Artigos

Introduction
University life brings new challenges and responsibilities along with important changes in students' lives, such as more time away from family, new social networks, academic requirements, and biological, physical, cultural, and psychosocial changes and adaptations 1. This may increase the risk of unhealthy behaviors, such as physical inactivity 2, sedentary lifestyle 3, sleep-related problems, eating disorders, alcohol and drug use, unsafe sex, stress, depression, and social isolation 4. Furthermore, these behaviors may become an important part of an individual’s lifestyle across the life course 5, 6.
Social resources can help, and encourage individuals to better deal with everyday situations and favor adopting healthier behaviors 7. Thus, a perception of low social support has been associated with a higher level of psychological stress. Chronic stress may result in problems, such as poor academic performance, maladjustment to university, and even college dropout 8, 9. In addition, social support has been considered an important resource for coping with stress 10, physical inactivity 11, and sedentary behavior 12 since a higher level of social support may contribute to overcoming difficulties, reducing vulnerabilities, and promoting healthy lifestyle habits 13. Since health behaviors learned during youth can be kept into later adulthood 14, it is important to comprehend the psychosocial factors influencing them.
Although the association between social support and physical and mental health-related behaviors in university students is relatively well established, few studies have investigated the interdependence among these variables in this population. To date, no study has examined gender differences while considering all these variables simultaneously. The intertwined influence among these variables can be understood through the lens of the buffering-stress framework 15 and the transactional stress model 16. According to these approaches, social support can influence stress either before or after an event is perceived as stressful by reducing or preventing the initial appraisal of stress, promoting a reassessment of the event, inhibiting maladaptive reactions, or encouraging adaptive responses to the stressful situation 17.
Physical inactivity and increasing levels of sedentary behavior represent a global trend 18, 19 that has also affected university students 20-24. The transition to university life may simultaneously lead to changes in daily routines, social relationships, motivation, and available resources for engaging in physical activity. It may also increase opportunities for sedentary behavior and elevate perceived stress levels due to academic workload, limited time to study, pressure for high academic performance, and sleep deprivation 6, 25. A study conducted during the pandemic with 5,720 students found a prevalence of 48.8% of physical inactivity 21, while another study involving 2,287 university students reported a prevalence of 50.4% of high sedentary behavior (six or more hours per day) 24. Although studies employing robust methodologies to assess the interrelationships among physical activity, sedentary behavior, social support, and perceived stress remain scarce in Brazil, the country has experienced a significant increase in both the number and social diversity of students entering higher education in recent decades26. This context highlights the need to investigate the emerging health dynamics within this population.
Thus, this study aimed to investigate the effects of social support on physical activity and sedentary behavior in university students, considering the mediating effects of perceived stress. We hypothesized that: (a) social support would have a direct effect on both physical activity and sedentary behavior; and (b) social support would exert an indirect effect on these outcomes through perceived stress. Given the well-documented gender differences in the reported of physical activity19 and sedentary behavior levels20, 22, as well as in the social support27, 28, and perceived stress29-31, a secondary and exploratory objective was to test these hypotheses separately for male and female students.

Methods
This cross-sectional study was conducted with students from a private university in the Brazilian Midwest, comprising campuses in three different cities. According to the 2010 Brazilian Census, the cities` Human Development Indexes were all above 0.70 with a combined population of around 1 million inhabitants. Data were collected through self-administered, standardized questionnaires from November to December 2018. The university had approximately 8000 students and five campuses. All the 2,658 university students regularly enrolled in health courses (physical education, nursing, pharmacy, physiotherapy, medicine, and dentistry) of both sexes, aged 18 years or older, were invited to participate.
A pilot study was conducted with students who were not eligible for participation to test the instruments and research logistics. Students were notified about the research and its purpose through a digital platform that all officially enrolled students can access. The anonymized forms were filled out during class hours, under the supervision of the research team. Absent students were excluded after three contact attempts. Ethical approval was obtained from the university ethics committee and all participants signed an informed consent form.
The main exposure was social support measured by the Multidimensional Scale of Perceived Social Support (MSPSS) 32. The MPSS evaluated emotional and social interaction supports received from friends, family, and significant others through 12 items, four to each source. Answers to these items were rated on a seven-point Likert scale from “strongly disagree” to “very strongly agree”. The Brazilian version of MPSS showed adequate construct validity evidence among workers 33.
