Pain self-efficacy mediates the relationship between illness perceptions and health-related quality of life in women with endometriosis

Endometriosis is a major health problem affecting about 190 million reproductive-aged women. There is no definite cure for endometriosis; however, there are many medical and surgical options for relieving the severity of the disease and improving the quality of life for these women. This study aims to examine the relationship between illness perception and health-related quality of life (HRQoL) among women who have been diagnosed with endometriosis, as well as examining the role of pain self-efficacy as a mediator between these two vari - ables. A cross-sectional design was employed with 300 participants. Data were collected using a structured, self-administered questionnaire that included sociodemographic and clinical characteristics, the Brief Illness Perception Questionnaire, the Pain Self-Efficacy Questionnaire, and the Health-Related Quality of Life: Endo - metriosis Health Profile-30 (EHP-30). Data were analyzed using. Data were analyzed using SPSS version 27 and SmartPLS 4.0. Partial Least Squares Structural Equation Modeling (PLS-SEM) with bootstrapping (5000 resamples) was also conducted to test both direct and mediating effects. Statistical significance was set at p < .05. The mean age of participants was 30.0 ± 5.5 years. The majority were predominantly married and attained a bachelor’s education, with a marked symptom burden. Two-thirds of participants were overweight and obese. It was found that 28.7% had Stage III endometriosis, and over 80% reported moderate-to-severe pelvic pain. Both Illness perceptions and pain self-efficacy were at moderate levels, while HRQoL impairment was sub - stantial, especially in pain and emotional domains as well. More negative illness perceptions were significantly associated with worse HRQoL (r = 0.458, p < .001) and lower pain self-efficacy (r = − 0.474, p < .001), whereas higher pain self-efficacy was associated with better HRQoL (r = − 0.542, p < .001). In regression analysis, illness perceptions and pain self-efficacy together explained 34.6% of the variance in HRQoL, with pain self-efficacy demonstrating the stronger independent association. This study demonstrated that illness perceptions and pain self-efficacy are related factors that influence HRQoL in endometriosis patients. Negative illness perceptions Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-74712-z were found to be associated with HRQoL, and increased levels of pain self-efficacy were found to be related to HRQoL. Pain self-efficacy also partially mediated the relationship between illness perceptions and HRQoL.

Illness perceptions · Health-related quality of life · Women · Endometriosis · Mediating role · Self-efficacy

Endometriosis represents an increasingly significant global health concern 1. Globally, it is impacting approxi - mately 190 million reproductive-age women2. Currently, there is no conclusive cure for endometriosis; however, several therapeutic approaches are available for alleviating symptoms and enhancing quality of life3. Management strategies comprise analgesics for pain relief, hormonal therapy, and surgical removal of endometriotic lesions2. Moreover, endometriosis is closely connected with a variety of symptoms, particularly long-standing pelvic pain, menorrhagia, dysmenorrhea, dysuria, dyspareunia, dyschezia, fatigue, and fertility challenges as well4. Furthermore, endometriosis also significantly impairs women’s productivity and overall health-related qual - ity of life (HRQoL)5. The HRQoL represents a multi-dimensional as well as multifaceted concept that involves physical and psychosocial aspects linked with the disease itself or its treatment 6. Recent epidemiological and clinical studies continue to confirm substantial reductions in HRQoL among women with endometriosis5,7. When women are challenged with such a condition, they create their own individualized conceptions to guide their logical responses to the challenges they really encounter. One of these models is the Common-Sense Model of Self-Regulation, which highlights the role of patients’ beliefs regarding their illness in shaping their coping strategies, as well as quality of life8. The core of this model is the concept of illness perceptions that have emerged as key predictors of patient out- comes in chronic diseases, including endometriosis9,10. Illness perceptions in which patients construct cognitive schemas about their own health conditions based on different factors, including perceptions of the consequences, causation, controllability, and the timeline of the health condition. In turn, these representations influence the individuals’ emotional responses and their own coping behaviors targeted to manage that health condition11. It's also worth mentioning that pain self-efficacy among women with endometriosis refers to belief in the women's ability to manage their own pain12. It is indispensable for well-being, where lower self-efficacy is linked to worse quality of life, increased stress, depression, and lower self-esteem, particularly in advanced stages 13,14. Concur- rently, painful self-efficacy was defined as the confidence in one’s ability to perform activities despite pain 12,15. It is a central determinant in chronic pain adjustment, including endometriosis. Higher pain self-efficacy predicts better functioning, reduced disability, and improved illness perception as well as HRQoL across those suffering from pain13,14. Several studies conducted on endometriosis revealed that higher pain self-efficacy levels were closely linked with better physical performance and enhanced HRQoL as well 12,16. Where women who feel more capable of handling their pain can engage more actively in daily life activities and report less impairment from symp - toms17. In contrast, reduced pain self-efficacy among those women was associated with greater disability, more prominent symptom distress, and diminished well-being, highlighting its central role in the adaptation process in chronic pain conditions18. Considering these relationships, including understanding the mediation pathway, illness perceptions, self-effi- cacy, and HRQoL may offer applicable insights for tailoring patient-centered interventions. Therefore, a media- tional framework between illness perceptions, pain self-efficacy, and HRQoL helps to explain the interplay among these variables. Negative illness perceptions can undermine pain self-efficacy by fostering feelings of helpless - ness and low control, which in turn amplify the burden of chronic pain on women’s lives and further diminish HRQoL. Otherwise, interventions that target maladaptive illness beliefs and enhance pain self-efficacy have the potential to reduce the detrimental effects of pain and illness uncertainty, ultimately improving HRQoL 19. Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-74712-z Hence, this study aims to investigate the association between illness perceptions and health-related quality of life (HRQoL) among women diagnosed with endometriosis, and to explore the mediating role of pain self-efficacy in this relationship. The study hypothesized that H1: Illness perceptions are significantly associated with health- related quality of life (HRQoL) in women who have been diagnosed with endometriosis. H2: Illness perceptions are significantly associated with pain self-efficacy in women who have been diagnosed with endometriosis. H3: Pain self-efficacy is significantly associated with health-related quality of life in women who have been diag - nosed with endometriosis. H4: Pain self-efficacy is consistent with a mediating role of the relationship between illness perceptions and health-related quality of life in women who have been diagnosed with endometriosis.

