Impact of a Healthy Lifestyle on the Psychological Well-being of University Students

Hanawi S. A.¹ , Saat N. Z. M.²*,  Zulkafly M.², Hazlenah H.³, Taibukahn N. H.², Yoganathan D.², Abdul Rahim N. N.², Mohd Bashid N. A. A.², Abdul Aziz F. A.², Low F. J.²

¹ Research Centre for Software Technology and Management, Faculty of Information Science and Technology, l Universiti Kebangsaan Malaysia, Malaysia.

² Programmer of Biomedical Science, School of Community Health, Faculty of Health Sciences Universiti Kebangsaan Malaysia, Malaysia.

³Faculty of Computer & Mathematical Science, MARA University of Technology, Kota Kinabalu, Sabah, Malaysia.

ABSTRACT

Health can influence eating habits and also mental and social well-being. This cross-sectional study was conducted to determine the relationship between healthy lifestyle and stress among 173 university students using Simple Lifestyle Indicator Questionnaire (SLIQ) and Depression, Anxiety and Stress Score-42 (DASS-42) to measure their emotional states of depression, anxiety and stress. The results indicated that 71.8% were categorized as having an unhealthy lifestyle and 28.2% an intermediate lifestyle. Based on the SLIQ stress domain, 50.7% are stressed. Based on DASS score, 46.8% have anxiety. There was a statistically significant difference in healthy lifestyle score between various types of residences (F=3.929, p<0.05). The conclusion is that students with poor lifestyles have higher anxiety, depression and stress. The implication of this study is that universities should provide healthy activities to encourage healthy lifestyle practices by students.

INTRODUCTION

Health is very important to us. Many factors contribute to health such as nutrition, physical activity, level of stress, personality and behaviour. Health affects a person's body, e.g. having a healthy lifestyle can help prevent cardiovascular disease [1]. According to Lewis (1987), good health contributes to a good quality of life which will influence physical, educational, emotional and spiritual dimensions [2]. The Malaysian National Health and Morbidity Survey (NHMS) by the Institute of Public Health (2015) estimates that 29.9% of adults in Malaysia experience mental health problems such as depression and anxiety that will disrupt the routine activity of daily life whilst influencing and contributing to various health problems [3-5].

A healthy lifestyle is measured by many parameters as reported in previous studies. For instance, a study among nursing students to determine the prevalence of stress measured depression, anxiety and stress using Depression, Anxiety and Stress Score (DASS) [6]. Another study indicated that a healthy lifestyle was measured using perceived stress and emotional distress which influence self-efficacy and optimism among medical students [7, 8]. A study by Kim and Kim (2009) indicated that due to stress, people’s appetites tend to increase [9]. Another study indicated that higher stress and working at night time contribute to poor eating habits [10].

A student's life can sometimes be challenging due to academic assignments and assessments [11], social life, mood disturbance [12, 13], and adaptation to the university life and environment [14, 15]. Another study indicated that the challenging life on campus and a failure to adapt and adjust to university can influence self-efficacy and sleep patterns [16]. Students sometimes feel stress due to family and career expectations and this can affect their social, emotional and physical health [17, 18].

Stress may occur due to various factors. However, excessive stress may result in the disruption of an individual’s lifestyle. According to previous study report, the relationship between stress and sleep is circular especially where an individual is experiencing stress, whether due to financial problems, health problems or relationships, causing the person to find it more difficult to sleep [19]. However, depression, anxiety and stress may also influence individual eating habits. A study among nurses indicated that higher stress levels will increase eating fast-food, binging and snacks whilst also reducing fruit and vegetable consumption [10].

Human life, regardless of age, can be affected by the stress we experience in everyday life. Each individual is stressed, especially students as a result of academic stress or peer stress. According to Hudd et al. (2000) college students with high levels of stress are more likely to see themselves as less healthy, have low levels of self-confidence and also have a less healthy lifestyle [20]. Various ways have been proposed to measure and control stress levels, such as exercise, relaxation and socializing. Chatting with friends and family is a step in overcoming stress [21]. Physical activity has a significant relationship with low stress levels. Students doing physical activity such as swimming and archery at university can cope with stress. Environmental factors also play an important role in encouraging students to adopt a healthy lifestyle. Promoting active club membership for students helps reduce their stress and promote a sense of spirit.

High stress levels that are not contained in the right way can cause problems for an individual's physical well-being. In fact, they can cause mental health disorders such as depression and anxiety. The rate of individuals with depression is high among college students, especially medical students. The use of a questionnaire based on a scale of depression, anxiety and stress can identify individual mental health rates. Many agree that anxiety, depression and stress are a form of general affective disorder [22].

