This study investigated the QoL of a cohort of Malaysian university students and its association with various factors and social supports at a time when the country is still battling the COVID-19 pandemic. As a comparison to the norms of the WHOQoL-BREF domain scores in the non-pandemic affected general population , the psychological (67.72[study] vs 70.6 [general population]) and social relationship QoL levels (68.32[study] vs 71.5[general population]) reported in our study were relatively low, whereas the physical health and environment QoL levels were comparable. This finding was not surprising because the prevalence rates of depression, anxiety and stress among the participants in this study were 36%, 37% and 42%, respectively, which may lead to lower psychological QoL. Furthermore, the practice of social distancing and the restriction on organising and attending social activities as preventive measures to curb the spread of COVID-19 may contribute to lower social relationship QoL.
We found that only a greater number of hours of online classes attended per week and higher family and friend support significantly predicted an increase in physical health QoL among the participants. The literature pointed out that chronic absenteeism from class is associated with a higher risk of engaging in health risk behaviours, such as cigarette smoking, chronic alcohol use and risky sexual behaviours. In contrast, a sense of academic achievement is associated with a higher level of general health [23, 24]. Hence, the finding that university students who attended a greater number of hours of classes had higher physical health QoL in this study was in line with what was described in the literature. For the relationship between family and friend support and physical health QoL, a survey of 2348 adults in the United States reported that having good friend networking and friend support predicted increases in good subjective health status. Conversely, family and friend relationship strain may dampen long-term physical health . In addition, greater family and friend support is related to increased moderate-and vigorous-intensity physical activity, which may enhance physical health–related QoL [26, 27]. Although our study did not assess the amount of physical activity engaged in by participants during the COVID-19 pandemic, increasing physical activities, such as exercise at home with family and friends, may be helpful to cope with boredom and a loss of daily routine, potentially enhancing the physical health QoL of the participants. Our findings identified that COVID-19-related stressors (e.g. frustration because of the loss of daily routine and frustration because of study disruption) and higher severity of anxiety symptoms significantly predicted a decrease in physical health QoL of the participants. Interestingly, further questioning of the participants indicated that they were complaining of uncertainty about their future as their study was prolonged, their graduation time would be delayed as a result of the COVID-19 pandemic and they were disturbed by loss of their daily academic routine, such as their usual classes and clinical sessions. These difficulties experienced by the participants were associated with increased severity of anxiety symptoms in this study. Similarly, a literature review conducted by Mendlowicz and Stein (2000) highlighted that panic disorder with agoraphobia and generalised anxiety disorder were linked to lower physical health QoL, whereas social phobia had a significant but lesser influence on the physical health QoL of anxiety disorder patients . Hence, our study findings further strengthened the link between higher severity of anxiety symptoms and lower physical health QoL.
Four factors were identified as significant predictors of higher psychological QoL, which were as follows: 1) participants who perceived religious coping as helpful to manage stress during the uncertain time of the COVID-19 pandemic and higher levels of 2) family, 3) friend and 4) significant other social support. Conversely, higher severity of depression and perception of living in an area with high prevalence of COVID-19 cases significantly predicted lowering of psychological QoL. It has been reported that 60% of 444 studies that quantitatively investigated the relationship between religious practices and beliefs and depression showed that engaging in more religious practices and activities reduced the severity of depression. Religious coping also increases the supportive community network of depressed people, allows depressed people to cope better in the presence of stressful life events, and facilitates the emergence of meaning and hope out of ordeals or traumatic events; all these factors reduce the severity of depression . Further, questioning of the participants in this study revealed that they believed spending more time in prayer with family at home strengthened their confidence and enabled them to spend more time practising their religion. They also created new meaning out of their ordeal (movement being restricted), believing that God created this pandemic as a test for humankind and that those who embraced this challenge with patience and alliance with God would become stronger. These points may explain the reciprocal relationship between religious coping and higher psychological QoL in this study. Studies on the general population and healthcare workers during the spread of the COVID-19 pandemic pinpointed that higher social support was associated with lower anxiety and depression, whereas lower social support was associated with higher anxiety and depression [30–34]. Greater family and friend support, greater integration into a social network and having a larger social network are also protective against depression . Higher family and friend support have also been shown to enhance psychological well-being . Hence, it is not surprising that higher family, friend and significant other social support for the participants in this study was associated with higher psychological QoL. Our finding that those who perceived the area in which they lived to have a high prevalence of COVID-19 cases showed reduced psychological QoL is similar to the findings of two studies in China, which also reported that those who live and work in close proximity to the epicentre of COVID-19 infection had higher odds of experiencing psychological symptoms, such as depressive and posttraumatic stress disorder symptoms [34, 37]. The tighter movement control and fear of contracting the COVID-19 infection (for the self and family) in those who perceived that they lived in an area with a high prevalence of COVID-19 cases may have led to the emergence of higher negative affect, depreciating respondents’ psychological QoL. Depression has been reported to diminish psychological QoL, and this is attributed to the mood disturbance experienced by the depressed person. The degree of decrement of psychological QoL is inversely proportional to the severity of depressive symptoms . A study of 394 depressive disorder patients in Ethiopia reported that the psychological QoL domain of the WHOQoL-BREF score were as low as 42.8 ± 8.2 . Hence, our finding of the inverse relationship between depressive symptoms’ severity and psychological QoL is well documented in the literature.