Design A cross-sectional design was employed in this study. Settings and participants The present study was carried out at the Gynecology outpatient clinics of a Maternity University Hospital. This setting was chosen because it is the only main university hospital in the Governorate that provides obstetrics and gynecology services, and the follow-up turnover of the women is suitable for the study. Additionally, women attending this hospital had nearly the same socioeconomic status, which preserved the homogeneity of the study participants. A purposive sample of women who met the following inclusion criteria: women diagnosed with endometriosis during their reproductive age, free from any chronic gynecological or medical disorders, had not received phar - macological treatment to alleviate pain, and consented to participate in the study. Endometriosis diagnosis was confirmed based on documented laparoscopic, surgical findings, and imaging findings based on a physician-doc- umented diagnosis in the medical record at the site of data collection. Women who were currently using, or had previously used, pharmacological treatments for pain, including analgesics, hormonal therapy (e.g., combined oral contraceptives, progestins, GnRH agonists/antagonists), or neuromodulators, were excluded from the study, regardless of whether such treatment had since been discontinued, to reduce the potential influence of pharma - cological treatment on self-reported pain self-efficacy and quality of life. Women currently receiving hormonal suppression for infertility treatment, or currently undergoing infertility treatment, were also excluded. Surgical treatment history (e.g., prior laparoscopic excision or ablation) was recorded for all participants. Instruments A structured, self-administered questionnaire was employed to collect the study data. It is composed of four Subsections: (1) Sociodemographic and Clinical Characteristics such as age, BMI, education level, marital status, occupation, duration, since formal diagnosis endometriosis stage, and average pelvic pain severity (past 4 weeks); disease stage was classified according to the revised American Society for Reproductive Medicine (rASRM) classification system, as recorded in the medical chart at the time of surgical/laparoscopic diagnosis rather than independently verified by the research team (2) Brief Illness Perception Questionnaire (Brief IPQ) that used to measure cognitive as well as emotional representations of endometriosis. The Brief IPQ was adopted from Broadbent et al. 20. The Brief IPQ contains 9 items. Eight items assess consequences, timeline, personal control, treatment control, identity (symptom experience), concern, coherence/understanding, and emotional response,the ninth question was an open-ended question on the three main causes of such disease. Since the focus of the present study was not to identify the causes of the disease, this question was excluded. Items 1–8 were rated Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-74712-z on an 11-point scale (0–10). Items 3, 4, and 7 are reverse-scored, yielding a total score of 0 to 80. Higher scores indicate stronger negative perceptions of disease threat. Cronbach’s alpha for this questionnaire was 0.8021,22. (3) Pain Self-Efficacy Questionnaire (PSEQ), which was adopted from Nicholas23. The PSEQ consists of 10 items assessing confidence in performing daily activities, coping, and functioning despite pain (e.g., household chores, social interactions, work). Each item is rated on a 7-point Likert scale (0 = not at all confident to 6 = completely confident). Total score ranges from 0 to 60, with higher total scores indicating greater pain-related self-efficacy. The PSEQ has shown strong reliability, one-dimensionality, and construct validity across chronic pain popula - tions. Its short form, the PSEQ-2, has also been psychometrically validated for efficient use in research and clini- cal contexts24,25. (4) Health-Related Quality of Life: Endometriosis Health Profile-30 (EHP-30), a core questionnaire that contains 30 items, which is an endometriosis-specific, patient-reported outcome originally designed by Jones et al.26 and is widely used internationally27,28. The core EHP-30 consists of 30 items distributed across five domains including: pain (11 items), control and powerlessness (6 items), emotional well-being (6 items), social support (4 items), and finally self-image (3 items). Each item was scored via a 5-point scale (0 = Never to 4 = Always). Domain scores are converted to a 0–100 scale, where 0 = best health status and 100 = worst health status. A sum- mary score (EHP-30 Core summed scale) can also be calculated by producing one overall score combining the five domains into one single score, again ranging from 0 to 10028. Scaled domain score calculation: (sum of raw item scores ÷ maximum possible raw score for that domain) × 100. With respect to internal consistency, it was high across domains (Cronbach’s α: pain = 0.96; control and powerlessness = 0.94; emotional wellbeing = 0.91; social support = 0.88; self-image = 0.88), as reported by Skinner and Kuijer29. Also, the total of 30 items demon- strates 0.97, suggesting excellent internal consistency as reported by Grundström et al.27. Ethical considerations Ethical approval for the study was granted by the Research Ethics Committee at the Faculty of Nursing, Univer- sity of Hail (Ref.# H-2025-1003). All methods were performed in accordance with the relevant guidelines and regulations. An official request letter was sent from the faculty to the relevant authorities at the study site to secure permission for data collection after explaining the study objectives. Before data gathering, and after a thorough explanation of the study’s purpose, written informed consent was secured from all study participants, witnessed by the head nurse. Participants were fully informed that their participation in the study was entirely voluntary, and that they were informed of their right to withdraw from the study at any time without any effect on the medical care they received at the hospital. Regarding confidentiality and privacy, these were strictly maintained through- out the overall study. Moreover, the collected data was securely handled and protected to ensure anonymity and safeguard participant information. Pilot study A pilot study was conducted on approximately 10–15% of the estimated sample to evaluate the clarity, feasi - bility, and reliability of the Arabic-translated questionnaire before full-scale data collection. Cronbach’s alpha coefficients will be calculated using SPSS version 27 to assess the internal consistency of the Brief IPQ, PSEQ, and EHP 30 scales. Only instruments demonstrating acceptable reliability (Cronbach’s α ≥ 0.70) were retained for inclusion in the main study, and participants included in the pilot test were excluded from the final analysis. As illustrated in Table 1, all instruments demonstrated acceptable-to-excellent internal consistency in the pilot sample (α = 0.813–0.968), exceeding the minimum criterion for scale retention. Specifically, the BIPQ (α = 0.861) and PSEQ (α = 0.846) showed good reliability, while the EHP-30 domains showed good-to-excellent reliability (α = 0.813–0.925) and the total EHP-30 score demonstrated excellent reliability (α = 0.968), supporting use of the Arabic-translated instruments in the main study. Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-74712-z Data collection procedure The researcher accessed women with inclusion criteria during their visits to the Gynecology clinic in the selected setting. These settings allowed the researcher to meet participants in environments that were familiar and com - fortable, thereby encouraging open and honest discussion. The fieldwork involved one-to-one, in-depth meetings with participants. Each interview was conducted in a private and supportive manner to ensure confidentiality and emotional safety. The researcher allowed women to guide the conversation while ensuring that key quality-of- life, illness perception, and pain expression domains were addressed. Each participant met once for a compre - hensive interview, which took approximately 20 min. The data collection process was conducted over a period of three months. Data analysis Two analytic strategies that are complementary in nature were adopted. First, multiple linear regression analysis was performed to perform a descriptive analysis and test whether illness perceptions and pain self-efficacy were significant individual contributors to poor HRQoL and multicollinearity between the predictors. Second, partial least squares structural equation modeling was carried out as the main analytic strategy, as it enabled simultane- ous testing of the measurement model (reliability and validity of the constructs) and the structural model (both direct, indirect, and total effects), with the mediation effect of pain self-efficacy considered. IBM SPSS Statistics (version 27) was used to conduct data analysis, and SmartPLS 4.0 software. At the out - set, descriptive statistical analysis, including frequencies, percentages, means, standard deviations, medians, and ranges were computed in SPSS in order to summarize demographic as well as clinical characteristics and evalu- ate the distribution of the collected data. Prior to conducting advanced statistical modeling, normality, linear - ity, homoscedasticity, multicollinearity, and the presence of outliers were comprehensively assessed. Regarding Cronbach’s alpha coefficients, they were computed using pilot testing data (10–15% of the intended sample) to ensure both reliability and internal consistency of the Arabic-translated scales (Brief IPQ, PSEQ, and EHP-30). Cronbach’s alpha values ≥ 0.70 were confirmed as acceptable for subsequent analysis. For research hypothesis testing (H1–H4), Partial Least Squares Structural Equation Modeling (PLS-SEM) using Smart PLS software was conducted. Building on the preliminary regression findings, PLS-SEM was then used as the primary ana - lytic framework to test the hypothesized structural model, including the mediating role of pain self-efficacy. The measurement model evaluation in Smart PLS included the assessments of the following: internal consistency reliability (Cronbach’s alpha and composite reliability [CR]), convergent validity (Average Variance Extracted [A VE] ≥ 0.50), and discriminant validity as well (Fornell–Larcker criterion and heterotrait–monotrait [HTMT] ratio). The reason that led to the selection of PLS-SEM over covariance-based structural equation modeling (CB- SEM) is that, while CB-SEM is mostly employed when confirmatory testing of a particular covariance structure is needed, in this study the main purpose is prediction and variance explanation of the endogenous variables, and PLS-SEM does not have a multivariate normality assumption, which is not true for the EHP-30 and BIPQ items. In addition to that, PLS-SEM was favored over the regression-based mediational method because it allows Instrument/domain No. of Items Cronbach’s α Brief Illness Perception Questionnaire (BIPQ) 8 0.861 Pain Self-Efficacy Questionnaire (PSEQ) 10 0.846 EHP-30 (Pain domain) 11 0.925 EHP-30 (Control and powerlessness domain) 6 0.919 EHP-30 (Emotional Well-being Domain) 6 0.900 EHP-30 (Social support domain) 4 0.866 EHP-30 (Self-image domain) 3 0.813 Total EHP-30 30 0.968 Table 1 Pilot internal con- sistency reliability of study instruments (N = 30). Cronbach’s alpha values were derived from the pilot sample. Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-74712-z simultaneous modeling of more than one reflective indicator per construct while taking into consideration their measurement errors. The structural model was assessed using bootstrapping with 5,000 resamples at a significance level of p < .05 to estimate the following: path coefficients (β), t-values, coefficient of determination (R 2), effect size (f 2), and predictive relevance (Q2) as well. In particular, direct effects (H1, H2, and H3) were confirmed by significant path coefficients with corresponding p values < .05 and bootstrap confidence intervals excluding zero. The mediation hypothesis (H4) was explicitly tested by examining indirect effects using bias-corrected bootstrap confidence intervals. Mediation was established if the indirect path from illness perceptions to HRQoL through pain self- efficacy was significant, with confidence intervals that didn't contain zero. In the current model, particular emphasis has been placed on illness perceptions and pain self-efficacy, two psychological variables that can be modified in line with the Common-Sense Model of Self-Regulation. Apart from illness perceptions and pain self-efficacy, several other psychological and clinical variables have the poten- tial to affect the quality of life among women suffering from endometriosis (pain intensity, disease duration, infertility, depression, anxiety, treatment history, dyspareunia, fatigue, BMI, disease stage. The adequacy of sample size for the PLS-SEM analysis was conducted according to the 10 times rule and the inverse square root (Kock and Hadaya 2018). The construct that included the highest number of indicators (HRQoL impairment EHP-30) included 30 indicators, and according to the 10 times rule for the highest number of structural paths directed toward a single construct rather than the number of indicators (PLS-SEM estimates via the measurement model), the sample size should be much smaller than N = 300. Using G*Power for the mul- tiple regression analysis part (two predictors, medium effect size f2 = 0.15, α = 0.05, power = 0.80)30, the minimal sample size needed is approximately 290; thus, the actual sample size of 300 is enough for both parts of the analysis.

Participant characteristics A total of 300 women with endometriosis completed the survey. Participants had a mean age of 30.01 years (SD = 5.47). The sample was predominantly composed of women with a bachelor's degree (42.3%) and who were married (56.0%). Just under half of participants were employed (49.0%), and most resided in urban areas (61.3%). Regarding disease history, nearly half of the sample (47.7%) reported a symptom onset of seven or more years and a time since formal diagnosis exceeding three years (47.7%). In terms of body mass index, most participants fell within the overweight (44.0%) or normal weight (37.0%) categories. Regarding disease severity, self-reported endometriosis stage was fairly evenly distributed across Stages I through IV , and pelvic pain sever- ity was most frequently rated as moderate (48.3%) on the 0–10 Numeric Rating Scale (NRS). Full demographic and clinical characteristics are presented in Table 2. Descriptive statistics of study variables As shown in Table 3, mean illness perceptions were mid-range on the BIPQ (M = 40.02, SD = 11.69), suggest- ing a moderate level of perceived illness threat. Pain self-efficacy was also mid-range on the PSEQ (M = 29.93, SD = 11.85). HRQoL impairment (EHP_TOTAL) averaged 45.06 (SD = 23.48) on a 0–100 scale (higher scores = worse HRQoL), with domain means indicating that pain-related impacts (M = 47.50, SD = 26.39) and emotional wellbeing impacts (M = 45.72, SD = 27.35) were particularly prominent within this sample. Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-74712-z Bivariate correlations among study variables Pearson correlation coefficients were computed to examine the bivariate relationships among illness percep - tions, pain self-efficacy, and health-related quality of life (HRQoL) impairment (Table 4). Illness perceptions (BIPQ total) were significantly and positively correlated with HRQoL impairment, r = 0.458, p < .001, indicating that more threatening illness perceptions were associated with greater impairment in HRQoL. Pain self-efficacy Characteristic M ± SD n % Age (years) 30.01 ± 5.47 Education level Primary or less 21 7.0 Secondary/high school 62 20.7 Diploma/technical 41 13.7 Bachelor’s degree 127 42.3 Postgraduate degree 49 16.3 Marital status Single 117 39.0 Married 168 56.0 Divorced 15 5.0 Occupation/status Homemaker 58 19.3 Employed 147 49.0 Student 55 18.3 Unemployed 34 11.3 Other 6 2.0 Residence Urban 184 61.3 Rural 51 17.0 Suburban/peri-urban 65 21.7 Symptom onset (approximately) 3 years 143 47.7 Not sure 13 4.3 BMI category Underweight (< 18.5 kg/m2) 4 1.3 Normal weight (18.5–24.9 kg/m2) 111 37.0 Overweight (25.0–29.9 kg/m2) 132 44.0 Obesity (≥ 30.0 kg/m2) 53 17.7 Endometriosis stage Stage I 64 21.3 Stage II 73 24.3 Stage III 86 28.7 Stage IV 54 18.0 Not sure/unknown 23 7.7 Pelvic pain severity category (NRS 0–10) Mild (0–3) 56 18.7 Moderate (4–6) 145 48.3 Severe (7–10) 99 33.0 Table 2 Demographic and clinical characteristics of participants (N = 300). Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-74712-z (PSEQ total) was significantly and negatively correlated with both HRQoL impairment, r = − 0.542, p < .001, and illness perceptions, r = − 0.474, p < .001. These findings indicate that higher pain self-efficacy was associated with lower HRQoL impairment and less threatening illness perceptions, and they provided preliminary support for the hypothesized relationships examined in subsequent regression and structural equation modeling analyses. Multiple linear regression predicting HRQoL impairment As a preliminary step before the confirmatory PLS-SEM analysis, a standard multiple linear regression was conducted to examine whether illness perceptions and pain self-efficacy predicted HRQoL impairment (EHP_ TOTAL). The overall model was statistically significant, R = 0.588, R2 = 0.346, adjusted R 2 = 0.342, F = 78.57, p < .001, indicating that the two predictors jointly accounted for approximately 34.6% of the variance in HRQoL impairment. As shown in Table 5, both predictors contributed significantly to the model. Illness perceptions were a significant positive predictor of HRQoL impairment (B = 0.52, β = 0.259, p < .001), such that more nega - tive illness perceptions were associated with greater impairment. Pain self-efficacy was a significant negative predictor (B = − 0.83, β = − 0.419, p < .001), such that greater confidence in managing pain was associated with lower impairment, and emerged as the stronger of the two predictors. Tolerance and VIF values (0.775 and 1.290, respectively, for both predictors) indicated no evidence of problematic multicollinearity. Measurement model: reliability and convergent validity The measurement model was assessed for indicator reliability, internal consistency reliability, and convergent validity. As shown in Supplementary Table S1, all outer loadings exceeded the recommended threshold of 0.70 (range 0.680–0.918), except for two EHP-30 indicators (EHP15 = 0.680; EHP26 = 0.685), which were retained Table 4 Correlations among illness perceptions, pain self-efficacy, and HRQoL impairment (N = 300). Variable 1 2 3 1. HRQoL impairment (EHP_TOTAL) – 2. Illness perceptions (BIPQ total) 0.458*** – 3. Pain self-efficacy (PSEQ total) − 0.542*** − 0.474*** – Pearson correlations (two-tailed). *** p < .0 01. Table 5 Multiple linear regression predicting HRQoL impairment (EHP_TOTAL) from illness perceptions and pain self- efficacy (N = 300). Predictor B SE B β t p 95% CI for B Tolerance VIF Constant 49.12 6.51 – 7.55 < .001 [36.31, 61.93] Illness perceptions (BIPQ total) 0.52 0.11 0.259 4.86 < .001 [0.31, 0.73] 0.775 1.290 Pain self-efficacy (PSEQ total) − 0.83 0.11 − 0.419 − 7.87 < .001 [− 1.04, − 0.62] 0.775 1.290 Model 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 HRQoL). CI = confidence interval. Variable Score range M SD Total illness perceptions (BIPQ total) 0–80 40.02 11.69 Pain self-efficacy (PSEQ total) 0–60 29.93 11.85 EHP-30 Pain 0–100 47.50 26.39 EHP-30 Control and powerlessness 0–100 44.00 24.93 EHP-30 Emotional wellbeing 0–100 45.72 27.35 EHP-30 Social support 0–100 41.31 25.59 EHP-30 Self-image 0–100 41.89 27.04 Total HRQoL impairment (EHP_TOTAL) 0–100 45.06 23.48 Table 3 Means and standard deviations of study variables (including EHP-30 domains) (N = 300). Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-74712-z given their contribution to content validity and because composite reliability and average variance extracted (A VE) for the parent construct remained acceptable. Internal consistency reliability was excellent for all three constructs, with Cronbach's alpha, rho_a, and rho_c values all exceeding 0.90 for BIPQ and HRQoL impairment (EHP-30), and exceeding 0.95 for PSEQ. Convergent validity was established for all constructs, as A VE val - ues exceeded the recommended minimum of 0.50 (BIPQ A VE = 0.758; PSEQ A VE = 0.693; HRQoL impairment A VE = 0.538), indicating that each construct explained more than half of the variance in its respective indicators. Discriminant validity Discriminant validity was evaluated using the heterotrait–monotrait ratio of correlations (HTMT) and the For - nell–Larcker criterion (Table 6). All HTMT ratios were well below the conservative threshold of 0.85 (range 0.489–0.564; Panel A), supporting discriminant validity among the three constructs. Consistent with this, the Fornell–Larcker criterion was satisfied for every construct, as the square root of the A VE on the diago - nal (BIPQ = 0.871; PSEQ = 0.832; HRQoL impairment = 0.733) exceeded that construct's correlations with the other latent variables (Panel B). Latent variable correlations mirrored the pattern observed at the item level: pain self-efficacy was negatively correlated with both illness perceptions (r = − 0.487) and HRQoL impairment (r = − 0.546), and illness perceptions were positively correlated with HRQoL impairment (r = 0.475; Panel C). Taken together, these results confirm that the three constructs are empirically distinct. Indicator cross-loadings As a further check on discriminant validity, indicator cross-loadings were examined (Table 7). Every indicator loaded most strongly on its intended construct relative to the other two constructs, providing additional sup - port for the distinctiveness of the measurement model. BIPQ indicators loaded highest on the BIPQ construct (0.790–0.918), EHP-30 indicators loaded highest on the HRQoL impairment construct (0.680–0.803), and PSEQ indicators loaded highest on the PSEQ construct (0.800–0.865), with no cross-loading exceeding its correspond- ing primary loading. Table 6 Discriminant validity diagnostics: HTMT ratios and Fornell–Larcker criterion. Construct pair HTMT Panel A. HTMT ratios BIPQ ↔ HRQoL impairment 0.489 PSEQ ↔ HRQoL impairment 0.564 PSEQ ↔ BIPQ 0.508 HRQoL impairment BIPQ PSEQ Panel B. Fornell–Larcker matrix (diagonal = √A VE) HRQoL impairment 0.733 BIPQ 0.475 0.871 PSEQ − 0.546 − 0.487 0.832 HRQoL impairment BIPQ PSEQ Panel C. Latent variable correlations HRQoL impairment 1.000 0.475 − 0.546 BIPQ 0.475 1.000 − 0.487 PSEQ − 0.546 − 0.487 1.000 Negative correlations reflect opposite scoring directions (higher PSEQ indicates better self-efficacy; higher EHP-30 indicates worse HRQoL). HRQoL impairment refers to the EHP-30 latent construct. Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-74712-z HRQoL impairment BIPQ PSEQ BIPQ1 0.445 0.918 − 0.450 BIPQ2 0.396 0.849 − 0.428 BIPQ3_R 0.383 0.877 − 0.402 BIPQ4_R 0.361 0.790 − 0.351 BIPQ5 0.421 0.896 − 0.447 BIPQ6 0.462 0.901 − 0.459 BIPQ7_R 0.419 0.844 − 0.420 BIPQ8 0.408 0.883 − 0.421 EHP01 0.750 0.346 − 0.356 EHP02 0.752 0.338 − 0.389 EHP03 0.711 0.315 − 0.365 EHP04 0.745 0.343 − 0.370 EHP05 0.781 0.419 − 0.433 EHP06 0.790 0.387 − 0.420 EHP07 0.768 0.380 − 0.389 EHP08 0.761 0.359 − 0.385 EHP09 0.803 0.390 − 0.423 EHP10 0.742 0.323 − 0.332 EHP11 0.778 0.356 − 0.403 EHP12 0.717 0.331 − 0.398 EHP13 0.682 0.353 − 0.371 EHP14 0.711 0.354 − 0.361 EHP15 0.680 0.321 − 0.366 EHP16 0.738 0.317 − 0.371 EHP17 0.704 0.299 − 0.357 EHP18 0.727 0.335 − 0.376 EHP19 0.709 0.309 − 0.379 EHP20 0.724 0.277 − 0.428 EHP21 0.748 0.326 − 0.416 EHP22 0.752 0.357 − 0.475 EHP23 0.748 0.330 − 0.417 EHP24 0.714 0.293 − 0.342 EHP25 0.686 0.354 − 0.394 EHP26 0.685 0.323 − 0.432 EHP27 0.705 0.389 − 0.426 EHP28 0.725 0.398 − 0.461 EHP29 0.728 0.358 − 0.438 EHP30 0.716 0.400 − 0.459 PSEQ1 − 0.405 − 0.446 0.803 PSEQ10 − 0.449 − 0.356 0.840 PSEQ2 − 0.495 − 0.333 0.830 PSEQ3 − 0.473 − 0.462 0.834 PSEQ4 − 0.489 − 0.397 0.837 PSEQ5 − 0.454 − 0.420 0.831 PSEQ6 − 0.405 − 0.409 0.800 PSEQ7 − 0.459 − 0.377 0.865 PSEQ8 − 0.438 − 0.400 0.832 PSEQ9 − 0.469 − 0.440 0.852 Table 7 Indicator cross- loadings (PLS-SEM). Each indicator is expected to load highest on its intended construct. Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-74712-z Structural model and hypothesis testing The structural model was assessed using bootstrapping with 5000 resamples to test the hypothesized direct and indirect relationships (Table 8). Illness perceptions had a significant positive direct effect on HRQoL impair - ment (H1: β = 0.274, t = 5.268, p < .001) and a significant negative effect on pain self-efficacy (H2: β = − 0.487, t = 10.575, p < .001). Pain self-efficacy, in turn, had a significant negative direct effect on HRQoL impairment (H3: β = − 0.413, t = 7.916, p < .001). The indirect path from illness perceptions to HRQoL impairment through pain self-efficacy was also significant (H4: β = 0.201, t = 6.429, p < .001). The indirect path from illness perceptions to HRQoL impairment through pain self-efficacy was also significant (H4: β = 0.201, t = 6.429, p < .001, 95% CI [0.139, 0.265]), with the bias-corrected bootstrap confidence interval excluding zero, confirming mediation. This pattern is consistent with partial mediation; however, because all variables were assessed concurrently, interpret this as a statistical association among constructs rather than evidence of a temporal or causal sequence. The total effect of illness perceptions on HRQoL impairment (direct plus indirect) was β = 0.475 (t = 10.419, p < .001). All hypothesized paths were statistically significant (p < .001). As the data were collected at a single time point, these path coefficients reflect the strength and direction of association specified by the hypothesized model rather than confirmed causal or temporal ordering among variables. Explanatory power and effect sizes The structural model explained a moderate proportion of variance in the endogenous constructs (Table 9, Panel A). Illness perceptions and pain self-efficacy jointly explained 35.5% of the variance in HRQoL impairment (R2 = 0.355, adjusted R 2 = 0.351), while illness perceptions alone explained 23.7% of the variance in pain self- efficacy (R2 = 0.237, adjusted R 2 = 0.234). Effect size analysis (f 2; Panel B) indicated that illness perceptions exerted a large effect on pain self-efficacy (f 2 = 0.311), whereas pain self-efficacy exerted a medium effect on HRQoL impairment (f2 = 0.202) and illness perceptions exerted a small-to-medium effect on HRQoL impairment (f2 = 0.089), consistent with the mediated pathway identified in the structural model. Table 8 Structural model path coefficients and mediation effects (PLS-SEM bootstrapping; 5,000 resamples). Hypothesis Structural Path β (O) STDEV t p 95% CI (BCa) H1 BIPQ → HRQoL impairment (EHP-30) 0.274 0.052 5.268 < .001 [0.169, 0.374] H2 BIPQ → PSEQ − 0.487 0.046 10.575 < .001 [− 0.569, − 0.383] H3 PSEQ → HRQoL impairment (EHP-30) − 0.413 0.052 7.916 < .001 [− 0.510, − 0.305] H4 (Indirect) BIPQ → PSEQ → HRQoL impairment (EHP-30) 0.201 0.031 6.429 < .001 [0.139, 0.265] Total effect BIPQ → HRQoL impairment (EHP-30) 0.475 0.046 10.419 < .001 [0.370, 0.553] HRQoL impairment denotes the SmartPLS latent construct representing the EHP-30 total score (higher scores indicate worse HRQoL). Table 9 Model explanatory power (R2) and effect sizes (f2). Endogenous Construct R2 Adjusted R2 Panel A. Explained variance (R2) HRQoL impairment (EHP-30) 0.355 0.351 PSEQ 0.237 0.234 Structural Path f2 Panel B. Effect sizes (f2) BIPQ → HRQoL impairment (EHP-30) 0.089 BIPQ → PSEQ 0.311 PSEQ → HRQoL impairment (EHP-30) 0.202 Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-74712-z Predictive relevance Finally, the out-of-sample predictive relevance of the model was assessed using PLSpredict (Table 10). Both endogenous constructs yielded positive Q2predict values (PSEQ = 0.231; HRQoL impairment = 0.219), indicating that the model possessed meaningful predictive relevance beyond the estimation sample. Root mean square error (RMSE) and mean absolute error (MAE) values were consistent across both constructs, further supporting the predictive adequacy of the structural model. Indicator reliability (outer loadings) All BIPQ indicators loaded strongly on their construct (λ = 0.790–0.918). PSEQ indicators also demonstrated strong loadings (λ = 0.800–0.865). EHP-30 indicators showed acceptable loadings overall (λ = 0.680–0.803), with a small number slightly below 0.70 (e.g., EHP13 = 0.682; EHP15 = 0.680; EHP25 = 0.686; EHP26 = 0.685). All constructs demonstrated excellent internal consistency reliability (Cronbach’s α = 0.951–0.970; ρA = 0.951–0.971; ρC = 0.958–0.972). Convergent validity was supported for all constructs, with A VE exceeding 0.50 (HRQoL impairment = 0.538; BIPQ = 0.758; PSEQ = 0.693). Internal consistency reliability was excellent for all three con- structs. Full item-level outer loadings and the corresponding detailed measurement model diagram are provided in Supplementary Table S1 and Supplementary Figure S1. As shown in Fig. 1, illness perceptions (BIPQ) significantly and negatively influenced pain self-efficacy (PSEQ; β = − 0.487, 95% CI [− 0.569, − 0.383]). Pain self-efficacy significantly and negatively influenced HRQoL impair- ment (β = − 0.413, 95% CI [− 0.510, − 0.305]). Illness perceptions also had a significant positive direct effect on HRQoL impairment (β = 0.274, 95% CI [0.169, 0.374]). The model explained 23.7% of the variance in pain self- efficacy (R2 = 0.237) and 35.5% of the variance in HRQoL impairment (R2 = 0.355). Table 10 Predictive relevance (Q2predict) for endogenous constructs. Endogenous Construct Q2predict RMSE MAE PSEQ 0.231 0.885 0.714 HRQoL impairment (EHP-30) 0.219 0.890 0.738 Positive Q2predict values indicate out-of-sample predictive relevance. Fig. 1 Structural model results showing standardized path coefficients (β), t-values, and p-values for the relation - ships between illness perceptions (BIPQ), pain self-efficacy (PSEQ), and health-related quality of life impairment, based on bootstrapping with 5000 resamples (N = 300). Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-74712-z

Importantly, the findings of the present study emphasize an association between illness and how confident women feel in pain management, instead of focusing exclusively on symptom control. Integrating psychological assess- ment as well as self-efficacy-enhancing interventions into the routine care of endometriosis may represent a promising pathway in improving quality of life and long-term adaptation for the affected women. Referring to illness perceptions, the current findings indicated that the mean illness perceptions among study participants were in the mid-range, reflecting a moderate level of perceived illness threat, which ultimately sug - gests that study participants perceived endometriosis neither as benign nor as a severely debilitating condition but rather as a chronic, persistent condition with notable life impacts. This finding is contrary to Moore et al.31, where they stated that the study participants held largely negative perceptions of their endometriosis, perceiving adverse consequences, an enduring timeline, and negative emotional representations of their condition as well. The dis - crepancy may be attributed to several factors, including differences in participants' characteristics, disease-related experiences, and healthcare context. Regarding total HRQoL, the participants of this study experienced considerable impairment in the overall HRQoL. This impairment, especially in pain and emotional well-being domains as well, reflects the multidimen- sional burden of endometriosis