Exploring anxiety as a potential mediator of the association between home destruction and PTSD symptoms among hemodialysis patients in Gaza after 7th Oct 2023

Home destruction is a severe traumatic event strongly associated with psychological distress, particularly in conflict settings. Hemodialysis patients face heightened vulnerability due to chronic illness and dependence on continuous medical care. This study examined whether anxiety mediates the relationship between home destruction and post-traumatic stress disorder (PTSD) among hemodialysis patients in Gaza following the military assault on October 7, 2023. A cross-sectional study was conducted across five dialysis centers in Gaza. Anxiety symptoms were measured using the Depression Anxiety Stress Scale (DASS-21), and PTSD symptoms were assessed using the PTSD Checklist for DSM-5 (PCL-5). Structural equation modeling with bootstrapped confidence intervals evaluated mediation effects. Among 383 participants, 83.6% reported moderate-to-extreme anxiety, and 58% met the PTSD cutoff. Home destruction was highly prevalent, affecting 66.1%, with 53.5% experiencing total loss of residence. Significant positive correlations were found among home destruction, anxiety, and PTSD. Mediation analysis showed that anxiety fully accounted for the association between home destruction and PTSD (significant indirect effect, non-significant direct effect after adjustment). In adjusted models controlling for gender and current residency, the total effect was no longer significant, consistent with full statistical mediation. The model explained 42% of the variance in PTSD scores, almost entirely through anxiety (R2 = 0.02 for anxiety from home destruction alone). Given the cross-sectional design, this mediation should be interpreted as a statistical association rather than evidence of a causal pathway, and longitudinal studies are needed to confirm temporal relationships. Although causality cannot be determined from this cross-sectional study, the observed indirect association suggests that integrating anxiety-focused mental health support into dialysis services may help reduce PTSD symptoms among conflict-affected hemodialysis patients. Pilot intervention studies are needed to test this hypothesis.