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Scientific Reports volume 14, Article number: 30980 (2024)
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The COVID-19 epidemic has affected the psychological well-being and daily life of college students, leading to a decrease in their quality of life. Health status can be influenced by a variety of factors. This study aims to assess the current health status of university students and explore the relationships among COVID-19 care knowledge, self-efficacy, healthy lifestyle behaviors, and health status and how these factors are influenced. Among the 1694 participants, 49.4% were male, 50.6% were female, and 82.2% were freshmen. The results revealed that health status across all dimensions decreased to some extent. COVID-19 care knowledge affected both physical and mental component summaries. The results suggest that improving COVID-19 care knowledge, strengthening self-efficacy, and promoting the development of healthy lifestyle behaviors can positively impact their health status. Here, we explore the health status of college students with COVID-19 infection and the factors and mechanisms that influence it to guide health interventions to better meet the challenges posed by future outbreaks.
Although the COVID-19 pandemic no longer constitutes a public health emergency of international concern, the potential evolution of SARS-CoV-2 remains uncertain. The World Health Organization recommends that COVID-19 be treated as an established and ongoing health problem, with long-term sustained disease prevention, control, and management1. The COVID-19 pandemic has taken a toll on the physical and mental health of the population2 and will likely have long-term consequences for people’s overall health and well-being3. Studies have shown that college students are relatively fit and generally experience mild symptoms when infected with COVID-194. However, a study by Wang et al. showed that anxiety and depression levels among college students increased during the pandemic5, and a study of Indian college students revealed that anxiety and depression were prevalent, with lifestyle changes such as sleep and diet strongly associated with mental and physical health6. Another study in the U.S. found that college students’ mental health deteriorated after the epidemic7. The impact of COVID-19 on college students may have been underestimated.
It is essential to determine the current health status of college students, identify potential related factors that may affect it, and explore how the COVID-19 virus influences their health. COVID-19 causes stress in young people, and some sequelae may persist after infection with SARS-CoV-2. For example, respiratory symptoms, such as dyspnea, cough, sputum production, and sore throat, may persist; systemic symptoms such as fatigue, joint pain, myalgia, decreased function, and psychiatric symptoms may linger; and cardiovascular and digestive system symptoms may continue to be evident8. The COVID-19 pandemic has also impacted the psychological state and daily lives of college students9,10,11,12. For example, owing to a lack of daily socialization, lifestyle changes, and limited access to food and exercise, there have also been adverse changes in physiological aspects of life, including diet, sleep, and physical activity, which can increase vulnerability to multiple diseases13. Whether students contracted the disease or not, the pandemic may have affected their psychological condition5,14. Previous studies have focused on preventing SARS-CoV-2 infection and its impact on psychological status8,15; however, investigations into the health status and factors influencing college students who have experienced symptoms of infection are lacking. Therefore, it is essential to investigate their health status and the factors affecting it.
Based on the existing literature and related theory, we propose four hypotheses to explore the roles of self-efficacy and healthy lifestyles in the relationship between COVID-19 care knowledge and health status in a population of college students who have been infected with SARS-CoV-2.
Health literacy is one of the most critical determinants of adolescent health16 and is a nonmedical factor-influencing health outcomes. It plays a more fundamental causal role and represents the most important opportunity to improve health and reduce health disparities17. Research shows that knowledge and innovation are equally vital economic resources for improving health and promoting development18. Some studies have shown that participants with higher health-related knowledge scores in the general population have better self-reported health status than those with lower health-related knowledge scores19. Therefore, college students with adequate knowledge of COVID-19 care may be better equipped to face the challenges posed by the disease and maintain or promote good physical and mental health status when they are infected and exhibit symptoms of COVID-19. Based on the above analysis, we propose the first hypothesis:
H1: The level of COVID-19 care knowledge can positively affect health status.
