AI-Guided Relaxation for Hemodialysis Anxiety

Anxiety will be assessed using the Generalized Anxiety Disorder-7 (GAD-7) scale (Spitzer et al., 2006). It is a 7-item self-report tool where scores range from 0 to 21. Higher scores indicate greater anxiety (0-4: Minimal; 5-9: Mild; 10-14: Moderate; 15-21: Severe). Change will be calculated as the difference between baseline and post-intervention scores.

Assessed using the full Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983). The HADS comprises 14 items across two subscales: HADS-A (items 1, 3, 5, 7, 9, 11, 13) assessing anxiety symptoms, and HADS-D (items 2, 4, 6, 8, 10, 12, 14) assessing depressive symptoms. Each subscale is scored 0-21, with thresholds of 0-7 (normal), 8-10 (borderline), and 11-21 (clinically significant). This instrument is specifically designed to detect anxiety and depression in patients with physical health conditions such as chronic kidney disease by focusing on psychological rather than somatic symptoms. Change will be calculated as the difference between baseline and post-intervention scores.

Assessed using the Brief Coping Orientation to Problems Experienced (Brief COPE) Inventory (Carver, 1997). The inventory consists of 28 items covering 14 subscales including active coping, planning, positive reframing, acceptance, emotional support, and behavioral disengagement, among others. Each item is scored on a 4-point Likert scale ranging from 1 ("I haven't been doing this at all") to 4 ("I've been doing this a lot"). Scores for each subscale range from a minimum of 2 to a maximum of 8. Higher scores on adaptive coping subscales indicate greater reliance on constructive coping strategies. Change will be calculated as the difference between baseline scores and post-intervention scores.

Perceived relaxation will be assessed using two complementary instruments administered immediately following each AI-guided relaxation session. First, the Relaxation State Questionnaire (RSQ; Steghaus & Poth, 2022) is a validated 10-item self-report instrument measuring momentary subjective relaxation states across four subscales: Muscle Scale, Cardiovascular Scale, General Relaxation Scale, and Sleepiness Scale. Each item is rated on a 5-point Likert scale (1 = Not correct at all to 5 = Entirely correct), with reverse-scored items as indicated. Second, a 100mm Visual Analog Scale for Relaxation (VAS-R) will be used, where the left anchor (0) represents "Not relaxed at all" and the right anchor (100) represents "Completely relaxed." Patients mark a point on the line representing their current relaxation state. Higher scores on both instruments indicate a deeper and more effective state of perceived relaxation. Both measures are administered to the intervention group only.

Semi-structured interviews will be conducted with participants in the intervention group upon completion of the intervention period to explore their personal experiences, levels of engagement, perceived ease of use of the AI system, and overall satisfaction with the AI-guided relaxation sessions. The interviews will gather detailed insights into how the technology influenced participants' ability to cope with the dialysis procedure and manage treatment-related anxiety. Each interview will last approximately 20-30 minutes and will be audio-recorded with participants' prior informed consent. Data will be analyzed using thematic analysis following the six-phase framework described by Braun and Clarke (2006).