Symptom burden, comfort, and self-care agency in diabetic hemodialysis patients: a cross-sectional study with mediation analysis

BACKGROUND: Hemodialysis patients with diabetes experience substantial symptom burden that is significantly associated with lower levels of self-care behaviors. While comfort-based nursing interventions have been shown to reduce symptom severity, the specific mechanisms through which symptom burden relates to self-care agency remain unclear. This study aimed to examine the relationships among symptom burden, comfort, and self-care agency in hemodialysis patients with diabetes, and to determine whether comfort mediates the association between symptom burden and self-care agency. METHODS: A descriptive, cross-sectional study was conducted at a hemodialysis unit in Türkiye between May and December 2024. Ethical approval was obtained from the Ethics Committee of Health Sciences at Süleyman Demirel University (Decision No: 75/20, Date: 04/29/2024), and the study was conducted in accordance with the Declaration of Helsinki. A total of 125 hemodialysis patients with diabetes (mean age 66.31 ± 10.45 years) were recruited using convenience sampling. Data were collected using the Dialysis Symptom Index, Hemodialysis Comfort Scale, and Self-Care Agency Scale. Mediation analysis using the Baron and Kenny approach with bootstrap confidence intervals was performed. RESULTS: Symptom burden and self-care agency were significantly negatively correlated (r = - 0.402, p < 0.001), representing a moderate-sized association. Comfort showed no significant correlation with symptom burden (r = - 0.126, p = 0.160) or self-care agency (r = 0.117, p = 0.194). No significant mediating effect of comfort was observed in the relationship between symptom burden and self-care agency (indirect effect β = 0.005, 95% CI: -0.014 to 0.024). Symptom burden was directly and negatively associated with self-care agency (β = -0.407, p < 0.001). Taken together, these findings do not provide empirical support for the hypothesized mediation mechanism in which comfort serves as an intermediary in the pathway from symptom burden to self-care agency. The direct association between symptom burden and self-care agency was significant and unchanged after the inclusion of comfort in the model, further confirming the absence of a mediating role. CONCLUSIONS: Symptom burden was directly and negatively associated with self-care agency, independent of comfort levels, in diabetic hemodialysis patients. This relationship was not mediated by comfort. Healthcare professionals should prioritize direct, targeted symptom management interventions to improve self-care behaviors, rather than relying primarily on general comfort-enhancement approaches.