{"paper_id":"df9af79d-506b-4dfd-afdc-3d182fe42a5f","body_text":"ARTICLE | Article in Press\nScientific Reports https://doi.org/10.1038/s41598-026-74712-z\nScientific Reports\nThis Article in Press is shared early to give you faster access to new research. It is citable and carries a permanent DOI. \nThe final edited version will replace it automatically.\nPain self-efficacy mediates the relationship between \nillness perceptions and health-related quality of life in \nwomen with endometriosis\nHajer I. Motakef  · Salam Bani Hani  · Niven Basyouni  · Yazeed Z. Alshahithy ·  \nEmran A. Abu Aqoulah · Layla Salem Alshammari  · Sahar Mazied Alshammari  · \nSoha Kamel Mosbah Mahmoud  · Bahia Galal Abd Elrazik Siam  · Lina Aljabbab · \nSalwa Ali Marzouk\nReceived: 2 April 2026 / Accepted: 30 September 2026\n© The Author(s) 2026\nAbstract\nEndometriosis is a major health problem affecting about 190 million reproductive-aged women. There is no \ndefinite cure for endometriosis; however, there are many medical and surgical options for relieving the severity \nof the disease and improving the quality of life for these women. This study aims to examine the relationship \nbetween illness perception and health-related quality of life (HRQoL) among women who have been diagnosed \nwith endometriosis, as well as examining the role of pain self-efficacy as a mediator between these two vari -\nables. A cross-sectional design was employed with 300 participants. Data were collected using a structured, \nself-administered questionnaire that included sociodemographic and clinical characteristics, the Brief Illness \nPerception Questionnaire, the Pain Self-Efficacy Questionnaire, and the Health-Related Quality of Life: Endo -\nmetriosis Health Profile-30 (EHP-30). Data were analyzed using. Data were analyzed using SPSS version 27 \nand SmartPLS 4.0. Partial Least Squares Structural Equation Modeling (PLS-SEM) with bootstrapping (5000 \nresamples) was also conducted to test both direct and mediating effects. Statistical significance was set at p < .05. \nThe mean age of participants was 30.0 ± 5.5 years. The majority were predominantly married and attained a \nbachelor’s education, with a marked symptom burden. Two-thirds of participants were overweight and obese. \nIt was found that 28.7% had Stage III endometriosis, and over 80% reported moderate-to-severe pelvic pain. \nBoth Illness perceptions and pain self-efficacy were at moderate levels, while HRQoL impairment was sub -\nstantial, especially in pain and emotional domains as well. More negative illness perceptions were significantly \nassociated with worse HRQoL (r = 0.458, p < .001) and lower pain self-efficacy (r =  − 0.474, p < .001), whereas \nhigher pain self-efficacy was associated with better HRQoL (r =  − 0.542, p < .001). In regression analysis, illness \nperceptions and pain self-efficacy together explained 34.6% of the variance in HRQoL, with pain self-efficacy \ndemonstrating the stronger independent association. This study demonstrated that illness perceptions and pain \nself-efficacy are related factors that influence HRQoL in endometriosis patients. Negative illness perceptions \n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-74712-z\nwere found to be associated with HRQoL, and increased levels of pain self-efficacy were found to be related \nto HRQoL. Pain self-efficacy also partially mediated the relationship between illness perceptions and HRQoL.\nKeywords Illness perceptions · Health-related quality of life · Women · Endometriosis · Mediating role · \nSelf-efficacy\nIntroduction\nEndometriosis represents an increasingly significant global health concern 1. Globally, it is impacting approxi -\nmately 190 million reproductive-age women2. Currently, there is no conclusive cure for endometriosis; however, \nseveral therapeutic approaches are available for alleviating symptoms and enhancing quality of life3. Management \nstrategies comprise analgesics for pain relief, hormonal therapy, and surgical removal of endometriotic lesions2. \nMoreover, endometriosis is closely connected with a variety of symptoms, particularly long-standing pelvic pain, \nmenorrhagia, dysmenorrhea, dysuria, dyspareunia, dyschezia, fatigue, and fertility challenges as well4.\nFurthermore, endometriosis also significantly impairs women’s productivity and overall health-related qual -\nity of life (HRQoL)5. The HRQoL represents a multi-dimensional as well as multifaceted concept that involves \nphysical and psychosocial aspects linked with the disease itself or its treatment 6. Recent epidemiological and \nclinical studies continue to confirm substantial reductions in HRQoL among women with endometriosis5,7.\nWhen women are challenged with such a condition, they create their own individualized conceptions to guide \ntheir logical responses to the challenges they really encounter. One of these models is the Common-Sense Model \nof Self-Regulation, which highlights the role of patients’ beliefs regarding their illness in shaping their coping \nstrategies, as well as quality of life8.\nThe core of this model is the concept of illness perceptions that have emerged as key predictors of patient out-\ncomes in chronic diseases, including endometriosis9,10. Illness perceptions in which patients construct cognitive \nschemas about their own health conditions based on different factors, including perceptions of the consequences, \ncausation, controllability, and the timeline of the health condition. In turn, these representations influence the \nindividuals’ emotional responses and their own coping behaviors targeted to manage that health condition11. It's \nalso worth mentioning that pain self-efficacy among women with endometriosis refers to belief in the women's \nability to manage their own pain12. It is indispensable for well-being, where lower self-efficacy is linked to worse \nquality of life, increased stress, depression, and lower self-esteem, particularly in advanced stages 13,14. Concur-\nrently, painful self-efficacy was defined as the confidence in one’s ability to perform activities despite pain 12,15. \nIt is a central determinant in chronic pain adjustment, including endometriosis. Higher pain self-efficacy predicts \nbetter functioning, reduced disability, and improved illness perception as well as HRQoL across those suffering \nfrom pain13,14.\nSeveral studies conducted on endometriosis revealed that higher pain self-efficacy levels were closely linked \nwith better physical performance and enhanced HRQoL as well 12,16. Where women who feel more capable of \nhandling their pain can engage more actively in daily life activities and report less impairment from symp -\ntoms17. In contrast, reduced pain self-efficacy among those women was associated with greater disability, more \nprominent symptom distress, and diminished well-being, highlighting its central role in the adaptation process in \nchronic pain conditions18.\nConsidering these relationships, including understanding the mediation pathway, illness perceptions, self-effi-\ncacy, and HRQoL may offer applicable insights for tailoring patient-centered interventions. Therefore, a media-\ntional framework between illness perceptions, pain self-efficacy, and HRQoL helps to explain the interplay among \nthese variables. Negative illness perceptions can undermine pain self-efficacy by fostering feelings of helpless -\nness and low control, which in turn amplify the burden of chronic pain on women’s lives and further diminish \nHRQoL. Otherwise, interventions that target maladaptive illness beliefs and enhance pain self-efficacy have \nthe potential to reduce the detrimental effects of pain and illness uncertainty, ultimately improving HRQoL 19. \n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-74712-z\nHence, this study aims to investigate the association between illness perceptions and health-related quality of life \n(HRQoL) among women diagnosed with endometriosis, and to explore the mediating role of pain self-efficacy \nin this relationship. The study hypothesized that H1: Illness perceptions are significantly associated with health-\nrelated quality of life (HRQoL) in women who have been diagnosed with endometriosis. H2: Illness perceptions \nare significantly associated with pain self-efficacy in women who have been diagnosed with endometriosis. H3: \nPain self-efficacy is significantly associated with health-related quality of life in women who have been diag -\nnosed with endometriosis. H4: Pain self-efficacy is consistent with a mediating role of the relationship between \nillness perceptions and health-related quality of life in women who have been diagnosed with endometriosis.