhood, career-related responsibilities, and housekeeping. A considerable amount of time spent on dialysis, as well as economic problems, which are sometimes beyond the patient’s control, were associated with higher reported stress levels in women compared with men. The findings indicated a significant relationship between income and stress. However, the study by Yousefi et al. showed that there was no significant relationship between stress and income level in patients with gastrointestinal cancer, which was not in line with this study [16]. This inconsistency can be attributed to the difference in the data collection tools and the subject group.

In this study, there was a significant relationship between meaning-based coping style and gender. Although no studies were identified that specifically examined meaning-based coping in relation to gender among hemodialysis patients, previous research in this population has consistently demonstrated gender-related patterns in coping strategies [17]. Evidence suggests that women are more likely to use emotion-focused and meaning-oriented coping strategies, whereas men tend to rely more on problem-focused or avoidance coping styles [18]. Systematic reviews further indicate that coping in hemodialysis patients often includes emotional regulation, spiritual coping, and cognitive reappraisal processes [19].

These findings highlight that gender influences coping patterns, but general trends may be similar across patient populations. In this study, the meaning-based coping style in women was higher than in men, perhaps because of higher acceptance, adaptation, spiritual beliefs, and positive thinking in women, which may have contributed to higher scores in the substructures and the total score of the meaning-based coping style. The findings revealed that there is a significant association between stress level and positive reappraisal. Gillanders et al. showed that there was a significant positive correlation between positive reappraisal and mental health in hemodialysis patients [20]. Finkelstein's study also found that positive reappraisal often benefits a person's identity when dealing with the consequences of a potentially damaging HIV diagnosis. These findings suggest that positive reappraisal is associated with better health outcomes and self-management in patients with HIV [21]. A study by Nowlan et al. found that positive reappraisal was associated with positive emotions in the elderly, but not with negative emotions [22]. In fact, positive reappraisal was associated with reassessment of stressful situations and recognizing potential benefits and positive aspects in these experiences. This can highlight the positive aspects of people in controlling the stress that has developed.

The findings also indicated a meaningful relationship between stress level and revision of goals. Perhaps the reason for the significant relationship between stress level and goal revisions is that people establish their decisions, intentions, and actions upon their beliefs. Revising goals based on personal beliefs was associated with lower stress levels among study participants.

The results of this study showed that there is no significant correlation between stress level and spiritual beliefs. However, Najafi et al. showed that in people with chronic diseases, spiritual well-being had a significant effect on coping with the disease and its remission [11]. Sadeghifar et al. demonstrated that there was a significant negative relationship between spiritual components and depression and stress in dialysis patients [23]. Bonilla Sierra et al. also reported that there was a remarkable association between spirituality and resilience in hemodialysis patients [24]. Pham et al. showed that spiritual participation serves as a tool for processing the narrative of a person's life and their influence on life, and by constructing a narrative of life around positive meaning, participants experienced a strong desire to improve and self-care for their chronic kidney disease [25]. Since a large number of studies have reported a positive relationship between stress level and religious beliefs, it seems that one reason for the lack of consistency between the present study's findings and other studies was the smaller sample size, restricted to two dialysis centers. It should be noted that although different environments, economic, social, and cultural conditions can influence the results, they have not been the focus of this study.

In this study, no significant relationship was observed between stress level and positive thinking. Evidence from studies in hemodialysis patients indicates an inverse relationship between perceived stress and positive cognitive coping strategies, such as positive reappraisal and adaptive thinking. Higher stress levels are associated with reduced use of positive thinking and adaptive coping mechanisms, suggesting that psychological distress may limit positive cognitive engagement [18, 26].

The lack of meaningful association between stress level and positive thinking in this study may be due to less optimistic attitudes, thoughts, and behaviors in hemodialysis patients, which can reduce attention to positive aspects and increase focus on negative aspects of life. Despite the impact of the environment, economic, social, and cultural conditions on positive thinking, these factors were not included in our assessment.

The findings suggested an association between stress level and meaning-based coping, indicating that people who reported using meaning-based coping structures (e.g., positive reappraisal, revision of goals, spiritual beliefs, and positive thinking) also reported lower stress levels.

In the present study, a specific questionnaire was used to assess the meaning-based coping style in hemodialysis patients, but in most studies, general questionnaires were used. This cross-sectional study fails to determine the way the relationship is formed between stress level and meaning-based coping style (i.e., whether stress affects coping style or coping style affects the level of stress). The statistical population only includes hemodialysis patients, and patients undergoing peritoneal dialysis have not been considered. In this study, a questionnaire was used. In general, some people may refuse to provide the actual answer and may provide unrealistic responses to the questions. However, in this study, sufficient information and assurance were provided to the study subjects about observing the principle of confidentiality, which helped to obtain more realistic responses.

The stress and coping with it in patients with chronic diseases is a very important issue and demands more attention from researchers and community health planners. Meaning-based coping style can be used for stress level interventions in hemodialysis patients. In this respect, policies and programs can be considered to strengthen the structures of this coping style in order to better manage stress. Designing, planning, and implementing appropriate educational interventions with the emphasis on meaning-based coping by health care providers is regarded as an appropriate step to manage stress in hemodialysis patients. It is suggested that future research focus on implementing educational interventions aimed at reducing stress levels for hemodialysis patients, helping them cope with stress, practice self-care, and maintain mental well-being. Further studies should explore the relationship between different aspects of meaning-based coping and social support in this population. Additionally, conducting research in collaboration with the Treatment Deputy in private hospitals could provide valuable insights into improving the care and outcomes of hemodialysis patients.