Effect of a Structured Support Group Programme on Quality of Life Among Patients Undergoing Hemodialysis: A Quasi-Experimental Study

Hemodialysis (HD) is a life-sustaining therapy for patients with end-stage renal disease (ESRD), yet it imposes a significant burden on their physical, psychological, and social well-being. These patients experience multiple challenges, including chronic fatigue, dietary and fluid restrictions, dependency on treatment schedules, financial strain, and frequent hospital visits—all of which negatively impact their quality of life (QOL) [1,2]. QOL is a broad, multidimensional concept that includes subjective evaluations of both positive and negative aspects of life, encompassing domains such as physical health, emotional well-being, social functioning, and personal autonomy [3].

In recent years, the quality of life in patients undergoing hemodialysis has gained attention as a critical indicator of treatment success, beyond clinical and biochemical outcomes. Studies have shown that patients on long-term dialysis often suffer from poor QOL due to limited physical activity, persistent symptoms (such as itching, sleep disturbances, and pain), psychological distress (including anxiety and depression), and reduced social engagement [4,5]. Addressing these issues requires more than conventional medical care—it calls for comprehensive psychosocial support.

 Support group programmes have emerged as effective, low-cost, and accessible interventions that aim to improve coping skills, reduce emotional distress, and enhance QOL. These programmes provide a platform for peer interaction, emotional expression, shared experiences, and mutual support under the guidance of trained professionals [6]. Evidence suggests that group-based psychoeducational and behavioral interventions can significantly improve emotional well-being, treatment adherence, and social connectedness among HD patients [7].

Given the substantial psychosocial burden experienced by patients undergoing hemodialysis, it is essential to evaluate and implement supportive care strategies that focus on enhancing their quality of life. This study explores the effects of a structured support group programme on the QOL of patients undergoing maintenance hemodialysis, with the goal of integrating psychosocial care into routine nephrology services.

End-stage renal disease (ESRD) is a chronic, progressive condition requiring life-sustaining therapies such as hemodialysis (HD). While HD extends survival, it imposes considerable physical, psychological, and social burdens on patients. These burdens significantly reduce the quality of life (QoL), manifesting as chronic fatigue, dietary and fluid restrictions, limited mobility, anxiety, depression, and social withdrawal. Studies have shown that a large proportion of HD patients experience moderate to severe levels of perceived stress, which negatively impacts their QoL and overall clinical outcomes.

Despite advances in dialysis technology and medical management, psychosocial care is often overlooked. In low-resource settings, patients rarely receive structured support to cope with the psychological and lifestyle challenges associated with HD. Support group programmes, especially those incorporating cognitive-behavioral strategies, are known to be effective, low-cost interventions that improve coping skills, reduce mental distress, and enhance QoL in chronic illness. However, evidence from the Indian context—particularly in regional languages like Malayalam—is limited. Therefore, there is an urgent need to evaluate the effectiveness of structured support group programmes on quality of life among patients undergoing maintenance hemodialysis.

The primary objective of this study is to assess the effect of a structured support group programme on the quality of life (QoL) of patients undergoing hemodialysis. Quality of life will be evaluated from the patient’s perspective, encompassing physical health, mental well-being, and social functioning, using the Kidney Disease Quality of Life-36 (KDQOL™-36) instrument.

Research Approach and Design: This study adopts a quantitative research approach with a quasi-experimental pretest–posttest control group design. Specifically, a non-randomized controlled trial was used: one group of patients received the support group intervention (experimental group) while a comparison group received only routine care (control group). Both groups were assessed at baseline and at two follow-up points. This design allows for evaluating changes over time within each group and differences between groups, attributing any improvements in the experimental group to the intervention.

Setting and Sample: The research was conducted in the hemodialysis unit of a selected tertiary-care hospital in Ernakulam, Kerala (South India). The target population was adult ESRD patients on maintenance hemodialysis at this center. Key eligibility criteria included: patients aged 30 to 65 years, undergoing hemodialysis twice weekly for at least 6 months (via an arteriovenous fistula or tunneled catheter access), and able to communicate in Malayalam. Patients also needed to have access to an Android smartphone (to enable participation in virtual group sessions). Patients were excluded if they had significant sensory or cognitive impairments (which would hinder participation), if they were medically unstable or deteriorating during the study period, or if they were likely to miss sessions (e.g., due to plans of transfer to another center or transplantation during the study). A purposive sampling technique was used to recruit participants meeting these criteria from the dialysis unit.