MATERIALS AND METHODS

This study was conducted among undergraduate Biomedical Science students in Kuala Lumpur. The research design was a cross-sectional study and the sampling method was Stratified Sampling. 173 undergraduate Biomedical Science students were selected randomly according to their year of study. The data was collected via Simple Lifestyle Indicator questionnaire (SLIQ) and Depression Anxiety Stress Score-42 (DASS-42) questionnaire. SLIQ and DASS questionnaires have been tested for reliability and validity by previous researchers [22, 23]. According to DASS-42 domain, depression was categorized as severe if the score is more than 28, anxiety if the score is more than 19 and stress if the score is more than 26 [24, 25]. Meanwhile, the SLIQ questionnaire consists of 12 questions on diets, physical activity, smoking, stress and alcohol consumption. The diet questions include whether fruits, vegetables and cereals are eaten. The total score is categorized as unhealthy (0-4), intermediate (5-7) and healthy (8-10) [23]. The questionnaire consists of two sections. The first section requests socio-demographic data including students’ gender and types of residence. The second section of the questionnaire consists of several aspects to measure students’ stress level and whether their lifestyle is healthy. This study wants to compare healthy lifestyle and stress with demographic factors and to determine any relationships between a healthy lifestyle and stress.

RESULTS           

The total number of participants for this study was 173 with 20.2% male and 79.8% female (Table 1). Most of the participants live in campus (80.9%), 11.6% live in rented houses and 7.5% with family (Table 1). The results showed that 71.6% (n=124) are categorized as having an unhealthy lifestyle with 28.3% (n=49) having an intermediate healthy lifestyle based on the total score from the four SLIQ domains: diet, exercise, smoking and stress. No students were living a healthy lifestyle.

 

Table 1: Demographic data

Demographic profile	n	Percentage
Gender
Male	35	20.2
Female	138	79.8
Residences
On campus	140	80.9
Rented Houses	20	11.6
Family Home	13	7.5
Year of study
1	45	26.0
2	47	27.0
3	45	26.2
4	36	20.8

 

Table 2: Comparing SLIQ scores with demographic factors

Variable	Mean	SE	t/F	p
Gender
Male	2.26	0.21	2.09	0.038*
Female	1.81	0.09
Year of study
1	1.96	0.22	1.81	0.149
2	2.24	0.20
3	1.64	0.22
4	2.27	0.23
Residences
On campus	1.86	0.09	4.78	0.009*
Rented house	1.60	1.23
Family home	2.77	1.16

*p<0.05

               

Based on the data in Table 2, the average SLIQ score for males (2.26 ±0.21) is slightly but significantly higher than for females (1.81 ±0.09) with (t=2.096, p<0.05). Meanwhile considering the year of study, 2^nd year students have the highest average SLIQ score and year 3 the lowest SLIQ score (F=1.81, p>0.05). On the other hand, comparing types of residences, living in a family home has the highest score of 0.62 and the lowest score was living in rented houses; accordingly, there was a significant mean difference (F=4.78, df=2, p<0.05). Based on the post-hoc test, there was a significant mean difference between living on campus and in a family home (p<0.05) and between living in a rented house and in a family home (p<0.05). Meanwhile, according to Table 3, the results show that DASS score was significantly different between the types of residences (p=0.015). However, there was no mean difference in the DASS score between the year of study and gender (p>0.05).

Table 3. Comparing DASS score between demographic factors

Variable	Mean	SE	t/F	p
Gender
Male	40.14	4.94	1.26	0.210
Female	34.10	2.06
Year of study
1	40.33	4.33	1.245	0.286
2	30.94	2.94
3	37.09	3.58
4	32.61	4.62
Residences
On campus	37.65	2.16	4.273	0.015*
Rented house	30.55	5.47
Family home	17.62	3.97

*p<0.05

 

Table 4. Correlation between healthy lifestyle and domain in DASS

SLIQ	r	P
Depression	-0.126	0.09
Anxiety	-0.141	0.065
Stress	-0.143	0.61

 

In this study, two-way ANOVA test was used in order to determine the effect on healthy lifestyle, gender and type of residence. The results show that there was no statistically significant interaction between gender and type of residence (F=0.195, p=0.823, ŋ²=0.002). However, the main effect of type of residence was statistically significant (F=4.330, p=0.015, ŋ²=0.049) and the gender factor exhibited no statistically significantly difference (F=3.30, p=0.071, ŋ²=0.019). This indicates that the healthy lifestyle score was depending on type of residence as the sole factor and not depending on gender when analysed together. Regardless of whether students are male or female, both groups were affected by the type of residence and they feel that staying in a family home rather than in rented accommodation or on-campus helped them live a healthy lifestyle.

