The mediating role of health behaviors in the relationship between internal locus of control and life satisfaction in public health students

Searching for ways to optimize and increase the quality of life is a significant social challenge. In many highly developed countries, trends are constantly being examined, and solutions are being sought to provide satisfactory life satisfaction. In the USA, the last decade saw a slight upward trend in life satisfaction levels along with significant optimism for the future until the outbreak of the COVID-19 pandemic¹. In 2020, there was a decline in the life satisfaction index, and the most considerable difference between current life satisfaction and expected life satisfaction since 2008 was observed². There have been declines in many mental health indicators around the world, as well as the Human Development Index^3,4. In Poland, the level of overall life satisfaction increased successively from 1994 until 2019, after which this indicator decreased⁵. Generally, in EU countries, it was noted that a considerable decline occurred in the 18–24 age group, in which life satisfaction scores used to be among the highest and are now the lowest⁶. It is also worth noting that the pandemic has deepened the differences between the sexes. There is now a higher percentage of men who are satisfied with their lives than women, with the same level of dissatisfaction^5,6.

Life satisfaction in students of healthcare education

Life satisfaction is defined as a general assessment of satisfaction with one’s achievements and living conditions⁷. Satisfaction with life is one of the indicators of quality of life, which, together with indicators of mental and physical health, determine whether people develop properly⁸. We know from research that there are many concepts of achieving satisfaction in many areas, but it is difficult to isolate the factors that determine overall life satisfaction⁹. It turns out that in addition to social, financial, intellectual, emotional, personality, working and leisure, environmental, and political determinants, health conditions are also necessary, namely availability and satisfaction with various health-related services¹⁰.

The level of life satisfaction changes with the degree to which life needs are met, which are the source of valuable goals¹¹. Young adults believe that their lives will get better and more satisfying with age, but for most, life satisfaction does not improve over time. Research indicates stabilization or even periodic declines in the assessment of their own lives¹². Dispositional awe, mindfulness, and presence of meaning may also be important¹³. Numerous studies conducted among healthcare students in various regions of the world showed how, with the development of the COVID-19 pandemic, learning difficulties worsened, physical and mental well-being decreased, their emotional situation worsened, and life satisfaction decreased, regardless of gender^{14,15,16,17,18}.

Public health studies prepare graduates to promote health and improve the quality of people’s lives, they are directly or indirectly prepared to work on people’s well-being, and therefore, these people should be role models, especially in their way of life and attitude towards health behaviors¹⁹. It is a series of responsible tasks in the service of the most valuable social values. It turns out that stress and burnout in medical and medical-related professions are large and growing problems^20,21. Therefore, it seems essential to study the personality traits of people preparing to perform socially important professional roles, which, as is known, are correlated with subjective well-being, i.e., extraversion, self-esteem, positive affective disposition, mindfulness, optimism, the expectancy of perceived control, Pollyannaism, resilience, as well as the locus of control⁹.

Associations between healthy lifestyle and well-being

Health behaviors are shaped during adolescence as a result of socialization and many other environmental and personal factors of the individual. Bellis et al.²² showed that risky behavior occurring in adulthood, as well as poor mental and physical health, are the result of unfavorable childhood experiences. It is worth noting that the period of undertaking higher education, namely entering adulthood and independence, also seems to be critical for the development of an individual lifestyle. Overall, risky behaviors occur much more often among adolescents and young adults than in other age groups²³.

It is disturbing that during the COVID-19 pandemic, the health behaviors of nursing students, regardless of gender, have worsened²⁴. Generally, medical students demonstrate a higher level of health-related behaviors than students of other fields of study²⁵. It is known from many studies that gender differentiates individual health-related behaviors. Taking care of health, responsibility for one’s health, and nutrition are the domain of women, while men dominate in practices related to physical activity^26,27. Some researchers indicate that women generally provide a more healthy lifestyle than men²⁸. Longitudinal research shows that the general well-being of students has recently decreased, but men have a higher level of well-being, which is related to, among others, practicing behaviors such as getting more sleep, physical activity, greater social connections, less alcohol consumption, and less activity on social media²⁹.

Satisfying needs through everyday decisions shapes an individual lifestyle. Kesebir and Diener³⁰ claim that striving for happiness is one of the forms of a good life. In Western societies, diverse lifestyles are acknowledged, and they can often differ significantly. Among the younger population, healthy behaviors are influenced by numerous factors, including environmental challenges. One such recommended approach is a healthy lifestyle, which is characterized by a preponderance of behaviors that promote well-being over those that undermine it³¹. Health behaviors are any actions taken to prevent, detect disease, or improve health and well-being³².