as documented in numerous recent studies. This finding conforms to an inter - national cross-sectional study performed by Van Niekerk et al. 32, who indicate that endometriosis was closely associated with a significantly lower HRQoL across multiple domains, including physical functioning, pain, emotional well-being, and social functioning, which highlights its pervasive impact on daily life. It is also in line with a prior longitudinal study performed by Gete et al.33 in Australia. They concluded that endometriosis is significantly associated with worse HRQoL, including physical, mental, and social functioning and well-being. The current study showed that higher negative illness perceptions were moderately associated with worse HRQoL. This finding is in line with a study performed by Barberis et al. 34 who found that negative illness per - ceptions were significantly related to poorer HRQoL among women with endometriosis. Furthermore, the pres - ent result also concurs with Spinoni et al. 9,10, who used a path analysis among women with endometriosis and showed that illness perceptions were associated with maladaptive coping and reduced HRQoL among affected women. These findings are expected and support the role of negative illness perceptions in poorer well-being outcomes. The association between higher negative illness perceptions and worse HRQoL among women with endometriosis can be explained by the Model of Self-Regulation, where women who perceive their illness as highly threatening, uncontrollable, or long-lasting are more likely to experience emotional distress and maladap- tive coping, leading to lower HRQoL across physical, social, and emotional domains35,36. Regarding the correlation between pain self-efficacy and HRQoL, the current study showed that higher pain self-efficacy was moderately to strongly associated with better HRQoL. The current result reinforces the self- efficacy theory that demonstrates that individuals’ beliefs in their ability to manage symptoms and daily life tasks can significantly influence their psychological and physical well-being as well. In chronic conditions such as endometriosis, enhancing self-efficacy may act as a protective factor against the deterioration of patients' quality of life. The present study findings also align with a systematic review done by Dubé et al. 24, who indicates that pain self-efficacy is linked with less disability and better psychosocial outcomes among chronic pain patients. Meanwhile, it sympathizes with the population-based survey done by O’Hara et al. 12, where they found that greater self-efficacy was significantly associated with higher physical as well as mental quality of life among women with endometriosis. Additionally, current finding confesses with a study conducted by Van Niekerk et al. 32 that has shown pain severity contributes to reduced HRQoL. It also corresponds to a survey performed by Bień et al. 13 in east - ern Poland. They reported that higher self-efficacy was associated with better overall QoL among women with endometriosis. Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-74712-z Additionally, the present results agree with a cross-sectional survey done by Kovács-Szabó et al.37, who found that pain self-efficacy has been associated with significant outcomes on quality of life as well as physical func - tioning among Hungarian women with endometriosis. Referring to the correlation between illness perceptions and pain self-efficacy, it was clear that more negative illness perceptions were associated with lower pain self-efficacy. This finding is consistent with Moore 11, who observed that illness perceptions were linked with greater pain experience. This can be attributed to the important role played by illness perceptions in shaping pain severity among women with endometriosis. According to the Common-Sense Model of Self-Regulation, any woman who perceive their condition as severe, uncontrollable, and chronic is more likely to experience heightened emotional distress, reduced perceived control, and maladap- tive coping responses. All these factors can contribute to increased pain vigilance, central sensitization, as well as reduced effective engagement in pain-management strategies, ultimately amplifying pain severity. Moreover, pain and illness perceptions may interact bidirectionally, whereby increased pain reinforces negative beliefs about the illness, further perpetuating pain intensity. Notably, the self-efficacy theory proposes that individuals with higher self-efficacy are more capable of han - dling pain, engaging in daily activities, and preserving psychosocial functioning. In chronic conditions, self- efficacy has been linked with more adaptive coping, greater activity engagement, and better quality of life. Multiple Linear Regression demonstrated that higher negative illness perceptions independently predicted worse HRQoL. This finding is congruent with evidence from an Australian community survey, which reported that higher self-efficacy levels and dispositional optimism were identified as independent protective factors that are positively associated with emotional well-being, social support, and better sexual functioning14. The present findings also correspond with a qualitative study exploring illness perceptions among women with endometriosis. It was found that participants held largely negative representations of their condition, including fears about their future, perceived interference of life roles, and emotional distress, which may ultimately contrib- ute to reduced quality of life, illustrating how illness beliefs impact daily functioning and well-being31. Otherwise, the present study stated that higher pain self-efficacy independently predicted better HRQoL. This finding coincides with a cross-sectional study done by Kovács-Szabó et al. 37, who found that pain self-efficacy emerged as a consistent positive predictor of multiple domains of HRQoL among Hungarian women with endo- metriosis37. These findings can be better explained through Bandura’s Self-Efficacy Theory, which proposes that individuals’ beliefs and confidence in their ability to manage symptoms play a major role in guiding their behavioral engagement, emotional regulation, and functional outcomes. Within the scope of endometriosis, pain self-efficacy reflects women’s confidence in their ability to adapt with persistent pain, maintain their daily activi- ties, and regulate pain-related distress despite ongoing symptoms. Therefore, higher pain self-efficacy enables adaptive coping strategies, reduces activity avoidance, and mitigates the disabling effects of chronic pain, result- ing in better physical, emotional, and social aspects of HRQoL. Strengths and limitations The present study has several remarkable strengths. Firstly, it is mainly grounded in well-established theoretical frameworks, namely the Common-Sense Model of Self-Regulation and Bandura’s Self-Efficacy Theory, which provide a strong conceptual basis for interpreting the study findings. Secondly, this study employed validated, disease-specific instruments (Brief IPQ, PSEQ, and EHP-30), all of which demonstrated excellent reliability in the Arabic-translated versions, which strengthened measurement validity. Thirdly, the relatively large sample size (N = 300) enhances statistical power and enables robust multivariate and mediation analyses using both regres - sion and PLS-SEM approaches. Fourthly, the use of structural equation modeling with bootstrapping allows for a comprehensive examination of both direct and indirect relationships, offering deeper insight into the psycho - logical mechanisms underlying HRQoL impairment in endometriosis. Conversely, although key psychological variables were examined, other potentially relevant factors, such as depression, anxiety, social support, coping styles, and treatment adherence, were not included and may account for additional variance in HRQoL. Also, Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-74712-z due to