Further study was done to determine the effect of year of study and gender on healthy lifestyle. Using the two-way ANOVA, the result showed no statistically significant interactions (F=0.594, p=0.620, ŋ²=0.011). However, for main effects, gender was statistically significant (F=3.966, p=0.048, ŋ²=0.023). The year of study factor was not statistically significant (F=1.664, p=0.138, ŋ²=0.033). This indicates that controlling the year of study and gender will not affect living a healthy lifestyle. However, if only depending on the gender variable, there was a statistically significant difference in choosing a healthy lifestyle. On average, the results show that males have a higher healthy lifestyle score compared to females.

Furthermore, in order to determine the relationship between healthy lifestyle and psychological well-being, Pearson correlation test was used. Based on the correlation, as can be seen in Table 4, there was a negative relationship between healthy lifestyle and depression (r=-0.126), anxiety (r=-0.141) and stress (r=-0.143) scores. Regression analysis was used to determine the relation between healthy lifestyle and age, gender and the psychological well-being domain. The regression model was statistically significant with R²=0.102, p=0.007. Based on the regression coefficient in Table 5, the regression equation was:

SLIQ = 4.718 - 0.027*stress - 0.002*anxiety - 0.007*depression - 0.078*age - 0.488*gender + 0.163*Residences

According to the regression equation in Table 5, the results show that there was a negative relationship between healthy lifestyle and psychological well-being, age and gender. However, the type of residence was a positive predictor. This indicates that when students stayed in a family home, their healthy lifestyle score was increased. Based on the regression, the gender variable was a statistically significant predictor, indicating that when all the variables were analysed in combination, the gender variable was the most prominent factor.

Table 5: Regression coefficient and standard error of relationship between healthy lifestyle score and independent variable

Independent variable	Beta	Std. error	p
Stress	-0.027	0.021	0.184
Anxiety	-0.002	0.021	0.904
Depression	-0.007	0.019	0.692
Age	-0.078	0.056	0.166
Gender	-0.488	0.220	0.028*
Residences	0.163	0.163	0.318

*p<0.05

DISCUSSION

The present study shows that a high percentage of students are in the unhealthy lifestyle category with a low percentage in the intermediate healthy lifestyle category. There was a statistically significant mean difference in the healthy lifestyle score with type of residence and gender. However, there was no statistically significant mean difference for the DASS score between gender, year of study and type of residence. This indicates that having a healthy lifestyle depends on gender and type of residence.

The healthy lifestyle in this study involved diets, physical activity, smoking status and stress. The results showed that most of the students failed to achieve a healthy lifestyle. Diet was measured using good eating habits, such as eating fruit, vegetables and cereals. Analysis of the diet domain showed that there was no statistically significant difference in dietary habits between the genders. This result showed that both males and females have almost the same dietary habits. This was parallel with the previous study by VanKim et al. (2019) who showed that there was no statistically significant mean difference in terms of eating habits between the genders, even though male subjects showed a higher diet quality score [26]. This indicates that the dietary habits were not influenced by gender.

This study showed that there is no statistically significant difference in healthy lifestyle with the year of study. However, there is a statistically significant difference in the healthy lifestyle between gender and the types of residence. This study is parallel with a previous study by Bothmer and Fridlund (2005) where the results indicated that there was a statistically significant mean difference in healthy lifestyle habits between the genders [27]. In this study, male students had higher SLIQ scores compared to females, which indicates that male students practise a healthy lifestyle in terms of diet, physical activity, smoking and stress. A previous study by Shaheen et al. (2015) showed a statistically significant mean difference for healthy lifestyle between genders in the health responsibility domain [28]. In this study, the type of residence factor determines healthy lifestyle. A previous study showed that residence depends on green-space planning that takes into consideration the recreation, social and other facilities available [29].

Based on depression, anxiety and stress scores, this study showed that there were no students categorized as severe; however, more than 20% were in the moderate level for depression, anxiety and stress. This indicates that university students do have some psychological issues. There are many factors that contribute to the score such as smoking. In this study, we did not analyse smoking as a separate domain, even though there was a question on smoking in the healthy lifestyle questionnaire. A previous study by Chao et al. (2017), showed that smokers do have a higher fat food intake. However, from that study there was no statistically significant relationship between smokers and depression and stress [30]. Thus, in this study the moderate level of depression, anxiety and stress score may not relate only to the smoking factor.

