Chronic liver disease (CLD) is a progressive deterioration of liver functions, which gradually develops into fibrosis and cirrhosis. The total number of CLD cases is estimated at 1.5 billion worldwide (Moon et al., 2020). The most common causes of CLD are nonalcoholic fatty liver disease (NAFLD, 59%), hepatitis B (HBV, 29%), hepatitis C (HCV, 9%) and alcoholic liver disease (ALD, 2%) (Cheemerla and Balakrishnan, 2021). Incredibly, 257 million people are living with chronic HBV. 71 million people, half concentrated in six countries such as India, China, Egypt, Russia, United States, and Pakistan, are infected with chronic HCV. NAFLD has a 24% estimated prevalence rate (Younossi et al., 2016). Alcohol accounts for 30% to 50% of cirrhosis-related deaths (Moon et al., 2020). As the world is experiencing an increase in obesity and alcohol consumption, NAFLD and ALD are expected to increase.

CLD, as a leading cause of human death, is a major global health threat (De Siervi et al., 2023). In 2017, CLD caused 1.32 million deaths (GBD 2017 Cirrhosis Collaborators, 2020). In the United States, the mortality rate of patients with CLD was 10.3 per 100,000 inhabitants in 2010 (Šumskienė et al., 2015). In Canada, 2,748 deaths were attributed to CLDs in 2008. In Europe, 170,000 people die each year from CLDs (Zatoński et al., 2010). In China, the overall mortality was 7.3 per 1,000 person-years (Wu et al., 2020). Nowadays, CLD is one of the most common chronic diseases in the world (Bagherniya et al., 2018; GBD 2017 Disease and Injury Incidence and Prevalence Collaborators, 2018).

With the increasing emphasis on clinical outcomes for patients with chronic diseases, quality of life (QoL) has become a key indicator in clinical management (Younossi and Guyatt, 1998). QoL, as a measurable indicator, could be evaluated by SF-36 that contains a total of eight scales. Due to high comorbidity burden including mental, physical and social challenges, QoL of patients with CLD has been demonstrated to be impaired compared with the general population (Peng et al., 2019). Even worse, nearly 20% of these patients may die in the early stages of liver failure or hepatocellular carcinoma without effective management. Thus, it is essential to make comprehensive healthcare strategies. However, with an important hindrance being the limited understanding of the liver patients’ mental and social symptoms, relatively little attention has been paid to improving the QoL for those patients with CLD in China (Grønkjær and Lauridsen, 2021; Huang et al., 2021).

Reassuringly, illness perception (IP) plays key roles in the management of other types of chronic diseases (Koontalay et al., 2024; Xu et al., 2019). Unlike traditional biomedical approaches to illnesses, IP could explore a given individual’s beliefs and representations associated with their illness, which has become a part of patients’ understanding of their disease and treatment-related actions. Those illness beliefs are conceptualized within a framework of self-regulation known as the common-sense self-regulation model (CS-SRM) that explicates the processes by which patients become aware of a health threat, navigate affective responses to the threat, formulate perceptions of the threat and potential treatment actions, create action plans for addressing the threat, and integrate continuous feedback on action plan efficacy and threat-progression (Leventhal et al., 2016). According to the model, people make sense of a health threat by developing their own cognitive and emotional representations of a health threat (Hagger et al., 2017). Importantly, it also could be evaluated by Brief Illness Perception Questionnaire (BIPQ) that is a nine-item scale providing a rapid assessment of an individual’s perceptions of illness. Each item is designed to assess one dimension of illness perception.

Additionally, a preliminary study revealed that SS is another factors affecting QoL (Shojaei et al., 2019), which has been receiving increasing attention in the management of chronic diseases. SS is defined as the support that one receives from family, friends, organizations, and other people (Helgeson, 2003), which can be measured by Social Support Rating Scale (SSRS) that contains a total of 10 items encompassing three dimensions of social support, i.e., subjective support (Sb), objective support (OS) and utilization of support (US). Sb refers to moral support such as respect, understanding, and acceptance from family members. OS refers to support from friends, family and social networks that can meet the physical, psychological and social needs of the individual. US refers to the extent to which individuals utilize and participate in social support when they experience frustration.

While the mediational role of IP between SS and QoL is well-documented across chronic conditions (Chen et al., 2025), CLD possesses unique psychosocial characteristics that may meaningfully alter this pathway. Unlike diabetes or cardiovascular disease, CLD is often marked by prolonged asymptomatic progression, unpredictable prognosis, and significant stigma, particularly related to etiologies such as viral hepatitis or alcohol-associated liver disease, which can lead to feelings of etiology-related guilt or shame (Carol et al., 2022; Cortesi et al., 2020). These unique features suggest that the pathway between SS, IP, and QoL may operate through CLD-specific mechanisms, justifying the need for targeted investigation. The purpose of this study is to explore the relationship among IP, SS and QoL and provide comprehensive strategies for clinical management of CLD. Four hypotheses are proposed: (1) SS is correlated with QoL. (2) IP is correlated with QoL. (3) SS is correlated with IP. (4) IP mediates the relationship between SS and QoL. The theoretical model is presented in Figure 1.

