Journal of American College Health

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/vach20

Quality of life and life satisfaction among

university students: Exploring, subjective norms,
general health, optimism, and attitude as
potential mediators

Seyedeh Belin Tavakoly Sany, Najmeh Aman, Fatemeh Jangi, Elaheh Lael-
Monfared, Hadi Tehrani & Alireza Jafari

To cite this article: Seyedeh Belin Tavakoly Sany, Najmeh Aman, Fatemeh Jangi, Elaheh
Lael-Monfared, Hadi Tehrani & Alireza Jafari (2021): Quality of life and life satisfaction among
university students: Exploring, subjective norms, general health, optimism, and attitude as potential
mediators, Journal of American College Health, DOI: 10.1080/07448481.2021.1920597

To link to this article: https://doi.org/10.1080/07448481.2021.1920597

Published online: 09 Jul 2021.

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Journal of American College Health
https://doi.org/10.1080/07448481.2021.1920597

MAJOR ARTICLE

Quality of life and life satisfaction among university students: Exploring,

subjective norms, general health, optimism, and attitude as potential
mediators
Seyedeh Belin Tavakoly Sany, phda,b , Najmeh Aman, bscc, Fatemeh Jangi, bscc, Elaheh
Lael-Monfared, phdd , Hadi Tehrani, phde and Alireza Jafari, phdf*
a
Department of Health Education and Health Promotion, Faculty of Health, Mashhad University of Medical Sciences, Mashhad, Iran;
b
Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran; cStudent Research
Committee, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran; dStudent Research Committee, School of Public
Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran; eDepartment of Health Education and Health
Promotion, Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran; fHealth Sciences
Research Center, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran

ABSTRACT ARTICLE HISTORY

Objective: This study aims to examine the association of quality of life (QOL) with life Received 26 April 2020
satisfaction, subjective norms, general health, optimism, and attitude among university Revised 23 February 2021
students. Participants: Respondents include 632 university students (Mage=21.36, SD = 2.86). Accepted 18 April 2021
Methods: This cross-sectional study was conducted on university students in Torbat
Heydariyeh, Iran. Several statistical models were tested, including hierarchical regression and KEYWORDS
path analysis, to examine the direct or indirect association between a set of important Health promotion;
variables. Results: According to the results of path analysis, constructs of subjective norms, mental health;
general health, positive attitude, optimism, and life satisfaction were significant predictors path analysis;
of students’ QOL. Compared with other constructs, general health status (p < 0.001, R2 = 0.548) positive thinking;
and life satisfaction (p < 0.001, R2 = 0.253) showed the strongest association with QOL. psychology
Conclusions: The results indicate that efforts to improve life satisfaction by targeting general
health, subjective norms, optimism, and attitudes may provide promising ways to improve
QOL.

Abbreviations: QOL: Quality of life; SWLS: Satisfaction with Life Scale; GH: General health

Introduction In the fields of psychology and general medicine,

Health state was defined by the World Health Organization
(WHO) as “a state of complete mental, social, and phys-
ical well-being not merely the absence of disease”.1,2 The
World Health Organization emphasizes that health esti-
mation methods should not only include symptoms of
disease severity and frequency changes but also evaluate
new measures of wellbeing to improve the quality of life
(QOL).1 The QOL is defined as a people’s perception of
their situation in life in the context of the culture and
social system in which they live.1,3 Likewise, the concept
of ‘‘quality’’ is related to human values (e.g., health, sat-
isfaction, and happiness), and the concept of ‘‘life’’ is
related to the main dimension of human existence (e.g.,
family, work, and health).3–5 In general, a broad-ranging
concept influences subjective QOL, such as psychological
well-being, social relationships, salient features of envi-
ronment, life satisfaction, general health, and beliefs.4,6,7
QOL is usually equal to life satisfaction. For example,
in the American Psychiatric Association’s Handbook, all
three general targets of QOL measures in psychiatric
patients are equated with life satisfaction measures.4 Life
satisfaction is the important subjective component of
QOL that suggests a cognitive-judgmental process, in
which people evaluate their QOL according to set their
own criteria.8 Recent studies have shown that factors
such as career adaptability, optimism, and hope are asso-
ciated with higher life satisfaction among young people
because they can help people think positively about their
lives and make people more satisfied.8–10
Optimism, defined as the attitude or tendency to inter-
pret events and different situations positively, is consid-
ered as a human virtue and strength.8,9,11 Studies have
shown that there is a positive correlation between opti-
mism and several important factors in young people’s
lives, such as lower psychological maladjustment, life