Sample Size: A sample size of 120 patients (60 in the experimental group and 60 in the control group) was planned. The size was estimated based on prior data and power analysis to detect a meaningful difference in QoL scores, with an allowance for potential dropout. (Initial calculations suggested around 53 patients per group were needed; assuming ~10% attrition, this was increased to 58–60 per group for robust results.) Ultimately, 60 patients were enrolled into each arm of the study.

Data Collection Process

Data were collected at three time points:

• Pretest (Day 1) – Baseline measurements for both groups (O1)
• Posttest 1 (Day 42) – After 6 weeks of intervention/routine care (O2)
• Posttest 2 (Day 70) – Four weeks after Posttest 1 to assess sustained effects (O3)

The experimental group received the support group programme alongside routine dialysis care during weeks 1 to 6, while the control group continued to receive only standard medical care.

Intervention Details

The experimental group participated in a structured support group programme, designed using cognitive-behavioral principles and facilitated by a trained counselor. Sessions addressed stress management, emotional coping, and peer interaction, and were delivered weekly during dialysis hours over a 6-week period.

Table 1: Tools Used for Data Collection

Ethical Considerations

All participants provided written informed consent. The study adhered to ethical guidelines, and approval was obtained from the Institutional Ethics Board (Approval No: LH/EC/2022-29).

Quality of Life (QoL): Domains Measured:

1.       Physical Health Composite Score (PCS)

2.       Mental Health Composite Score (MCS)

3.       Burden of Kidney Disease

4.       Symptoms/Problems of Kidney Disease

5.       Effects of Kidney Disease on Daily Life

Table 2: Comparison of Experimental and Control Groups on KDQOL™-36 Domains (N = 120)

1. SF-12 Physical Composite Score

This domain exhibited strong significant effects across all ANOVA tests. The experimental group showed dramatic improvements over time, while the control group remained nearly static. Paired comparisons confirmed significant gains within the experimental group at all intervals, whereas the control group showed no meaningful change. Between-group comparisons also showed large, statistically significant differences at both post-tests, emphasizing the intervention’s effectiveness in enhancing patients' physical health and functional status. [Table 2, Figure 1]

Fig1: Physical Composite Scores across time and groups

2. SF-12 Mental Composite Score

Both groups started with similar mental health scores. While the experimental group showed a consistent and statistically significant upward trend across all post-tests, the control group remained mostly unchanged. The interaction effect was significant, indicating a different change pattern over time. Though between-group differences at individual time points were not statistically significant, the experimental group's internal progression suggests that the intervention had a meaningful positive impact on mental well-being. [Table 2, Figure 2]

Fig2: Mental Composite Score across time and groups

3. Burden of Kidney Disease

Findings demonstrated significant group, time, and interaction effects, with a marked upward trajectory in the experimental group’s scores, reflecting a reduction in perceived burden. The experimental group had significantly higher scores at both post-test 1 and post-test 2 compared to the control group. Within-group tests also showed significant improvements over time in both groups, though the magnitude of change was far greater in the experimental group, confirming the intervention's substantial benefit in alleviating disease burden.[Table 2, Figure 3]

Fig3: Burden of Kidney Disease Score across time and groups

4. Symptoms/Problems of Kidney Disease

At baseline, both groups had comparable scores. Over time, the control group remained stable, while the experimental group showed an initial decline followed by a marked improvement at post-test 2. However, repeated measures ANOVA showed no significant group, time, or interaction effects, suggesting that the intervention did not result in statistically meaningful differences across groups. The only notable change was a significant within-group improvement from post-test 1 to post-test 2 in the experimental group, possibly reflecting delayed benefits of the intervention. [Table 2, Figure 4]

