Anticipated stigma and perceived social support among maintenance hemodialysis patients in Syria: a multicentre cross-sectional study in a conflict-affected setting

IMPORTANCE: Stigma is a significant psychosocial challenge among patients receiving maintenance hemodialysis (HD). Evidence from conflict-affected, resource-limited settings is scarce, particularly regarding anticipated stigma, perceived social support, and site-level differences in dialysis care. OBJECTIVE: To assess the prevalence of anticipated stigma and its association with perceived social support and clinical factors among maintenance HD patients in Syria. DESIGN, SETTING, AND PARTICIPANTS: This multicenter cross-sectional study was conducted from June 30 to December 4, 2025, among 507 adult patients receiving maintenance hemodialysis across five Syrian governorates. Data were collected using interviewer-administered questionnaires. EXPOSURES: Perceived social support measured by the Multidimensional Scale of Perceived Social Support (MSPSS), and clinical and dialysis-related characteristics, including blood transfusion history, erythropoietin therapy, chronic pruritus, perceived dialysis-related financial burden, and hemodialysis hospital/governorate. MAIN OUTCOMES AND MEASURES: The primary outcome was anticipated stigma, defined operationally as a Chronic Illness Anticipated Stigma Scale (CIASS) total score > 24. Secondary measures included CIASS and Multidimensional Scale of Perceived Social Support (MSPSS) total and domain scores. Analyses included Spearman correlations, nonparametric group comparisons, hierarchical block-wise binary logistic regression, and a sensitivity analysis treating CIASS total score as a continuous variable. RESULTS: The mean age was 48.3 years (SD 14.9), and 57.0% of participants were male. Anticipated stigma was identified in 39.6% of patients, with a median CIASS score of 24 (IQR 19-28). Median MSPSS score was 67 (IQR 58-73), and 66.9% of participants reported high perceived social support. CIASS and MSPSS scores were inversely correlated (rₛ = -0.170, p < 0.001). In the fully adjusted hierarchical model, blood transfusion history was independently associated with higher odds of anticipated stigma (OR 2.09, 95% CI 1.27-3.45), while higher MSPSS score was associated with lower odds (OR 0.965, 95% CI 0.949-0.983). Hemodialysis hospital/governorate remained significantly associated with anticipated stigma in the final model (p < 0.001). Sensitivity analysis using CIASS as a continuous outcome showed consistent direction of associations. CONCLUSIONS AND RELEVANCE: Anticipated stigma was common among maintenance HD patients in this conflict-affected setting. Higher perceived social support was consistently associated with lower anticipated stigma, whereas blood transfusion history was associated with higher stigma. These findings should be interpreted as associative and exploratory rather than predictive, and do not represent a clinical screening or prediction tool. Future research should address psychological and institutional determinants to better explain stigma mechanisms in this population.