CONTACT Alireza Jafari Jafari.ar94@gmail.com  Department of Public Health, School of Health, Torbat Heydariyeh University of Medical Sciences,
Torbat Heydariyeh, Iran; Health Sciences Research Center, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran.
*
Department of Public Health, School of Health, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
© 2021 Taylor & Francis Group, LLC
2 S. B. TAVAKOLY SANY ET AL.
satisfaction, more engagement in their educational and
career planning, and a positive attitude.8,12,13 Optimism
and a positive attitude are two related constructs that
focus on motivation and the way to achieve desired goals
in the future. These constructs can be implemented as
dual indicators or single-dimensional internal structures
to reflect possible positive health outcomes and orienta-
tion toward future.12–14 Optimism and attitude about life
satisfaction also could be affected by subjective norms,
which can influence an individual’s ability and motivation
to be proactive.15 In turn, all these cognitive structures
may independently affect the QOL related to health,
which is the main indicator of mental, physical, and
social well-being, particularly among young people.4,15,16
In the recent century, phenomena such as interna-
tionalization, rapid technological, and fast-moving global
economy influence health state and people’s QOL, par-
ticularly in developing and Middle East countries.4 In
these countries, the economic recession has reduced
insurance, employment, and pension securities.4 In Iran,
more studies have shown that the QOL and life satis-
faction of college students are lower than other students
in developed countries.17,18 Therefore, the problem of
poor QOL among Iranian college students is still an
open issue. Several studies have shown that many con-
founding factors related to life satisfaction may also
affect the QOL of Iranian students. According to the
literature, QOL and life satisfaction of Iranian students
are positively related to postmodern values and identity
status, health literacy, perceived self-efficacy and self-es-
teem, individualism, emotional intelligence, 6,19,20 and
negatively related to emotional loneliness and hopeless-
ness.18,19,21 Although, as documented, the relation between
QOL and other variables in university students has been
well studied, the potential link between QOL, the seem-
ingly important subjective norms, and the situation of
general health, optimism, and positive attitude seem
essential to investigate. As far as we know, the associa-
tion between these variables has not been estimated with
Iranian students before.
Therefore, it seems important to better understand
the role of key variables, which deserve more attention
in predicting QOL among university students. With this
awareness, education and psychological intervention pro-
grams could be designed to promote students’ personal
adaptation and academic achievements.4,22 In this context,
the aim of this study was to examine the association of
QOL with life satisfaction, subjective norms, general
health, optimism, and positive attitude among university
students.
Methods
Study design and sampling
This study has been carried out through a cross-sec-
tional design on 632 students, from all universities in
Torbat Heydariyeh from January 2018 to November
2018. There are several public higher education insti-
tutions in this city, which are recognized by the Iranian
Ministry of Science and Technology.
The students were included if they (a) study at one
of the universities of Torbat Heydariyeh; (b) able to
complete all relevant questionnaires; (c) hadn’t suffered
mental illness, (d) didn’t use depression drugs, and (e)
were willing to participate in this study. The required
sample size was estimated by the following formula.
Where, Z is the standard normal value that is considered
to be a 5% type 1 error (p < 0.05), and S is the expected
standard deviation (SD) in population according to the
previous study.23 After adjusting the 20% non-response,
632 students were enrolled as a sample size.
There are five public universities in Torbat Heydariyeh
city. We provided different lists of universities in the
Torbat Heydariyeh based on the stratification of student
populations in each department and study group, and
all departments and study groups were assigned num-
bers. We used the multi-stage sampling design because
it is a cost-efficient sampling method and requires less
time to implement. Each university was considered as
a class (or cluster). The first stage of sampling used
probability sampling to select three departments. These
probability samples were weighted by the number of
students in each of these universities (the total number
of 15 departments from 5 universities). The second-stage
sampling included a simple random sampling to select
two study groups from each department.
Then, a simple random sampling was used to select
students from each study group who were willing to par-
ticipate in this study. In total, 660 students were willing
to participate in the study, and their physical and mental
health has been checked through the electronic health
records (EHRs) system. This national system allows us to
access students’ health history based on information from
various sources, including doctors, hospitals, clinics, phar-
macies, and laboratories.
Finally, 632 students met the inclusion criteria and
completed the consent form. Likewise, they completed
study instruments in a written format based on a self-re-
port method. Data were gathered through the question-
naires of attitude and subjective norms in connection
with Optimism, Orientation to Life scale (optimism),
Satisfaction with Life Scale, General Health, and QOL.
After obtaining permission and a code of ethics (IR.
THUMS.REC.1396.35), researchers described the purpose
of the study to all university students in the selected
study groups.
Instruments
Attitude and subjective norms questionnaire
This questionnaire consists of 11 questions measured by
a 5-points Likert scale from “totally agree” to “totally
disagree”. The score of this scale was ranged from 11 to

