Exploratory factor analysis of items for evaluating healthy lifestyles related to mental health among undergraduate students.

Abstract Introduction: A healthy lifestyle is pivotal for improving mental health. As the concept of a healthy lifestyle is comprehensive, there is a need to prioritise components related to mental health in planning proper mental health interventions. In this regard, physical activity, diet, sleep quality, substance abuse and social support have been identified to enhance mental health. It is necessary to develop a valid scale for assessing healthy lifestyles related to mental health. Thus, this study aimed to adapt and validate an existing scale to evaluate healthy lifestyles related to mental health. Method: This study included 177 (men: n=73, women: n=104) participants from University Teknologi MARA, Puncak Alam, Selangor. The data were presented using descriptive statistics and subjected to an exploratory factor analysis. Results: The 22 scale items evaluated were valid and reliable in assessing the five components of healthy lifestyles related to mental health. The total variance explained for measuring the construct was 68.610%. The Cronbachs alpha value for the five components ranged from 0.784 to 0.903. Conclusion: The adapted scale is acceptable and reliable in evaluating healthy lifestyles related to mental health within the target population. Thus, it can be used to assess significant components of healthy lifestyles to promote mental health. Accordingly, relevant authorities can formulate the best strategies to enhance mental health.


Introduction
Undergraduate students are susceptible to mental health problems due to academic stress and social issues.It has been reported that 49% and 41% of health sciences and accountancy students at Universiti Teknologi MARA (UiTM), Puncak Alam, Selangor, experience anxiety, respectively, 1 while students in Shah Alam experience severe depression, anxiety and stress. 2Healthy lifestyle components, including relationships, social support, healthy diet, smoking, alcohol consumption, sleep quality and physical exercise, could in uence mental health bidirectionally. 3,4Promoting healthy lifestyles can enhance mental health, and interventions should consider protective and modi able factors to ensure the e ectiveness of behavioural changes. 5Appropriate instruments are necessary to assess protective factors.
Many studies have emphasised the role of physical activity, diet, substance abuse, sleep quality and social support in mental health.us, there is a need to explore the bene ts of a healthy lifestyle owing to the potential e ect on mental health.Physical activity comprises various movement activities, including any skeletal muscle-driven body movements requiring the use of energy beyond the resting levels. 6Past studies have shown that physical activity enhances mental health, as it boosts mood and self-esteem and reduces stress.Engaging in 150 min of moderate-tovigorous physical activity weekly could reduce symptoms of depression. 7Moreover, 60-min aerobic activities three to ve times a week are recommended for optimal well-being.
A healthy diet consists of food that positively impacts health or, at the very least, has no adverse health e ects. 8According to the World Health Organization, inadequate nutrient intake increases the risk of diseases such as hypertension. 9A diet comprising fruits, vegetables, sh, legumes, lean meats, olive oil and whole grains can improve mental health and reduce the risk of depression. 9In contrast, a diet consisting of processed, fried and sugary foods is linked to depression and anxiety, especially among adolescents.Undergraduate students generally consume unhealthy diets, which could impact their mental health.Unhealthy dietary habits such as skipping breakfast, reducing fruit intake, snacking too frequently and eating fried and fast food could a ect the body's oxidative stress indicators, immune system markers and in ammatory factors and subsequently disrupt one's mental health. 10bstance abuse refers to repeated or continuous use of addictive substances such as alcohol, tobacco, and drugs. 11It is commonly linked to health issues, including mental health problems.Studies have found that university students who smoke and consume alcohol as stress coping mechanisms are more susceptible to depression and anxiety. 12Hence, there is a high prevalence of mental health issues among students who smoke and drink alcohol. 13Numerous studies have con rmed the adverse impacts of substance abuse on one's health.For instance, binge drinking can lead to a high glucose level and blood pressure, while smoking is linked to adverse lipid and lipoprotein pro les.
ese conditions could subsequently lead to depression. 14eep quality is a crucial aspect of quality of life, as it denotes one's satisfaction with all aspects of sleeping experience. 15Research has shown that sleep quality can signi cantly a ect overall health.Su cient high-quality sleep can improve psychological well-being and prevent mental health issues. 16Conversely, low-quality sleep can lead to hypertension, depression, and anxiety.Academic and psychological pressures and extracurricular activities are probable causes of poor sleep quality among undergraduate students. 17In this regard, adolescents need at least 7 h of sleep each night to ensure a healthy lifestyle.
Social support includes access to resources and aids such as coping mechanisms, resource sharing and personality attributes.It is an essential component of healthy lifestyles and mental health. 18Social support signi cantly improves health, preventing unhealthy behaviours and mental health issues, especially among adolescents. 18Youths with adequate social support typically have positive interactions with others and, subsequently, better mental health.For students, social support includes relationships with teachers and peers, who signi cantly impact their behaviour.Undergraduate students often obtain essential social support and mental health bene ts from their housemates or good friends in their campus.is shows the importance of friendship in providing social support.Friends provide optimal social support through shared interests, secure relationships, and peer recognition. 19Hence, social support is crucial for maintaining emotional well-being, e ectively protecting against mental health issues.In this regard, having close friends and family creates a sense of safety and support.Previous studies 7,9,12,13,16,18 have indicated the bene ts of a healthy lifestyle on mental health.
us, this study aimed to adapt and validate a healthy lifestyle questionnaire to ensure its suitability in the context of mental health among the target population.An instrument's validity and reliability are the most important factors to ensure accuracy and data usefulness.Owing to population disparities, questionnaires used to evaluate healthy lifestyles are often inappropriate.For instance, the validity of a quality of life questionnaire could be compromised if used in contexts other than where it is initially intended. 20refore, a questionnaire should be in line with the characteristics of the study population, such as age, sex, cultural context and educational background, and the purpose of the study. 21