\nMaterials and methods\nDesign\nA cross-sectional design was employed in this study.\nSettings and participants\nThe present study was carried out at the Gynecology outpatient clinics of a Maternity University Hospital. This \nsetting was chosen because it is the only main university hospital in the Governorate that provides obstetrics and \ngynecology services, and the follow-up turnover of the women is suitable for the study. Additionally, women \nattending this hospital had nearly the same socioeconomic status, which preserved the homogeneity of the study \nparticipants.\nA purposive sample of women who met the following inclusion criteria: women diagnosed with endometriosis \nduring their reproductive age, free from any chronic gynecological or medical disorders, had not received phar -\nmacological treatment to alleviate pain, and consented to participate in the study. Endometriosis diagnosis was \nconfirmed based on documented laparoscopic, surgical findings, and imaging findings based on a physician-doc-\numented diagnosis in the medical record at the site of data collection. Women who were currently using, or had \npreviously used, pharmacological treatments for pain, including analgesics, hormonal therapy (e.g., combined \noral contraceptives, progestins, GnRH agonists/antagonists), or neuromodulators, were excluded from the study, \nregardless of whether such treatment had since been discontinued, to reduce the potential influence of pharma -\ncological treatment on self-reported pain self-efficacy and quality of life. Women currently receiving hormonal \nsuppression for infertility treatment, or currently undergoing infertility treatment, were also excluded. Surgical \ntreatment history (e.g., prior laparoscopic excision or ablation) was recorded for all participants.\nInstruments\nA structured, self-administered questionnaire was employed to collect the study data. It is composed of four \nSubsections: (1) Sociodemographic and Clinical Characteristics  such as age, BMI, education level, marital \nstatus, occupation, duration, since formal diagnosis endometriosis stage, and average pelvic pain severity (past \n4 weeks); disease stage was classified according to the revised American Society for Reproductive Medicine \n(rASRM) classification system, as recorded in the medical chart at the time of surgical/laparoscopic diagnosis \nrather than independently verified by the research team (2) Brief Illness Perception Questionnaire (Brief IPQ) \nthat used to measure cognitive as well as emotional representations of endometriosis. The Brief IPQ was adopted \nfrom Broadbent et al. 20. The Brief IPQ contains 9 items. Eight items assess consequences, timeline, personal \ncontrol, treatment control, identity (symptom experience), concern, coherence/understanding, and emotional \nresponse,the ninth question was an open-ended question on the three main causes of such disease. Since the focus \nof the present study was not to identify the causes of the disease, this question was excluded. Items 1–8 were rated \n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-74712-z\non an 11-point scale (0–10). Items 3, 4, and 7 are reverse-scored, yielding a total score of 0 to 80. Higher scores \nindicate stronger negative perceptions of disease threat. Cronbach’s alpha for this questionnaire was 0.8021,22. (3) \nPain Self-Efficacy Questionnaire (PSEQ), which was adopted from Nicholas23. The PSEQ consists of 10 items \nassessing confidence in performing daily activities, coping, and functioning despite pain (e.g., household chores, \nsocial interactions, work). Each item is rated on a 7-point Likert scale (0 = not at all confident to 6 = completely \nconfident). Total score ranges from 0 to 60, with higher total scores indicating greater pain-related self-efficacy. \nThe PSEQ has shown strong reliability, one-dimensionality, and construct validity across chronic pain popula -\ntions. Its short form, the PSEQ-2, has also been psychometrically validated for efficient use in research and clini-\ncal contexts24,25.\n(4) Health-Related Quality of Life: Endometriosis Health Profile-30 (EHP-30), a core questionnaire that \ncontains 30 items, which is an endometriosis-specific, patient-reported outcome originally designed by Jones et \nal.26 and is widely used internationally27,28. The core EHP-30 consists of 30 items distributed across five domains \nincluding: pain (11 items), control and powerlessness (6 items), emotional well-being (6 items), social support \n(4 items), and finally self-image (3 items). Each item was scored via a 5-point scale (0 = Never to 4 = Always). \nDomain scores are converted to a 0–100 scale, where 0 = best health status and 100 = worst health status. A sum-\nmary score (EHP-30 Core summed scale) can also be calculated by producing one overall score combining the \nfive domains into one single score, again ranging from 0 to 10028. Scaled domain score calculation: (sum of raw \nitem scores ÷ maximum possible raw score for that domain) × 100. With respect to internal consistency, it was \nhigh across domains (Cronbach’s α: pain = 0.96; control and powerlessness = 0.94; emotional wellbeing = 0.91; \nsocial support = 0.88; self-image = 0.88), as reported by Skinner and Kuijer29. Also, the total of 30 items demon-\nstrates 0.97, suggesting excellent internal consistency as reported by Grundström et al.27.\nEthical considerations\nEthical approval for the study was granted by the Research Ethics Committee at the Faculty of Nursing, Univer-\nsity of Hail (Ref.# H-2025-1003). All methods were performed in accordance with the relevant guidelines and \nregulations. An official request letter was sent from the faculty to the relevant authorities at the study site to secure \npermission for data collection after explaining the study objectives. Before data gathering, and after a thorough \nexplanation of the study’s purpose, written informed consent was secured from all study participants, witnessed \nby the head nurse. Participants were fully informed that their participation in the study was entirely voluntary, and \nthat they were informed of their right to withdraw from the study at any time without any effect on the medical \ncare they received at the hospital. Regarding confidentiality and privacy, these were strictly maintained through-\nout the overall study. Moreover, the collected data was securely handled and protected to ensure anonymity and \nsafeguard participant information.\nPilot study\nA pilot study was conducted on approximately 10–15% of the estimated sample to evaluate the clarity, feasi -\nbility, and reliability of the Arabic-translated questionnaire before full-scale data collection. Cronbach’s alpha \ncoefficients will be calculated using SPSS version 27 to assess the internal consistency of the Brief IPQ, PSEQ, \nand EHP 30 scales. Only instruments demonstrating acceptable reliability (Cronbach’s α ≥ 0.70) were retained \nfor inclusion in the main study, and participants included in the pilot test were excluded from the final analysis. \nAs illustrated in Table 1, all instruments demonstrated acceptable-to-excellent internal consistency in the pilot \nsample (α = 0.813–0.968), exceeding the minimum criterion for scale retention. Specifically, the BIPQ (α = 0.861) \nand PSEQ (α = 0.846) showed good reliability, while the EHP-30 domains showed good-to-excellent reliability \n(α = 0.813–0.925) and the total EHP-30 score demonstrated excellent reliability (α = 0.968), supporting use of the \nArabic-translated instruments in the main study.\n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-74712-z\nData collection procedure\nThe researcher accessed women with inclusion criteria during their visits to the Gynecology clinic in the selected \nsetting. These settings allowed the researcher to meet participants in environments that were familiar and com -\nfortable, thereby encouraging open and honest discussion. The fieldwork involved one-to-one, in-depth meetings \nwith participants. Each interview was conducted in a private and supportive manner to ensure confidentiality and \nemotional safety. The researcher allowed women to guide the conversation while ensuring that key quality-of-\nlife, illness perception, and pain expression domains were addressed. Each participant met once for a compre -\nhensive interview, which took approximately 20 min. The data collection process was conducted over a period \nof three months.