Health-related quality of life after injury: examining the roles of perceived daily-life stress and injury perceptions



The present study aimed to examine the effects of injury perceptions and perceived daily stress on health-related quality of life (HRQL) of individuals affected by a physical injury.


Two hundred and forty injured individuals completed questionnaires assessing HRQL (Medical Outcome Health Survey short-form 36), perceived daily-life stress (Perceived Stress Scale), and injury perceptions (Brief-InjPQ).


The direct effects of stress on HRQL scores were not moderated by gender. Emotional representation of the injury significantly mediated the links between PSS and all HRQL subscales only among women, but not among men. However, the mediation of the HRQL total score by emotional representations was significant for both genders. In addition, treatment control perceptions of the injury mediated the link between PSS and self-assessed health among men but not women, and injury-self perceptions mediated the link between PSS and physical functioning among men but not women.


These findings underscore the importance of perceived daily stress, gender, and injury perceptions as key factors for explaining variance in HRQL following injury. In addition to their conceptual contributions, the findings have clinical implications for treating injured populations.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6


  1. 1.

    Comparisons between this sample and a comparable healthy sample were reported elsewhere (10).

  2. 2.

    We did not ask participants for the specific treatments they have received, but the health system in Israel is universal and participation in a medical insurance plan is compulsory. Every resident has a right to receive all of the services included in the medical services basket at a reasonable quality level. The Health Basket covers all costs of medical diagnosis and treatment in a variety areas of medicine, including first aid, hospitalization, surgery, and paramedical services such as physiotherapy and occupational therapy, and mental healthcare. (see also:


  1. 1.

    Cao, X. Y., Chen, L., Tian, L., & Jiang, X. L. (2015). Psychological distress and health-related quality of life in relocated and nonrelocated older survivors after the 2008 Sichuan earthquake. Asian Nursing Research,9(4), 271–277.

    Article  PubMed  Google Scholar 

  2. 2.

    Gauffin, E., Oster, C., Sjoberg, F., Gerdin, B., & Ekselius, L. (2016). Health-related quality of life (EQ-5D) early after injury predicts long-term pain after burn. Burns,42(8), 1781–1788.

    Article  PubMed  Google Scholar 

  3. 3.

    Gopinath, B., Jagnoor, J., Harris, I. A., Nicholas, M., Casey, P., Blyth, F., . . . Cameron, I. D. (2017). Health-related quality of life 24 months after sustaining a minor musculoskeletal injury in a road traffic crash: A prospective cohort study. Traffic Injury Prevention, 18(3), 251–256.

  4. 4.

    Hagger, M. S., Chatzisarantis, N. L. D., Griffin, M., & Thatcher, J. (2005). Injury representations, coping, emotions, and functional outcomes in athletes with sports-related injuries: A test of self-regulation theory. Journal of Applied Social Psychology,35(11), 2345–2374.

    Article  Google Scholar 

  5. 5.

    Bryant, R. A., O'Donnell, M. L., Creamer, M., McFarlane, A. C., Clark, C. R., & Silove, D. (2010). The psychiatric sequelae of traumatic injury. American Journal of Psychiatry,167(3), 312–320.

    Article  PubMed  Google Scholar 

  6. 6.

    Skogstad, L., Tøien, K., Hem, E., Ranhoff, A. H., Sandvik, L., & Ekeberg, Ø. (2014). Psychological distress after physical injury: A one-year follow-up study of conscious hospitalised patients. Injury,45(1), 289–298.

    Article  PubMed  Google Scholar 

  7. 7.

    Wiese-Bjornstal, D. M., Smith, A. M., Shaffer, S. M., & Morrey, M. A. (1998). An integrated model of response to sport injury: Psychological and sociological dynamics. Journal of Applied Sport Psychology,10(1), 46–69.

    Article  Google Scholar 

  8. 8.

    Shiloh, S., Heruti, I., & Leichtentritt, R. (2016). A common-sense model of injury perceptions. Journal of Health Psychology,21(8), 1516–1526.

    Article  PubMed  Google Scholar 

  9. 9.

    Leventhal, H., Phillips, L. A., & Burns, E. (2016). The common-sense model of self-regulation (CSM): A dynamic framework for understanding illness self-management. Journal of Behavioral Medicine,39(6), 935–946.

    Article  PubMed  Google Scholar 

  10. 10.

    Heruti, I., Levy, S., & Avitsur, R. (2018). Physical injury, health, and well-being: Role of stress perception. Injury-International Journal of the Care of the Injured,49(8), 1546–1551.

    Article  Google Scholar 

  11. 11.