55. The attitude section consists of 8 questions (for
example, I feel that my life is meaningful and purposeful
when I think positive) and the subjective norm contains
3 questions (for example, my friends expect me to have
positive thoughts when I’m with them). The content
validity ratio (CVR) and content validity index (CVI)
for attitude and subjective norms questionnaire were 0.84
and 0.67, which were acceptable in Jafari et al. study.24
Life orientation Test-Revised (LOT-R) questionnaire
(optimism)
This questionnaire consists of 11 validated short questions
on the optimistic mode and pessimistic mode. These
questions rated using a five-point Likert scale ranging
from 1 (completely agree) to 5 (completely disagree). The
range of scores for LOT-R is from 6 to 30.25 The validity
and reliability of this questionnaire have been investigated
and approved in Iran (Cronbach’s alpha= 0.94).26
General health questionnaire (GHQ-12)
The GHQ-12 is one of the most useful and commonly
used self-report tools for evaluating health and QOL.
Factor analysis studies have found that GHQ-12 is a
multi-dimensional tool for evaluating depression and
anxiety symptoms, perceived stress, and loss of confi-
dence. This questionnaire contains 12 questions, which
are rated using a five-point Likert scale ranging from 1
(never) to 4 (more than usual). The range of score for
GHQ-12 is from 12 to 48. The psychomotricity of GHQ-
12 has been carried out in Iran. The study indicated
that the Iranian version of the GHQ-12 has a suitable
structural design and is a valid and reliable questionnaire
to examine self-rated health. The test-retest correlation
for the whole sample was ranged from 0.84 to 0.93.27
Quality of life questionnaire (SF-12)
The SF-12, a shorter form of the SF-36, is a reliable,
brief, and well-tested questionnaire for clinical practice
or research purposes when studying health related QOL.28
Most participants completed the SF-12 in less than a third
of the usual time needed to complete the SF-36. The
SF-12 is commonly used to assess the QOL, overall health
status, physical health status, and psychological problems.
The range of score for SF-12 is from 12 to 47. The SF-12
has also been tested for reliability and validity in Iran.
The study indicated that the Iranian version of SF-12 was
a psychometrically sound questionnaire, and it is suitable
for use in the Iranian population, both in rehabilitation
and clinical settings. Face validity and Content Validity
Index for SF-12 were acceptable (85.6%).29
Satisfaction with life scale (SWLS) questionnaire
This scale consists of 5 sections on subjective well-being
sense that assess individual’ opinions about life
Journal of American College Health 3
satisfaction (e.g., how satisfied are you with your life?
Or how much life is close to your ideal life?). This
questionnaire is rated using a seven-point Likert scale
ranging from 1 (completely disagree) to 7 (completely
agree). The range of scores for SWLS is from 5 to 35.
It should be noted that in this tool, the higher score
shows more satisfaction. Bayani et al. investigated the
reliability and validity of the questionnaire, and
Cronbach’s alpha coefficient was 0.887.30
Statistical analyses
Statistical Package for Social Sciences software (SPSS 22,
Chicago, Illinois) and R version 3.0.2 were used to pro-
duce accurate estimates. In the present study, descriptive
statistics (mean, standard deviation) and inferential sta-
tistics (Independent samples t-Test, One-way ANOVA,
Pearson correlation) were used to compare clinical and
socio-demographic characteristics. The level of statistical
significance was considered as p < 0.05. The path analysis
fit criteria were tested by Chi-square (x2), the root mean
square error of approximation (RMSEA), adjusted good-
ness of fit index (AGFI), goodness of fit index (GFI),
incremental fit index (IFI), relative fit index (RFI), normed
fit index (NFI), and comparative fit index (CFI). The Path
model is considered as an acceptable and a good fit if
Chi-square (x2) <5, RMSEA < 0.08, AGFI >0.8, GFI, NFI,
IFI, RFI and CFI > 0.9.31–33
Results
Descriptive statistics and correlation analysis
This study was conducted on 632 students. In this study,
34.1% of the participants were male (n = 214) and 65.9%
were female (n = 413). The mean (± SD) age of eligible
students was 21.36 (± 2.86) years old. The majority of
students were single (n = 456, 73.5%), less than a diploma
or high school diploma, and satisfied with their field of
study (n = 434, 91.6%), and their mothers and father
were the housekeeper and employee, respectively
(Table 1).
Based on the correlation analysis, there was a sig-
nificant relationship between gender and student’s
attitude, subjective norms, and optimism. There was
also a significant relationship between marital status
and life satisfaction (p = 0.022), and fathers’ education
level and students’ QOL (p = 0.032) were significantly
correlated together. The correlation analysis showed
an insignificant relationship between the mother’s edu-
cation level, parents’ job, number of friends, attitude,
subjective norms, optimism, life satisfaction, general
health, and students’ QOL. There was a significant
relationship between students’ interest in their field
of study and their attitude, life satisfaction, general
health, and QOL (p < 0.05) (Table 1).
4 S. B. TAVAKOLY SANY ET AL.