\nData analysis\nTwo analytic strategies that are complementary in nature were adopted. First, multiple linear regression analysis \nwas performed to perform a descriptive analysis and test whether illness perceptions and pain self-efficacy were \nsignificant individual contributors to poor HRQoL and multicollinearity between the predictors. Second, partial \nleast squares structural equation modeling was carried out as the main analytic strategy, as it enabled simultane-\nous testing of the measurement model (reliability and validity of the constructs) and the structural model (both \ndirect, indirect, and total effects), with the mediation effect of pain self-efficacy considered.\nIBM SPSS Statistics (version 27) was used to conduct data analysis, and SmartPLS 4.0 software. At the out -\nset, descriptive statistical analysis, including frequencies, percentages, means, standard deviations, medians, and \nranges were computed in SPSS in order to summarize demographic as well as clinical characteristics and evalu-\nate the distribution of the collected data. Prior to conducting advanced statistical modeling, normality, linear -\nity, homoscedasticity, multicollinearity, and the presence of outliers were comprehensively assessed. Regarding \nCronbach’s alpha coefficients, they were computed using pilot testing data (10–15% of the intended sample) to \nensure both reliability and internal consistency of the Arabic-translated scales (Brief IPQ, PSEQ, and EHP-30). \nCronbach’s alpha values ≥ 0.70 were confirmed as acceptable for subsequent analysis. For research hypothesis \ntesting (H1–H4), Partial Least Squares Structural Equation Modeling (PLS-SEM) using Smart PLS software \nwas conducted. Building on the preliminary regression findings, PLS-SEM was then used as the primary ana -\nlytic framework to test the hypothesized structural model, including the mediating role of pain self-efficacy. The \nmeasurement model evaluation in Smart PLS included the assessments of the following: internal consistency \nreliability (Cronbach’s alpha and composite reliability [CR]), convergent validity (Average Variance Extracted \n[A VE] ≥ 0.50), and discriminant validity as well (Fornell–Larcker criterion and heterotrait–monotrait [HTMT] \nratio). The reason that led to the selection of PLS-SEM over covariance-based structural equation modeling (CB-\nSEM) is that, while CB-SEM is mostly employed when confirmatory testing of a particular covariance structure \nis needed, in this study the main purpose is prediction and variance explanation of the endogenous variables, \nand PLS-SEM does not have a multivariate normality assumption, which is not true for the EHP-30 and BIPQ \nitems. In addition to that, PLS-SEM was favored over the regression-based mediational method because it allows \nInstrument/domain No. of Items Cronbach’s α\nBrief Illness Perception Questionnaire (BIPQ) 8 0.861\nPain Self-Efficacy Questionnaire (PSEQ) 10 0.846\nEHP-30 (Pain domain) 11 0.925\nEHP-30 (Control and powerlessness domain) 6 0.919\nEHP-30 (Emotional Well-being Domain) 6 0.900\nEHP-30 (Social support domain) 4 0.866\nEHP-30 (Self-image domain) 3 0.813\nTotal EHP-30 30 0.968\nTable 1 Pilot internal con-\nsistency reliability of study \ninstruments (N = 30).\nCronbach’s alpha values were \nderived from the pilot sample.\n \n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-74712-z\nsimultaneous modeling of more than one reflective indicator per construct while taking into consideration their \nmeasurement errors.\nThe structural model was assessed using bootstrapping with 5,000 resamples at a significance level of p < .05 \nto estimate the following: path coefficients (β), t-values, coefficient of determination (R 2), effect size (f 2), and \npredictive relevance (Q2) as well. In particular, direct effects (H1, H2, and H3) were confirmed by significant path \ncoefficients with corresponding p values < .05 and bootstrap confidence intervals excluding zero. The mediation \nhypothesis (H4) was explicitly tested by examining indirect effects using bias-corrected bootstrap confidence \nintervals. Mediation was established if the indirect path from illness perceptions to HRQoL through pain self-\nefficacy was significant, with confidence intervals that didn't contain zero.\nIn the current model, particular emphasis has been placed on illness perceptions and pain self-efficacy, two \npsychological variables that can be modified in line with the Common-Sense Model of Self-Regulation. Apart \nfrom illness perceptions and pain self-efficacy, several other psychological and clinical variables have the poten-\ntial to affect the quality of life among women suffering from endometriosis (pain intensity, disease duration, \ninfertility, depression, anxiety, treatment history, dyspareunia, fatigue, BMI, disease stage.\nThe adequacy of sample size for the PLS-SEM analysis was conducted according to the 10 times rule and \nthe inverse square root (Kock and Hadaya 2018). The construct that included the highest number of indicators \n(HRQoL impairment EHP-30) included 30 indicators, and according to the 10 times rule for the highest number \nof structural paths directed toward a single construct rather than the number of indicators (PLS-SEM estimates \nvia the measurement model), the sample size should be much smaller than N = 300. Using G*Power for the mul-\ntiple regression analysis part (two predictors, medium effect size f2 = 0.15, α = 0.05, power = 0.80)30, the minimal \nsample size needed is approximately 290; thus, the actual sample size of 300 is enough for both parts of the \nanalysis.\nResults\nParticipant characteristics\nA total of 300 women with endometriosis completed the survey. Participants had a mean age of 30.01 years \n(SD = 5.47). The sample was predominantly composed of women with a bachelor's degree (42.3%) and who \nwere married (56.0%). Just under half of participants were employed (49.0%), and most resided in urban areas \n(61.3%). Regarding disease history, nearly half of the sample (47.7%) reported a symptom onset of seven or \nmore years and a time since formal diagnosis exceeding three years (47.7%). In terms of body mass index, most \nparticipants fell within the overweight (44.0%) or normal weight (37.0%) categories. Regarding disease severity, \nself-reported endometriosis stage was fairly evenly distributed across Stages I through IV , and pelvic pain sever-\nity was most frequently rated as moderate (48.3%) on the 0–10 Numeric Rating Scale (NRS). Full demographic \nand clinical characteristics are presented in Table 2.\nDescriptive statistics of study variables\nAs shown in Table 3, mean illness perceptions were mid-range on the BIPQ (M = 40.02, SD = 11.69), suggest-\ning a moderate level of perceived illness threat. Pain self-efficacy was also mid-range on the PSEQ (M = 29.93, \nSD = 11.85). HRQoL impairment (EHP_TOTAL) averaged 45.06 (SD = 23.48) on a 0–100 scale (higher \nscores = worse HRQoL), with domain means indicating that pain-related impacts (M = 47.50, SD = 26.39) and \nemotional wellbeing impacts (M = 45.72, SD = 27.35) were particularly prominent within this sample.