This study collected clinical data from 220 young and middle-aged MHD patients treated at the Blood Purification Center of the Second Affiliated Hospital, Zhejiang University School of Medicine between April 2024 and April 2025. The patient screening flowchart is shown in Fig. 1. Inclusion criteria: (1) 18–59 years; (2) receiving regular MHD for $\ge$3 months; (3) presence of complete clinical data; (4) having adequate communication and cognitive abilities to complete the questionnaire.

Fig. 1.

Flow chart of participant screening and enrollment in the study. MHD, maintenance hemodialysis.

Exclusion criteria: (1) presence of immunodeficiency, hematological disorders, or autoimmune diseases; (2) severe impairment of other vital organs (heart, brain, liver, lungs, etc.); (3) chronic or acute infectious disease within the past month; (4) previous participation in similar studies; (5) severe mental or psychological disorders or recent major negative life events.

Statistical analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). A p-value 0.05 was considered statistically significant. The Levene test was used to assess homogeneity of variance, and the Kolmogorov-Smirnov test was applied to examine normality. Measurement data following a normal distribution were expressed as mean $\pm$ standard deviation (SD). The independent sample t-test and one-way analysis of variance (ANOVA, F) were employed for group comparisons.

Multiple linear regression analysis was conducted to identify factors influencing subjective well-being among young and middle-aged MHD patients, with a test level of $\alpha$ = 0.05 (two-tailed). The diagnosis of multicollinearity is based on the variance inflation factor (VIF). The entry method was used to introduce independent variables, ensuring that assumptions of linearity, independence, and absence of multicollinearity were satisfied.

The average GWB score among the 220 young and middle-aged MHD patients was 62.44 $\pm$ 3.12 (Table 1).

This study included a total of 220 young and middle-aged MHD patients, comprising 129 males and 91 females. In terms of educational background, the majority (144 cases) had a high school education or below. Most patients reported a family per capita monthly income between 4001 and 6000 Chinese yuan (1 Chinese yuan =0.14 US dollars, 61 cases). The differences in GWB scores among young and middle-aged MHD patients with varying education levels and per capita monthly family income were statistically significant (p 0.05; Table 2).

The differences in GWB scores among young and middle-aged MHD patients with varying self-care ability, self-management ability, and levels of symptom distress were statistically significant (p 0.05; Table 3).

The GWB scores in young and middle-aged MHD patients differed significantly according to the financial burden and social support of their families (p 0.001; Table 4).

Variables with p 0.05 in the univariate analysis were entered as independent variables, and the subjective well-being score of young and middle-aged MHD patients was set as the dependent variable. Multivariate linear regression analysis revealed that education, per capita monthly family income, self-care ability, self-management ability, symptom distress, financial burden to the family, and social support were all significant influencing factors of subjective well-being in young and middle-aged MHD patients (p 0.05; Tables 5,6).

These factors could be broadly classified into three domains, each reflecting different levels of influence on patients’ well-being. First, socioeconomic resources, such as higher education and greater family income, provided a stronger material foundation and enhanced resilience against illness-related stressors. Second, personal ability and physical condition, including stronger self-care and self-management abilities, as well as lower symptom distress, directly determined a patient’s quality of daily life and sense of independence and dignity. Third, external environmental pressure and support, such as reduced financial burden and stronger social support, served as crucial psychological buffers that contributed to alleviating feelings of isolation and economic anxiety.

Due to frequent and prolonged hospital visits, the physical and social abilities of MHD patients gradually decline, contributing to adverse psychological conditions [12]. In addition to physical symptoms, the present study found that the subjective well-being (GWB score: 62.44 $\pm$ 3.12) of young and middle-aged MHD patients was at a moderate level, which provided empirical support for previous research [13] reporting that 60.3% of patients experienced psychological symptoms such as depression and anxiety. The moderate level of well-being observed in this study further quantifies the relatively low mental health status of this population.

Although medical insurance policies help alleviate part of the perceived burden among MHD patients, the cumulative cost of long-term treatment continues to impose a substantial financial burden on patients’ families and caregivers. This financial pressure leads to a reduced quality of life and diminished subjective well-being, which may in turn exacerbate physical and psychological distress, creating a vicious cycle [14]. By incorporating quantitative measures of well-being, our research not only aligns with previous findings but also provides robust data to better characterize the psychological state of young and middle-aged MHD patients. The findings clearly demonstrate that their subjective well-being remains within a relatively low to moderate range, underscoring the need for targeted psychological and social support interventions.

The findings of this study confirmed that education is a significant factor influencing the subjective well-being of young and middle-aged MHD patients. This is consistent with the results reported by Hao et al. [15], which indicated a positive association between educational level and overall quality of life among MHD patients. Furthermore, this study revealed specific psychological pathways through which education influences subjective well-being. Patients with lower educational levels often exhibit poorer acceptance of dialysis treatment, as limited disease awareness contributes to a heightened psychological burden and consequently lower subjective well-being.

Conversely, patients with higher educational levels demonstrate a greater capacity to access and utilize diverse information sources, which enhances their understanding of the disease, reduces psychological stress, and contributes to higher subjective well-being. Similarly, Peng et al. [16] reported that visualized health education based on the Health Belief Model significantly improves disease cognition and self-management abilities across different educational backgrounds. This suggests that systematic and visualized dissemination of health information can effectively compensate for cognitive gaps associated with lower educational levels, thereby improving self-efficacy and subjective well-being.

In clinical practice, these findings suggest that graphic manuals and short educational videos (preferably in the local dialect) should be used to explain dialysis-related knowledge to young and middle-aged MHD patients with lower educational levels. Additionally, establishing a “Question and Answer (Q & A) wall” in dialysis centers to answer common questions in an accessible language may enhance patients’ understanding and knowledge of the disease and further improve their subjective well-being.

