Association of Social Support and Mental Health Literacy with Quality of Life among University Students During the Covid-19 Pandemic

Social support is one of the main factors that influence the quality of one’s life. In this regard, mental health literacy is consistently associated with positive outcomes for students, in terms of their wellbeing and academic achievement. The present study is especially important to young people because understanding their quality of life can facilitate their life as a student and preparing them to their future of work. This study investigated the relationship between social support and mental health literacy in relation to the quality of life among Malaysian university students. A quantitative research paradigm was adopted, with a cross-sectional design using data collected from 140 randomly selected university students. The data was analyzed by SPSS software version 25 using the Pearson correlation and multiple linear regression. The results showed positive relationships between social support and mental health literacy towards quality of life. Thus, hypothesis 1 and hypothesis 2 was accepted. In the multiple linear analysis, nevertheless, mental health literacy was not found to influence the quality of life independently of social support. Appropriate programs should be designed and implemented to enhance the level of mental health literacy and, more importantly, to ensure adequate social support for students in order to promote a high quality of life.


Introduction
The current Covid-19 pandemic has caused a global crisis in higher education. Fear of being infected with the Covid-19 virus and uncertainty about the future resulting from the socioeconomic downturn and the academic disruption stemming from this global pandemic have had enormous psychological effects on university students (Scott et al., 2021;Farris et al., 2021;Dubey et al., 2020). When the pandemic was initially announced, the Malaysian government introduced a movement control order (MCO) that closed state borders, brought economic activities to a standstill, and stopped lectures in all academic institutions. Imposition of the MCO stranded several thousands of students who were unable to return home as they could not leave their residential colleges (Cheah et al., 2021). As movement lockdown and social distancing became the new norm in daily life, there was a significant reduction in students' activities, and this invariably impacted their quality of life (QoL) (Szczepanska & Pietrzyka, 2021). Besides various uncertainties, including personal financial situations, students also needed to confront numerous issues associated with academic work, social life, and emotional well-being. Furthermore, being separated from their families generated stress and anxiety among the students (Kamaludin et al., 2020). Amidst such crises, the universities in Malaysia introduced new modes of teaching and learning, essentially shifting to emergency remote teaching (ERT), online teaching, new forms of assessment, and innovative digital communication tools (Kumar et al., 2022;Yusuf & Ahmad, 2020), Such changes exacerbated the stress already faced by students, and as such, their quality of life was further affected (Abdullah et al., 2021). Even though the strict measures were imposed to curb the spread of the Covid virus, they inevitably had a psychological impact on many students, inducing symptoms of stress, anxiety, and depression associated with lower QoL (Marques et al., 2020); similarly, the general population was likewise affected (Cheah et al., 2021;Abdullah et al., 2021). It is important to investigate the factors which impacted students' quality of life so that measures could be taken to mitigate the situation and ensure that students continue to strive for academic excellence.
QoL is a perception consisting of life satisfaction, emotional wellbeing, and individual functional characteristics that collectively influence an individual's perception of the overall satisfaction with his/her life (Cheah, 2021). Accordingly, QoL can plausibly be impacted by many factors (Ribeiro et al., 2018), both internal and external. To the best of our knowledge, data on QoL assessment of university students during the COVID-19 pandemic are lacking, particularly following the end of movement lockdown. The various measures taken by the authorities took a toll on many, creating uncertainty and anxiety among students, thus affecting their mental health (Fegert et al., 2020). With the return to normality following the peak phase of the pandemic, the worries of economic recession and lasting mental health problems are important issues to take cognizance of . Given these circumstances, it is important to have a closer monitoring of the factors closely related to QoL. Therefore, this study was conducted to obtain a better understanding of these issues so that institutions of higher education can be provided with accurate information to help formulate effective strategies and approaches to safeguard the well-being of students should there be similar pandemics in future. This study fills the research gap in (1) evaluating the QoL of university students in relation to the Covid-19 pandemic, and (2) assessing the roles of mental health literacy and social support as significant predictors of QoL of university students.