the cross-sectional nature of the research, the conclusions about the mediation effect have to be made with reservations. Although the statistical model confirms the logical sequence of the mediation effect from illness perception to HRQoL through pain self-efficacy, the data are not sufficient to draw any conclusions about the time precedence and causality between the variables. Moreover, excluding women who were being managed pharmacologically for pain relief purposes, which was aimed at minimizing confounders related to the effects of drugs, may have created selection bias by failing to include a good number of women with endometriosis whose management included pharmacological treatment. The generalizability of the results to women with endometriosis could thus be undermined since several women would not be included in the study sample, especially women suffering more from endometriosis who required pharmacological treatment. Future research can include such women in the study sample, but with treatment and dosage controlled for statistically. Additionally, endometriosis staging was based on medical records rather than independent verification by the research team, which may have introduced some degree of diagnostic misclassification. Also, a key limitation of this study is its cross-sectional design. Although the structural model was consistent with a mediating role of pain self-efficacy in the relationship between illness perceptions and HRQoL impairment, the simultaneous measurement of all variables precludes any conclusion about temporal precedence or causality. Longitudinal or experimental designs are needed to confirm the directionality implied by the proposed model. Additionally, since women who had or have received pharmacological or hormonal treatment for pain, in the form of analgesics, hormonal treatment, or neuromodulators, were excluded from this study, the final sample is one that consists of a specific subset of women suffering from endometriosis who were not being treated when they participated in this study. The reason for excluding such women was to reduce any possibility of the results being confounded by their current pharmacological pain management, but this exclusion criterion could also indicate that the results of this study cannot be applied to all women suffering from endometriosis, as the majority of them have received some kind of medical treatment for pain. Furthermore, this investigation did not control for several clinically significant covariates known to impact HRQoL in patients with endometriosis, namely pain intensity, disease stage, disease duration, history of treat - ment, infertile state, depression, anxiety, social support, dyspareunia, fatigue, and BMI. Though pain intensity and disease stage were measured as descriptive parameters in this investigation, they were not controlled for in regression and structural analysis; it can thus be stated that part of the correlations between illness perceptions, pain self-efficacy, and HRQoL impairment found in the present research may be associated with the effects of these uncontrolled parameters. Depression, anxiety, and social support were not measured in the current investi- gation. Future studies will need to validate this model by controlling for pain intensity, disease stage, and other clinically significant covariates to find out if the illness perceptions-pain self-efficacy-HRQoL relationship is valid independently of these parameters. Study implications and recommendations Interventions to address maladaptive illness beliefs, such as perceptions of uncontrollability, consequences, and emotions, could have a positive impact on the psychological burden and coping strategies. Meanwhile, inter - ventions to enhance pain self-efficacy, such as cognitive behavioral therapy, pain self-management education, acceptance-based interventions, and structured programs to enhance self-efficacy, could have a positive impact on the functional outcomes and HRQoL of women with endometriosis. Nurses and other health professionals are best positioned to implement such interventions, considering their close and continuous contact with women with endometriosis. From the nursing perspective, the study findings suggest the need to incorporate psychological interventions into the management of endometriosis. Nurses have a significant role to play in the education of women with endometriosis by helping them to change their misconceptions about endometriosis, construct posi- tive and hopeful illness representations, and adopt active coping strategies. Nurses could also play a significant Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-74712-z role in enhancing the pain self-efficacy of women with endometriosis, which could have a positive impact on their HRQoL by helping them to stay active and engaged in daily activities despite the pain.

In conclusion, this study has found compelling evidence that illness perceptions and pain self-efficacy are impor- tant and interconnected factors that influence HRQoL for women living with endometriosis. For example, nega- tive illness perceptions are related to poorer HRQoL, whereas pain self-efficacy is positively related to HRQoL. Moreover, pain self-efficacy was found to be a partial mediator of the relationship between illness perceptions and HRQoL, emphasizing the importance of pain self-efficacy as a psychological mechanism through which illness perceptions influence HRQoL. Given the cross-sectional design of this study, the mediating role of pain self-efficacy identified here should be regarded as preliminary. Longitudinal studies that measure illness percep- tions, pain self-efficacy, and HRQoL impairment at multiple time points are needed to test true mediation and to establish the temporal and causal ordering of these relationships. Supplementary Information The online version contains supplementary material available at https://doi.org/10.1038/ s41598-026-74712-z.

The Authors would like to thank all participants in this study for their valuable contribution. This research has been funded by the Scientific Research Deanship at the University of Ha’il, Saudi Arabia, through project number <>. Author contributions HIM: Conceptualization, project administration and funding acquisition, HIM; SBH: methodology; YZA; software and formal analysis, BGAS and SBH; validation; formal analysis, LSA; investigation, SMA; resources, SKMM and BGAS; data curation; LA; writing—original draft preparation; SBH; writing—review and editing. SAM: Data curation. All authors have read and agreed to the published version of the manuscript. Funding This research has been funded by the Scientific Research Deanship at the University of Ha’il, Saudi Arabia, through Project Number <>. Data availability Data are available upon reasonable request. Declarations Ethics approval and consent to participate Informed consent was obtained from all participants. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 Interna- tional License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Cre- ative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will 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 n s . o r g / l i c e n s e s / b y - n c - n d / 4 . 0 / . Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-74712-z