Participants
In this study, a survey was conducted among rst-to fourth-year undergraduate students aged 19-23 years at UiTM, Puncak Alam.e lottery method was used to select a random sample from the sampling frame.Students from six faculties and two colleges at UiTM, Puncak Alam, who could read and understand Malay or English were included.e sample consisted of 177 respondents selected randomly; this size was considered su cient in generalising the results to the population and appropriate for an exploratory factor analysis (EFA).Most scholars agree that the number of participants should be at least 100. 22

Instrument
e study instrument was adapted from the Adolescent Healthy Lifestyle Questionnaire (AHLQ), 23 one of the questionnaires used in populations in Klang Valley.
e AHLQ has a similar goal and target population to the present study.Hence, this questionnaire is the most suitable questionnaire that can be adapted to the target population.e original AHLQ was developed to evaluate healthy lifestyles among adolescents aged 13-17 years in Klang Valley.
e AHLQ has 64 items across various healthy lifestyle components.Since the AHLQ targets school students, some items and components might not be relevant to this study.Hence, the original instrument was slightly modi ed to suit undergraduate students at UiTM, Puncak Alam.e items were re ned, and the constructs were summarised, focusing on the relationship of diet, physical activity, social support, sleep quality and substance abuse with mental health.
e related constructs, such as social health and interpersonal relationships, were combined with social support, and the terms 'teacher' and 'school' were changed to 'lecturer' and 'campus', respectively.e rst section assessed the respondents' demographic background.
e next section contained 25 items on the ve constructs related to healthy lifestyles.e respondents were asked to rate their agreement on the statements using a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).Five experts were consulted to ensure the questionnaire's content validity based on the content clarity, relevance, and quality.According to Mohd Noah and Ahmad's formula, 24 a value of 0.80 indicates a good content validity.

Ethical considerations
is study was approved by UiTM Research Ethics Committee under reference number ED/REC/F/10319.Informed consent was obtained from all participants.