There is a statistically significant link between self-efficacy, an individual’s belief in their ability to perform a specific task or achieve a specific goal20, and health. Individuals with high levels of health self-efficacy are likelier to make greater efforts to achieve health goals21. Improving college students’ health knowledge through certain educational methods promotes self-efficacy and attitudes toward health and behaviors, ultimately promoting health status22,23. Therefore, based on the above analysis, we propose a second hypothesis:
H2: COVID-19 care knowledge influences health status through the mediating role of self-efficacy.
Health status can be influenced by many factors, such as diet, sleep patterns, and physical activity24. Healthy lifestyle programs are key in health promotion, leading to positive and sustained long-term outcomes. Studies have shown that promoting healthy lifestyle behaviors improves health knowledge and beliefs25. Appropriate knowledge is necessary for behavioral changes26, and a lack of health knowledge hinders healthy lifestyle behaviors27. Therefore, the healthy lifestyle behaviors of college students may positively impact their health status28. At the same time, there may also be a relationship between health knowledge and healthy lifestyle behaviors29. Based on the above analysis, we propose a third hypothesis:
H3: COVID-19 care knowledge affects health status through the mediating effect of healthy lifestyle behaviors.
To comprehensively analyze the occurrence mechanism and factors influencing individual health behaviors and promoting behavioral changes by using intervenable factors, the Capability, Opportunity, Motivation-Behavior (COM-B) model was proposed by Michie et al.25. This model suggests that a particular behavioral change can be achieved only when an individual possesses the capability, opportunity, and motivation. Capability and opportunity can influence behavior both directly and indirectly through motivation. Michie et al.30 also noted that capability includes physical skills and knowledge, that motivation includes self-efficacy, and that goal and motivation include self-efficacy and goals. In this study, COVID-19 care knowledge may influence healthy lifestyle behaviors directly or indirectly through self-efficacy and health-promoting care behaviors, emphasizing that active lifestyles can improve health and quality of life31. Therefore, we propose the fourth hypothesis:
H4: COVID-19 care knowledge can affect health status through the multiple mediating effects of self-efficacy and healthy lifestyle behaviors.
In brief, this study sought to understand the current health status of college students and explore the relationships between COVID-19 care knowledge, self-efficacy, healthy lifestyle behaviors, and health status. We applied a multiple mediation model to examine these associations among university students. This approach has important implications for the early identification and prevention of health problems and could encourage students to respond better to the challenges posed by future public health emergencies.
This study used a convenience sampling method to conduct a cross-sectional online survey of college students enrolled at a university in Jilin Province. The questionnaire was distributed to the students with the teacher’s help, and gifts were provided to encourage participation. Participation in this study was entirely voluntary. We randomly surveyed several classes, collected data on student responses, and screened samples for inclusion in the analysis using the following inclusion criteria: (a) voluntary participation and informed consent; (b) enrolled university students; (c) symptoms of COVID-19; and (d) confirmed SARS-CoV-2 infection (doctor confirmed/home COVID-19 Antigen Detection Kit/Government Nucleic Acid Testing Organization).
The study used a convenience sampling method to conduct a cross-sectional online survey of 2101 college students enrolled at a university in Jilin Province from April–May 2023 using the Wenjuanxing survey platform. The data were then examined, and to ensure the data quality, we excluded those that met the following exclusion criteria: (a) incomplete questionnaires; (b) short (< 240 s) or long (> 3600 s) questionnaire response times; (c) no prior symptoms of COVID-19 and no viral testing; and (d) testing negative. In total, 10 basic information items and 30 questionnaire dimensions were covered, resulting in 40 variables. According to the Kendall sample estimation method, the sample size should be 10–20 times the number of variables, resulting in an estimated minimum sample size of 400–800 (plus 20% = approximately 480–960 participants). Finally, 1694 valid questionnaires were obtained, for an effective recovery rate of 80.63%.
