Education level amplifies the mediating pathway of rehabilitation motivation between metacognition and quality of life in stroke survivors

BACKGROUND: Stroke is a leading cause of long-term disability globally, substantially impairing quality of life (QoL) in survivors. While maladaptive metacognitive beliefs is regarded as a potentially influential factor, the underlying mechanism through which it influences QoL remains unclear. AIMS: To investigate QoL among stroke survivors, identify its influencing factors, and explore the mediating role of rehabilitation motivation between maladaptive metacognitive beliefs and QoL as well as the moderating role of education level. METHODS: In this cross-sectional study, 772 convalescent stroke survivors were recruited from four Grade A tertiary hospitals in Henan Province, China, between October 2024 and August 2025. Data were collected using general characteristics questionnaire, the Metacognition Questionnaire, the Stroke Rehabilitation Motivation Scale, the Short-Version Stroke-Specific Quality of Life Scale, and the Barthel Index. Model 7 in process version 4.1 was used to test the moderated mediation model. RESULTS: QoL was significantly correlated with occupation, residential status, stroke family history, stroke type, activities of daily living (ADL), metacognition, and rehabilitation motivation. The moderated mediation model involving rehabilitation motivation and education level for explaining how metacognition was associated with QoL was validated. Specifically, the mediating pathway through rehabilitation motivation was stronger among stroke survivors with higher education compared with those with lower education. CONCLUSION: Among stroke survivors, the association of metacognition with QoL is mediated by rehabilitation motivation, with this association being amplified by education level. For stroke survivors with varying education levels, interventions such as metacognitive therapy may improve metacognitive abilities, enhance rehabilitation motivation, and thereby promote QoL.