The demographic questionnaire that was developed by the researchers contained questions on sociodemographic and disease-related characteristics of the patients such as gender, age, education, marital status, primary caregiver, employment, dialysis duration, presence of a co-morbid disease, kidney transplant experience, self-perceived degree of knowledge of disease-related information, self-perceived burden of medical expenses for disease, self-perceived degree of impact of disease on life.

The PERMA scale is a 23-item measure of flourishing developed by Kern et al. (8). Widely utilized in the United States, Australia, Korea, Japan, and other global populations, it has been adapted by our research group into a Chinese version, demonstrating commendable reliability (8, 23–26). The scale encompasses 15 items measure PERMA (Positive emotions, Engagement, Relationships, Meaning and Accomplishments). There are additional three item subscales examine Overall Happiness, Loneliness, Physical Health and Negative Emotion. Each item is rated on a Likert-type scale ranging from 0 to 10. Dimension scores were calculated as the average score of the corresponding items. The flourishing score is derived from adding the PERMA Total to the Overall Happiness item. The research team translated the PERMA scale into Chinese and conducted an exploratory factor analysis on the survey results from 376 samples. The Chinese version retained all original items and factor analysis identified two dimensions: Positive experience and Self-accomplishment. The original subdomains of Positive emotions and Relationships were consolidated into a unified “positive experience” dimension, while Engagement, Meaning, and Accomplishment were combined to form a “Self-accomplishment” dimension. The two dimensions obtained by EFA were used for model fitting, and the results of model fitting indices showed χ2/df=3.234, RMSEA=0.095, GFI=0.858, CFI=0.894, IFI=0.895, and TLI=0.875. The Cronbach’s α of the scale in this study was 0.895 (95% CI [0.879, 0.910]).

The Ten-Item Personality Inventory in China (TIPI-C), developed by Gosling et al. (27), serves as a tool to assess Big-Five personality traits. Jinde Li translated the TIPI into the Chinese version (28). Comprising 10 items distributed across five dimensions (E-Extroversion, A-Agreeableness, C-Conscientiousness, ES-Emotional Stability and O-Openness), the TIPI utilizes two items for each Big-Five personality dimension. Notably, items 2, 4, 6, 8, and 10 should be reverse-coded when computing the dimension score. Responses were recorded on a Likert scale ranging from 1 to 7 (1=strongly disagree, 7=strongly agree), with higher scores indicating a greater expression of the respective trait. The Cronbach’s α of the scale in this study was 0.6439 (95%CI [0.608, 0.678]). CFA proved that the goodness-of-fit indicators were acceptable (28).

The Regulatory Emotional Self-Efficacy Scale (RES), initially designed by Caprara et al. and later revised by Yu Guoliang et al. (29), comprises a total of 12 questions distributed across three dimensions: Perceived self-efficacy in expressing positive affect (POS, 4 items), Perceived self-efficacy in managing despondency (DES, 5 items), and Perceived self-efficacy in managing anger (ANG, 3 items). Respondents provide ratings for each item on a 5-point Likert scale, ranging from 1 to 5. A higher score indicates a higher level of regulatory emotional self-efficacy exhibited by the investigator. The Cronbach’s α of the scale in this study was 0.872 (95% CI [0.850, 0.894]). Goodness-of-fit indicators were within acceptable levels (29).

The Perceived Social Support Scale (PSSS) was employed to assess an individual’s perceived social support (30). Each participant’s responses were evaluated using a 12-item scale, comprising two subscales: family support (4 items) and friends and important others support (8 items). Participants provided responses to each item on a 7-point Likert scale. The scores of items within each dimension were aggregated, with higher scores indicating a greater perception of social support. The Cronbach’s α of the scale in this study was 0.875 (95%CI [0.853, 0.897]). Fit measures fell within the range of acceptability (30).

The EuroQol five-dimensional questionnaire (EQ-5D), a globally recognized patient-reported outcome instrument renowned for its succinct and lucid items, is widely employed for health measurement and valuation due to its effective assessment capabilities. It has also become a commonplace tool for evaluating the quality of life among patients grappling with chronic kidney disease (31). The EQ-5D comprises two parts: a multidimensional health classification system and a visual analog assessment system. For this study, only the Multidimensional Health Classification System was utilized for assessment, considering the potential impact of personal researcher perception on the scoring values. The EQ-5D evaluates health across five dimensions—mobility (MOB), self-care (SC), usual activities (UA), pain/discomfort (PA), and anxiety/depression (MOOD)—with three severity levels in each dimension. It has established a corresponding utility value point system in China (1=no problems, 2=some/moderate problems, 3=extreme problems/unable) (32). The Cronbach’s α of the scale in this study was 0.766 (95%CI [0.735, 0.797]).

The study found that several sociodemographic factors influence the flourishing among MHD patients, supporting Hypothesis 1 (H1). Higher education levels and a greater understanding of disease-related information were associated with higher levels of flourishing, consistent with previous research findings (39, 40). Patients with higher education tend to have better self-regulation skills, which contributes to improved quality of life and mental health (41). The study’s findings suggest that intimate relationships stemming from marriage, stable employment status positively influence the flourishing of MHD patients. Previous research has indicated that MHD patients with a partner feel more cared for and supported, and a stable and warm intimate relationship promotes their mental health (42). Employment status emerged as the sole sociodemographic variable entering the hierarchical linear regression equation in this study. Univariate analysis results further highlight that MHD patients with full-time employment exhibit the highest level of flourishing. Despite the impact of MHD on their daily lives, individuals with full-time jobs can still engage in work activities, derive a sense of value from completing tasks, and thereby bolster their mental health (43).