Results
A total of 177 students who ful lled the inclusion criteria completed the questionnaire.In particular, the sample consisted of 104 (58.81%) female and 73 (41.2%) male rst-to fourth-year students aged 19-23 years (Table 1).EFA is study adapted items from an existing questionnaire to suit the target population's requirements.An EFA was used to re-evaluate each item to ensure applicability to the present study.Twenty-ve items were analysed via principal component analysis extraction and varimax rotation.
e factor loading for the study was set at a minimum of 0.50.e study extracted items with factor loadings of at least 0.50 and eliminated three items (SS23, SS24 and SS25) with factor loadings below 0.50.As shown in Table 2, the result of Bartlett's test of sphericity was signi cant (P<0.05).Additionally, the sampling adequacy based on the Kaiser-Meyer-Olkin (KMO) value (0.857) was acceptable.A KMO value of 0.60-0.70 is considered adequate for an EFA. e screen plot in Figure 1 shows that ve components emerged from the EFA.e EFA grouped the 25 items into ve distinct components with certain numbers of items.e rotated component matrix shows the items grouped under each component.
Table 4 lists the factor loadings for the ve components in the EFA.e factor loading for each item was higher than 0.50, except for SS23 ('I disagree with my lectures on many things'), SS24 ('I disagree with my friends on many things') and SS25 ('I disagree with my parents on many things').Twenty-two items were retained to measure the relationship between healthy lifestyles and mental health.Internal reliability of the instrument e Cronbach's alpha value for each component of the scale was determined to evaluate its internal reliability.e values for the ve components ranged from 0.784 to 0.903, exceeding the accepted alpha value of 0.65-0.80 for the human dimension.Generally, an alpha value of 0.76-0.95 is considered fairly high. 26

Discussion
is study aimed to adapt and validate the AHLQ 23 to examine the relationship of physical activity, diet, substance abuse, sleep quality and social support with mental health.A few items needed to be revised owing to the di erent study population.An EFA was needed to identify the appropriate items, as the existing questionnaire targeted a di erent population.Hence, an EFA was performed to determine the number and nature of common factors explaining the correlation pattern between the items and the suitable number of factors needed to reproduce the item correlation matrix. 27Compared with a con rmatory factor analysis (CFA), an EFA allows researchers to nd elements empirically unrelated to the intended construct and assess a questionnaire's psychometric properties during the initial instrument development or adaptation phase to determine validity.In this study, the EFA revealed a ve-factor structure with a high reliability for each factor (0.784-0.903).e scale's total variance 68.610%.
ere were 22 items representing ve vital components of a healthy lifestyle linked to mental health derived from the literature review. 9,11,15,16,18 results showed that the questionnaire had good validity, suggesting that it can be used for assessing healthy lifestyles related to mental health in the target population.
Regarding healthy lifestyles and mental health, the Simple Lifestyle Indicator Questionnaire 28 contains 12 items under ve constructs: diet, physical activity, smoking, stress, and alcohol consumption.All forms of substance abuse (e.g.alcohol, drugs or tobacco) should be considered.Other important aspects to consider for improving mental health are social support and sleep quality.Similar to the AHLQ, the Healthy Lifestyle Questionnaire 29 for Ecuadorian University Students (EVS-EUE) has ve constructs.However, the EVS-EUE does not include social support and other substance abuse linked to mental health.
e study provides evidence supporting the instrument's validity and reliability.is suggests that the questionnaire is well suited for use among undergraduate students at UiTM, Puncak Alam.Employing an appropriate instrument is essential in the current context, as it enables the identi cation of the signi cant components of a healthy lifestyle that may help improve mental health.Accordingly, this aids in evaluating current policies and developing more targeted interventions or strategies to promote a healthy lifestyle and enhance mental health within the speci ed population.In this context, the promotion of a healthy lifestyle and mental health aligns with the pursuit of Sustainable Development Goal 3, especially in terms of mental health, well-being, and substance abuse.e present ndings' generalisability to all Malaysian undergraduate students may be limited owing to the sample being limited to undergraduate students at UiTM, Puncak Alam.Future research should expand its sample to all university students in Malaysia, considering the validity of the AHLQ and the importance of a healthy lifestyle in mental health.
e AHLQ could be translated into various languages to accommodate cultural and environmental di erences, potentially yielding valuable ndings and discussions.Additionally, future researchers could conduct a CFA to test constructs across di erent populations.
e study did not perform a CFA owing to the questionnaire's adaptability and the need to identify latent factors within 22 items.A CFA could verify these factors using a priori factors explored in the EFA.An appropriate questionnaire is essential to accurately assess healthy lifestyles relative to mental health among undergraduate students at UiTM, Puncak Alam.Based on the ndings, the AHLQ is suitable for use in this population because the items are aligned with the cognitive abilities and characteristics including the cultural background of the students.

Table 4 .
Five components and items of the questionnaire on healthy lifestyles related to mental health.
a Rotation converged in six iterations