\n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-74712-z\nBivariate correlations among study variables\nPearson correlation coefficients were computed to examine the bivariate relationships among illness percep -\ntions, pain self-efficacy, and health-related quality of life (HRQoL) impairment (Table 4). Illness perceptions \n(BIPQ total) were significantly and positively correlated with HRQoL impairment, r = 0.458, p < .001, indicating \nthat more threatening illness perceptions were associated with greater impairment in HRQoL. Pain self-efficacy \nCharacteristic M ± SD n %\nAge (years) 30.01 ± 5.47\nEducation level\n Primary or less 21 7.0\n Secondary/high school 62 20.7\n Diploma/technical 41 13.7\n Bachelor’s degree 127 42.3\n Postgraduate degree 49 16.3\nMarital status\n Single 117 39.0\n Married 168 56.0\n Divorced 15 5.0\nOccupation/status\n Homemaker 58 19.3\n Employed 147 49.0\n Student 55 18.3\n Unemployed 34 11.3\n Other 6 2.0\nResidence\n Urban 184 61.3\n Rural 51 17.0\n Suburban/peri-urban 65 21.7\nSymptom onset (approximately)\n < 3 years 30 10.0\n 4–6 years 113 37.7\n ≥ 7 years 143 47.7\n Not sure 14 4.7\nTime since formal diagnosis (approximately)\n ≤ 1 year 84 28.0\n 2–3 years 60 20.0\n > 3 years 143 47.7\n Not sure 13 4.3\nBMI category\n Underweight (< 18.5 kg/m2) 4 1.3\n Normal weight (18.5–24.9 kg/m2) 111 37.0\n Overweight (25.0–29.9 kg/m2) 132 44.0\n Obesity (≥ 30.0 kg/m2) 53 17.7\nEndometriosis stage\n Stage I 64 21.3\n Stage II 73 24.3\n Stage III 86 28.7\n Stage IV 54 18.0\n Not sure/unknown 23 7.7\nPelvic pain severity category (NRS 0–10)\n Mild (0–3) 56 18.7\n Moderate (4–6) 145 48.3\n Severe (7–10) 99 33.0\nTable 2 Demographic and \nclinical characteristics of \nparticipants (N = 300).\n \n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-74712-z\n(PSEQ total) was significantly and negatively correlated with both HRQoL impairment, r =  − 0.542, p < .001, and \nillness perceptions, r =  − 0.474, p < .001. These findings indicate that higher pain self-efficacy was associated with \nlower HRQoL impairment and less threatening illness perceptions, and they provided preliminary support for the \nhypothesized relationships examined in subsequent regression and structural equation modeling analyses.\nMultiple linear regression predicting HRQoL impairment\nAs a preliminary step before the confirmatory PLS-SEM analysis, a standard multiple linear regression was \nconducted to examine whether illness perceptions and pain self-efficacy predicted HRQoL impairment (EHP_\nTOTAL). The overall model was statistically significant, R = 0.588, R2 = 0.346, adjusted R 2 = 0.342, F = 78.57, \np < .001, indicating that the two predictors jointly accounted for approximately 34.6% of the variance in HRQoL \nimpairment. As shown in Table 5, both predictors contributed significantly to the model. Illness perceptions \nwere a significant positive predictor of HRQoL impairment (B = 0.52, β = 0.259, p < .001), such that more nega -\ntive illness perceptions were associated with greater impairment. Pain self-efficacy was a significant negative \npredictor (B =  − 0.83, β =  − 0.419, p < .001), such that greater confidence in managing pain was associated with \nlower impairment, and emerged as the stronger of the two predictors. Tolerance and VIF values (0.775 and 1.290, \nrespectively, for both predictors) indicated no evidence of problematic multicollinearity.\nMeasurement model: reliability and convergent validity\nThe measurement model was assessed for indicator reliability, internal consistency reliability, and convergent \nvalidity. As shown in Supplementary Table S1, all outer loadings exceeded the recommended threshold of 0.70 \n(range 0.680–0.918), except for two EHP-30 indicators (EHP15 = 0.680; EHP26 = 0.685), which were retained \nTable 4 Correlations among illness perceptions, pain self-efficacy, and HRQoL impairment (N = 300).\nVariable 1 2 3\n1. HRQoL impairment (EHP_TOTAL) –\n2. Illness perceptions (BIPQ total) 0.458*** –\n3. Pain self-efficacy (PSEQ total)  − 0.542*** − 0.474*** –\nPearson correlations (two-tailed). *** p < .0 01.\nTable 5 Multiple linear regression predicting HRQoL impairment (EHP_TOTAL) from illness perceptions and pain self-\nefficacy (N = 300).\nPredictor B SE B β t p 95% CI for B Tolerance VIF\nConstant 49.12 6.51 – 7.55 < .001 [36.31, 61.93]\nIllness perceptions (BIPQ total) 0.52 0.11 0.259 4.86 < .001 [0.31, 0.73] 0.775 1.290\nPain self-efficacy (PSEQ total) − 0.83 0.11 − 0.419 − 7.87 < .001 [− 1.04, − 0.62] 0.775 1.290\nModel fit: R = .588, R2 = . 3 4 6 ,  a d j u s t e d  R2 = .342, SE of estimate = 19.05, F = 78.57, p < .001. Dependent variable: EHP_TOTAL (higher = worse \nHRQoL). CI = confidence interval.\nVariable Score range M SD\nTotal illness perceptions (BIPQ total) 0–80 40.02 11.69\nPain self-efficacy (PSEQ total) 0–60 29.93 11.85\nEHP-30 Pain 0–100 47.50 26.39\nEHP-30 Control and powerlessness 0–100 44.00 24.93\nEHP-30 Emotional wellbeing 0–100 45.72 27.35\nEHP-30 Social support 0–100 41.31 25.59\nEHP-30 Self-image 0–100 41.89 27.04\nTotal HRQoL impairment (EHP_TOTAL) 0–100 45.06 23.48\nTable 3 Means and standard \ndeviations of study variables \n(including EHP-30 domains) \n(N = 300).\n \n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-74712-z\ngiven their contribution to content validity and because composite reliability and average variance extracted \n(A VE) for the parent construct remained acceptable. Internal consistency reliability was excellent for all three \nconstructs, with Cronbach's alpha, rho_a, and rho_c values all exceeding 0.90 for BIPQ and HRQoL impairment \n(EHP-30), and exceeding 0.95 for PSEQ. Convergent validity was established for all constructs, as A VE val -\nues exceeded the recommended minimum of 0.50 (BIPQ A VE = 0.758; PSEQ A VE = 0.693; HRQoL impairment \nA VE = 0.538), indicating that each construct explained more than half of the variance in its respective indicators.\nDiscriminant validity\nDiscriminant validity was evaluated using the heterotrait–monotrait ratio of correlations (HTMT) and the For -\nnell–Larcker criterion (Table 6). All HTMT ratios were well below the conservative threshold of 0.85 (range \n0.489–0.564; Panel A), supporting discriminant validity among the three constructs. Consistent with this, \nthe Fornell–Larcker criterion was satisfied for every construct, as the square root of the A VE on the diago -\nnal (BIPQ = 0.871; PSEQ = 0.832; HRQoL impairment = 0.733) exceeded that construct's correlations with the \nother latent variables (Panel B). Latent variable correlations mirrored the pattern observed at the item level: \npain self-efficacy was negatively correlated with both illness perceptions (r =  − 0.487) and HRQoL impairment \n(r =  − 0.546), and illness perceptions were positively correlated with HRQoL impairment (r = 0.475; Panel C). \nTaken together, these results confirm that the three constructs are empirically distinct.\nIndicator cross-loadings\nAs a further check on discriminant validity, indicator cross-loadings were examined (Table 7). Every indicator \nloaded most strongly on its intended construct relative to the other two constructs, providing additional sup -\nport for the distinctiveness of the measurement model. BIPQ indicators loaded highest on the BIPQ construct \n(0.790–0.918), EHP-30 indicators loaded highest on the HRQoL impairment construct (0.680–0.803), and PSEQ \nindicators loaded highest on the PSEQ construct (0.800–0.865), with no cross-loading exceeding its correspond-\ning primary loading.\nTable 6 Discriminant validity diagnostics: HTMT ratios and Fornell–Larcker criterion.\nConstruct pair HTMT\nPanel A. HTMT ratios\nBIPQ ↔ HRQoL impairment 0.489\nPSEQ ↔ HRQoL impairment 0.564\nPSEQ ↔ BIPQ 0.508\nHRQoL impairment BIPQ PSEQ\nPanel B. Fornell–Larcker matrix (diagonal = √A VE)\nHRQoL impairment 0.733\nBIPQ 0.475 0.871\nPSEQ − 0.546 − 0.487 0.832\nHRQoL impairment BIPQ PSEQ\nPanel C. Latent variable correlations\nHRQoL impairment 1.000 0.475 − 0.546\nBIPQ 0.475 1.000 − 0.487\nPSEQ − 0.546 − 0.487 1.000\nNegative correlations reflect opposite scoring directions (higher PSEQ indicates better self-efficacy; higher EHP-30 indicates worse HRQoL). \nHRQoL impairment refers to the EHP-30 latent construct.\n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-74712-z\nHRQoL impairment BIPQ PSEQ\nBIPQ1 0.445 0.918 − 0.450\nBIPQ2 0.396 0.849 − 0.428\nBIPQ3_R 0.383 0.877 − 0.402\nBIPQ4_R 0.361 0.790 − 0.351\nBIPQ5 0.421 0.896 − 0.447\nBIPQ6 0.462 0.901 − 0.459\nBIPQ7_R 0.419 0.844 − 0.420\nBIPQ8 0.408 0.883 − 0.421\nEHP01 0.750 0.346 − 0.356\nEHP02 0.752 0.338 − 0.389\nEHP03 0.711 0.315 − 0.365\nEHP04 0.745 0.343 − 0.370\nEHP05 0.781 0.419 − 0.433\nEHP06 0.790 0.387 − 0.420\nEHP07 0.768 0.380 − 0.389\nEHP08 0.761 0.359 − 0.385\nEHP09 0.803 0.390 − 0.423\nEHP10 0.742 0.323 − 0.332\nEHP11 0.778 0.356 − 0.403\nEHP12 0.717 0.331 − 0.398\nEHP13 0.682 0.353 − 0.371\nEHP14 0.711 0.354 − 0.361\nEHP15 0.680 0.321 − 0.366\nEHP16 0.738 0.317 − 0.371\nEHP17 0.704 0.299 − 0.357\nEHP18 0.727 0.335 − 0.376\nEHP19 0.709 0.309 − 0.379\nEHP20 0.724 0.277 − 0.428\nEHP21 0.748 0.326 − 0.416\nEHP22 0.752 0.357 − 0.475\nEHP23 0.748 0.330 − 0.417\nEHP24 0.714 0.293 − 0.342\nEHP25 0.686 0.354 − 0.394\nEHP26 0.685 0.323 − 0.432\nEHP27 0.705 0.389 − 0.426\nEHP28 0.725 0.398 − 0.461\nEHP29 0.728 0.358 − 0.438\nEHP30 0.716 0.400 − 0.459\nPSEQ1 − 0.405 − 0.446 0.803\nPSEQ10 − 0.449 − 0.356 0.840\nPSEQ2 − 0.495 − 0.333 0.830\nPSEQ3 − 0.473 − 0.462 0.834\nPSEQ4 − 0.489 − 0.397 0.837\nPSEQ5 − 0.454 − 0.420 0.831\nPSEQ6 − 0.405 − 0.409 0.800\nPSEQ7 − 0.459 − 0.377 0.865\nPSEQ8 − 0.438 − 0.400 0.832\nPSEQ9 − 0.469 − 0.440 0.852\nTable 7 Indicator cross-\nloadings (PLS-SEM).