The impact of healthy behaviors on life satisfaction has been the subject of extensive research. Life satisfaction, a critical cognitive component of subjective well-being, is influenced by various factors, including health behaviors³³. In particular, regular physical activity is consistently associated with higher life satisfaction across different populations, including health professionals, older adults, and the general population^{34,35,36,37,38,39}. Also, consuming a healthy diet, particularly with sufficient intake of fruits and vegetables, is linked to higher life satisfaction^{34,35,38,39,40,41}. Good sleep quality is also a significant predictor of higher life satisfaction^34,39,41. Engaging in and having an interest in daily activities was associated with higher life satisfaction among health professionals³⁴. Finally, the absence of smoking was positively associated with higher life satisfaction^34,38,40,41. Healthy lifestyle behaviors, such as healthy nutrition, stress management, regular exercise, spiritual well-being, and high-quality interpersonal relations, were related positively to life satisfaction in a sample of Turkish university students and staff⁴². However, these studies showed that healthy lifestyle behaviors and life satisfaction among university students and staff varied based on demographic variables, highlighting the need for targeted health strategies.

Health locus of control as a factor affected healthy behavior

Health-related locus of control (HLOC) refers to an individual’s belief about the extent to which their health is controlled by internal factors (i.e., self), powerful others (e.g., doctors, physiotherapists), or chance (fate, case). People with an internal HLC believe that they can control events related to their life and health. In contrast, people with an external HLC believe that external factors, like chance or other people, determine their health and quality of life and are therefore not willing to take preventive actions⁴³. Studies suggest that a higher Internal Health Locus of Control (I-HLOC) is associated with engaging in health-promoting behaviors, including physical activity, healthy diet, and adherence to medical advice^44,45,46,47. Overall, people with an internal locus of control are more likely to eat well and exercise regularly and derive greater satisfaction from these activities⁴⁸. Furthermore, I-HLOC is associated with better self-assessed health, physical health, mental health, and well-being^49,50,51. In particular, a longitudinal study showed that a higher internal locus of control in childhood is a predictor of better health outcomes and behaviors in adulthood, including reduced risk of obesity and psychological distress⁵⁰. The relationship between Powerful Others Health Locus of Control (P-HLOC) and health behaviors is more ambiguous and context-dependent. Some studies show that individuals who believe powerful others control their health engage in health-promoting behaviors, especially when influenced by healthcare professionals^44,47,52. P-HLOC is particularly associated with preventive behaviors in patients with chronic diseases⁵². A high Chance Health Locus of Control (C-HLOC) is generally associated with poorer health behaviors, such as a lower likelihood of engaging in physical activity and healthy eating, as they believe their health is determined by fate^45,47,53.

The key feature of a healthy lifestyle, a pattern of specific behaviors, is the ability to make choices. Health-related behaviors depend on beliefs regarding generalized expectations in three dimensions of locus of control^54,55. Smoleń et al.⁵⁶ found that university students predominantly exhibit an internal locus of health control without significant gender differences. According to Wardle et al.⁵⁷, students from Central and Eastern European countries showed lower levels of life satisfaction than their counterparts from the Western EU. Students with low levels of life satisfaction were convicted that their health is largely determined by chance. However, an overall high level of internal locus of health control was found in students from Central and East Europe, as compared to those from West⁵⁷. Ghorbani-Dehbalaei et al.⁵⁸ showed that health literacy, health-related beliefs, and self-efficacy are essential factors for preventive behaviors among students. The internal health locus of control (HLC) promotes making independent decisions regarding one’s health, that is, health-promoting behaviors, regardless of the influence of other people or environmental factors. It manifests itself in individuals taking responsibility for one’s health. It is more beneficial from the point of view of public health policy⁵⁹.

Theoretical background of the hypothetical research model on associations between HLOC, healthy behavior, and life satisfaction

Studies suggest that an internal health locus of control is generally associated with higher life satisfaction and better mental health^{51,60,61,62,63,64,65,66,67,68}. Popova⁵¹ showed that higher levels of internal locus of control are related to healthier lifestyles, which in turn contribute to higher life satisfaction in young adults (aged between 19 and 30). During the COVID-19 pandemic, individuals with a high internal locus of control were also more likely to engage in pro-environmental behaviors, which also contributed to their life satisfaction⁶¹. Furthermore, physical activity and social interactions were found as pathways through which an internal locus of control can enhance life satisfaction⁶⁰. Mei et al.⁶⁸ showed that both life satisfaction and a healthy lifestyle are positively associated with the internal HLC as well as the powerful others HLC, but chance HLC correlates negatively in a sample of Chinese students.

