The Influence of Social Support on Health-related Quality of Life: Exploring the Mediating Role of Self-Efficacy Among the Zhengzhou Sample

Health-related quality of life (HRQoL) is a key construct that reflects university students’ overall health status and social adaptation, and improvements in HRQoL have significant practical implications for both individual well-being and sustainable social development [1-3]. According to the United Nations Sustainable Development Goals (SDGs), the health and development of university students are regarded as a core issue matter for sustainable development, extending beyond individual-level concern [4-7]. As a core component of SDG 3: Good Health and Well-Being, the concept of HRQoL suggests that health is more than the absence of illness, encompassing psychological well-being, supportive social relationships, and overall life satisfaction [8]. For university students in the emerging adulthood stage, the level of HRQoL has a direct impact on their academic adjustment, lifestyle choices, and future career and social development trajectories [5, 6].

Recent research increasingly demonstrates that psychosocial resources play a significant role in improving HRQoL among university students [9-12]. In particular, social support functions as a key external factor that helps students to better cope with pressures arising from academic demands and daily life [11]. This support can come from family, friends, and significant others in the form of emotional, informational, and instrumental assistance, as well as from schools, neighborhoods, and government entities [13]. Social support can directly alleviate negative emotions and foster positive health behaviors by enhancing coping confidence [14]. Additionally, it offers vulnerable student groups additional psychological and material resources, enabling them to better adapt and develop during the transitional phase of emerging adulthood [15]. This closely aligns with SDGs Goal 10 (Reducing Inequalities), highlighting social support as a crucial component of well-being and a pathway to advancing equity in education and health.

In social cognitive theory, Bandura proposed that self-efficacy refers to the belief in one’s ability to complete tasks or overcome challenges [16]. As a core psychological resource, self-efficacy shapes whether students have the motivation to persevere and engage when facing challenges [17]. Moreover, self-efficacy influences university students’ persistence and effort in academics and interpersonal relationships and plays a vital role in stress regulation and the development of healthy behaviors [18]. Higher levels of self-efficacy enhance confidence and motivation, support academic and mental well-being, and contribute to improved HRQoL [19]. Additionally, the development of self-efficacy often depends on institutional and social resources, including campus mental health services, supportive relationships between teachers and students, and community organization initiatives [20]. In overview, social support and self-efficacy are critical determinants of HRQoL among university students, shaping their overall academic, psychological, and social adaptation.

Accordingly, investigating the interplay between social support and self-efficacy contributes to a deeper understanding of HRQoL among university students, particularly when examined through the lens of sustainable development. In addition, this research provides practical guidance for health education, psychological interventions, and the development of social support networks within higher education institutions. Furthermore, this study offers important implications for advancing the implementation of SDGs 3 (Good Health and Well-Being), 4 (Quality Education), and 10 (Reduced Inequalities).

3.1 Participants

The present study selected Zhengzhou, the capital city of Henan Province, as the study area. As a national central city and a major transportation hub in central China, Zhengzhou is highly accessible and regionally influential, and reflects the overall characteristics of university students in central China. Additionally, the city concentrates higher education resources and features diverse range of institutions, including comprehensive universities, teacher training colleges, and vocational colleges. This diversity results in a rich student population structure that provides an ideal sample base for this research.

Against this backdrop, a questionnaire was conducted in Zhengzhou in June 2025. The survey was conducted in the Longzihu University Town area of Zhengzhou, which hosts a high concentration of higher education institutions and a diverse student population. Three universities located within this area participated in the study. A campus-based convenience sampling approach was employed, with students approached in teaching buildings, libraries, and other public areas on campus. A total of 620 questionnaires were distributed. After data screening, 22 questionnaires were excluded because they were either not completed or showed the same responses across all items, which indicated invalid answering. A completion rate of below 5 percent was applied as the criterion for identifying questionnaires with substantial missing data [33]. After removing these cases, 598 valid questionnaires were retained for the subsequent analysis, resulting in an effective response rate of 96.4 percent. Participants completed the self-report questionnaire in approximately 15-20 minutes.

During the data collection process, all participants voluntarily participated in this study after being fully informed about its purpose and procedures. Students were explicitly informed that they had the complete autonomy to withdraw at any time without facing negative consequences. In addition, the research team was committed to strictly protecting the privacy and personal information of the participants. All data were recorded and analyzed anonymously and were used exclusively for academic purposes in this study. The data were not used for commercial purposes nor disclosed to third parties.

3.2 Measures

This study employed three standardized and validated instruments. All measurement instruments in this study employed a five-point Likert scale, ensuring consistency and comparability across variables. Specifically, to measure the independent variable of social support, this study employed the 12-item Multidimensional Scale of Perceived Social Support (MSPSS), which captures support from family, friends, and significant others [33, 34]. Among university students, this instrument has been shown to demonstrate strong reliability and validity [35]. To measure the mediator, self-efficacy, the research employed the General Self-Efficacy Scale (GSES), which comprises 10 items designed to assess confidence in overcoming difficulties and challenges [35, 36]. This scale is widely applied among Chinese university students [37].