This concise health survey scale was developed by the Boston Health Institute in the United States and is based on the Medical Outcomes Study Questionnaire (MOS-SF)32. It was translated into the Chinese version short form (SF-36) in 1991 and revised in 1996 to create the SF-36 v233. The scale has 36 items, including 8 dimensions—physical functioning (PF), role-physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional (RE), and mental health (MH)—and an indicator of health change. Factor and principal component analyses have identified two principal components: the physical component summary (PCS) and the mental component summary (MCS). The PCS includes the first four dimensions, and the MCS includes the last four dimensions. The score range of each dimension is 0–100, with the size of the score representing different health statuses; the higher the score is, the better the health status. In the present study, the scale had a Cronbach’s alpha coefficient of 0.803.
Self-efficacy was measured using the General Self-Efficacy Scale (GSES) developed by Schwarzer et al., with the Chinese version demonstrating good reliability, validity, and widespread use34. The scale consisted of 10 questions on a four-point Likert scale, with scores ranging from 1 to 4, from “not at all” to “completely”. The higher the score, the higher the self-efficacy level of the individual. The Cronbach’s alpha coefficient for this scale in this study was 0.921.
The revised version of the Healthy Lifestyle Behaviors Scale for College Students compiled by Dong Wang was used35. The scale contains 8 dimensions, including exercise behavior, regular behavior, nutritional behavior, health risk behavior, health responsibility, social support, stress management, and life appreciation, with a total of 33 items. Each question was scored on a 5-point Likert scale from 1 to 5, indicating “never” to “always”, respectively. Health risk behaviors were scored inversely, with higher scores indicating a healthier lifestyle. The Cronbach’s alpha coefficient of the scale in this study was 0.901.
COVID-19 care knowledge was measured using the researcher’s scale, designed based on the COVID-19 Rehabilitation Knowledge Manual36. The scale has 20 items across four dimensions: knowledge of managing breathlessness, knowledge of physical activity and fatigue management, knowledge of voice and swallowing problems, and knowledge of nutritional and psychological problems. Reliability testing yielded a Cronbach’s alpha coefficient of 0.949 for the total score, a fold‒half reliability of 0.965, a Cronbach’s alpha coefficient of 0.815–0.911 for each dimension, a split-half reliability range of 0.818–0.907, and an exploratory factor analysis with KMO = 0.933, p < 0.001. Validation factor analysis was performed using structural equation modeling, and the results of the goodness-of-fit test revealed that CMIN/DF < 3, RMR < 0.05, GFI > 0.8, TLI > 0.9, CFI > 0.9, and RMSEA < 0.1 were acceptable. The scale was based on a 5-point Likert scale, with scores ranging from 1 to 5 for each question, indicating “very little understanding” to “great understanding”, respectively. Higher scores indicated better knowledge of COVID-19 care.
Tests, including frequency analysis, reliability and validity, and Pearson’s correlation analysis, were conducted using SPSS 26.0. We subsequently examined the mediating effect of self-efficacy and healthy lifestyle behaviors using Model 6 of the SPSS PROCESS macro 3.3 software developed by Hayes. We estimated the 95% confidence intervals of the mediating effect with 5,000 resamples.
This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Online informed consent instructions/options for all participants were obtained, and anonymity and confidentiality of participation and their rights to withdraw freely at any time were guaranteed. The principles of the Helsinki Declaration were followed in all stages of this study. This study was approved by the ethics committee of Jilin University, Changchun, Jilin, China (Approval number: 2023041101; Date: 2023.04.11).
Table 1 presents the statistical analysis of the demographic characteristics of the participants. Among the 1694 participants, 49.4% were male and 50.6% female; 82.2% were freshmen; and 14.0% and 11.2% were overweight and obese, respectively. A total of 36.5% of the students came from rural areas. Additionally, 6.5% had living expenses of less than 1000 yuan per month, 2.8% had underlying disease, and 19.7% had taken medication recently.