In this study, the mean (± SD) of the variables of
attitude, subjective norms, optimism, general health, life
satisfaction, and QOL was 30.45 (± 5.14), 11 (± 2.24),
20.28 (± 3.29), 21.39 (±7.01), 32.78 (± 6.11), and 34.92
(± 6.03), respectively. The results of the Pearson correla-
tion test showed that there was a direct significant cor-
relation between students’ attitude (r = 0.345), subjective
norms (r = 0.134), optimism (r = 0.330), life satisfaction
(r = 0.527), and general health (r = 0.674) with QOL
(p < 0.001). There was also a direct correlation between
general health (r = 0.500) and optimism (r = 0.313) with
life satisfaction (p < 0.001).
Path results
The results of the path analysis showed that the fitting
index of the final model had an acceptable value and
confirms the model (X2 = 11.23, df = 5, X2/df = 2.225,
p-value = 0.049, GFI = 0.99, AGFI = 0.97, RMSEA =
0.044, NFI = 0.99, CFI = 0.99, IFI = 0.99, RFI = 0.96).
The final model is shown in Figure 1. The obtained
results showed that variables of attitude, subjective
norms, optimism, and general health were able to pre-
dict 30% of life satisfaction variance in students.
Overall, the variables of attitude, subjective norms,
optimism, life satisfaction, and general health were able
to predict 50% of QOL variance. The results suggested
that there was a direct effect of general health on QOL,
whereas, there was a significant indirect effect of atti-
tude through enhancing life satisfaction and optimism
on the QOL. Likewise, based on the results obtained,
direct effects accounted for 65.64% of total effects on
the QOL while indirect effects accounted for 35.35%
of the estimated total effects (Table 2).
Discussion
This study evaluated the effect of bio-psycho-social fac-
tors (subjective norms, general health, positive attitude,
and optimism) on QOL and life satisfaction of college
students. Our finding indicated that demographic vari-
ables, (excepting father’s education level and marital
status) had no significant effect on QOL and life satis-
faction. There is some evidence that thefather’s education
level is the main factor determining a students’ academic
achievement and improving their QOL. The National
Bureau of Statistics report stated that, compared with
students whose fathers had a higher education, students
whose fathers had low education experience the highest
risk of course failure and the lowest achievement.34
Likewise, little is known about the impact of having an
educated father on students’ QOL compared with the
mothers’ impact on students’ QOL, which is the main
consideration, since father and mothers differ in terms
of parental care, parenting styles, and parental involve-
ment.34 This study contributed to fill these gaps in
knowledge by investigating how fathers’ education and
job in the family are associated with students’ QOL.
Our research study found a significant association
between students’ life satisfaction and marital status,
which suggested that being married may increase life