Fig4: Symptoms/ Problems Composite Score across time and groups

5. Effects of Kidney Disease

This domain showed significant time and interaction effects, meaning scores changed over time and differently between the groups. While the control group showed mild improvements, the experimental group exhibited a substantial decline in perceived disease effects, especially at post-test 2. These changes were statistically significant both within the experimental group (pre- vs post-2 and post-1 vs post-2) and between groups at post-test 2, indicating that the intervention had a strong impact on reducing perceived disease burden on daily life.[ Table 2, Figure 5]

Fig5: Effect of Kidney Disease Score across time and groups

Hemodialysis patients often experience compromised quality of life (QoL) due to physical, emotional, and disease-related stressors. Interventions such as support group programs can potentially enhance QoL outcomes. This study is aim to assess the effect of a structured support group programme on various KDQOL™-36 domains among patients undergoing maintenance hemodialysis.
The present study demonstrated that a structured support group programme significantly improved the quality of life (QoL) across multiple domains among patients undergoing maintenance hemodialysis. The SF-12 Physical Composite Score showed highly significant group, time, and interaction effects (F = 8.1, 5.757, 5.903; p = 0.001), highlighting substantial gains in physical functioning among the intervention group. The SF-12 Mental Composite Score also improved significantly over time within the experimental group (p < 0.05), though between-group differences were not statistically significant. Similarly, the Burden of Kidney Disease and Effects of Kidney Disease domains reflected significant improvements post-intervention (F = 3.239, p = 0.025; F = 5.928, p = 0.001). In contrast, the Symptoms/Problems of Kidney Disease domain showed no significant group, time, or interaction effects, although a notable within-group improvement from post-test 1 to post-test 2 was observed in the experimental group, suggesting possible delayed benefits. These findings affirm the effectiveness of structured psychosocial interventions in alleviating physical, psychological, and disease-related challenges faced by hemodialysis patients.
The results align with Mansouri et al. (2020), who reported significant post-intervention improvements in QoL scores following an 8-session educational supportive therapy program for hemodialysis patients. Similar to our findings, they found no baseline differences but statistically significant improvements post-intervention (p = 0.0001). This supports the notion that structured group interventions, even within short timelines, can be impactful.
Lii et al. (2007) also highlighted the effectiveness of psychosocial group interventions, with significant improvements noted in depression, self-efficacy, and QoL as measured by SF-36. Their use of weekly two-hour group sessions aligns with the present study’s emphasis on continuous and structured engagement, underscoring the psychological and behavioral benefits of group therapy models.
Further supporting evidence comes from Ghane et al. (2017), who focused on caregivers of hemodialysis patients. Their randomized controlled trial found significantly improved QoL post-supportive education sessions (p < 0.001). Though targeting caregivers, the study emphasizes the broader relevance of psychosocial interventions in renal care ecosystems and complements our findings from the patient perspective.
In line with our study, Bakarman et al. (2019) demonstrated significant post-intervention improvements in multiple QoL dimensions, including role-physical and role-emotional domains, after an 8-week structured education program. They also noted improvement in clinical parameters like hemoglobin levels. While our study did not measure clinical indicators post-intervention, their inclusion suggests that patient education may yield tangible biological benefits alongside psychosocial gains.
Shahnavazi et al. (2018) offered a different but related perspective by integrating emotional intelligence (EI) training. Their study reported significant increases in QoL scores post-intervention (p = 0.032), particularly at 12 weeks. This adds credence to the argument that tailored psychological training — whether EI, CBT, or group therapy — can positively impact long-term well-being in chronic disease settings.
Lazarus (2019) further expands this discussion by combining education with supervised exercise. Their intervention significantly improved QoL in ESRD patients (p < 0.01), particularly in both physical and mental health components. This holistic approach supports our conclusion that physical engagement, in conjunction with educational support, can produce synergistic effects on QoL.
Collectively, the findings from these six studies and our own suggest that support-based, structured interventions — whether educational, psychosocial, or behavioral — are consistently effective in improving QoL among hemodialysis patients. Our study adds to this growing evidence base by demonstrating significant improvements across the Physical Composite, Mental Composite, and Disease Burden domains using a CBT-based support group format delivered during dialysis sessions, thereby increasing feasibility and adherence.
These findings advocate for the integration of structured psychosocial interventions into routine hemodialysis care to enhance patient outcomes. Future studies should aim to evaluate long-term sustainability of benefits, incorporate biochemical markers, and explore hybrid models combining exercise, education, and therapy to further optimize QoL in this vulnerable population.

