Needs, Acceptability, and Functional Requirements of Gamified Cardiopulmonary Resuscitation Training Kits Among Children and Their Parents in China: Cross-Sectional Qualitative Study.

Hemodialysis is a life-sustaining but highly burdensome treatment for patients with end-stage renal disease []. Despite advances in dialysis technology and clinical management, many patients undergoing chronic hemodialysis experience persistent psychological distress due to the long-term nature of the treatment and related complications [,]. Demoralization, characterized by loss of meaning, hopelessness, and impaired coping [], is increasingly recognized in nephrology, with 59.4% of patients receiving hemodialysis exceeding the clinical cutoff in a multicenter study []. Heightened demoralization has been strongly and consistently linked to adverse psychological outcomes, poorer treatment adherence, and diminished quality of life among these patients []. An understanding of its mechanisms and the development of effective interventions are thus critical for improving patients’ mental health and quality of life. A growing body of evidence suggests that the symptom burden is a central pathway through which hemodialysis exerts its psychological toll. Defined as the cumulative incidence, frequency, and severity of disease-related symptoms and the associated distress [], the symptom burden has emerged as one of the most robust predictors of emotional dysfunction in chronically ill populations []. In patients receiving hemodialysis, high levels of fatigue, pain, sleep disturbance, and autonomic discomfort create persistent physiological strain that can overwhelm psychological resilience. Greater symptom burdens have been significantly associated with elevated demoralization [,], but the mechanisms linking these 2 constructs remain insufficiently understood, limiting the development of targeted clinical strategies. According to the stress and coping theory [], individuals appraise illness-related stressors not only based on their objective severity but also in terms of their coping styles. Thus, coping styles may regulate cognition regarding physiological symptoms, resulting in different health outcomes []. Among patients, these styles are commonly classified as centered on confrontation, avoidance, and resignation []. As mediators, coping styles link stressors to health outcomes [-]. Positive coping (eg, confrontation) buffers demoralization [], whereas avoidance and resignation predict greater distress and demoralization []. Prior research has shown that symptom burden increases demoralization through resignation coping among patients with cancer []. However, this focus on resignation leaves unresolved whether different coping strategies exert differential effects along the symptom burden-demoralization pathway in patients receiving hemodialysis. Moreover, whether this indirect pathway is moderated by other potential protective factors remains unexplored. Identifying such moderators is particularly valuable for guiding the development of targeted and scalable intervention strategies.