Table 1. Frequency distribution of students’ demographic factors and their relationship with attitude, subjective norms, optimism, general health,
satisfaction with life scale, and quality of life.
General Satisfaction
Attitude Subjective norms Optimism Health with Life Scale Quality of Life
Variables n (%) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Gender* Male 214(34.1) 29.42(5.19)# 10.63(2.29)^ 19.94(3.60)^ 32.63(6.21) 20.84(7.08) 35.05(6.29)
Female 413(65.9) 30.98(5.06) 11.21(2.19)^# 20.49(3.10)^ 32.86(6.09) 21.70(7.00) 34.86(5.91)
Marital Single 456(73.5) 30.46(4.98) 10.96(2.27) 20.29(3.16) 32.66(6.15) 21.01(6.97)^ 35.00(6.04)
status* Married 164(26.5) 30.40(5.59) 11.10(2.19) 20.30(3.58) 33.24(6.01) 22.48(7.04)^ 34.60(5.92)
Father’s Illiterate 24(3.9) 29.45(5.06) 10.24(2.54) 19.76(3.22) 33.52(4.83) 22.79(7.21) 34.24(5.65)
education ^
level** Diploma and 395(63.6) 30.36(5.05) 11.01(2.17) 20.20(3.18) 32.45(6.04) 20.95(6.85) 34.42(6.01)^
Under diploma
Academic 202(32.5) 30.58(5.37) 11.05(2.34) 20.42(3.52) 33.15(6.40) 21.77(7.24) 35.76(5.99)^
Mother’s Illiterate 49(7.9) 29.94(4.48) 10.48(2.14) 20.43(3.28) 33.09(5.47) 21.35(6.06) 34.28(5.55)
education Diploma and 425(68.4) 30.41(5.12) 11.01(2.16) 20.17(3.23) 32.54(6.08) 21.01(6.96) 34.67(5.99)
level** Under diploma
Academic 147(23.7) 30.71(5.47) 11.17(2.50) 20.56(3.44) 33.48(6.10) 22.36(7.20) 35.92(5.76)
Mother’s Housewife 507(80.7) 30.39(5.03) 10.98(2.20) 20.30(3.19) 32.71(596) 21.13(6.92) 34.69(6.05)
job * Working outside 121(19.3) 30.75(5.60) 11.10(2.42) 20.21(3.68) 32.95(6.74) 22.33(7.34) 35.66(5.86)
the home
Father’s Job* Employee 337(54.4) 30.46(5.13) 10.98(2.220) 20.33(3.08)) 32.61(6.15) 21.35(6.86) 34.59(6.20)
Self-employed 282(45.6) 30.38(5.21) 11.01(2.29) 20.19(3.49) 32.91(6.09) 21.43(7.16) 35.23(5.82)
Interest about Yes 434(91.6) 30.79(4.78)^ 11.02(2.18) 20.46(3.22) 33.12(6.19)# 21.88(6.73) 35.22(5.84)#
filed of No 40(8.4) 28.33(6.95)^ 10.41(2.53) 20.16(3.08) 29.19(6.28) 18.34(8.21)^ 31.66(6.60)#
education* #
Number of ≤3 238(42.7) 30.53(5.05) 11.02(2.37) 20.23(3.21) 32.66(6.15) 21.41(6.86) 34.48(5.84)
friends 4-8 203(36.4) 30.86(4.41) 11.29(2.04) 20.58(3.06) 33.01(6.16) 21.13(6.77) 35.16(6.15)
>8 116(20.8) 30.21(5.92) 10.84(1.97) 20.19(3.79) 32.69(6.78) 21.88(7.36) 35.01(6.89)
*Independent samples- t test, **ANOVA, #p < 0.001, ^p < 0.05.
 Journal of American College Health 5

Figure 1. Path analysis between Attitude, Subjective norms, optimism, General Health, Satisfaction with Life Scale (SWLS), and Quality of life (R2:
R-Squared, → *p < 0.05, → **p < 0.001).

Table 2.  Direct and indirect effects of constructs.

