chronic renal failure is very common around the world as a health problem ( 1 ) . outbreak of end - stage renal disease ( esrd ) is increasing by 8% annually , while the increase in population is 1.3% ( 2 ) . usually , all patients with esrd require replacement treatments , including hemodialysis , peritoneal dialysis , and kidney transplantation ( 3 ) . with regard to the increase in the number of patients with esrd , it is anticipated that the need for replacement treatments will increase significantly in later decades . in 2005 , nearly 1.5 million patients with renal failure used replacement treatments ( 2 ) . in fact , the number of patients under treatment is increasing ( 4 ) in such a way that , in 2005 , it was anticipated that the number of patients in need of replacement renal treatments would double in the next decade . hemodialysis , peritoneal dialysis , and kidney transplantation are replacement renal treatments , among which hemodialysis is the most common . therefore , increase in the number of patients under hemodialysis treatment is a global problem ( 2 ) . patients under hemodialysis treatment suffer from different physical and mental problems ( 5 ) in such a way that for prevalence of depression is 10 to 30% in these patients ( 4 ) . among mood disorders , anxiety in patients with esrd is twice that of normal people in such a way that it is observed in 38% of these patients ( 4 ) . anxiety is related to poor health outcomes , including decrease of following medication regimen and quality of life and increase in hospitalization along with mortality and morbidity ( 47 ) . social interactions are very important in chronic patients , since these interactions have significant benefits for their health ( 8) . patients participating in social activities suffer from mental disorders to a lesser extent ( 8) . social support would reduce the risk factors of chronic diseases , including smoking , inactivity , and the change and maintenance of health behaviors ( 9 ) . by increasing social support , stress reduces and cells and blood immune responses increase ( 8) . those people who access more social support can manage their stress better and experience better health outcomes ( 10 ) . studies show that social support is related to the quality of life in such a way that people who receive social support and are part of a larger social network enjoy a higher quality of life ( 11 ) . however , people with lower social support face more challenges in coping with stress and are more vulnerable ( 10 ) . in addition , reduction of social support increases the possibility of mortality ( 9 ) . social support is defined as a network of family , friends , and neighbors who are available when one requires mental , physical , or financial support ( 10 ) . perceived social support refers to the personal perception of access to support , while received support refers to the support that is practically received by individuals ( 10 ) . there are two reasons for more recognition of mental - social aspects of patients under hemodialysis treatment , i.e. , 1 ) increase in the number of these patients and 2 ) help to facilitate the application of therapies that increase quality of life ( 5 ) . however , the number of studies conducted on mental - social aspects and their results on patients under hemodialysis treatment is limited ( 4 ) . the current study was conducted to investigate anxiety and perceived social support in patients under hemodialysis treatment and to study the relation between these two variables in these patients . this cross - sectional study is a descriptive - analytic study of correlation type conducted on patients under hemodialysis treatment in 2012 in isfahan . with regard to the statistics available about hemodialysis patients in isfahan in 2010 , for about 500 patients and considering the study power of 80% , the least required sample size was obtained as 120 patients using the following formula ( 12 ) : n = ( z1-/2 + z1-)(1 + 2)/(1 - 2 ) = ( 1.96 + 0.84)(2662 + 2662)/(200 ) = 119.6 . for sampling , first all hospitals in isfahan with hemodialysis ward were selected ( alzahra , zahraye marzie , shariati , hojatiye and khorshid hospitals ) ; then they were numbered , and three numbers were selected randomly . the inclusion criteria in this study were 1 ) the ability to understand and speak persian , 2 ) the desire to participate the study , 3 ) the ability to complete the questionnaire by the patient or with the help of a researcher , and 4 ) hemodialysis therapy two or three times a week and at least three months have passed from the first of hemodialysis treatment . data collection tools in this study included state - trait anxiety and perceived social support inventory . the first section determines trait anxiety , and the second section determines state anxiety . based on the answer to each one of 20 items in the above sections , a 1 to 4 scale score is allocated , and the total score of each one of the trait and state anxiety scales ranged between 20 and 80 . depending on the acquired score in each section , the participant was classified in one of three groups , i.e. , mild anxiety ( 20 to 39 ) , average anxiety ( 40 to 59 ) , and severe anxiety ( 60 to 80 ) . the inventory of perceived social support was prepared and adjusted by davari and cheraghi ( 13 ) . this inventory consists of three dimensions of social support : 1 ) emotional support ( questions 1 to 12 ) , 2 ) informational dimension ( questions 13 to 