    Heruti, I., Levy, S., Avitsur, R., Deutscher, D., Gutvirtz, M., Berkovitz, T., et al. (2018). Development of the injury perceptions questionnaire (InjPQ). Psychology & Health,33(5), 614–633.

    Article  Google Scholar 

  12. 12.

    Shiloh, S., Heruti, I., Diamis, A., Levy, S., Avitsur, R., Deutscher, D., . . . Berkovitz, T. (2018). The role of centrality to self-concept in moderating the associations between injury perceptions and outcomes. Psychology & Health, 33(12), 1519–1536

  13. 13.

    Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.

    Google Scholar 

  14. 14.

    Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior,24(4), 385–396.

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    Hewitt, P. L., Flett, G. L., & Mosher, S. W. (1992). The Perceived Stress Scale: Factor structure and relation to depression symptoms in a psychiatric sample. Journal of Psychopathology and Behavioral Assessment,14(3), 247–257.

    Article  Google Scholar 

  16. 16.

    Shields, G. S., & Slavich, G. M. (2017). Lifetime stress exposure and health: A review of contemporary assessment methods and biological mechanisms. Social and Personality Psychology Compass.

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Malamardi, S. N., Kamath, R., Tiwari, R., Nair, B. V., Chandrasekaran, V., & Phadnis, S. (2015). Occupational stress and health-related quality of life among public sector bank employees: A cross-sectional study in Mysore, Karnataka, India. Indian Journal of Occupational and Environmental Medicine,19(3), 134–137.

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    De Civita, M., Regier, D., Alamgir, A. H., Anis, A. H., FitzGerald, M. J., & Marra, C. A. (2005). Evaluating health-related quality-of-life studies in paediatric populations: Some conceptual, methodological and developmental considerations and recent applications. Pharmacoeconomics,23(7), 659–685.

    Article  PubMed  Google Scholar 

  19. 19.

    Seid, M., Varni, J. W., & Jacobs, J. R. (2000). Pediatric health-related quality-of-life measurement technology: Intersections between science, managed care, and clinical care. Journal of Clinical Psychology in Medical Settings,7, 17–27.

    Article  Google Scholar 

  20. 20.

    Simon, A. E., Chan, K. S., & Forrest, C. B. (2008). Assessment of children's health-related quality of life in the United States with a multidimensional index. Pediatrics,121(1), e118–126.

    Article  PubMed  Google Scholar 

  21. 21.

    Lewin-Epstein, N., Sagiv-Schifter, T., Shabtai, E. L., & Shmueli, A. (1998). Validation of the 36-item short-form Health Survey (Hebrew version) in the adult population of Israel. Medical Care,36(9), 1361–1370.

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Ware, J. E., & Sherbourne, C. D. (1992). The mos 36-item short-form health survey (Sf-36) 1. conceptual-framework and item selection. Medical Care,30(6), 473–483.

    Article  PubMed  Google Scholar 

  23. 23.

    Giladi, A. M., McGlinn, E. P., Shauver, M. J., Voice, T. P., & Chung, K. C. (2014). Measuring outcomes and determining long-term disability after revision amputation for treatment of traumatic finger and thumb amputation injuries. Plastic and Reconstructive Surgery,134(5), 746e–755e.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    McHorney, C. A., Ware, J. E., Jr., Lu, J. F., & Sherbourne, C. D. (1994). The MOS 36-item short-form health survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Medical Care,32(1), 40–66.

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Cohen, S., & Janicki-Deverts, D. (2012). Who's stressed? Distributions of psychological stress in the United States in probability samples from 1983, 2006, and 2009. Journal of Applied Social Psychology,42(6), 1320–1334.

    Article  Google Scholar 

  26. 26.

    Bend, G.(2007). The association between perceived stress, burnout and sperm quality in young men. M.A. Thesis. Sackler Faculty of Medicine. Tel-Aviv University.

  27. 27.

    Peduzzi, P., Concato, J., Kemper, E., Holford, T. R., & Feinstein, A. R. (1996). A simulation study of the number of events per variable in logistic regression analysis. Journal of Clinical Epidemiology.,49(12), 1373–1379.

    CAS  Article  Google Scholar 

  28. 28.

    Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York, NY: Guilford Press.

    Google Scholar 

  29. 29.

    Kim, K., & Kim, J. S. (2017). Factors influencing health-related quality of life among Korean cancer survivors. Psycho-oncology,26(1), 81–87.

    Article  PubMed  Google Scholar 

  30. 30.

    McKinley, S., Fien, M., Elliott, R., & Elliott, D. (2016). Health-related quality of life and associated factors in intensive care unit survivors 6 months after discharge. American Journal of Critical Care,25(1), 52–58.