\nEach indicator is expected to \nload highest on its intended \nconstruct.\n \n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-74712-z\nStructural model and hypothesis testing\nThe structural model was assessed using bootstrapping with 5000 resamples to test the hypothesized direct and \nindirect relationships (Table 8). Illness perceptions had a significant positive direct effect on HRQoL impair -\nment (H1: β = 0.274, t = 5.268, p < .001) and a significant negative effect on pain self-efficacy (H2: β =  − 0.487, \nt = 10.575, p < .001). Pain self-efficacy, in turn, had a significant negative direct effect on HRQoL impairment (H3: \nβ =  − 0.413, t = 7.916, p < .001). The indirect path from illness perceptions to HRQoL impairment through pain \nself-efficacy was also significant (H4: β = 0.201, t = 6.429, p < .001). The indirect path from illness perceptions \nto HRQoL impairment through pain self-efficacy was also significant (H4: β = 0.201, t = 6.429, p < .001, 95% CI \n[0.139, 0.265]), with the bias-corrected bootstrap confidence interval excluding zero, confirming mediation. This \npattern is consistent with partial mediation; however, because all variables were assessed concurrently, interpret \nthis as a statistical association among constructs rather than evidence of a temporal or causal sequence. The total \neffect of illness perceptions on HRQoL impairment (direct plus indirect) was β = 0.475 (t = 10.419, p < .001). All \nhypothesized paths were statistically significant (p < .001). As the data were collected at a single time point, these \npath coefficients reflect the strength and direction of association specified by the hypothesized model rather than \nconfirmed causal or temporal ordering among variables.\nExplanatory power and effect sizes\nThe structural model explained a moderate proportion of variance in the endogenous constructs (Table 9, Panel \nA). Illness perceptions and pain self-efficacy jointly explained 35.5% of the variance in HRQoL impairment \n(R2 = 0.355, adjusted R 2 = 0.351), while illness perceptions alone explained 23.7% of the variance in pain self-\nefficacy (R2 = 0.237, adjusted R 2 = 0.234). Effect size analysis (f 2; Panel B) indicated that illness perceptions \nexerted a large effect on pain self-efficacy (f 2 = 0.311), whereas pain self-efficacy exerted a medium effect on \nHRQoL impairment (f2 = 0.202) and illness perceptions exerted a small-to-medium effect on HRQoL impairment \n(f2 = 0.089), consistent with the mediated pathway identified in the structural model.\nTable 8 Structural model path coefficients and mediation effects (PLS-SEM bootstrapping; 5,000 resamples).\nHypothesis Structural Path β (O) STDEV t p 95% CI (BCa)\nH1 BIPQ → HRQoL impairment (EHP-30) 0.274 0.052 5.268 < .001 [0.169, 0.374]\nH2 BIPQ → PSEQ − 0.487 0.046 10.575 < .001 [− 0.569, − 0.383]\nH3 PSEQ → HRQoL impairment (EHP-30) − 0.413 0.052 7.916 < .001 [− 0.510, − 0.305]\nH4 (Indirect) BIPQ → PSEQ → HRQoL impairment (EHP-30) 0.201 0.031 6.429 < .001 [0.139, 0.265]\nTotal effect BIPQ → HRQoL impairment (EHP-30) 0.475 0.046 10.419 < .001 [0.370, 0.553]\nHRQoL impairment denotes the SmartPLS latent construct representing the EHP-30 total score (higher scores indicate worse HRQoL).\nTable 9 Model explanatory power (R2) and effect sizes (f2).\nEndogenous Construct R2 Adjusted R2\nPanel A. Explained variance (R2)\nHRQoL impairment (EHP-30) 0.355 0.351\nPSEQ 0.237 0.234\nStructural Path f2\nPanel B. Effect sizes (f2)\nBIPQ → HRQoL impairment (EHP-30) 0.089\nBIPQ → PSEQ 0.311\nPSEQ → HRQoL impairment (EHP-30) 0.202\n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-74712-z\nPredictive relevance\nFinally, the out-of-sample predictive relevance of the model was assessed using PLSpredict (Table 10). Both \nendogenous constructs yielded positive Q2predict values (PSEQ = 0.231; HRQoL impairment = 0.219), indicating \nthat the model possessed meaningful predictive relevance beyond the estimation sample. Root mean square error \n(RMSE) and mean absolute error (MAE) values were consistent across both constructs, further supporting the \npredictive adequacy of the structural model.\nIndicator reliability (outer loadings)\nAll BIPQ indicators loaded strongly on their construct (λ = 0.790–0.918). PSEQ indicators also demonstrated \nstrong loadings (λ = 0.800–0.865). EHP-30 indicators showed acceptable loadings overall (λ = 0.680–0.803), with \na small number slightly below 0.70 (e.g., EHP13 = 0.682; EHP15 = 0.680; EHP25 = 0.686; EHP26 = 0.685). All \nconstructs demonstrated excellent internal consistency reliability (Cronbach’s α = 0.951–0.970; ρA = 0.951–0.971; \nρC = 0.958–0.972). Convergent validity was supported for all constructs, with A VE exceeding 0.50 (HRQoL \nimpairment = 0.538; BIPQ = 0.758; PSEQ = 0.693). Internal consistency reliability was excellent for all three con-\nstructs. Full item-level outer loadings and the corresponding detailed measurement model diagram are provided \nin Supplementary Table S1 and Supplementary Figure S1.\nAs shown in Fig. 1, illness perceptions (BIPQ) significantly and negatively influenced pain self-efficacy (PSEQ; \nβ =  − 0.487, 95% CI [− 0.569, − 0.383]). Pain self-efficacy significantly and negatively influenced HRQoL impair-\nment (β =  − 0.413, 95% CI [− 0.510, − 0.305]). Illness perceptions also had a significant positive direct effect on \nHRQoL impairment (β = 0.274, 95% CI [0.169, 0.374]). The model explained 23.7% of the variance in pain self-\nefficacy (R2 = 0.237) and 35.5% of the variance in HRQoL impairment (R2 = 0.355).\nTable 10 Predictive relevance (Q2predict) for endogenous constructs.\nEndogenous Construct Q2predict RMSE MAE\nPSEQ 0.231 0.885 0.714\nHRQoL impairment (EHP-30) 0.219 0.890 0.738\nPositive Q2predict values indicate out-of-sample predictive relevance.\nFig. 1 Structural model results showing standardized path \ncoefficients (β), t-values, and p-values for the relation -\nships between illness perceptions (BIPQ), pain self-efficacy \n(PSEQ), and health-related quality of life impairment, based \non bootstrapping with 5000 resamples (N = 300).\n \n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-74712-z\nDiscussion\nImportantly, the findings of the present study emphasize an association between illness and how confident women \nfeel in pain management, instead of focusing exclusively on symptom control. Integrating psychological assess-\nment as well as self-efficacy-enhancing interventions into the routine care of endometriosis may represent a \npromising pathway in improving quality of life and long-term adaptation for the affected women.\nReferring to illness perceptions, the current findings indicated that the mean illness perceptions among study \nparticipants were in the mid-range, reflecting a moderate level of perceived illness threat, which ultimately sug -\ngests that study participants perceived endometriosis neither as benign nor as a severely debilitating condition but \nrather as a chronic, persistent condition with notable life impacts. This finding is contrary to Moore et al.31, where \nthey stated that the study participants held largely negative perceptions of their endometriosis, perceiving adverse \nconsequences, an enduring timeline, and negative emotional representations of their condition as well. The dis -\ncrepancy may be attributed to several factors, including differences in participants' characteristics, disease-related \nexperiences, and healthcare context.