20 ) , and 3 ) tangible dimension ( question 21 to 30 ) . questions of this inventory were scaled as never ( score 1 ) , always ( score 4 ) according to a 4-point likert scale . the scores obtained for perceived social support were classified in three groups ( low , average , high ) in such a way that scores between 30 and 59 were specified as low perceived social support , between 60 and 89 as average perceived social support , and between 90 and 120 as high perceived social support . reliability and validity of state - trait anxiety inventory was verified inside and outside iran with correlation coefficients of r = 0.93 and r = 0.89 , respectively ( 14 ) . reliability and validity of perceived social support inventory was verified through correlation coefficient ( r = 0.895 ) and cronbach s alpha ( 87% ) ( 13 ) . data were analyzed using descriptive statistics and the spearman correlation coefficient test along with spss software . the research ethics committee of the nursing and midwifery school of islamic azad university , isfahan branch ( khorasgan ) approved this study . in order to access the subjects , first then , the treatment records of all patients under hemodialysis treatment in these three centers were investigated . afterwards , the researcher gave some information about the aim of the study and data collection methods to the patients who were in the hemodialysis ward for treatment . a total of 126 patients entered the study after acquiring information about the study and signing a written consent form after being assured about the confidentiality of their information . this cross - sectional study is a descriptive - analytic study of correlation type conducted on patients under hemodialysis treatment in 2012 in isfahan . with regard to the statistics available about hemodialysis patients in isfahan in 2010 , for about 500 patients and considering the study power of 80% , the least required sample size was obtained as 120 patients using the following formula ( 12 ) : n = ( z1-/2 + z1-)(1 + 2)/(1 - 2 ) = ( 1.96 + 0.84)(2662 + 2662)/(200 ) = 119.6 . for sampling , first all hospitals in isfahan with hemodialysis ward were selected ( alzahra , zahraye marzie , shariati , hojatiye and khorshid hospitals ) ; then they were numbered , and three numbers were selected randomly . the inclusion criteria in this study were 1 ) the ability to understand and speak persian , 2 ) the desire to participate the study , 3 ) the ability to complete the questionnaire by the patient or with the help of a researcher , and 4 ) hemodialysis therapy two or three times a week and at least three months have passed from the first of hemodialysis treatment . data collection tools in this study included state - trait anxiety and perceived social support inventory . state - trait anxiety inventory consisted of two 20-question sections . the first section determines trait anxiety , and the second section determines state anxiety . based on the answer to each one of 20 items in the above sections , a 1 to 4 scale score is allocated , and the total score of each one of the trait and state anxiety scales ranged between 20 and 80 . depending on the acquired score in each section , the participant was classified in one of three groups , i.e. , mild anxiety ( 20 to 39 ) , average anxiety ( 40 to 59 ) , and severe anxiety ( 60 to 80 ) . the inventory of perceived social support was prepared and adjusted by davari and cheraghi ( 13 ) . this inventory consists of three dimensions of social support : 1 ) emotional support ( questions 1 to 12 ) , 2 ) informational dimension ( questions 13 to 20 ) , and 3 ) tangible dimension ( question 21 to 30 ) . questions of this inventory were scaled as never ( score 1 ) , always ( score 4 ) according to a 4-point likert scale . the scores obtained for perceived social support were classified in three groups ( low , average , high ) in such a way that scores between 30 and 59 were specified as low perceived social support , between 60 and 89 as average perceived social support , and between 90 and 120 as high perceived social support . reliability and validity of state - trait anxiety inventory was verified inside and outside iran with correlation coefficients of r = 0.93 and r = 0.89 , respectively ( 14 ) . reliability and validity of perceived social support inventory was verified through correlation coefficient ( r = 0.895 ) and cronbach s alpha ( 87% ) ( 13 ) . data were analyzed using descriptive statistics and the spearman correlation coefficient test along with spss software . the research ethics committee of the nursing and midwifery school of islamic azad university , isfahan branch ( khorasgan ) approved this study . in order to access the subjects , first then , the treatment records of all patients under hemodialysis treatment in these three centers were investigated . afterwards , the researcher gave some information about the aim of the study and data collection methods to the patients who were in the hemodialysis ward for treatment . a total of 126 patients entered the study after acquiring information about the study and signing a written consent form after being assured about the confidentiality of their information . the average age of the participants in this study was 14.51  53.11 , and 60.3% of them were males . in addition , 56.3% of the subjects were illiterate or had only an elementary education . furthermore , 59.5% of the subjects reported that their families as low - income , 22.5% as average