We conducted a descriptive statistical analysis of college students’ COVID-19 care knowledge level and health status and compared the means. The results revealed that college students had lower health status scores than the norm and were likely to be in better health if they possessed a higher level of knowledge.
After experiencing COVID-19, the college students’ mean physical and mental health levels were 75.97 (SD = 14.85) and 68.78 (SD = 14.89), respectively. Compared with the normative data of the Chinese general population from a one-sample t test, college students’ health status was lower on all dimensions to some extent (P < 0.01). Notably, PF showed the smallest decrease, and MH exhibited the largest decrease. See Table 2 for details.
Participants were categorized based on their COVID-19 care knowledge scores, with thresholds of 60 and 80 used to classify respondents as having a “qualified” or “good” level of knowledge, respectively. The distribution of the percentages of people with scores < 60, 60–79, and ≥ 80 were 12.8%, 56.1%, and 31.1%, respectively. One-way analysis of variance found that participants with a good level of COVID-19 care knowledge had significantly higher PCS and MCS scores than those who failed or passed (P < 0.001).
Table 3 presents Pearson’s correlation analysis of college students’ COVID-19 care knowledge, self-efficacy, healthy lifestyle behaviors, and health status (PCS and MCS). The results revealed positive correlations between college students’ COVID-19 care knowledge, self-efficacy, healthy lifestyle behaviors, and health status (PCS and MCS).
State of health (PCS and MCS) was the dependent variable, COVID-19 care knowledge was the independent variable and self-efficacy and healthy lifestyle behaviors were the mediators. The mediation pathway model is illustrated in Fig. 1. Path coefficients revealed that all relationships in the model were significantly positive, except for the direct effect of COVID-19 care knowledge on the MCS. After including the mediators of self-efficacy and healthy lifestyle behaviors, the direct effect of COVID-19 care knowledge on PCS was still statistically significant.
Multiple mediations of self-efficacy and healthy lifestyle behaviors between COVID-19 care knowledge and state of health (PCS and MCS) PCS physical component summary, MCS mental component summary.
To test whether the mediating effect of self-efficacy and healthy lifestyle behaviors was statistically significant, after controlling for demographic data such as gender, place of origin, and comorbidities, we conducted a bootstrap estimation procedure with 5000 bootstrap samples. The bootstrap results indicated that when the path coefficient of a 95% CI did not include 0, the effect was statistically significant. As shown in Table 4, the significance of the direct effect of COVID-19 care knowledge on PCS (estimate = 0.059, 95% CI [0.011, 0.113], 28.59%) remained when the mediators (self-efficacy and healthy lifestyle behaviors) were included in the model; however, the direct effect on MCS scores was not statistically significant. COVID-19 care knowledge was found to indirectly affect the state of health through three statistically significant mediation pathways (PCSs/MCSs): (1) self-efficacy (estimate = 0.022/0.038, 95% CI [0.004, 0.041]/[0.021, 0.057], 10.57%/19.49%), (2) healthy lifestyle behaviors (estimate = 0.094/0.117, 95% CI [0.073, 0.116]/[0.094, 0.142], 45.24%/60.00%), and (3) self-efficacy and healthy lifestyle behaviors (estimate = 0.032/0.040, 95% CI [0.023, 0.043]/[0.029, 0.052], 15.60%/20.51%). The total mediating effect on PCS was 71.41%.