HRQoL (the dependent variable) was measured using the KIDSCREEN-10 Index. The Chinese versions of this 10-item single-factor scale have been validated [38]. Prior to data collection, the KIDSCREEN-10 items were adapted and subsequently assessed for content validity to determine their suitability for use among university students. Following standard procedures for evaluating content validity [39], two experts, one specializing in psychology and the other in education, independently assessed the relevance of each adapted item independently using a four-point scale. Inter-rater consistency was examined using Cohen’s Kappa coefficient [40]. The percent agreement between the reviewers was 70%, resulting in a Kappa value of 0.783. According to the interpretive guidelines proposed by Landis and Koch [41], this value represents a substantial level of agreement and provides acceptable support for the content validity of the adapted items when administered to a university student population.

This study performed reliability analyses on each scale to assess the internal consistency of the instruments used. The results showed that the Cronbach’s α coefficient for the Multidimensional Scale of Perceived Social Support (MSPSS) was 0.902. For its three dimensions, the α coefficients were 0.844 for Family Support, 0.778 for Friend Support, and 0.848 for Significant Other Support. All values exceeded commonly accepted thresholds for high reliability. The GSES showed a Cronbach’s α of 0.838, and the KIDSCREEN-10 Index reported a Cronbach’s α of 0.826. Values above 0.70 indicate acceptable reliability [42]. Hence, each of the methods used in this research showed strong internal consistency (see Table 1 for detailed results).

Table 1. Reliability statistics (N = 598)

3.3 Data analysis

This study utilized SPSS version 27.0 for data analysis. Initially, descriptive statistics were performed on the participants’ basic demographic characteristics (e.g., gender, age, grade, major, and arrangement) to present their fundamental characteristics. Then, Pearson correlation analyses were performed to investigate the two-way relationships among social support, self-efficacy, and HRQoL. To assess internal consistency, Cronbach’s α coefficients were calculated for each scale. Following this, multiple regression analyses were carried out to determine the direct effects of social support on HRQoL. Finally, to test whether self-efficacy mediated the relation found between social support and HRQoL, a mediation analysis was performed using the SPSS PROCESS Macro (version 4.1). Bias-corrected bootstrapping was employed to estimate the mediation effect and its 95% confidence interval, and mediation was deemed significant if zero was not contained within the confidence interval [43].

Hypothesis H1 was supported, showing that social support significantly and positively influences HRQoL among university students. The evidence suggests that students who perceive higher social support tend to experience better HRQoL. Social support accounted for approximately 16.8% of the variance in HRQoL. This finding is consistent with the emphasis placed on social support in cross-cultural research. Specifically, social support provides emotional comfort and functions as a key resource for enhancing HRQoL by alleviating stress and promoting positive behaviors. Evidence from Indonesia indicates that social support effectively promotes HRQoL of university students by helping them establish healthy lifestyles and coping mechanisms [6]. Similarly, evidence from Korean medical students demonstrates that social support significantly enhances HRQoL, potentially through its role in improving mental health and strengthening resilience in highly stressful academic contexts [24]. Additionally, a survey of German university students offers a complementary perspective, showing that social support influences individuals’ psychological well-being and mitigates academic and life pressures at the broader social level. This significantly enhances happiness and satisfaction [25]. Collectively, the evidence emphasizes the crucial role of social support as a reliable factor across different cultural contexts. The findings of this research further demonstrate that this role applies equally to Chinese college students, particularly during the “emerging adulthood” stage, when students experience greater psychological independence alongside a rapid expansion of their social ties.

A likely explanation for the specific circumstances of Chinese university students lies in their developmental stage of “emerging adulthood.” During this period, their psychological independence and social relationships are still in process of development, making them particularly sensitive to external resources. Support from family, friends, and significant others helps alleviate academic and life pressures and enhances confidence in and adherence to healthy behaviors, thereby improving HRQoL [46]. Furthermore, Chinese universities typically feature arrangements, such as collective dormitories and class systems, that strengthen access to interpersonal support networks [47]. The present study highlights the essential importance of social support within the cultural and educational context of China. These results help address the gaps in the literature identified during the review, further demonstrating that social support plays a critical role in promoting HRQoL among Chinese university students.

The analysis provides evidence supporting Hypothesis H2, revealing that social support notably and effectively influences university students’ self-efficacy. Social support accounted for more than half of the variance in self-efficacy, suggesting a substantial contribution to university students’ self-efficacy levels. This finding is consistent with Cassaretto et al. [48], who discovered that social support significantly enhances young adults’ self-efficacy levels by providing emotional encouragement and instrumental resource. These results demonstrate that external support systems offer immediate assistance in specific situations and shape individuals’ broader beliefs about their capabilities.