and 18% as high - income families . the majority of subjects received average support ( 68.3% ) . respectively , 13.5% ( 17 subjects ) and 18.2% ( 23 subjects ) of the patients received low and high perceived social support . the average of social support dimensions are respectively reported as emotional dimension 54.45 , information dimension 55.05 , and tangible dimension 40.02 . considering the above results , the subjects received lower tangible support compared to other dimensions . respectively , 65 and 67.5% of participants suffered from average trait and state anxiety ( table 2 ) . the spearman correlation coefficient demonstrated that there was an inverse relationship between state and trait anxiety and total perceived social support ( p < 0.01 ) ( r = 0.229 ) and emotional ( p < 0.001 ) ( r = 0.364 ) and informational ( p < 0.002 ) ( r = 0.27 ) dimensions . this is while it had no significant relationship with tangible dimension ( p < 0.196 ) ( r = 0.006 ) . trait anxiety has the highest relation with social support in terms of emotional dimension , while it is significantly related to social support in terms of informational dimension ( table 3 ) . the current study reported the results of investigating the relationship between perceived social support and anxiety in patients with esrd under hemodialysis treatment . in this study , over half of the subjects ( 59.5% ) reported that they were from low - income families . one of main complications of chronic diseases is that the sufferers must retire early because of their disease . unemployment of these patients results in the reduction of their incomes ( 8 , 15 ) . by reducing their incomes the results of this study demonstrated that the majority of subjects ( 68.3% ) received average social support . the important issue is that family members and a social network offer more social support when an acute disease occurs . in addition , in patients under hemodialysis treatment , having mental perception of the situation could have negative effect on performing their social role ( 15 ) , which results in the reduction of being understood and receiving social support . reduction of social support is related to the feeling of hopelessness and loneliness and , finally , their sense of well - being . obviously , we must remember that hope plays an important role in continuing treatment and sense of well - being ( 17 ) . however , based on the results of previous studies , social support affects mortality in patients under hemodialysis treatment ( 18 ) . considering that social support plays an important role in coping with chronic diseases ( 9 ) , it should be attempted to increase social support in these patients to increase their ability to cope with this disease and its conditions and , as a result , to reduce mortality and morbidity of patients with chronic renal failure who are taking hemodialysis treatment . according to the results , the subjects received lower tangible support than other dimensions ( average 40.02 ) . in previous studies , it was demonstrated that informational and emotional support play an important and significant role in the diagnosis and treatment of chronic diseases ( 16 ) , in such a way that , in patients receiving higher emotional support , there is a lower possibility of diagnosing hypertension ( 16 ) . it is noteworthy that hypertension is one of the main risk factors of renal diseases . it should be noted that males are looking for tangible support more than females , while females are inclined to receive emotional support ( 20 ) . considering that , in this study , the majority of subjects were seeking tangible support , they had not perceived this dimension of social support . with regards to the results of this study , it was specified that over half of the participants suffered from an average state and trait anxiety . ( 2008 ) , a significant percentage of hemodialysis patients suffer from anxiety and depression ( 4 ) . patients under hemodialysis treatment suffer from state anxiety more than patients with other chronic diseases ( 15 ) . found a direct relationship between hemodialysis and anxiety , in such a way that they believed that hemodialysis causes the occurrence of anxiety in patients ( 21 ) . in a study by nazemian et al . , more than half of the participants suffered average state and trait anxiety ( 14 ) . scientists believe that changing the integrity of tissues with vascular access and changes of life conditions result in anxiety that affects the self - confidence of patients and results in depression and anxiety ( 21 , 15 ) . since serious problems occur in patients with anxiety and depression , it is important to take this issue into account . these problems affect the family s psychological status and impact the patient s quality of life , rate of attempting suicide and successful suicide , long hospitalization , and even the lifetime of the patient ( 4 , 22 ) . however , losing financial resources increases these patients anxiety about the future ( 15 ) . the results of this study showed that there is an inverse relationship between state and trait anxiety and perceived social support ( r = 0.340 , r = 0.229 ) . it was stated before that there is a close relationship between state and trait anxiety and social demographic features ( 23 ) . researchers believe that perceived social support is effective in reducing economic problems , unemployment , low income , losing job security and health expenditures . in addition , improving social network decreases depression and anxiety of patients and results in health satisfaction and reduction of anxiety ( 24 ) . furthermore , offering emotional support plays an important role in increasing performance and coping with stress and improves people s mental and physical health ( 19 ) . ( 25 ) believed that social support acts as a moderator in anxiety and depression disorders and that there is a negative relationship between social support and anxiety and depression . considering that social support is a subjective sense of belonging , acceptance and love and being loved , it creates a safe and secure relation the main features of which are sense of intimacy and closeness . social support is a bilateral assistance that results in creation of positive impression of oneself , self - acceptance , and sense of love and worthiness therefore , when a person receives social support , her or his social anxiety increases significantly because this support acts as a protective shield . however , the lack of support and of a secure relation that is created in the light of other s social support results in the reduction of a positive impression of oneself and provides the background for anxiety ( 25 ) . effects of social support and religiousness as the coping method for anxiety indicate that higher social support is correlated with lower anxiety , and the highest effect of religiousness in reducing anxiety is provided through social support , which represents the mediator role of social support ( 26 ) . . believed that social support is the most powerful and most important predictive factor of mental health . in fact , mental health is endangered by the reduction of supportive resources ( 26 ) . the remarkable issue is that patients under hemodialysis treatment who suffer from mental problems have their perception of social support affected by this treatment ( 19 ) . emotional and information dimensions of social support are inversely related to anxiety ( p < 0.05 ) , while the tangible dimension of social support is not significantly related to anxiety ( p > 0.05 ) . patients under hemodialysis treatment with lower education suffer from higher trait anxiety ( 15 ) . trait anxiety is highly related to social support in terms of emotional dimension ( r = 0.364 ) . lack of emotional support creates anxiety in the patient more than other dimensions of social support . state anxiety is highly related to social support in terms of informational dimension ( r = .402 ) . therefore , to reduce state anxiety , more and detailed information should be provided for the patients . however , it could be stated that lack of awareness about the future increases state anxiety in these patients . among the limitations of this study , it could be stated that subjects may have not reflected their real feeling when answering the questions . in addition , the current study did not include other dimensions of social support ( such as the inductive dimension and self - esteem ) . the results of this study showed that patients under hemodialysis treatment suffer from average perceived social support and state and trait anxiety . in addition , perceiving emotional and informational support is inversely related to state and trait anxiety . therefore , hemodialysis affects different aspects of patients lives including their social and mental dimension , and each one of these life dimensions affects other dimensions as well . therefore , it is suggested to pay special attention to other aspects of life , especially mental and social aspects in these patients . conducting a semi - experimental complementary study on the effects of improving perceived social support on different aspects of life including quality of life and lifestyle in patients under hemodialysis treatment , could be a suitable course for later studies in this field .
introductionthe increase in the number of patients under hemodialysis treatment is a universal problem . with regard to the fact that there have been few social - psychological studies conducted on patients under hemodialysis treatment , 
 the current study was conducted to investigate anxiety and perceived social support and the relation between them among these patients.methodsthis cross - sectional study was conducted on 126 patients under hemodialysis treatment in isfahan in 2012 . 
 after randomly selecting a hospital with a hemodialysis ward , purposive sampling was conducted . 
 data collection tools included state - trait anxiety and perceived social support inventory . 
 the data were analyzed using the spearman correlation coefficient.resultsamong the participants , 68.3% received average perceived social support . 
 in addition , perceiving the tangible dimension of support was lower compared to other dimensions ( mean 40.02 ) . 
 level of trait and state anxiety ( 65 and 67.5% ) of over half of the participants was average . 
 there was in inverse relationship between state and trait anxiety and total perceived social support and emotional and information dimensions ( r = 0.340 , r = 0.229 ) . 
 state and trait anxiety had the highest relation with emotional and information dimension of social support , respectively.conclusionpatients under hemodialysis treatment suffer from numerous psychological and social problems . 
 low awareness and emotional problems result in the increase of anxiety and reduction of perceived social support . 
 reduction of social support has negative effect on treatment outcomes .