Causal Effect
Determinants or Predictors Direct Indirect Total effects
Attitude → Quality of Life – 0.265** 0.265
Subjective norms → Quality of Life – 0.139* 0.139
Optimism → Quality of Life – 0.193* 0.193
GH → Quality of Life 0.548** 0.104* 0.652
SWLS → Quality of Life 0.253** – 0.253
Attitude → SWLS 0.122* 0.181* 0.303
Subjective norms → SWLS 0.100* 0.131* 0.231
Optimism → SWLS 0.090* 0.107* 0.197
GH → SWLS 0.409** – 0.409
Subjective norms → Attitude 0.431** – 0.431
Subjective norms → Optimism – 0.196* 0.196
Attitude → Optimism 0.456** – 0.456
Subjective norms → GH – 0.148* 0.148
Attitude → GH 0.224** 0.119* 0.343
Optimism → GH 0.262** – 0.262
Through total causal effect 2.895 1.583 4.478
Percentage of direct and indirect effects 2.895/4.478 =64.65% 1.583/4.478 =35.35%
*p < 0.05, **p < 0.001, SWLS: Satisfaction with Life Scale, GH: General health.

satisfaction. Marital status has a significant effect on life
satisfaction among the adult population because it has
a protective effect on mental illnesses and depressive
symptoms during adulthood. It is noteworthy that even
in a community with the highest social violence, such
as Juarez City in the Mexican state of Chihuahua, marital
status has been considered as a “protective mechanism”
against feelings of despair, social isolation, anxiety, and
depression.35 Therefore, it is important to include the
need to model the impact of the marital status of adults
in different communities on QOL and life
satisfaction.”
The results of present study showed that gender dif-
ferences in attitude, subjective norms, and optimism.
However, their findings are contradictory in different
communities because gender differences in psychological
factors could be explained by differences in clinical and
socio-demographic characteristics.36 Therefore, relevant
evidence is still controversial. The results of path analysis
showed a good fit between the QOL and the biological
psychosocial factors. Interestingly, the constructs of sub-
jective norms, general health, positive attitude, optimism,
and life satisfaction explained 50% of the total variance
of QOL in university students.
In this study, among all the constructs, general health
emerges as the strongest direct path of QOL and life sat-
isfaction that mediates the effects of attitude and optimism
on a student’s QOL. Our finding suggests that university
students who have a better health status (convenient daily
lives and physical health, positive emotions, cognitions,
self-control, and self-steam) showed a greater life satisfac-
tion and QOL within a broader context of mental and
physical health, emotional, general well-being, and social
functioning performance. This result is consistent with
6 S. B. TAVAKOLY SANY ET AL.
other similar studies that showed a higher QOL, positive
attitudes, and emotions may significantly influence physical
and mental well-being by the promotion of optimism and
a healthy lifestyle.3,4
Life satisfaction was a second strong direct pathway.
This construct mediates the effects of subjective norms,
attitude, general health, and optimism on the student’s
QOL, which was consistent with the previous literature.9
In this study, most of the students (around 60%) either
agreed or strongly agreed with the specific life satisfac-
tion statements include “I am satisfied with my life or
so far, I’ve gained whatever I wanted in life”.
Consequently, these students showed a high degree of
positivity and optimism toward their QOL. Several stud-
ies have reported that a positive feeling and sense
toward life conditions are more likely to promote an
individual’s life satisfaction.4,9 The Path analysis showed
that attitude significantly affected students’ QOL via
significant indirect pathways that mediate the effects of
subjective norms. Also, the significant indirect pathway
that was strongly mediated by attitude causes the overall
impact of optimism on the QOL.
Notably, most of the participants either agreed or
strongly agreed with the specific attitude statements include
“I feel that when I think positively, my life is meaningful
and purposeful or I feel that when I think positively, I
think better”. Likewise, nearly half of the students believed
that optimism will lead to better health and communica-
tion. However, some students (38%) believed that optimism
does not contribute to the QOL in difficult situations in
life. According to the previous studies, a high positive
attitude and belief toward the benefits of optimism are
more likely to improve an individual’s QOL. Also,
Sosnowski et al. pointed out that attitudes in difficult
situations may cause specific emotional and behavioral
responses, which in turn have a significant impact on the
QOL and physical function.4
There is evidence that attitudes constitute two psy-
chological adaptation strategies when life is difficult. The
first strategy is the constructive (more active, optimistic,
and highly self-sufficient fight with the problem), which
is often associated with a better QOL and with better
mental, emotional, social functioning, and physical over-
all.4,9,37 Second is the destruction (dominated by feelings
of anxiety, hopelessness, helplessness, low self-sufficiency,
a fatalistic attitude, and less active), which is associated
with a poorer QOL and with worse functioning in all
aspects of life.4,15,38,39
Our finding showed that subjective norms positively
affected student’s QOL via significant indirect pathways;
accounting for 14–16% of the explained variance. This
finding highlights the role of friends, parents, and uni-
versity lecturers as influential people on the student’s
QOL by giving social support and encouraging them to
be optimistic. This result was consistent with other
health promotion studies that indicated subjective norms
could potentially lead to long-term changes in an
individual’s QOL in adhering to healthy behaviors.40,41
Likewise, several studies have shown that family mem-
bers should be considered as positive role models when
designing health education programs to promote QOL.
Furthermore, our results showed that student’s QOL is
significantly associated with fathers ‘education level.4,42
According to the literature, parents’ education level is
associated with life satisfaction in children and young
people, because parents with high education have easy
access to financial and social resources.4 There is evi-
dence that students with strong financial and social con-
ditions will benefit from a higher QOL due to easy
access to socio-economic support structures. In general,
these subjective norms could be considered as important
mediators in changing the QOL. 4,41 There is a gap
between the identification of the role of subjective norms
and their implementation in skill-based operationaliza-
tion. Therefore, more research is needed to evaluate the
impact of subjective norms on the QOL through cultural
and socio-economic practices.
Implication
Our research is one of the first to use life satisfaction,
subjective norms, general health, optimism, and attitude
constructs to provide a database related to identifying
potential determinants of QOL among Iranian students.
Testing the application of these potential constructs in
different populations and cultures is essential to better
understand the mechanisms that promote the underlying
determinants of QOL. Understanding the theory of QOL
has become an important issue in health promotion
programs. Indeed, potential determinants that influence
QOL allow public health policy educators and health
promoters to conduct a better study on individual’s needs
and intentions in different populations.
Limitation
Our study is subject to limitations. Although self-reported
questionnaires are commonly used in a cross-sectional
study, it may lead to biased results and the possibility of
representativeness. Likewise, the contribution of female
students in this study was higher than that of male stu-
dents. This study was designed based on the cross-sec-
tional method without any restrictions on gender
selection. Gender differences are beyond the design and
scope of this study, indicating that there is potential for
future research on this issue. However, our findings indi-
cate that the relationship between gender differences,
overall health status, satisfaction with the scale of life,
and QOL is negligible. Since gender differences in psy-
chological factors can be explained by differences in
clinical and socio-demographic characteristics, relevant
issues in different countries are contradictory. In future
research, we aim to examine gender differences in