This study also shows that there is a negative relationship between healthy lifestyle and psychological well-being. This indicates that if someone practises a healthy lifestyle the scores for depression, anxiety and stress will be low. This is parallel with a previous study by Polanski et al. (2016), indicating that quality of life increases when people have low levels of anxiety, depression and stress [31]. Furthermore, family engagement, community engagement, physical activity [32] and healthy eating practices can encourage teenagers practise a healthy lifestyle [33]. Therefore, universities, the government and the private sector need to have a holistic approach to encourage communities to adopt a healthy lifestyle and increase the psychological well-being factors. There should be interventions or activities to overcome the problems of communities diagnosed as having low psychological health so that they can achieve a better lifestyle.

CONCLUSION

This study demonstrates that university students have a poor perception of the effect of a healthy lifestyle that can affect their psychological well-being.  Therefore, it is important for universities, the government and the private sector to provide interventions to overcome the problems of low healthy lifestyles and high scores for depression, anxiety and stress. This will have positive implications as the younger generation should practise healthy lifestyles to prevent social problems in the community.

ACKNOWLEDGEMENT

The authors would like to thank CRIM, Universiti Kebangsaan Malaysia for the financial support of this study.

REFERENCES

1. Chomistek, A. K., Chiuve, S. E., Eliassen, A. H., Mukamal, K. J., Willett, W. C., Rimm, E. B. Healthy life style in the primordial prevention of cardiovascular disease among young women. Journal of the American College of Cardiology, 2015 ; 65(1), 43-5
2. Lewis, S. M., Collier, I. C. Medical surgical nursing assessment and management of clinical problems. Mc Graw-Hill Book Company, USA, 1978.
3. Rapaport, M. H., Clary, C., Fayyad, R., amp; Endicott, J. Quality-of-life impairment in depressive and anxiety disorders. American Journal of Psychiatry, 2005 ; 162(6), 1171-1178.
4. Lim, L., Jin, A. Z., amp; Ng, T. P. Anxiety and depression, chronic physical   conditions, and quality of life in an urban population sample study. Social psychiatry and psychiatric epidemiology, 2012 ; 47(7), 1047-1053.
5. Gordon, A. R., Krieger, N., Okechukwu, C. A., Haneuse, S., Samnaliev, M., Charlton, B. M., Austin, S. B. Decrements in health-related quality of life associated with gender nonconformity among US adolescents and young adults. Quality of Life Research, 2017 ; 26(8), 2129-2138.
6. Cheung, T., Yip, P. S. Workplace violence towards nurses in Hong Kong: prevalence and correlates. BMC public health, 2017 ; 17(1), 19
7. Heinen, I., Bullinger, M., Kocalevent, R. D. Perceived stress in first year medical students-associations with personal resources and emotional distress. BMC medical education, 2017 ;  17(1), 4.
8. Shamsuddin, K., Fadzil, F., Ismail, W. S. W., Shah, S. A., Omar, K., Muhammad, N. A, Jaffar, A., Ismail, A., Mahadevan, R. J. Correlates of depression, anxiety and stress among Malaysian university students. Asian Journal Psychiatry, 2013 ; 6:318-23.
9. Kim, H. K., Kim, J. H. Relationship between stress and eating habits of adults in Ulsan. Korean Journal of Nutrition, 2009 ; 42(6), 536-546.
10. Almajwal, A. M. Stress, shift duty, and eating behavior among nurses in Central Saudi Arabia. Saudi Medical Journal, 2016 ; 37(2), 191.
11. Siraj, H. H., Salam, A., Roslan, R., Hasan, N. A., Jin, T. H., Othman, M. N. Stress and its association with the academic performance of undergraduate fourth year medical students at Universiti Kebangsaan Malaysia. The International Medical Journal Malaysia, 2014 ; 13(1), 19-24.
12. Spadaro, K. C., Hunker, D. F. Exploring the effects of an online asynchronous mindfulness meditation intervention with nursing students on stress, mood, and cognition: A descriptive study. Nurse Education Today, 2016 ; 39, 163-169.
13. Ross, S., Cleland, J., Macleod, M. J. Stress, debt and undergraduate medical student performance. Medical Education, 2006 ; 40(6), 584-589.