The duration of MHD treatment, the perceived impact of the disease on life, and the financial burden of medical expenses were all found to be negatively associated with flourishing, supporting Hypothesis 2 (H2). These findings align with existing literature, which suggests that prolonged dialysis leads to weakened physiological functions, decreased immunity, and an increased burden of chronic diseases, all of which negatively impact quality of life and flourishing (44). With the prolonged duration of MHD, patients experience weakened physiological functions, decreased immunity, increased chronic diseases, and a heightened impact on their daily lives (45). Consequently, the quality of life is further compromised, adversely affecting the level of flourishing. Existing studies corroborate the significant impact of patients’ quality of life on mental health, particularly in MHD patients who often contend with elevated levels of depression and anxiety due to the influence of the disease and its treatment (46, 47). The long-term treatment regimen places greater economic and life pressure on MHD patients, may negatively influence their flourishing (48). Regression analysis underscores that quality of life has the most substantial impact on flourishing, highlighting the critical need for interventions aimed at alleviating the burden of disease and improving quality of life.

Personality traits were found to significantly influence flourishing, with extroversion, conscientiousness, and openness being positively associated with higher flourishing levels. Neuroticism scores were reverse-coded (i.e., higher scores reflect emotional stability), resolving the apparent contradiction. Neuroticism was negatively associated with flourishing. Hypothesis 3 were proved. Personality traits are known to shape daily behaviors and mental health outcomes, with extroverted and conscientious individuals more likely to experience strong mental health (49). The univariate analysis of this study revealed that extroversion among the Big Five personality traits of maintenance hemodialysis patients had a higher correlation with the dimension of positive experience, while conscientiousness and openness had a higher correlation with the dimension of self-accomplishment. Extroversion is characterized by sociability, talkativeness, self-confidence, and preferred emotional expression (50). People receive MHD who are extroverted may experience more positive emotions through social and emotional expression. People with openness are imaginative and creative, eager to try and learn new things, and more likely to adopt new ways of achieving goals (51). Conscientious individuals are organized and prefer to plan, leading to better disease management and goal achievement (52).

Regulatory emotional self-efficacy, the cognitive process by which individuals regulate mood changes in this study, POS and ANG entered the regression equation for the factors associated with flourishing. Zhenghong et al. also showed that regulatory emotional self-efficacy can positively influence well-being (53). Expressing positive emotions is one of the types of disclosure, and individuals who express positive emotions have certain positive tendencies in both explicit and implicit situations and being good at disclosure also plays an important role in the promotion of mental health (54). Patients who can effectively manage their emotions are better equipped to cope with the psychological challenges posed by chronic illness, leading to higher levels of flourishing (55).

Social support was strongly associated with flourishing in all dimensions in this study, further supporting Hypothesis 3 (H3). This implicates that better and broader social relationships are positive affect the level of flourishing, which is in line with the other studies (56, 57). Social support is a major external factor that affects the psychological state and quality of life of patients. Good social support has been shown to predict better emotional states and increase resilience in coping with traumatic events (58, 59). Patients discussing and sharing their feelings with others can receive helpful advice and assistance, which may lead to increased confidence in coping with the illness and ultimately positive emotions (60, 61). Social support provides patients with necessary resources such as emotional, informational, and financial assistance to encourage patients to rethink the meaning of life (62). Therefore, social support has a facilitating effect on flourishing. In this study, family support was more correlated with patients’ flourishing level compared to friends and others support. Family caregivers had the highest percentage of caregivers in this study. The role of family caregivers, who often provide the primary support for MHD patients, was particularly emphasized. They may be burdened by physical, psychological, financial, and time constraints, potentially limiting the support they can provide. (63). Peer support, such as sharing experiences with fellow patients, can offer significant benefits, including information, emotional support, and a sense of community (64), which may enhances quality of life and flourishing.

Given the positive correlation between knowledge of disease and flourishing, tailored educational programs can be designed to enhance patients’ understanding of their condition. These programs should aim to empower patients with knowledge about disease management, coping strategies, and the importance of adherence to treatment protocols.

The significant impact of personality traits and emotional self-efficacy on flourishing suggests the need for psychological interventions. Cognitive-behavioral therapy (CBT) and resilience training can be integrated into patient care to bolster emotional regulation skills, reduce anxiety and depression, and promote positive affect (65). Griva et al. developed an intervention program known as HED-Start. This program integrates CBT, positive psychology, and self-management strategies to assist new patients in successfully transitioning to the hemodialysis phase (66).

Facilitating support networks is crucial. Healthcare providers can organize support groups where patients share experiences and coping strategies. Additionally, involving family members in educational sessions can strengthen the support system, ensuring that patients receive comprehensive care both within and outside clinical settings (67).

Adopting a patient-centered care approach that integrates physical, psychological, and social aspects of health can lead to better outcomes. Multidisciplinary teams, including nephrologists, psychologists, social workers, and nutritionists, can collaboratively develop and implement individualized care plans.