psychological factors and health-related QOL and to show
the extent to which this difference can be described by
differences in the clinical and socio-demographic char-
acteristics of Iranian students.
In this study, we selected participants from university
students who were studying in universities of Torbat
Heydariyeh. Therefore, these results may not apply to
students from other universities in Iran. Thus, further
study on these constructs with longitudinal data among
other populations is essential to test whether results are
comparable.
Conclusion
Our findings support the effectiveness of life satisfaction,
subjective norms, general health, optimism, and attitudes,
which are the underlying constructs for testing QOL deter-
minants among Iranian college students. We found that
students’ general health and life satisfaction were the
strongest constructs to predict the QOL among university
students. It seems that the use of these constructs may
offer a promising educational technique to promote QOL.
Another implication of our study is that policymakers and
psychologists should be aware of the effect of a father’s
education level and students’ marital status on QOL and
life satisfaction. The key direction of future research is to
explore why the QOL of Iranian students whose fathers
are less educated is different. This is just a step toward a
better understanding of the potential impact of potential
determinants (such as life satisfaction, subjective norms,
general health, optimism, and positive attitudes) on the
QOL of Iranian students.
Conflict of interest disclosure
The authors have no conflicts of interest. Informed consent
was obtained from all individual participants included in
the study. This study is based on a research project
approved by the Student Research Committee of Torbat
Heydariyeh University of Medical Sciences with the code
of ethics IR.THUMS.REC.1396.35. We would like to thank
the students who assisted the authors to run this research
project. We would like to thank the students who assisted
the authors to run this research project.
Funding
No financial support was received for this study.
ORCID
Seyedeh Belin Tavakoly Sany http://orcid.org/0000-0002-
7891-4449
Elaheh Lael-Monfared http://orcid.org/0000-0003-3212-1571
Hadi Tehrani http://orcid.org/0000-0001-8747-8717
Alireza Jafari http://orcid.org/0000-0003-1390-9830
Journal of American College Health 7
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