14. Desa, A., Yusooff, F., Kadir, N. B. Y. A. Acculturative stress among international postgraduate students at UKM. Procedia-Social and Behavioral Sciences, 2012 ; 59, 364-369.
15. Norafifah, A. S., Saat, N. Z. M., Aishah, H. S., Devanthini, D. G., Juliana, S., Noryantimarlina, A., Rasyidah, M. B. Relationship between generic skills, academic performance and stress level among undergraduate students. Asian Journal of Applied Sciences, 2016 ; 9(2), 70-74.
16. Klassen, R. M., Durksen, T. L. Weekly self-efficacy and work stress during the teaching practicum: A mixed methods study. Learning and Instruction, 2014 ; 33, 158-169.
17. Franco, M., Hsiao, Y. S., Gnilka, P. B., Ashby, J. S. Acculturative stress, social support, and career outcome expectations among international students. International Journal for Educational and Vocational Guidance, 2019 ; 19(2), 275-291.
18. Dong Wang, Xiao-Hui Xing, Xian-Bo Wu. Healthy life styles of university students in China and influential factors. The Scientific World Journal, 2013.
19. Bao, Z., Chen, C., Zhang, W., Zhu, J., Jiang, Y., Lai, X. Family economic hardship and Chinese adolescents' sleep quality: a moderated mediation model involving perceived economic discrimination and coping strategy. Journal of adolescence, 2016 ; 50, 81-90.
20. Hudd, S. S., Dumlao, J., Erdmann-Sager, D., Murray, D., Phan, E., Soukas, N., &amp; Yokozuka, N.  Stress at college: Effects on health habits, health status and self- esteem. College Student Journal, 2000 ; 34(2).
21. Chew‐Graham, C. A., Rogers, A., Yassin, N. ‘I wouldn't want it on my CV or their records': medical students' experiences of help‐seeking for mental health problems. Medical education, 2003 ; 37(10), 873-880.
22. Akin, A., Çetın, B. The Depression Anxiety and Stress Scale (DASS): The study of Validity and Reliability. Educational Sciences: Theory & Practice, 2007 ; 7(1).
23. Godwin, M., Streight, S., Dyachuk, E., et al. (2008). Testing the simple life style indicator questionnaire: initial psychometric study. Canadian Family Physician, 54(1), 76-77.
24. Lovibond, P. F., Lovibond, S. H. The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour research and therapy, 1995 ; 33(3), 335-343.
25. Al-Gelban, K. S., Al-Amri, H. S., Mostafa, O. A. Prevalence of depression, anxiety and stress as measured by the depression, anxiety, and stress scale (DASS-42) among secondary school girls in Abha, Saudi Arabia. Sultan Qaboos University Medical Journal, 2009 ; 9(2), 140.
26. VanKim, N. A., Corliss, H. L., Jun, H. J., Calzo, J. P., AlAwadhi, M., Austin, S. B. Gender expression and sexual orientation differences in diet quality and eating habits from adolescence to young adulthood. Journal of the Academy of Nutrition and Dietetics, 2019.
27. Von Bothmer, M. I., Fridlund, B. Gender differences in health habits and in motivation for a healthy life style among Swedish university students. Nursing & Health Sciences, 2005 ; 7(2), 107-118.
28. Shaheen, A. M., Nassar, O. S., Amre, H. M., Hamdan Mansour, A. M. Factors affecting health-promoting behaviors of university students in Jordan. Health, 2015 ; 7(01), 1.
29. Mansor, M., Harun, N. Z. Health issues and green space as reinforcement for a healthy life style in Malaysia. Journal of Asian Behavioural Studies, 2018 ; 3(9), 69-77.
30. Chao, A. M., White, M. A., Grilo, C. M., Sinha, R. Examining the effects of cigarette smoking on food cravings and intake, depressive symptoms, and stress. Eating Behaviors, 2017 ; 24, 61-65.
31. Polanski, J., Jankowska-Polanska, B., Rosinczuk, J., Chabowski, M., Szymanska-Chabowska, A. Quality of life of patients with lung cancer. OncoTargets and Therapy, 2016 ; 9, 1023.
32. Zulkepli, Z., Saat, N. Z. M., Fauzi, N. F. M., Hanawi, S. A., Zin, N. M. Relationship between physical activity level and cardiovascular risk factors among teachers. Asian Journal of Epidemiology, 2019 ; 12(1), 1-8.
33. Lewallen, T. C., Hunt, H., Potts‐Datema, W., Zaza, S., Giles, W. The whole school, whole community, whole child model: A new approach for improving educational attainment and healthy development for students. Journal of School Health, 2015 ; 85(11), 729-739.