    Article  PubMed  Google Scholar 

  31. 31.

    Gemmell, L. A., Terhorst, L., Jhamb, M., Unruh, M., Myaskovsky, L., Kester, L., et al. (2016). Gender and racial differences in stress, coping, and health-related quality of life in chronic kidney disease. Journal of Pain and Symptom Management,52(6), 806–812.

    Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Breuer, K., Goldner, F. M., Jager, B., Werfel, T., & Schmid-Ott, G. (2015). Chronic stress experience and burnout syndrome have appreciable influence on health-related quality of life in patients with psoriasis. Journal of the European Academy of Dermatology and Venereology,29(10), 1898–1904.

    CAS  Article  PubMed  Google Scholar 

  33. 33.

    Bugge, I., Dyb, G., Stensland, S. O., Ekeberg, O., Wentzel-Larsen, T., & Diseth, T. H. (2017). Physical injury and somatic complaints: The mediating role of posttraumatic stress symptoms in young survivors of a terror attack. Journal of Traumatic Stress,30(3), 229–236.

    Article  PubMed  Google Scholar 

  34. 34.

    Cardoso, J., Almeida, T., Ramos, C., & Sousa, S. (2018). Relationship between childhood trauma and sleep disturbances: The role of perceived stress as a mediator. Journal of Aggression Maltreatment & Trauma,27(10), 1075–1089.

    Article  Google Scholar 

  35. 35.

    Grynderup, M. B., Nabe-Nielsen, K., Lange, T., Conway, P. M., Bonde, J. P., Francioli, L., . . . Hansen, A. M. (2016). Does perceived stress mediate the association between workplace bullying and long-term sickness absence? Journal of Occupational and Environmental Medicine, 58(6), E226–E230.

  36. 36.

    Lamis, D. A., Hirsch, J. K., Pugh, K. C., Topciu, R., Nsamenang, S. A., Goodman, A., et al. (2018). Perceived cognitive deficits and depressive symptoms in patients with multiple sclerosis: Perceived stress and sleep quality as mediators. Multiple Sclerosis and Related Disorders,25, 150–155.

    Article  PubMed  Google Scholar 

  37. 37.

    Smith, M. A., Riccalton, V. C., Kelly-Hughes, D. H., Craw, O. A., Allen, S. F., O'Connor, D. B., et al. (2018). The relationship between Type D personality and physical health complaints is mediated by perceived stress and anxiety but not diurnal cortisol secretion. Stress-The International Journal on the Biology of Stress,21(3), 229–236.

    CAS  Article  Google Scholar 

  38. 38.

    Schnurr, P. P., & Green, B. L. (2004). Trauma and health: Physical health consequences of exposure to extreme stress (1st ed.). Washington, DC: American Psychological Association.

    Google Scholar 

  39. 39.

    Schnurr, P. P., & Jankowski, M. K. (1999). Physical health and post-traumatic stress disorder: Review and synthesis. Seminars in Clinical Neuropsychiatry,4(4), 295–304.

    CAS  PubMed  Google Scholar 

  40. 40.

    Hammen, C., Henry, R., & Daley, S. E. (2000). Depression and sensitization to stressors among young women as a function of childhood adversity. Journal of Consulting and Clinical Psychology,68(5), 782–787.

    CAS  Article  PubMed  Google Scholar 

  41. 41.

    Tolin, D. F., & Foa, E. B. (2006). Sex differences in trauma and posttraumatic stress disorder: A quantitative review of 25 years of research. Psychological Bulletin,132(6), 959–992.

    Article  PubMed  Google Scholar 

  42. 42.

    Hajian-Tilaki, K., Heidari, B., & Hajian-Tilaki, A. (2017). Are gender differences in health-related quality of life attributable to sociodemographic characteristics and chronic disease conditions in elderly people? International Journal of Preventive Medicine.

    Article  PubMed  PubMed Central  Google Scholar 

  43. 43.

    Wijnhoven, H. A. H., Kriegsman, D. M. W., Snoek, F. J., Hesselink, A. E., & de Haan, M. (2003). Gender differences in health-related quality of life among asthma patients. Journal of Asthma,40(2), 189–199.

    Article  PubMed  Google Scholar 

  44. 44.

    Aitken, L. M., Chaboyer, W., Kendall, E., & Burmeister, E. (2012). Health status after traumatic injury. The Journal of Trauma and Acute Care Surgery.,72(6), 1702–1708.

    Article  PubMed  Google Scholar 

  45. 45.