\nRegarding total HRQoL, the participants of this study experienced considerable impairment in the overall \nHRQoL. This impairment, especially in pain and emotional well-being domains as well, reflects the multidimen-\nsional burden of endometriosis as documented in numerous recent studies. This finding conforms to an inter -\nnational cross-sectional study performed by Van Niekerk et al. 32, who indicate that endometriosis was closely \nassociated with a significantly lower HRQoL across multiple domains, including physical functioning, pain, \nemotional well-being, and social functioning, which highlights its pervasive impact on daily life. It is also in \nline with a prior longitudinal study performed by Gete et al.33 in Australia. They concluded that endometriosis is \nsignificantly associated with worse HRQoL, including physical, mental, and social functioning and well-being.\nThe current study showed that higher negative illness perceptions were moderately associated with worse \nHRQoL. This finding is in line with a study performed by Barberis et al. 34 who found that negative illness per -\nceptions were significantly related to poorer HRQoL among women with endometriosis. Furthermore, the pres -\nent result also concurs with Spinoni et al. 9,10, who used a path analysis among women with endometriosis and \nshowed that illness perceptions were associated with maladaptive coping and reduced HRQoL among affected \nwomen. These findings are expected and support the role of negative illness perceptions in poorer well-being \noutcomes. The association between higher negative illness perceptions and worse HRQoL among women with \nendometriosis can be explained by the Model of Self-Regulation, where women who perceive their illness as \nhighly threatening, uncontrollable, or long-lasting are more likely to experience emotional distress and maladap-\ntive coping, leading to lower HRQoL across physical, social, and emotional domains35,36.\nRegarding the correlation between pain self-efficacy and HRQoL, the current study showed that higher pain \nself-efficacy was moderately to strongly associated with better HRQoL. The current result reinforces the self-\nefficacy theory that demonstrates that individuals’ beliefs in their ability to manage symptoms and daily life tasks \ncan significantly influence their psychological and physical well-being as well. In chronic conditions such as \nendometriosis, enhancing self-efficacy may act as a protective factor against the deterioration of patients' quality \nof life. The present study findings also align with a systematic review done by Dubé et al. 24, who indicates that \npain self-efficacy is linked with less disability and better psychosocial outcomes among chronic pain patients. \nMeanwhile, it sympathizes with the population-based survey done by O’Hara et al. 12, where they found that \ngreater self-efficacy was significantly associated with higher physical as well as mental quality of life among \nwomen with endometriosis.\nAdditionally, current finding confesses with a study conducted by Van Niekerk et al. 32 that has shown pain \nseverity contributes to reduced HRQoL. It also corresponds to a survey performed by Bień et al. 13 in east -\nern Poland. They reported that higher self-efficacy was associated with better overall QoL among women with \nendometriosis.\n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-74712-z\nAdditionally, the present results agree with a cross-sectional survey done by Kovács-Szabó et al.37, who found \nthat pain self-efficacy has been associated with significant outcomes on quality of life as well as physical func -\ntioning among Hungarian women with endometriosis.\nReferring to the correlation between illness perceptions and pain self-efficacy, it was clear that more negative \nillness perceptions were associated with lower pain self-efficacy. This finding is consistent with Moore 11, who \nobserved that illness perceptions were linked with greater pain experience. This can be attributed to the important \nrole played by illness perceptions in shaping pain severity among women with endometriosis. According to the \nCommon-Sense Model of Self-Regulation, any woman who perceive their condition as severe, uncontrollable, \nand chronic is more likely to experience heightened emotional distress, reduced perceived control, and maladap-\ntive coping responses. All these factors can contribute to increased pain vigilance, central sensitization, as well \nas reduced effective engagement in pain-management strategies, ultimately amplifying pain severity. Moreover, \npain and illness perceptions may interact bidirectionally, whereby increased pain reinforces negative beliefs \nabout the illness, further perpetuating pain intensity.\nNotably, the self-efficacy theory proposes that individuals with higher self-efficacy are more capable of han -\ndling pain, engaging in daily activities, and preserving psychosocial functioning. In chronic conditions, self-\nefficacy has been linked with more adaptive coping, greater activity engagement, and better quality of life.\nMultiple Linear Regression demonstrated that higher negative illness perceptions independently predicted \nworse HRQoL. This finding is congruent with evidence from an Australian community survey, which reported \nthat higher self-efficacy levels and dispositional optimism were identified as independent protective factors that \nare positively associated with emotional well-being, social support, and better sexual functioning14.\nThe present findings also correspond with a qualitative study exploring illness perceptions among women with \nendometriosis. It was found that participants held largely negative representations of their condition, including \nfears about their future, perceived interference of life roles, and emotional distress, which may ultimately contrib-\nute to reduced quality of life, illustrating how illness beliefs impact daily functioning and well-being31.\nOtherwise, the present study stated that higher pain self-efficacy independently predicted better HRQoL. This \nfinding coincides with a cross-sectional study done by Kovács-Szabó et al. 37, who found that pain self-efficacy \nemerged as a consistent positive predictor of multiple domains of HRQoL among Hungarian women with endo-\nmetriosis37. These findings can be better explained through Bandura’s Self-Efficacy Theory, which proposes \nthat individuals’ beliefs and confidence in their ability to manage symptoms play a major role in guiding their \nbehavioral engagement, emotional regulation, and functional outcomes. Within the scope of endometriosis, pain \nself-efficacy reflects women’s confidence in their ability to adapt with persistent pain, maintain their daily activi-\nties, and regulate pain-related distress despite ongoing symptoms. Therefore, higher pain self-efficacy enables \nadaptive coping strategies, reduces activity avoidance, and mitigates the disabling effects of chronic pain, result-\ning in better physical, emotional, and social aspects of HRQoL.\nStrengths and limitations\nThe present study has several remarkable strengths. Firstly, it is mainly grounded in well-established theoretical \nframeworks, namely the Common-Sense Model of Self-Regulation and Bandura’s Self-Efficacy Theory, which \nprovide a strong conceptual basis for interpreting the study findings. Secondly, this study employed validated, \ndisease-specific instruments (Brief IPQ, PSEQ, and EHP-30), all of which demonstrated excellent reliability in \nthe Arabic-translated versions, which strengthened measurement validity. Thirdly, the relatively large sample size \n(N = 300) enhances statistical power and enables robust multivariate and mediation analyses using both regres -\nsion and PLS-SEM approaches. Fourthly, the use of structural equation modeling with bootstrapping allows for \na comprehensive examination of both direct and indirect relationships, offering deeper insight into the psycho -\nlogical mechanisms underlying HRQoL impairment in endometriosis. Conversely, although key psychological \nvariables were examined, other potentially relevant factors, such as depression, anxiety, social support, coping \nstyles, and treatment adherence, were not included and may account for additional variance in HRQoL. Also, \n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-74712-z\ndue to the cross-sectional nature of the research, the conclusions about the mediation effect have to be made with \nreservations. Although the statistical model confirms the logical sequence of the mediation effect from illness \nperception to HRQoL through pain self-efficacy, the data are not sufficient to draw any conclusions about the time \nprecedence and causality between the variables.