This study aimed to understand the current health status of college students and explore the relationships between COVID-19 care knowledge, self-efficacy, healthy lifestyle behaviors, and health status and the pathways through which they are influenced. The cross-sectional survey results revealed that participants who experienced COVID-19 had overall lower health status scores than normative data from the general population of China before the COVID-19 pandemic37. This suggests a need for attention to the health status of the student population to manage epidemic diseases properly and promote health for all. In addition, this study examined the relationship between COVID-19 care knowledge and college students’ health status (PCS and MCS). It explored whether self-efficacy and healthy lifestyle behaviors mediated this relationship. The results of the data analysis revealed that the level of COVID-19 care knowledge among college students who experienced COVID-19 positively impacted both the PCS and MCS, with improved care knowledge related to disease rehabilitation benefiting their physical and mental health. Self-efficacy and healthy lifestyle behaviors mediated the relationship between COVID-19 care knowledge and health status (PCS and MCS). The mediating effects accounted for 71.41% of the total effect of COVID-19 care knowledge on the PCS, and self-efficacy and healthy lifestyle behaviors fully mediated the relationship between COVID-19 care knowledge and MCS. The health of college students, especially their mental health, may be improved by increasing their self-efficacy and promoting healthy living behaviors. Therefore, it is valuable to improve knowledge of disease care and the ability to recover from disease, increase self-efficacy, and promote a healthy lifestyle.
This study also examined the direct and indirect effects of COVID-19 care knowledge on health status (PCS and MCS). First, there was a positive effect of COVID-19 care knowledge on health status (PCS and MCS). In particular, COVID-19 care knowledge directly affected the PCS, with an effective value of 0.059 and a total effect value of 0.207, with the direct effect value accounting for 28.59% of the total effect value. In contrast, the direct effect of COVID-19 care knowledge on the MCS was not statistically significant, with a total mediated effect value of 0.195. Therefore, Hypothesis H1 was tested, although there was no direct effect on psychological health or social adjustment. Although knowledge of COVID-19 care has no direct impact on the mental health of college students infected with SARS-CoV-2, it is still an essential factor influencing their health status. In terms of the physical domain, college students infected with SARS-CoV-2 have good COVID-19 care knowledge, which allows them to consciously take proactive measures for better health outcomes. Thus, for infectious diseases, the focus should be prevention and treatment and improving rehabilitation care knowledge and related skills. In the current era of highly developed networks and information technology, publicity and popularization can be increased in various ways to promote health status and improve health outcomes38.
The results of this study revealed that self-efficacy plays a mediating role in the relationship between COVID-19 care knowledge and health status, with mediating effect values of 0.022 for the PCS, accounting for 10.57% of the total effect and 0.038 for the MCS, accounting for 19.49% of the total impact; thus, Hypothesis H2 of this study was verified. This finding is consistent with previous findings that knowledge and self-efficacy were positively correlated with the PCS and that self-efficacy played a somewhat mediating role39,40. In addition, these results are consistent with earlier findings by Wang et al., who reported that pandemic-related knowledge and self-efficacy are positively correlated and indirectly affect mental health, playing a partially mediating role in the relationship between self-efficacy and mental health status41. According to the health belief model42, health knowledge plays a decisive role in implementing health-promoting health behaviors, and the ability to perceive the susceptibility to and severity of certain diseases is a prerequisite for implementing health-promoting health behaviors. Self-efficacy is an essential component of health promotion. It can also be described in terms of whether college students believe that they can control factors to actively adopt behaviors and achieve desired health outcomes4. Students’ perceptions of health are closely related to their health43. This study indicated that college students with greater COVID-19 care knowledge following SARS-CoV-2 infection would benefit from increased self-efficacy and better identification of triggers for health problems if they understood their adverse health factors and the value of consciously managing health problems during a pandemic44. Thus, they were able to consciously and proactively take health-friendly measures to address the serious threats posed by COVID-19 and promote health outcomes.
Healthy lifestyle behaviors also mediated the relationship between COVID-19 care knowledge and health status; therefore, Hypothesis H3 was also tested. For PCS, the mediating effect value was 0.094, accounting for 45.24% of the total effect; for the MCS, the mediating effect value was 0.117, accounting for 60.00% of the total effect; and the effect size of healthy lifestyle behaviors as a mediating pathway was the largest of all paths, regardless of physical or mental health. Previous studies have shown that having more health knowledge promotes the maintenance of healthy lifestyle behaviors, and more knowledgeable individuals can regulate their daily lifestyles to some extent and become more aware of healthy lifestyle behaviors45. Healthy lifestyle behaviors are how knowledge and understanding evolve into practical actions that guide behavior. Unhealthy lifestyle behaviors, such as a lack of physical activity, a sedentary lifestyle, and an unhealthy diet, are widespread and pose serious threats46,47. These public health issues are related to mental health problems and physical quality of life. Lifestyle changes can improve health outcomes48,49, and changing and maintaining healthy lifestyle behaviors for the sake of health can reduce the risk of disease, thereby meeting the need for improved health and overall quality of life.