This study aims to examine the complex relationships between life satisfaction, health locus of control (HLC), and health behaviors among public health students, accounting for gender. Based on previous studies^51,60,61,68 we expect that HLC and healthy behavior determine life satisfaction, and healthy behavior plays a mediating role in the relationship between HLOC and life satisfaction. Several theories can explain the expected relationships between HLOC, healthy behaviors, and life satisfaction. The eudaimonic concept of happiness assumes that life satisfaction is a cognitive component of the quality of life. Eudaimonism, as a philosophical trend, assumes involvement in the axiological sphere. The most critical factors determining well-being are self-development, the ability to change one’s life, striving to discover meaning in the actions undertaken, and fulfillment in pursuing the so-called purposeful good life^9,69. Engagement in health-promoting behaviors can be considered as one of the challenges that increases self-development and leads to better physical and mental health, as well as higher well-being. It should be noted that health behaviors help to obtain the value of health, which facilitates success in life and achieving a high quality of life^70,71.

The salutogenetic concept of health explains the relationship between health behaviors and the HLC as a process requiring decision-making and actions to maintain or build health⁷². This concept underlies contemporary health promotion, in which an essential element is emphasizing the ability to exercise control over one’s health and that of others, which is important at both individual and systemic levels of public policy^73,74. The attribution theory⁷⁵ assumes that HLOC serves as a crucial dynamic mechanism for motivating people to maintain healthy behaviors, which may lead to the development of life satisfaction.

The integration of all the theories mentioned above is possible from the perspective of living systems⁷⁶. According to living systems analysis, Forrest⁷⁶ proposed that health arises from the specific hierarchical organization of interactions between various health assets, such as energetics, restoration, mind, reproduction, and capabilities, which collectively contribute to the development of adaptation, goal attainment, needs satisfaction, and survival. Health develops throughout the lifespan due to the dynamic, non-linear interactions between individuals and their environments. The attainment of well-being for individuals is not only impacted by their health but also determined by the goals they select to pursue based on their moral values, cultural background, preferences, aspirations, and temporal context. The present study demonstrates the interaction between the mind (defined as the capacity to receive, process, and interpret data from the internal and external environments to create information that can be stored as memories and used to formulate options for action plans) and capabilities (understood as an instrumental value of health in such behavioral domains that enable individuals to move around, communicate with others, care for oneself, and interact in social situations) among university students of various public health majors, in the Polish cultural context. Based on living systems model⁷⁶, we assume the dynamic interactions between the mind (represented in this study by HLOC and life satisfaction cognitive assessment) and capabilities (as healthy behaviors) assets that lead to better adaptation and well-being. We presume that individuals with a strong sense of health control (mind) can better manage their health-promoting behaviors (capabilities), which ultimately contribute to better self-evaluation of life satisfaction (primarily health-related) and enhanced well-being.

Understanding the relationships in the assumed research model of mediation is the basis for taking individual responsibility for health and life satisfaction, which is beneficial from the point of view of public health. Students of various health fields should be role models for their future patients. Therefore, it is crucial to investigate health and well-being behaviors and beliefs in the public health student population. Our previous studies showed that healthy behaviors can play a mediating role in the relationship between optimism and life satisfaction in healthcare students⁷⁷. In particular, positive mental attitudes, a component of healthy behaviors, mediate the relationship between optimism and life satisfaction⁷⁷. However, the mediating role of healthy behaviors was never examined in the relationship between HLOC and life satisfaction among healthcare students. Previous research⁶⁸ has proven that a healthy lifestyle is a mediator in the relationship between HLOC in all scales (I-HLOC, P-HLOC, and C-HLOC) and life satisfaction in Chinese university students of various fields and majors. However, it is unclear whether the same associations would be observed among public health students in a different cultural context. The present study fills this gap and aims to examine the mediating effect of health behaviors in the relationship between health locus of control and life satisfaction among students of various public health majors from Poland. In the context of the previous research, the following hypotheses were formulated (Fig. 1):

The mediating effect of health behaviors on the relationships between health locus of control (HLC) and life satisfaction (hypothetical model of mediation).

Women have higher levels of health behaviors than men²⁸, while men have a higher level of I-HLOC than women⁷⁸.

Health behaviors are positively predicted by an I-HLOC (Fig. 1, path a₁) and P-HLOC (Fig. 1, path a₂) while negatively predicted by C-HLOC (Fig. 1, path a₃)^{44,45,46,47,48,50,52,53,68}.

Health behaviors are positively related to life satisfaction (Fig. 1, path b)^{33,34,35,36,37,38,39,40,41,42,66,68}.

Life satisfaction is positively predicted by an internal HLC (Fig. 1, path c₁) and powerful others HLC (Fig. 1, path c₂) while negatively predicted by chance HLC (Fig. 1, path c₃)^{51,60,61,62,63,64,65,66,67,68}.

Health behaviors mediate the relationship between all three dimensions of HLC and life satisfaction⁶⁸.