\nMoreover, excluding women who were being managed pharmacologically for pain relief purposes, which was \naimed at minimizing confounders related to the effects of drugs, may have created selection bias by failing to \ninclude a good number of women with endometriosis whose management included pharmacological treatment. \nThe generalizability of the results to women with endometriosis could thus be undermined since several women \nwould not be included in the study sample, especially women suffering more from endometriosis who required \npharmacological treatment. Future research can include such women in the study sample, but with treatment and \ndosage controlled for statistically.\nAdditionally, endometriosis staging was based on medical records rather than independent verification by the \nresearch team, which may have introduced some degree of diagnostic misclassification. Also, a key limitation \nof this study is its cross-sectional design. Although the structural model was consistent with a mediating role \nof pain self-efficacy in the relationship between illness perceptions and HRQoL impairment, the simultaneous \nmeasurement of all variables precludes any conclusion about temporal precedence or causality. Longitudinal or \nexperimental designs are needed to confirm the directionality implied by the proposed model.\nAdditionally, since women who had or have received pharmacological or hormonal treatment for pain, in the \nform of analgesics, hormonal treatment, or neuromodulators, were excluded from this study, the final sample is \none that consists of a specific subset of women suffering from endometriosis who were not being treated when \nthey participated in this study. The reason for excluding such women was to reduce any possibility of the results \nbeing confounded by their current pharmacological pain management, but this exclusion criterion could also \nindicate that the results of this study cannot be applied to all women suffering from endometriosis, as the majority \nof them have received some kind of medical treatment for pain.\nFurthermore, this investigation did not control for several clinically significant covariates known to impact \nHRQoL in patients with endometriosis, namely pain intensity, disease stage, disease duration, history of treat -\nment, infertile state, depression, anxiety, social support, dyspareunia, fatigue, and BMI. Though pain intensity \nand disease stage were measured as descriptive parameters in this investigation, they were not controlled for in \nregression and structural analysis; it can thus be stated that part of the correlations between illness perceptions, \npain self-efficacy, and HRQoL impairment found in the present research may be associated with the effects of \nthese uncontrolled parameters. Depression, anxiety, and social support were not measured in the current investi-\ngation. Future studies will need to validate this model by controlling for pain intensity, disease stage, and other \nclinically significant covariates to find out if the illness perceptions-pain self-efficacy-HRQoL relationship is \nvalid independently of these parameters.\nStudy implications and recommendations\nInterventions to address maladaptive illness beliefs, such as perceptions of uncontrollability, consequences, and \nemotions, could have a positive impact on the psychological burden and coping strategies. Meanwhile, inter -\nventions to enhance pain self-efficacy, such as cognitive behavioral therapy, pain self-management education, \nacceptance-based interventions, and structured programs to enhance self-efficacy, could have a positive impact \non the functional outcomes and HRQoL of women with endometriosis. Nurses and other health professionals are \nbest positioned to implement such interventions, considering their close and continuous contact with women with \nendometriosis. From the nursing perspective, the study findings suggest the need to incorporate psychological \ninterventions into the management of endometriosis. Nurses have a significant role to play in the education of \nwomen with endometriosis by helping them to change their misconceptions about endometriosis, construct posi-\ntive and hopeful illness representations, and adopt active coping strategies. Nurses could also play a significant \n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-74712-z\nrole in enhancing the pain self-efficacy of women with endometriosis, which could have a positive impact on their \nHRQoL by helping them to stay active and engaged in daily activities despite the pain.\nConclusion\nIn conclusion, this study has found compelling evidence that illness perceptions and pain self-efficacy are impor-\ntant and interconnected factors that influence HRQoL for women living with endometriosis. For example, nega-\ntive illness perceptions are related to poorer HRQoL, whereas pain self-efficacy is positively related to HRQoL. \nMoreover, pain self-efficacy was found to be a partial mediator of the relationship between illness perceptions \nand HRQoL, emphasizing the importance of pain self-efficacy as a psychological mechanism through which \nillness perceptions influence HRQoL. Given the cross-sectional design of this study, the mediating role of pain \nself-efficacy identified here should be regarded as preliminary. Longitudinal studies that measure illness percep-\ntions, pain self-efficacy, and HRQoL impairment at multiple time points are needed to test true mediation and to \nestablish the temporal and causal ordering of these relationships.\nSupplementary Information  The online version contains supplementary material available at https://doi.org/10.1038/\ns41598-026-74712-z.\nAcknowledgements The Authors would like to thank all participants in this study for their valuable contribution. This \nresearch has been funded by the Scientific Research Deanship at the University of Ha’il, Saudi Arabia, through project \nnumber <<RG-25 061>>.\nAuthor contributions HIM: Conceptualization, project administration and funding acquisition, HIM; SBH: methodology; \nYZA; software and formal analysis, BGAS and SBH; validation; formal analysis, LSA; investigation, SMA; resources, \nSKMM and BGAS; data curation; LA; writing—original draft preparation; SBH; writing—review and editing. SAM: Data \ncuration. All authors have read and agreed to the published version of the manuscript.\nFunding This research has been funded by the Scientific Research Deanship at the University of Ha’il, Saudi Arabia, \nthrough Project Number <<RG-25 061>>.\nData availability Data are available upon reasonable request.\nDeclarations\nEthics approval and consent to participate Informed consent was obtained from all participants.\nConsent for publication Not applicable.\nCompeting interests The authors declare no competing interests.\nOpen Access  This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 Interna-\ntional License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as \nlong as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, \nand indicate if you modified the licensed material. You do not have permission under this licence to share adapted material \nderived from this article or parts of it. The images or other third party material in this article are included in the article’s Cre-\native Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s \nCreative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you \nwill need to obtain permission directly from the copyright holder. To view a copy of this licence, visit  h t t p : / / c r e a t i v e c o m m o \nn s . o r g / l i c e n s e s / b y - n c - n d / 4 . 0 /     .  \n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-74712-z\nReferences\n 1. Falcone, T. & Flyckt, R. Clinical management of endometriosis. Obstet. Gynecol. 131(3), 557–571 (2018).\n 2. Gete, D. G., Doust, J., Mortlock, S., Montgomery, G. & Mishra, G. D. Impact of endometriosis on women’s health-\nrelated quality of life: A national prospective cohort study. Maturitas 174, 1–7 (2023).\n 3. Czubak, P. et al. Understanding endometriosis: A broad review of its causes, management, and impact. Int. J. Mol. Sci. \n26(18), 8878 (2025).\n 4. Ortega-Gutiérrez, M., Muñoz-Gamez, A. & Girón-Prieto, MdlS. Primary care approach to endometriosis: Diagnostic \nchallenges and management strategies—A narrative review. J. Clin. Med. 14(13), 4757 (2025).