Mental Health Literacy and Quality of Life
The quality of life is reflected in the dimensions of physical and mental health as influenced by various economic, social, mental, and physical factors (Goodyear et al., 2021;Jafari et al., 2021). Observance of mental health literacy (MHL) is one of the most important strategies to reducing mental health disorders (Renwick et al., 2022). MHL refers to "knowledge and beliefs about mental disorders which aid their recognition, management or prevention" (Jorm, 2000). Increasing the level of MHL facilitates prevention, early detection of disease, ability to intervene, and eventually a decrease mental disorders in the community (Kelly et al., 2007).
Given the current situation, Cao et al (2020) note that university students are particularly susceptible to changes in teaching practices; the psychological impact of COVID-19 is manifested by greater levels of anxiety and other m ental health issues. In Malaysia, Gan and Yuen Ling (2019) note that students with symptoms of excessive anxiety are more likely to have lower scores in the psychological, social and environmental domains; in other words, the quality of their life is likely to be adversely affected. One way to resolve mental health problems is by promoting mental health literacy (Teixeira et al., 2022;Lee et al., 2020;Bjørnsen et al., 2019) so that steps can be taken by the individuals themselves to overcome depression should the symptoms emerge. According to Lam (2014), individuals with low or deficient levels of MHL tend to have poorer mental health outcomes and an increased risk of developing mental health disorders. Jafari et al (2021) have found that those who are equipped with information about mental illness have a significantly higher quality of life. Similarly,  found that health literacy in the mental, functional and social aspects significantly was positively linked to the quality of life of Norwegian adolescents.
Based on the discussion thus far regarding the important role of mental health literacy in predicting quality of life, the following hypothesis is stated: H1: Mental health literacy significantly influences quality of life of undergraduate university students.

Social Support and Quality of Life
Social support is a multidimensional construct which is widely studied by researchers on mental and social well-being. Social support is defined as the function and quality of social relationships that one receives from other people, such as help and support (Schwarzer et al., 2004). A lack of social support has a negative impact on the mental health of university students (Bukhari & Afzal, 2017), and will result in a lower quality of life for students (Dafaalla et al., 2016). According to Cleofas (2020), students who are actively involved in social organizations tend to experience lower levels of depression. Similarly, Wittrup and Hurd (2019) state that participation in extra-curricular activities is negatively associated with symptoms of depression. Findings from cross-sectional studies reveal the important role that social support plays in ensuring students' wellbeing so that they can continue to strive academically (Ye et al, 2021;Li et al., 2018). Similarly, Bradley et al (2021) have found that students' academic performance is impacted by the level of social support that they receive. Studies have shown that peer support, which is the interpersonal connections among agematched individuals established in common activities and mutual cooperation, is an important source of social support for college students (Burns et al., 2020). For instance, social support from family and friends is found to have a substantial positive impact on the emotional and social well-being of students, as well as their academic performance, thus leading to their having higher satisfaction with life (Yang et al., 2020;Mai et al., 2021). Essentially, empirical evidence has confirmed that social support enhances quality of life (Keener et al., 2021;Leung & Fung, 2021). Alsubaie et al (2019) found that QoL was significantly predicted by social support from family and friends. Social support, therefore, represents a valuable resource for maintaining good mental health.
Based on the discussion thus far regarding the important role of social support in preserving quality of life, the following hypothesis is stated: H2: Social support significantly influences quality of life of undergraduate university students

Conceptual Framework
As mentioned earlier, this study was aimed at investigating the impact of mental health literacy and social support on the quality of life among university students in Malaysia ( Figure  1).

Method Sampling
The study adopted a cross-sectional design involving 140 Malaysian undergraduate students, aged 18 to 21 years, from Universiti Putra Malaysia. Informed consent was obtained from the participants while approval to conduct the study was granted by the Ethics Committee for Research Involving Human Subjects (JKEUPM-2021-805). Data were collected from questionnaires distributed during a mental health forum held at the university. This study employed a purposive sampling technique in which all participants in the forum were selected as respondents.

Measures
To measure the quality of life, the WHO QOL-BREF was applied (World Health Organization, 1998;Zhang et al., 2012). The scale used a five-point Likert response format ranging from 1 (strongly disagree) to 5 (strongly agree). The Cronbach alpha for quality of life was 0.901. Next, mental health literacy was assessed on a scale by O' Connor and Casey (2015). Each item in this construct was measured using a five-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree); the Cronbach alpha for this study was 0.700. Social support was measured using the Multidimensional Scale of Perceived Social Support (MSPSS) by Zimet et al. (1988). The scores were rated on a 7-point Likert scale from 1 -(very strongly disagree) to 7 -(very strongly agree). The MSPSS had three sub-scales (viz. significant other, family, and friends) with 4 items for each sub-scale. High internal consistency was found for social support at 0.901 in this study.