It is worth noting that this study selected general self-efficacy rather than focusing solely on academic or situation-specific self-efficacy. Unlike contextual measures such as academic or athletic self-efficacy, general self-efficacy provides a more comprehensive reflection of college students’ overall confidence in handling tasks and their perseverance across diverse challenges, including academic, social, and life adaptation challenges [43-45]. This approach enabled the study to examine the relationship between social support and the overall well-being of university students, instead of limiting the analysis to one specific domain. Consequently, this research, which is applicable across diverse cultural contexts, emphasizes the fundamental role of social support in fostering self-efficacy among university students. Given the realities faced by Chinese university students, a likely explanation lies in the cultural emphasis on collectivism and family dependence in China. This cultural orientation predisposes students to seek psychological comfort and practical assistance from family, peers, and teachers when confronting academic and life pressures. Such support alleviates their anxiety at emotional level and strengthens their confidence at cognitive level in tackling challenges. Thus, the study’s outcomes corroborate earlier findings and empirically demonstrate the particular nature of how social support relates to self-efficacy among Chinese university students.

Hypothesis H3 was upheld, as the findings confirmed that self-efficacy significantly and consistently improves HRQoL among university students. Self-efficacy accounted for about 20.1% of the variance in HRQoL, indicating its role as a core psychological resource that significantly contributes to students’ overall health and well-being. This finding corroborates the conclusion from the literature review that self-efficacy as a psychological resource that support both learning outcomes and broader aspects of quality of life including HRQoL. As shown by Joseph et al. [30], higher self-efficacy among university students was connected to significantly better psychological well-being and living standards relative to those with lower self-efficacy. This suggests that self-efficacy influences overall well-being beyond specific task-related contexts. Similarly, Tao et al. [29] discovered that enhanced self-efficacy helps university students achieve exercise and health goals, reduce anxiety, and improve psychological well-being. Taken together, these findings indicate that self-efficacy supports students’ success across both academic and daily life domains, serving as a generalized psychological resource that shapes adaptation and HRQoL across multiple life domains.

Facing the dual challenges of academic pressure and social adaptation, Chinese university students increasingly rely on self-efficacy as a crucial internal driving force that influences their HRQoL [49]. Students with high self-efficacy can maintain a positive mindset and engage in healthy lifestyles when facing academic competition, employment pressures, or interpersonal challenges [50]. This capacity contributes to their physical and mental well-being, thereby enhancing their HRQoL. Conversely, students exhibiting lower self-efficacy may be particularly vulnerable to negative affect and maladaptive behaviors when exposed to stress [51]. Thus, the results of this study are consistent with prior research and provide empirical support that deepens understanding of the link between self-efficacy and HRQoL in Chinese university students.

This study further validated Hypothesis H4, revealing that self-efficacy significantly mediated the relationship between social support and HRQoL, with the indirect effect accounting for 60.46% of the total effect. This finding implies that social support exerts a direct effect on improving the HRQoL of university students and primarily operates indirectly by enhancing their self-efficacy. Through this pathway, students are better able to actively tackle academic and life challenges, ultimately leading to improvements in their HRQoL [22]. This result is consistent with the studies carried out by Shi et al. [32] and Zhou and Yu [31], both of which validate self-efficacy as a core psychological resource. These studies explain how social support consistently influences HRQoL in different educational and cultural contexts. This mediating mechanism appears to be particularly salient within the Chinese cultural context. Moreover, this external support translates into enhanced self-efficacy, helping students navigate academic competition, employment pressures, and interpersonal adaptation more effectively. Consequently, it significantly improves their HRQoL during the critical stage of “emerging adulthood.” Hence, these findings extend previous conclusions and provide new empirical evidence in the context of Chinese university students.

This research holds considerable significance, encompassing both theoretical and practical implications. At the theoretical level, the study employs social ecological theory to systematically elucidate the pathways linking social support, self-efficacy, and HRQoL. Moreover, the study specifically stresses the importance of self-efficacy as a factor that mediates outcomes. The study enriches existing knowledge of university students’ mental health and quality of life while providing fresh insights into how interpersonal and individual levels jointly shape health outcomes. For practical purposes, the findings suggest that universities should prioritize the development and implementation of social support systems for health promotion and psychological interventions. Students’ self-efficacy can be enhanced by drawing on support from family, friends, and significant others, thereby indirectly improving their psychological and physical health, as well as their HRQoL. Lastly, in the unique context of Chinese university students navigating their “emerging adulthood,” this initiative provides academic support to advance the achievement of three SDGs: Goal 3 (Good Health and Well-Being), Goal 4 (Quality Education), and Goal 11 (Sustainable Cities and Communities).

In summary, this study reveals that social support both directly enhances HRQoL and primarily operates indirectly through self-efficacy. These findings are based on a survey of 598 university students in Zhengzhou, Henan. Moreover, these findings advance understanding of the mechanisms linking social support, self-efficacy, and HRQoL. Also, they emphasize the particular significance of this mechanism within the cultural and educational context of Chinese university students’ “emerging adulthood.” From a sustainable development perspective, these findings align with SDG 3 (Good Health and Well-Being) by promoting the physical and mental health of youth, with SDG 4 (Quality Education) by highlighting the importance of educational systems providing psychological and social support, and with SDG 11 (Sustainable Cities and Communities) by improving the overall quality of life of university students through broader, more supportive social environments. Overall, this research expands the theoretical foundation for studying university students’ mental health and quality of life and offers practical insights for higher education management and sustainable development policies.