This study demonstrates that a structured support group programme significantly enhances the quality of life among hemodialysis patients, particularly in the physical and mental health domains, as well as in reducing the perceived burden and effects of kidney disease. The intervention led to statistically significant improvements in multiple QoL subdomains within the experimental group over time, with notable differences from the control group, affirming the therapeutic value of integrating psychosocial support into routine dialysis care. These findings underscore the importance of holistic patient-centered approaches in managing chronic kidney disease and advocate for the inclusion of support group programmes in standard hemodialysis protocols to improve patient well-being and treatment outcomes.

Conflict of interest:  Nil.

1.       Li PK, Lu W, Mak SK, Boudville N, Yu X, Wu MJ, Cheng YL, Chan CT, Goh BL, Tian N, Chow KM. Peritoneal dialysis first policy in Hong Kong for 35 years: global impact. Nephrology. 2022 Oct;27(10):787-94.Kimmel PL. Psychosocial factors in dialysis patients. Kidney Int. 2001;59(4):1599–1613.

2.       Group TW. The World Health Organization quality of life assessment (WHOQOL): development and general psychometric properties. Social science & medicine. 1998 Jun 15;46(12):1569-85.

3.       Sathvik BS, Parthasarathi G, Narahari MG, Gurudev KC. An assessment of the quality of life in hemodialysis patients using the WHOQOL-BREF questionnaire. Indian journal of nephrology. 2008 Oct 1;18(4):141-9.

4.       Hedayati SS, Minhajuddin AT, Toto RD, Morris DW, Rush AJ. Prevalence of major depressive episode in CKD. American Journal of Kidney Diseases. 2009 Sep 1;54(3):424-32.

5.       Mansouri S, Jalali A, Rahmati M, Salari N. Educational supportive group therapy and the quality of life of hemodialysis patients. Biopsychosoc Med. 2020;14:27. doi:10.1186/s13030-020-00200-z

6.       Cukor D, Cohen SD, Peterson RA, Kimmel PL. Psychosocial aspects of chronic disease: ESRD as a paradigmatic illness. J Am Soc Nephrol. 2007;18(12):3042–3055.

7.       Mansouri B, Haghdoost AA, Moeini M, Sheibani V. Educational supportive group therapy and the quality of life of hemodialysis patients: a quasi-experimental interventional study. J Educ Health Promot. 2020;9:294. doi:10.4103/jehp.jehp_297_20

8.       Lii YC, Tsay SL, Wang TJ. Group intervention to improve quality of life in haemodialysis patients. J Clin Nurs. 2007 Jan;16(1):268–75. doi:10.1111/j.1365-2702.2005.01462.x

9.       Ghane G, Farahani MA, Seyedfatemi N, Haghani H. The effect of supportive educative program on the quality of life in family caregivers of hemodialysis patients: a randomized controlled clinical trial. Int J Community Based Nurs Midwifery. 2017 Apr;5(2):153–62.

10.    Bakarman MA, Al-Ghamdi SA, Al-Ghamdi AJ, Kinsara AJ, Al-Sayyad JJ, Alnashri YM, et al. The effect of an educational program on quality of life in patients undergoing hemodialysis in western Saudi Arabia: a randomized controlled trial. Saudi Med J. 2019 Feb;40(2):129–36.

11.    Shahnavazi H, Alizadeh S, Valizadeh L, Zaman Azadeh SA, Namadi Vosoughi M. The effect of emotional intelligence education on the quality of life in patients undergoing hemodialysis: a quasi-randomized controlled trial. Int J Community Based Nurs Midwifery. 2018 Jul;6(3):234–43.

12.    Lazarus ER. Effectiveness of education and exercise on quality of life among patients undergoing hemodialysis. Clinical Epidemiology and Global Health. 2019 Sep 1;7(3):402-8.