Furthermore, this study confirmed that per capita monthly family income significantly influences patients’ subjective well-being, supporting the conclusions of Intas et al. [17], who reported that economic stress negatively affects patients’ quality of life and family burden. This research further investigated the specific impact of economic factors among young and middle-aged MHD patients, identifying subjective well-being as a key indicator. For patients with low per capita monthly family income, targeted interventions such as transportation or nutrition subsidies, the establishment of low-income patient support groups, and the integration of social work resources to facilitate benefit applications may help enhance their subjective well-being.

The findings of this study confirmed that self-care ability has a significant influence on the subjective well-being of young and middle-aged MHD patients. Those who cannot care for themselves experience limitations in daily activities, loss of adult independence, and feelings of uselessness. Furthermore, the presence of dialysis catheters, skin pigmentation, and emaciation or edema can worsen their physical self-image, leading to social withdrawal, loneliness, and ultimately reduced subjective well-being [18]. This study further revealed the central role of “self-care capacity loss” within this psychological pathway, as it affects patients’ subjective experience by impairing their sense of independence and self-worth.

For young and middle-aged MHD patients with limited self-care abilities, the provision of assistive devices, such as wheelchairs and bath chairs, can facilitate functional rehabilitation training. At the same time, psychological counseling can be offered to reduce feelings of shame. Family collaboration programs should also be developed to train caregivers to avoid excessive protectiveness and to ensure that daily activities remain within the patient’s capability, thereby enhancing their subjective well-being.

Moreover, the self-management ability was shown to be closely associated with subjective well-being among young and middle-aged MHD patients. Irregular dialysis or non-cooperative behaviors of young and middle-aged MHD patients, such as arbitrarily shortening dialysis sessions, may result in toxin accumulation, skin itching, and insomnia, leading to further decline in quality of life. MHD patients who perceive themselves as burdens to their families and believe they make no meaningful contribution are more prone to social withdrawal and escapist ideation, significantly increasing their risk of severe psychological distress [19]. For young and middle-aged MHD patients exhibiting poor self-management abilities, setting staged goals, by breaking large objectives into smaller, achievable tasks, can help reduce frustration. Moreover, enhancing confidence and self-efficacy through exposure to successful patient role models and positive feedback from healthcare providers can further improve their subjective well-being.

Symptom distress was also found to significantly impact the subjective well-being of young and middle-aged MHD patients. The results confirmed the key role of symptom management in improving well-being and provided empirical support for the existing “symptom distress-happiness decline” theory within this age group. Young and middle-aged MHD patients experiencing severe symptom distress may suffer direct physical discomfort, which can lead to a marked decline in their subjective well-being. Accordingly, a stepped-care approach to symptom management can be employed. This may include basic interventions for mild symptoms (providing symptom management manuals and encouraging patients to maintain symptom diaries); enhanced interventions for patients with moderate symptoms (specialist consultation, psychological intervention, and cognitive-behavior therapy to alleviate negative emotions); and advanced interventions for patients with severe symptoms (developing a functional rehabilitation plan through a multidisciplinary team). Implementing such graduated symptom management strategies can effectively enhance the subjective well-being of young and middle-aged MHD patients.

This study revealed that the financial burden on families significantly affected the subjective well-being of young and middle-aged MHD patients. The cost of MHD treatment is high, with an average annual expenditure reaching tens of thousands of yuan. Even after medical insurance reimbursement, the out-of-pocket expenses remained substantial, which constrained patients’ basic living needs. Moreover, most young and middle-aged patients were compelled to reduce working hours or become unemployed due to treatment schedules and decreased physical strength, further reducing family income and forming a vicious cycle that led to reduced subjective well-being. These findings further deepen the understanding of the vicious circle mechanism linking financial burden and quality of life, highlighting the heightened vulnerability of young and middle-aged patients to income disruption. For young and middle-aged MHD patients experiencing heavy family financial burden, targeted medical assistance programs can be implemented, the reimbursement ratio for dialysis expenses can be increased, and nursing training for family members can be provided to lessen the burden of caregiving, prevent households from falling into poverty, and ultimately improve the subjective well-being of patients.

This study also confirmed that social support is a significant factor influencing subjective well-being in young and middle-aged MHD patients, consistent with the findings reported by Luo et al. [20]. Additionally, this study further supplemented the specific manifestations of insufficient social support from the perspective of patients’ subjective experiences, including emotional repression expressed as “no one understands”, and discrimination from being misunderstood as having an “infectious disease” due to visible body changes, thus refining the internal mechanism of how social support influences well-being. Young and middle-aged MHD patients with limited social support often lack confidants, leading to feelings of being misunderstood and emotionally repressed. Some patients may experience social discrimination due to the visibility of dialysis catheters or reduced physical strength, causing self-isolation and loneliness. When families and social networks fail to provide financial support or emotional support, patients may be compelled to reduce dialysis frequency or discontinue essential medications, thereby compromising their quality of life and further diminishing their subjective well-being.

For young and middle-aged MHD patients with low social support, family support can be strengthened through educational programs that train family members to provide emotional support and appropriate care. Meanwhile, establishing mutual aid networks can foster participation in dialysis patient communities, facilitate the sharing of experiences, reduce loneliness, and improve patients’ subjective well-being.

A limitation of this study is that the sample primarily consisted of young and middle-aged patients. Therefore, the findings may not be directly generalizable to MHD populations with different demographic characteristics (such as elderly patients), geographic regions, cultural backgrounds, or healthcare systems. Future research should include more diverse populations and larger sample sizes to validate the generalizability of these findings and provide a more comprehensive understanding of the factors influencing subjective well-being among MHD patients in varied settings.