Our research revealed that the scores of PCS and MCS were 60.839 and 64.481, respectively. These scores are higher than those reported in earlier studies in 2013 (Gao et al., 2013), indicating that QoL of patients with CLD in China has been improved. The reasons for improvement may be as follows: (1) Over the past ten years, with the development of the economy, there has been increased focus on nursing interventions and patients’ self-management in China. Meanwhile, the whole society works together to raise awareness and alleviate the stigma associated with CLD, significantly contributing to a decrease in mortality rates (Sun et al., 2019). This shift may have helped reduce psychological stress among patients. (2) QoL is known to vary based on the stage of the disease. As CLD progresses from a non-cirrhotic to an advanced cirrhotic stage, a decline in QoL is observed (Gao et al., 2012). At the advanced stage of CLD, patients suffered from fatigue, loss of self-esteem, inability to function at work, anxiety, depression, and other emotional problems that severely diminish their QoL and well-being. To delay the progression of the disease, it is imperative for healthcare professionals and patients or their caregivers to enhance the management of disease.

Social support showed no direct effect on QoL, with statistical full mediation by IP. In contrast, patients with diabetes or hypertension have more tangible symptom markers (e.g., blood glucose, blood pressure) that allow for direct QoL impacts from SS independent of IP. CLD patients often lack the resources to understand their illness or cope with its consequences, making IP the sole pathway linking SS to QoL, likely due to CLD’s unique stigma, complex and unpredictable disease course and etiology-related guilt amplifying patients’ dependence on SS to form coherent illness appraisals. For interventions, targeting IP may be more impactful than generic SS. Prior researches illustrated that self-management behaviors are influenced by IP (Xiong et al., 2023) and better clinical outcomes can be achieved by addressing IP. IP is emotional and cognitive representations of health threats, and reflect patients’ own beliefs about their illness. Higher scores indicate a higher perceived threat regarding the illness (Kuiper et al., 2022). In our study, the average score of IP was 43.420 points. Based on a cut-off score of ≥ 42 points (Kuiper et al., 2022), patients with CLD may be considered to have at least a moderate threatening view of their illness. Person and family-centered care (PFCC) could help patients better manage complex chronic conditions and have reduced anxiety and stress (Osborn and Squires, 2012). Also, cognitive-behavioral therapy (CBT), as an evidence-based psychological intervention for treating anxiety disorders, is widely used to help patients develop more positive and adaptive perceptions (Preston et al., 2011). Of note, the coping style has been identified as a mediator between IP and QoL in other chronic disease (Tu et al., 2022). Further research is needed to determine whether IP affects QoL by coping style among patients with CLD. These findings collectively provide additional insights for enhancing the management of disease by addressing IP.

The present findings extend the general chronic illness literature by validating the mediational model in a population with unique psychosocial challenges. Specifically, the stigma and etiology-related guilt inherent to CLD may amplify the role of IP. Patients with stronger SS may be better able to reframe negative IP (e.g., reducing guilt or perceived stigma), thereby protecting QoL—a mechanism that may be more pronounced in CLD than in conditions with less stigma. Additionally, the asymptomatic yet potentially life-threatening nature of CLD may make patients’ cognitive appraisals particularly salient in translating SS into adaptive outcomes. Thus, this study refines existing models by demonstrating their applicability and contextual relevance to CLD, providing a CLD-specific framework for understanding psychosocial adaptation and informing targeted interventions.

However, there are certain limitations to this study. First, the research’s cross-sectional design makes it impossible to establish causal relationships. The statistical full mediating effect of IP only reflects a correlational pattern in the study sample at a single time point, rather than a definitive causal pathway. Reverse causality cannot be excluded. Additionally, unmeasured confounding variables (e.g., disease severity, duration of CLD, or prior psychological interventions) may affect the observed associations. Future longitudinal studies or intervention studies are required to verify the potential causal direction of these relationships. Second, a notable limitation of this study is the omission of key clinical factors known to influence QoL in CLD, including disease stage (e.g., fibrosis, compensated/decompensated cirrhosis), etiology (e.g., NAFLD, HBV, HCV), and the presence of major symptoms or complications (e.g., ascites, hepatic encephalopathy). These clinical indicators may act as confounders or moderators of the observed relationships between SS, IP, and QoL. The lack of clinical data thus limits the generalizability of our findings. Future research should integrate objective clinical measures (e.g., disease stage, etiology, Child-Pugh score, laboratory markers, and complication status) into mediation models to clarify whether the mediating role of IP varies by disease stage or etiology in CLD. Including these clinical factors as covariates or moderators would allow for a more nuanced understanding of how SS and IP operate across different clinical profiles, and improve the clinical relevance and predictive utility of the model. Third, convenience sampling from a single tertiary hospital may introduce selection bias and limit external validity, restricting generalizability to other CLD populations and settings. Excluding patients with depression may have systematically biased the sample toward better psychosocial functioning. Given the high prevalence of depression in CLD and its strong association with negative IP and poor QoL, this exclusion may have attenuated the strength of the observed relationships, limiting applicability to patients with comorbid depression. Therefore, reducing biases should be focused on by evaluating and controlling the representativeness of a sample in further research. Also, the diversity of samples should be increased through distributing questionnaires at different times and locations to achieve an appropriate cross-section of the target population. Additional longitudinal studies are necessary for a more accurate assessment.

In conclusion, the achievements of this research illustrate that social support and illness perception were considerably related with the quality of life in Chinese patients with CLD. Statistically, illness perception acts as a complete mediator in the association between social support and quality of life. As such, healthcare professionals should focus more on understanding and addressing patients’ illness perceptions to enhance their quality of life.