Data Analysis
The SPSS ® software version 25.0 was used for statistical analysis. Descriptive statistics were employed for the students' characterization. Absolute and relative frequencies were used to describe qualitative variables, and the mean and standard deviation (SD) were used to Mental health literacy Social support Quality of life describe quantitative variables. Pearson's correlation coefficient was employed to determine the correlation between the mental health literacy, social support and QoL. Multiple linear regression analysis was carried out to assess the influence of the independent variables on the dependent variable, QoL.

Demographic Profile
The study sample comprised 140 university students aged 22 to 26 years. The highest proportion of respondents (49.3%) were aged 22 -23 years. Female students (77.9%) outnumbered male students (22.1%). Most participants were Malay (90%), followed by Indian (5.7%) and Chinese (4.3%). The respondents were from different years of study, with 50.7% in their fourth year, followed by second year students (20%). The demographic profiles of the respondents are shown in Table 1.

Bivariate Correlation
The relationships between mental health literacy and social support with quality of life were analyzed using the Pearson product-moment correlation. Bivariate correlation coefficients for each variable pair are shown in Table 2. The Pearson product-moment correlation analysis results (Table 2) depicted a positive correlation of mental health literacy and social support with quality of life. The higher relationship value was between social support and quality of life (r=0.638, p < 0.001). Mental health literacy also revealed a positive relationship with quality of life (r =0.335, p < 0.001). Table 3 shows the results of the regression analysis conducted to test the hypotheses pertaining to the main effects of mental health literacy and social support with respect to the quality of life among university students. In determining the extent to which the research data fitted the multiple linear regression model, it was found that social support explained a significant amount of the variance that accounted for the quality of life among the university students (F= 126.687, p < 0.05; β = 0.242, p= 0.000). Hence, social support made the stronger unique contribution in explaining the variation in quality of life, whereas the effect of mental health literacy was no longer significant (p= 0.301). The coefficient of determination, R 2 = 0.707 indicated that about 70% of the variance in quality of life among university students was explained, mainly by social support. Table 3 Multiple

Discussion
This study was aimed at determining the impact of mental health literacy and social support on the QoL (quality of life) of university students. Like members of the public, university students experienced substantial changes in their daily routine during the COVID-19 pandemic, with each responding differently to new challenges. It is important to ensure that students' QoL would not be too greatly compromised. Hence, there is a need to identify the factors that were predictors of the QoL of students who had to cope with life under lockdown during the Covid-19 pandemic. In this regard, the present study found that social support played a significant role in the students' QoL. The results of this study could help university educators plan strategies for maintaining or improving students' sense of well-being. When students receive help and feel appreciated and connected with various social networks, they will experience a better quality of life. The findings are consistent with various studies that highlight the important role of social support in enhancing the quality of life of university students (Jafry et al., 2021;Alsubaie et al., 2019;Dafaalla et al., 2016). Having a network of friends, family, and others with whom a meaningful and fulfilling relationship can be built contributes positively to the quality of one's life. Our findings offer useful pointers with regard to the importance of social support in enhancing QoL of students.
Next, the present research study results show that mental health literacy has an affirmative and positive influence on the QoL of university students. It is likely that students who are equipped with information about mental health, and who seek help regarding mental health have a significantly higher quality of life. This conclusion is consistent with a study of Jafari et al (2021) A study during the COVID 19 pandemic showed that health literacy, including aspects that characterized the pandemic environment, had a significant association with the quality of life of adolescents in terms of health-related issues . In the present study, university students who sought information on mental health and were literate in mental health issues were more likely to have maintained their quality of life even though they had to cope with new challenges during the COVID-19 pandemic. Nonetheless, the variables of mental health literacy and social support were themselves correlated (Table 2). Consequently, the relationship of QoL with mental health literacy did not appear to be maintained independently of social support which was the more prominent variable determining the students' QoL.

Limitations, Implications and Future Recommendations
In this study, as information was collected via a self-administered questionnaire, there might have been recall bias and reporting bias by participants. This study was cross-sectional and, therefore, it was not possible to examine the causality between the variables. The sample in this study comprised university students in their early twenties; in future research, the study population could consist of respondents from different age groups across different social cohorts. In this study, the data collected were mainly from female respondents. It is suggested that future studies have a fairer representation from both genders.
The results from this study could help organizations understand the predictors of quality of life of youth, especially university students. This study adds to the literature on social support and mental health literacy in relation to the quality of life of university students during the Covid-19 pandemic in Malaysia.