Our study indicated that using religious coping to manage their stress during the COVID-19 pandemic and having higher family, friend and significant other support predicted increased social relationship QoL among university students. No factors were significantly associated with lower social relationship QoL. Religious practices like attending religious services often increase the social network of attendees and allow frequent exchanges and sharing of information compared with attending such services less frequently . It has been found that persons who attend religious services with one or both parents have greater promoted feelings of well-being, and those who attend religious services with their spouses exhibit enhanced relationship commitment . Further questioning of the participants in our study revealed that those who attempted to cope with the MCO and COVID-19 pandemic with religious coping spent more time in prayers with family at home during the MCO; hence, they strengthened their family ties and enhanced their social relationship QoL further. These results may explain the reason behind our finding that those who utilised religious coping to manage stress reported better social relationship QoL. The COVID-19 pandemic has changed the quality of social relationships, where people receive more good support from their family, feel more caring towards family and others and share their feelings with others more often . These shifts in social relationships support the association between higher family, friend and significant other support and greater social relationship QoL reported by the university students in this study.
The current study also highlighted that religious coping and greater family, friend and significant other support predicted an increase in the environmental QoL, while increasing age was associated with lower environmental QoL among university students during the COVID-19 pandemic. Like our study, in which most participants were Muslim, Gardner et al. (2014) surveyed 114 Muslim university students in New Zealand and highlighted that religious coping was positively related with QoL . Assessment of the individual domains of the WHOQoL-BREF also indicated that positive religious coping is associated with an increase in environmental QoL , supporting our finding that religious coping increased environmental QoL. Greater family, friend and significant other social support allow persons to strengthen their family ties, increase their social network size with friends and strengthen the positive relationship of a couple or partners. This may improve access of the person to resources and material goods, including financial support. Greater self-efficacy, competence and self-esteem as a result of good support from social networks may increase the sense of security of the physical surroundings and daily living, heightening environmental QoL . Hence, it is not surprising that greater family, friend and significant other social support leads to higher environmental QoL, as reported by this study. The relationship between age and QoL is still controversial. A few studies have reported that increasing age worsens QoL, particularly after controlling for a wide number of variables [46–48]. Similarly, our study indicated that older age worsened the environmental QoL after controlling for other demographic, personal, clinical and psychological factors, as well as social support.
Based on the findings of this study, we can highlight a few recommendations to improve the QoL of university students during the COVID-19 pandemic. First, higher education institutions (HEIs) should pay more attention to older students and those who live in areas where COVID-19 cases are highly prevalent because these groups of students may have impaired QoL. Second, several psychological factors were reported to dampen QoL in this study, such as frustration because of loss of daily routine and study disruption and higher severity of depressive and anxiety symptoms. During the COVID-19 pandemic, when social distancing is pivotal as an infection preventive measure, online psychosocial interventions that help curb these psychological complications are of utmost importance. Hence, HEIs should consider arranging online counselling or psychotherapy for university students needing these services. An example of an effective online psychosocial intervention for university students is the MePlusMe programme, which promotes psychological well-being, supports mood and daily functioning and enhances the study skills of university students . Third, as religious coping and family, friend, and significant other social support increased the QoL of university students, HEIs and the government may focus on efforts to organise more online social support groups, encourage the use of web-conferencing applications to sustain social communication and relationships and organise more online religious talks through HEI websites during the COVID-19 pandemic. Fourth, because students with a history of pre-existing medical illness are more likely to have impaired QoL, telemedicine services that involve online consultation with doctors are vital to maintain physical health and improve the QoL of these students. Finally, a sufficient duration of online classes should be arranged to enhance the sense of academic satisfaction and reduce feelings of uncertainty among university students, considering that a greater number of hours of online classes attended improve the QoL of university students.
There are a few limitations to take note of in this study. First, the cross-sectional design of this study did not allow the causal relationship between various factors and QoL to be determined across time. Second, as the distribution of demographic characteristics of the participants did not reflect the demographic distribution of all Malaysian university students, our findings may not be generalised as representative of the Malaysian university student population. Despite these limitations, this study filled the research gap of the scarcity of data on QoL of Malaysian university students during the COVID-19 pandemic and allowed several recommendations to be made.