1. Falcone, T. & Flyckt, R. Clinical management of endometriosis. Obstet. Gynecol. 131(3), 557–571 (2018). 2. Gete, D. G., Doust, J., Mortlock, S., Montgomery, G. & Mishra, G. D. Impact of endometriosis on women’s health- related quality of life: A national prospective cohort study. Maturitas 174, 1–7 (2023). 3. Czubak, P. et al. Understanding endometriosis: A broad review of its causes, management, and impact. Int. J. Mol. Sci. 26(18), 8878 (2025). 4. Ortega-Gutiérrez, M., Muñoz-Gamez, A. & Girón-Prieto, MdlS. Primary care approach to endometriosis: Diagnostic challenges and management strategies—A narrative review. J. Clin. Med. 14(13), 4757 (2025). 5. Della Corte, L. et al. The burden of endometriosis on women’s lifespan: A narrative overview on quality of life and psychosocial wellbeing. Int. J. Environ. Res. Public Health 17(13), 4683 (2020). 6. Mousa, M. et al. Impact of endometriosis in women of Arab ancestry on: Health-related quality of life, work productivity, and diagnostic delay. Front. Glob. Women’ s Health 2, 708410 (2021). 7. Maulenkul, T. et al. Understanding the impact of endometriosis on women’s life: An integrative review of systematic reviews. BMC Womens Health 24(1), 524 (2024). 8. Hagger, M. S. & Orbell, S. The common sense model of illness self-regulation: A conceptual review and proposed extended model. Health Psychol. Rev. 16(3), 347–377 (2022). 9. Spinoni, M., Capano, A. U., Porpora, M. G. & Grano, C. Understanding the psychological factors linking pelvic pain and health-related quality of life in endometriosis: The influence of illness representations and coping strategies. Am. J. Obstet. Gynecol. 233(1), 54.e51-e54.e10. https://doi.org/10.1016/j.ajog.2024.12.027 (2025). 10. Spinoni, M. et al. The association between dream activity and alexithymia during pregnancy: A cross‐sectional study in a sample of pregnant women. J. Sleep Res. 34(4), e14423 (2025). 11. Moore, C. A mixed-methods investigation into the role of illness perceptions and coping in endometriosis-related quality of life (2024). 12. O’Hara, R., Rowe, H. & Fisher, J. Self-management factors associated with quality of life among women with endometriosis: A cross-sectional Australian survey. Hum. Reprod. 36(3), 647–655 (2021). 13. Bień, A. et al. Quality of life in women with endometriosis: The importance of socio-demographic, diagnostic-therapeutic, and psychological factors. J. Clin. Med. 14(12), 4268 (2025). 14. Bień, A. et al. Clinical factors affecting the quality of life of women with endometriosis. J. Adv. Nurs. 81(8), 4667–4680 (2025). 15. Stahlschmidt, L., Hübner-Möhler, B., Dogan, M. & Wager, J. Pain self-efficacy measures for children and adolescents: A systematic review. J. Pediatr. Psychol. 44(5), 530–541 (2019). 16. Kovács-Szabó, Z. et al. PCR139 Beneficial effect of physical activity on pain-related self-efficacy among women with endometriosis and chronic pelvic pain, cross-sectional study. Value Health 27(6), S321–S322 (2024). 17. Bouchard, S., Choinière, M., Masse, J., Labourot, J. & Vachon, B. (2025). Empowering people living with chronic pain to use self-management strategies in their daily lives: Understanding occupational therapy practices. Disability Rehabil. 1–15. 18. Leuenberger, J. et al. Living with endometriosis: Comorbid pain disorders, characteristics of pain and relevance for daily life. Eur. J. Pain 26(5), 1021–1038 (2022). 19. Spinoni, M., Di Gesto, C., Porpora, M. G. & Grano, C. The role of catastrophizing in enhancing pain interference and depressive symptoms in endometriosis: A longitudinal examination. Eur. J. Pain 30(1), e70198 (2026). 20. Broadbent, E., Petrie, K. J., Main, J. & Weinman, J. The brief illness perception questionnaire. J. Psychosom. Res. 60(6), 631–637 (2006). 21. Liu, Y .-R., Wang, Y ., Wang, J. & Wang, X. Association between illness perception and adherence to inhaler therapy in elderly Chinese patients with chronic obstructive pulmonary disease. Chronic Respir. Dis. 21, 14799731241286837 (2024). 22. Rezaei, S. & Vakilian, M. The mediating role of illness perception in the relationship between psychological hardiness and 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 5 / 0 0 1 c . 2 4 8 3 9 (2021). 23. Nicholas, M. K. The pain self-efficacy questionnaire: Taking pain into account. Eur. J. Pain 11(2), 153–163 (2007). 24. Dubé, M.-O., Langevin, P. & Roy, J.-S. Measurement properties of the Pain Self-Efficacy Questionnaire in populations with musculoskeletal disorders: A systematic review. Pain Rep. 6(4), e972 (2021). 25. Nicholas, M. K., McGuire, B. E. & Asghari, A. A 2-item short form of the Pain Self-efficacy Questionnaire: Development and psychometric evaluation of PSEQ-2. J. Pain 16(2), 153–163 (2015). 26. Jones, G., Kennedy, S., Barnard, A., Wong, J. & Jenkinson, C. Development of an endometriosis quality-of-life instrument: The Endometriosis Health Profile-30. Obstet. Gynecol. 98(2), 258–264 (2001). 27. Grundström, H., Rauden, A., Wikman, P. & Olovsson, M. Psychometric evaluation of the Swedish version of the 30-item endometriosis health profile (EHP-30). BMC Womens Health 20(1), 204 (2020). Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-74712-z 28. Jaeger, M., Niederkrotenthaler, T., Till, B. & Werneck, H. Associations between health-related quality of life, infertility- related psychological well-being, and relationship quality in individuals with endometriosis: A cross-sectional study. BMC Womens Health 24(1), 657 (2024). 29. Skinner, C. M. & Kuijer, R. G. Self-compassion and health-related quality of life in individuals with endometriosis. Psychol. Health 40(9), 1479–1496 (2025). 30. Faul, F., Erdfelder, E., Buchner, A. & Lang, A.-G. Statistical power analyses using G* Power 3.1: Tests for correlation and regression analyses. Behav. Res. Methods 41(4), 1149–1160 (2009). 31. Moore, C., Cogan, N. & Williams, L. Illness perceptions among individuals with endometriosis and their longitudinal associations with psychological distress and pain. J. Health Psychol. https://doi.org/10.1177/13591053251320595 (2025). 32. Van Niekerk, L., Johnstone, L. & Matthewson, M. Predictors of self-compassion in endometriosis: The role of psychological health and endometriosis symptom burden. Hum. Reprod. 37(2), 264–273 (2022). 33. Gete, D. G. et al. Hospitalisations and length of stays in women with endometriosis: A data linkage prospective cohort study. EClinicalMedicine https://doi.org/10.1016/j.eclinm.2024.103030 (2025). 34. Barberis, N., Cannavò, M., Cuzzocrea, F., Saladino, V . & Verrastro, V . Illness perceptions and factors of distress as mediators between trait emotional intelligence and quality of life in endometriosis. Psychol. Health Med. 28(7), 1818– 1830 (2023). 35. Magnavacca, A., Di Gesto, C., Aminoff, D., Spinoni, M. & Grano, C. Antecedents of mental health in parents of individuals born with ARM: The association between illness representations, negative and positive coping, and depressive symptoms. J. Pediatr. Surg. https://doi.org/10.1016/j.jpedsurg.2025.162755 (2025). 36. Sofiani, Y ., Rahim Kamil, A. & Rayasari, F. The relationship between illness perceptions, self-management, and quality of life in adult with type 2 diabetes mellitus (2022). 37. Kovács-Szabó, Z., Ács, P., Prémusz, V ., Makai, A. & Hock, M. Psychological, symptom-related, and lifestyle predictors of health-related quality of life in Hungarian women with endometriosis. J. Clin. Med. 14(19), 7004 (2025). Publisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Authors and Affiliations Hajer I. Motakef1  · Salam Bani Hani2  · Niven Basyouni3,4  · Yazeed Z. Alshahithy5 · Emran A. Abu Aqoulah2 · Layla Salem Alshammari6  · Sahar Mazied Alshammari7  · Soha Kamel Mosbah Mahmoud8  · Bahia Galal Abd Elrazik Siam9  · Lina Aljabbab10 · Salwa Ali Marzouk1 Salam Bani Hani [email protected]; [email protected] 1 Department of Maternal and Child Health, College of Nursing, University of Hail, Hail, Saudi Arabia 2 Department of Nursing, Faculty of Nursing, Irbid National University, Irbid, Jordan 3 Obstetrics and Gynecologic Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt 4 Irbid National University, Irbid, Jordan 5 Department of Nursing, Faculty of Medicine, Health Sciences, Sana’a University, Sana’a, Yemen 6 Department of Medical Surgical Nursing, College of Nursing, University of Hail, Hail, Saudi Arabia 7 Department of Maternal and Child Health, College of Nursing, University of Hail, Hail, Saudi Arabia 8 Department of Community Health Nursing, College of Nursing, Hail University, Hail, Saudi Arabia 9 Department of Medical Surgical Nursing, College of Nursing, University of Hail, Hail, Saudi Arabia 10 Creative and Innovation Development, Al-Jouf Health Cluster, Sakaka, Saudi Arabia