Lived experiences of health-related quality of life among hemodialysis patients in rural Iran: a qualitative study

Health-related quality of life (HRQoL) is a multidimensional, patient-centered outcome in end-stage renal disease (ESRD), encompassing physical, psychological, social, and existential dimensions. Despite extensive quantitative research, most evidence derives from urban or high-resource settings, leaving rural and culturally distinct populations underrepresented—particularly in the Middle East. Understanding how environmental and cultural contexts shape HRQoL can inform equitable and patient-centered nephrology care. This qualitative study, employing reflexive thematic analysis, explored HRQoL experiences among 27 adults (≥ 18 years, on hemodialysis ≥ 12 months) at Zabol’s only dialysis center in southeastern Iran. In-depth semi-structured interviews (45–60 min) were conducted face-to-face in Persian by a researcher trained in qualitative health research, then transcribed and translated into English. The interview guide addressed seven domains: symptoms, treatment burden, social relations, daily activities, finances, health literacy, and coping. Data were analyzed using reflexive thematic analysis following Braun and Clarke. Methodological rigor was ensured through triangulation, member checking (20/27participants), peer debriefing, reflexive journaling, and an audit trail. Four interrelated themes were identified: (1) Living Between Survival and Exhaustion—dialysis as a lifeline amid persistent fatigue and travel hardship; (2) The Silent Burden of Financial and Social Strain; economic hardship, social stigma, and thoughts of discontinuing dialysis; (3) Faith as a Source of Endurance and Meaning; Islamic sabr (patience) and belief in divine purpose as coping mechanisms; and (4) Seeking Dignity and Connection in a Constrained System; patients’ desire for empathetic care and improved health literacy. HRQoL among rural Iranian hemodialysis patients reflects a complex interplay of survival, suffering, faith, and dignity under systemic constraints. These findings point to tailored interventions—such as subsidized transport, mobile dialysis units, spiritual counseling, and accessible visual health education—as promising avenues to enhance equity and holistic care in resource-limited regions, although their effectiveness has not been directly tested in this study and warrants future evaluation. Not applicable.