\n 5. Della Corte, L. et al. The burden of endometriosis on women’s lifespan: A narrative overview on quality of life and \npsychosocial wellbeing. Int. J. Environ. Res. Public Health 17(13), 4683 (2020).\n 6. Mousa, M. et al. Impact of endometriosis in women of Arab ancestry on: Health-related quality of life, work productivity, \nand diagnostic delay. Front. Glob. Women’ s Health 2, 708410 (2021).\n 7. Maulenkul, T. et al. Understanding the impact of endometriosis on women’s life: An integrative review of systematic \nreviews. BMC Womens Health 24(1), 524 (2024).\n 8. Hagger, M. S. & Orbell, S. The common sense model of illness self-regulation: A conceptual review and proposed \nextended model. Health Psychol. Rev. 16(3), 347–377 (2022).\n 9. Spinoni, M., Capano, A. U., Porpora, M. G. & Grano, C. Understanding the psychological factors linking pelvic pain \nand health-related quality of life in endometriosis: The influence of illness representations and coping strategies. Am. J. \nObstet. Gynecol. 233(1), 54.e51-e54.e10. https://doi.org/10.1016/j.ajog.2024.12.027 (2025).\n 10. Spinoni, M. et al. The association between dream activity and alexithymia during pregnancy: A cross‐sectional study in \na sample of pregnant women. J. Sleep Res. 34(4), e14423 (2025).\n 11. Moore, C. A mixed-methods investigation into the role of illness perceptions and coping in endometriosis-related quality \nof life (2024).\n 12. O’Hara, R., Rowe, H. & Fisher, J. Self-management factors associated with quality of life among women with \nendometriosis: A cross-sectional Australian survey. Hum. Reprod. 36(3), 647–655 (2021).\n 13. Bień, A. et al. Quality of life in women with endometriosis: The importance of socio-demographic, diagnostic-therapeutic, \nand psychological factors. J. Clin. Med. 14(12), 4268 (2025).\n 14. Bień, A. et al. Clinical factors affecting the quality of life of women with endometriosis. J. Adv. Nurs. 81(8), 4667–4680 \n(2025).\n 15. Stahlschmidt, L., Hübner-Möhler, B., Dogan, M. & Wager, J. Pain self-efficacy measures for children and adolescents: A \nsystematic review. J. Pediatr. Psychol. 44(5), 530–541 (2019).\n 16. Kovács-Szabó, Z. et al. PCR139 Beneficial effect of physical activity on pain-related self-efficacy among women with \nendometriosis and chronic pelvic pain, cross-sectional study. Value Health 27(6), S321–S322 (2024).\n 17. Bouchard, S., Choinière, M., Masse, J., Labourot, J. & Vachon, B. (2025). Empowering people living with chronic pain \nto use self-management strategies in their daily lives: Understanding occupational therapy practices. Disability Rehabil. \n1–15.\n 18. Leuenberger, J. et al. Living with endometriosis: Comorbid pain disorders, characteristics of pain and relevance for daily \nlife. Eur. J. Pain 26(5), 1021–1038 (2022).\n 19. Spinoni, M., Di Gesto, C., Porpora, M. G. & Grano, C. The role of catastrophizing in enhancing pain interference and \ndepressive symptoms in endometriosis: A longitudinal examination. Eur. J. Pain 30(1), e70198 (2026).\n 20. Broadbent, E., Petrie, K. J., Main, J. & Weinman, J. The brief illness perception questionnaire. J. Psychosom. Res. 60(6), \n631–637 (2006).\n 21. Liu, Y .-R., Wang, Y ., Wang, J. & Wang, X. Association between illness perception and adherence to inhaler therapy in \nelderly Chinese patients with chronic obstructive pulmonary disease. Chronic Respir. Dis.  21, 14799731241286837 \n(2024).\n 22. Rezaei, S. & Vakilian, M. The mediating role of illness perception in the relationship between psychological hardiness \nand the health status of COVID-19 (coronavirus disease) survived patients. Health Psychol. Res.  h t t p s : / / d o i . o r g / 1 0 . 5 2 9 6 \n5 / 0 0 1 c . 2 4 8 3 9     (2021).\n 23. Nicholas, M. K. The pain self-efficacy questionnaire: Taking pain into account. Eur. J. Pain 11(2), 153–163 (2007).\n 24. Dubé, M.-O., Langevin, P. & Roy, J.-S. Measurement properties of the Pain Self-Efficacy Questionnaire in populations \nwith musculoskeletal disorders: A systematic review. Pain Rep. 6(4), e972 (2021).\n 25. Nicholas, M. K., McGuire, B. E. & Asghari, A. A 2-item short form of the Pain Self-efficacy Questionnaire: Development \nand psychometric evaluation of PSEQ-2. J. Pain 16(2), 153–163 (2015).\n 26. Jones, G., Kennedy, S., Barnard, A., Wong, J. & Jenkinson, C. Development of an endometriosis quality-of-life instrument: \nThe Endometriosis Health Profile-30. Obstet. Gynecol. 98(2), 258–264 (2001).\n 27. Grundström, H., Rauden, A., Wikman, P. & Olovsson, M. Psychometric evaluation of the Swedish version of the 30-item \nendometriosis health profile (EHP-30). BMC Womens Health 20(1), 204 (2020).\n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-74712-z\n 28. Jaeger, M., Niederkrotenthaler, T., Till, B. & Werneck, H. Associations between health-related quality of life, infertility-\nrelated psychological well-being, and relationship quality in individuals with endometriosis: A cross-sectional study. \nBMC Womens Health 24(1), 657 (2024).\n 29. Skinner, C. M. & Kuijer, R. G. Self-compassion and health-related quality of life in individuals with endometriosis. \nPsychol. Health 40(9), 1479–1496 (2025).\n 30. Faul, F., Erdfelder, E., Buchner, A. & Lang, A.-G. Statistical power analyses using G* Power 3.1: Tests for correlation \nand regression analyses. Behav. Res. Methods 41(4), 1149–1160 (2009).\n 31. Moore, C., Cogan, N. & Williams, L. Illness perceptions among individuals with endometriosis and their longitudinal \nassociations with psychological distress and pain. J. Health Psychol.  https://doi.org/10.1177/13591053251320595 \n(2025).\n 32. Van Niekerk, L., Johnstone, L. & Matthewson, M. Predictors of self-compassion in endometriosis: The role of \npsychological health and endometriosis symptom burden. Hum. Reprod. 37(2), 264–273 (2022).\n 33. Gete, D. G. et al. Hospitalisations and length of stays in women with endometriosis: A data linkage prospective cohort \nstudy. EClinicalMedicine https://doi.org/10.1016/j.eclinm.2024.103030 (2025).\n 34. Barberis, N., Cannavò, M., Cuzzocrea, F., Saladino, V . & Verrastro, V . Illness perceptions and factors of distress as \nmediators between trait emotional intelligence and quality of life in endometriosis. Psychol. Health Med. 28(7), 1818–\n1830 (2023).\n 35. Magnavacca, A., Di Gesto, C., Aminoff, D., Spinoni, M. & Grano, C. Antecedents of mental health in parents of individuals \nborn with ARM: The association between illness representations, negative and positive coping, and depressive symptoms. \nJ. Pediatr. Surg. https://doi.org/10.1016/j.jpedsurg.2025.162755 (2025).\n 36. Sofiani, Y ., Rahim Kamil, A. & Rayasari, F. The relationship between illness perceptions, self-management, and quality \nof life in adult with type 2 diabetes mellitus (2022).\n 37. Kovács-Szabó, Z., Ács, P., Prémusz, V ., Makai, A. & Hock, M. Psychological, symptom-related, and lifestyle predictors \nof health-related quality of life in Hungarian women with endometriosis. J. Clin. Med. 14(19), 7004 (2025).\nPublisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional \naffiliations.\nAuthors and Affiliations\nHajer I. Motakef1  · Salam Bani Hani2  · Niven Basyouni3,4  · Yazeed Z. Alshahithy5 · \nEmran A. Abu Aqoulah2 · Layla Salem Alshammari6  · Sahar Mazied Alshammari7  · \nSoha Kamel Mosbah Mahmoud8  · Bahia Galal Abd Elrazik Siam9  · Lina Aljabbab10 · \nSalwa Ali Marzouk1\n Salam Bani Hani\nBanihani.salam@yahoo.com; s.banihani@inu.edu.jo\n1 Department of Maternal and Child Health, College of Nursing, University of Hail, Hail, Saudi Arabia\n2 Department of Nursing, Faculty of Nursing, Irbid National University, Irbid, Jordan\n3 Obstetrics and Gynecologic Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt\n4 Irbid National University, Irbid, Jordan\n5 Department of Nursing, Faculty of Medicine, Health Sciences, Sana’a University, Sana’a, Yemen\n6 Department of Medical Surgical Nursing, College of Nursing, University of Hail, Hail, Saudi Arabia\n7 Department of Maternal and Child Health, College of Nursing, University of Hail, Hail, Saudi Arabia\n8 Department of Community Health Nursing, College of Nursing, Hail University, Hail, Saudi Arabia\n9 Department of Medical Surgical Nursing, College of Nursing, University of Hail, Hail, Saudi Arabia\n10 Creative and Innovation Development, Al-Jouf Health Cluster, Sakaka, Saudi Arabia","source_license":"CC0","license_restricted":false}