    Hasselberg, M., Kirsebom, M., Bäckström, J., Berg, H. Y., & Rissanen, R. (2019). I did NOT feel like this at all before the accident: Do men and women report different health and life consequences of a road traffic injury? Injury Prevention,25(4), 307–312.

    Article  PubMed  Google Scholar 

  46. 46.

    Silver, K. E., Kumari, M., Conklin, D., & Karakurt, G. (2018). Trauma and health symptoms in a community sample: Examining the influences of gender and daily stress. The American Journal of Family Therapy.,46(2), 153–167.

    Article  PubMed  PubMed Central  Google Scholar 

  47. 47.

    Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Wittchen, H. U. (2012). Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International Journal of Methods in Psychiatric Research,21(3), 169–184.

    Article  PubMed  PubMed Central  Google Scholar 

  48. 48.

    Street, A. E., & Dardis, C. M. (2018). Using a social construction of gender lens to understand gender differences in posttraumatic stress disorder. Clinical Psychology Review,66, 97–105.

    Article  PubMed  Google Scholar 

  49. 49.

    Grace, S. L., Krepostman, S., Brooks, D., Arthur, H., Scholey, P., Suskin, N., . . . Stewart, D. E. (2005). Illness perceptions among cardiac patients: Relation to depressive symptomatology and sex. Journal of Psychosomatic Research, 59(3), 153–160.

  50. 50.

    Edelstein, O. E., Werner, P., Dresner-Pollak, R., Tordjman, K., Jaffe, A., Toledano, Y., et al. (2012). Illness perceptions among osteoporotic men and women: Correlates and gender differences. Journal of Men's Health,9(3), 168–175.

    Article  Google Scholar 

  51. 51.

    Fink, G. (2016). Stress: Concepts, cognition, emotion, and behavior. Boston: Academic Press.

    Google Scholar 

  52. 52.

    Diefenbach, M. A., & Leventhal, H. (1996). The common-sense model of illness representation: Theoretical and practical considerations. Journal of Social Distress and the Homeless,5(1), 11–38.

    Article  Google Scholar 

  53. 53.

    Moss-Morris, R., Weinman, J., Petrie, K. J., Horne, R., Cameron, L. D., & Buick, D. (2002). The revised Illness Perception Questionnaire (IPQ-R). Psychology & Health,17(1), 1–16.

    Article  Google Scholar 

  54. 54.

    Hagger, M. S., Koch, S., Chatzisarantis, N. L. D., & Orbell, S. (2017). The common sense model of self-regulation: Meta-analysis and test of a process model. Psychological Bulletin,143(11), 1117–1154.

    Article  PubMed  Google Scholar 

  55. 55.

    Arran, N., Craufurd, D., & Simpson, J. (2014). Illness perceptions, coping styles and psychological distress in adults with Huntington's disease. Psychology, Health & Medicine.,19(2), 169–179.

    Article  Google Scholar 

  56. 56.

    Costa, E. C. V., Vale, S., Sobral, M., & Graça Pereira, M. (2016). Illness perceptions are the main predictors of depression and anxiety symptoms in patients with chronic pain. Psychology, Health & Medicine.,21(4), 483–495.

    Article  Google Scholar 

  57. 57.

    de Heer, E. W., Vriezekolk, J. E., & van der Feltz-Cornelis, C. M. (2017). Poor illness perceptions are a risk factor for depressive and anxious symptomatology in fibromyalgia syndrome: A longitudinal cohort study. Frontiers in Psychiatry,8, 217.

    Article  PubMed  PubMed Central  Google Scholar 

  58. 58.

    Karademas, E. C., Barouxi, E., & Mavroeides, G. (2019). Positive and negative affect and well-being in cardiac patients and their spouses: The mediating role of illness representations. Psychology and Health,34(3), 289–305.

    Article  PubMed  Google Scholar 

  59. 59.

    Langston, S., Edwards, M. S., Lyvers, M., & Stapleton, P. (2016). Illness perceptions and treatment outcomes in Hepatitis C. New Zealand Journal of Psychology,45(2), 22–28.

    Google Scholar 

  60. 60.

    Mo, P. K., Lau, J. T., & Wu, X. (2018). Relationship between illness representations and mental health among HIV-positive men who have sex with men. AIDS Care,30(10), 1246–1251.

    Article  PubMed  Google Scholar 

  61. 61.

    Sadeghi, M., Ghasemi, G., & Karimi, M. (2019). Effect of 12-week rebound therapy exercise on static stability of patients with spinal cord injury. Journal of Sport Rehabilitation,28(5), 464–467.