Finally, self-efficacy and healthy lifestyle behaviors were chain-mediated in the relationship between COVID-19 care knowledge and health status, indicating that Hypothesis H4 was tested. For PCS, the chain-mediated effect value was 0.032, accounting for 15.60% of the total effect; for MCS the mediated effect value was 0.040, accounting for 20.51% of the total effect value; and its effect was the second most crucial indirect effect and should not be neglected. According to knowledge, attitudes, and practices (KAP) theory50, health knowledge is the foundation for establishing positive and correct beliefs and attitudes, followed by gradual changes in health-related behaviors and, ultimately, improvements in and maintenance of health status, and self-efficacy plays a cognitive-based mediating role in promoting health behavior changes51. In other words, having more knowledge can help build self-confidence, making one more willing to change one’s behavior and achieve more promising health outcomes.
It is important to acknowledge certain limitations to this study. First, although we discussed data on health status, self-reported data may be less objective and accurate than clinical data, and those who are asymptomatic and unaware of their infection may be overlooked. Since some samples were self-tested to determine whether they were infected, this also introduces bias to the results. Second, our data were primarily collected from freshmen and sophomores at city universities, and we did not investigate the ages of the students; future studies may need to focus on a broader population and obtain more accurate data in conjunction with clinical settings.
The overall health status of college students infected with COVID-19 decreased after experiencing the pandemic at this stage. There was a positive correlation between college students’ COVID-19 care knowledge, self-efficacy, healthy lifestyle behaviors, and health status. When the mediating variables were considered, the single and chain mediating effects of self-efficacy and healthy lifestyle behaviors were statistically significant. Therefore, to improve the health status of college students, it is critical to pay attention to their health issues, enhance their health-related care knowledge and skills, improve their self-efficacy, develop healthy lifestyle behaviors, and actively address challenges to maintain good health status.
The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.
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This project was supported by the Graduate Innovation Fund of Jilin University (Project No. 2023CX224) and the Research Program on Teaching Reform of Graduate Education at Jilin University (Project No. 2022JGP017).
Mingzhu Zhao and Yongheng Xin contributed equally.
Jilin University School of Nursing, No. 965 Xinjiang Street, Changchun, 130021, Jilin, China
Mingzhu Zhao, Qian Liu, Yiwen Ding, Sitao Zhang, Xuechun Bai, Ming Wang, Siyu Wu & Huiru Yin
Jilin University College of Software, Changchun, China
Yongheng Xin
Jilin University Physical Education College, Changchun, China
Weiguang Ni
The First Hospital of Jilin University, Changchun, China
Huali Song
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MZZ: Investigation, Formal analysis, Writing-original draft. YHX: Methodology, Formal analysis, Writing-review and editing. WGN: Resources, Formal analysis. QL: Resources, Investigation. YWD: Resources, Investigation. STZ: Resources, Investigation. XCB: Resources, Investigation. HLS: Resources, Formal analysis. MW: Resources, Investigation. SYW: Writing-review. HRY: Conceptualization, Methodology, Data curation.
Correspondence to Huiru Yin.
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Zhao, M., Xin, Y., Ni, W. et al. Self-efficacy and healthy lifestyle behaviors as mediators between COVID-19 care knowledge and health status. Sci Rep 14, 30980 (2024). https://doi.org/10.1038/s41598-024-82099-y
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