    Article  PubMed  Google Scholar 

  62. 62.

    Hopman, P., & Rijken, M. (2015). Illness perceptions of cancer patients: relationships with illness characteristics and coping. Psychooncology,24(1), 11–18.

    Article  PubMed  Google Scholar 

  63. 63.

    Kidd, T., Poole, L., Leigh, E., Ronaldson, A., Jahangiri, M., & Steptoe, A. (2016). Health-related personal control predicts depression symptoms and quality of life but not health behaviour following coronary artery bypass graft surgery. Journal of Behavioral Medicine,39(1), 120–127.

    Article  PubMed  Google Scholar 

  64. 64.

    Pai, H. C., Li, C. C., Tsai, S. M., & Pai, Y. C. (2019). Association between illness representation and psychological distress in stroke patients: A systematic review and meta-analysis. International Journal of Nursing Studies,94, 42–50.

    Article  PubMed  Google Scholar 

  65. 65.

    Rassart, J., Apers, S., Kovacs, A. H., Moons, P., Thomet, C., Budts, W. . . Luyckx, K., APPROACH-IS consortium and the International Society for Adult Congenital Heart Disease (ISACHD). (2017). Illness perceptions in adult congenital heart disease: A multi-center international study. International Journal of Cardiology, 244, 130–138.

  66. 66.

    Lee, S. Y., & Park, C. L. (2018). Trauma exposure, posttraumatic stress, and preventive health behaviours: A systematic review. Health Psychology Review,12(1), 75–109.

    Article  Google Scholar 

  67. 67.

    Cloitre, M., Khan, C., Mackintosh, M. A., Garvert, D. W., Henn-Haase, C. M., Falvey, E. C., et al. (2019). Emotion regulation mediates the relationship between ACES and physical and mental health. Psychological Trauma,11(1), 82–89.

    Article  PubMed  Google Scholar 

  68. 68.

    Greenberg, L. S. (2004). Emotion-focused therapy. Clinical Psychology & Psychotherapy,11(1), 3–16.

    Article  Google Scholar 

  69. 69.

    Cameron, L. D., & Jago, L. (2008). Emotion regulation interventions: A common-sense model approach. British Journal of Health Psychology,13, 215–221.

    Article  PubMed  Google Scholar 

  70. 70.

    Claar, R. L., & Blumenthal, J. A. (2003). The value of stress-management interventions in life-threatening medical conditions. Current Directions in Psychological Science,12(4), 133–137.

    Article  Google Scholar 

  71. 71.

    Martelli, M. F., Auerbach, S. M., Alexander, J., & Mercuri, L. G. (1987). Stress management in the health-care setting: Matching interventions with patient coping styles. Journal of Consulting and Clinical Psychology,55(2), 201–207.

    CAS  Article  PubMed  Google Scholar 

  72. 72.

    Jones, A. S. K., Fernandez, J., Grey, A., & Petrie, K. J. (2017). The impact of 3-d models versus animations on perceptions of osteoporosis and treatment motivation: A randomised trial. Annals of Behavioral Medicine,51(6), 899–911.

    Article  PubMed  Google Scholar 

  73. 73.

    Krasnoryadtseva, A., Dalbeth, N., & Petrie, K. (2019). Does seeing personal medical images change beliefs about illness and treatment in people with gout? A randomised controlled trial. Psychology and Health.,11, 1–17.

    Article  Google Scholar 

Download references


The authors would like to thank the following students for contributing to the data collection as a part of this study: MA students: Gabriela Alimi, Amiad Abrahams, Elena Gurevich, Naama Reiter, Or Aharon-Dvir; BA students: Adar Elharar, Sheer Almagor, Shay Bejerano, Moran Zohar Harshoshanim, Liat Genkin, Anton Kotlyar, Dorli Kuntz, and Nitzan Shlessinger.


This study was partially supported by a seed grant provided by the Academic College of Tel Aviv-Yaffo (SL, IH, RA). The funding source had no involvement in the study design, analysis of the data, or writing the manuscript.

Author information



Corresponding author

Correspondence to Ronit Avitsur.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Research involving human participants

All procedures performed the study were approved by the ethics committee of The Academic College of Tel Aviv-Yaffo (#2014003/01) and in accordance with the ethical standards the 1964 Helsinki declaration and its later amendments.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary file1 (XLSX 61 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Shiloh, S., Levy, S., Heruti, I. et al. Health-related quality of life after injury: examining the roles of perceived daily-life stress and injury perceptions. Qual Life Res (2020).

Download citation


  • Injury
  • Perceptions
  • Stress
  • Health-related quality of life