The outcomes were physical activity and sedentary behavior. Physical activity was measured using the short version of the International Physical Activity Questionnaire (IPAQ) 34 which measures the frequency, intensity, and duration of leisure, work, commuting, and household activities. Total energy expenditure was calculated using the following formulae: duration in minutes x frequency in days x Metabolic Equivalent of Task - METs (walk x 3.3 METs, moderate physical activity x 4.0 METs, and vigorous physical activity x 8.0 METs)] 35. Higher scores represented higher physical activity practice. Sedentary behavior was measured through time spent (in hours) in a day watching television, using the computer for work, study, or leisure, playing video games (on any electronic device), and commuting by car, motorcycle, or bus from home to work or college 36. The time spent in each activity was recorded, and higher scores represented longer periods of sedentary behavior.
The mediating variable was psychological stress measured by the Perceived Stress Scale (PSS-10) 37. THE PSS-10 assessed the degree to which participants believed that their lives had been unpredictable, uncontrollable, and overloaded in the last 30 days. It consisted of 10 items (four positive items and six negative items) answered on a five-point Likert scale from never to very frequent. Positive items were reversed, and higher scores represent a higher level of stress. PSS-10 showed acceptable validity and reliability for the Brazilian context 38.
Exogenous variables included the following sociodemographic, socioeconomic, behavioral, and nutritional characteristics: gender (male/female), age (in years), marital status (with/without a partner), economic classes (A-richest/B/C-poorest) 39, smoking (smoker/non-smoker), illicit drug use (use/non-use), and Body Mass Index – BMI (kg/m2).
EpiData version 3.1 software was used for data entry and STATA version 15.1 for descriptive and univariate analysis. The association between outcomes, exposures, and mediator with sociodemographic and behavioral variables was tested through the Student t-test, ANOVA, Mann-Whitney, Wilcoxon, and Spearman correlation.
Structural equations modeling (SEM) was used to investigate the relationships between the exposure, mediator, and outcome using the Mplus program, version 8.4 40, and the Weighted Least Squares Mean and Variance Adjusted (WLSMV) as the estimation method. Latent variables were defined for stress and each social support resource, while a second-order latent variable represented total social support. The paths were informed by the literature, which reports a negative association between social support and both stress and sedentary behavior 17, 41, as well as a positive association between social support and physical activity 17, 42. Exposure, mediator, and outcomes were adjusted by sociodemographic variables, nutritional status, and behavioral confounders.
The adjustment of the models was assessed by non-significant chi-square (?2), Comparative Fit Index (CFI) and Tucker-Lewis Index (TLI) >0.9, Root Mean Square Error Approximation (RMSEA) ?0.06, and Standardized Root Mean Square Residual (SRMR) <0.080 43. MODINDICES command was used to achieve a better adjustment. In the final model, total, direct, and indirect effects of exposure on outcomes were evaluated. All analyses were conducted in the total sample and stratified by sex. A level of statistical significance of less than 5% was adopted.
Results
Of the 2,658 eligible students, 353 were absent, eight refused, and two dropped out, yielding an initial sample of 2,295 students (1596 females and 699 males). Due to missing data in key variables, final analysis was conducted with 2042 students (1414 females and 628 males).
Most participants were aged between 20 and 24 years and belonged to economic classes A or B. Men reported higher means of physical activity levels (2618 METs), and lower average social support (SS=77.7 points) compared to women (PA=1717 METs; SS=83.4 points). Conversely, women reported higher levels of emotional stress (52.7 points), and lower mean of sedentary behavior (6.4 hours) compared to men (Stress=44.4 points; SB=7.0 hours) (Table 1).
The adjustment for the social support in the measurement model was: ?2=2,635 (g.l.363); RMSEA=0.055; CFI=0.980; TLI=0.976; SRMR=0.045. Correlations were added between the items that evaluated the existence of a close person for need and to share joys and sorrows, as well as a person for comfort and who cared about their feelings (items 1 and 2; 5 and 10, respectively). For the stress model, the adjustment parameters were: ?2=1384 (g.l.32); RMSEA=0.136; CFI=0.943; TLI=0.919; SRMR=0.042. Correlations were added between items 4, 5, and 8 that assessed the existence of self-trust to solve problems, perception of control, and self-will in personal activities.
The final path model showed good fit: ?2=1938 (g.l.360); RMSEA=0.046; CFI=0.986; TLI=0.984; SRMR=0.042. The initial hypotheses were partially supported. A direct effect of social support on sedentary behavior, mediated by stress levels, was identified (?=0.08; 95% CI: 0.02, 0.14; p=0.007). However, no significant direct association was observed between social support and physical activity (p=0.901) (Table 2, Figure 1). Social support demonstrated a significant indirect effect on both sedentary behavior (?= -0.07; 95% CI: -0.10, -0.05; p<0.001) and physical activity (?=0.03; 95% CI: 0.01, 0.05; p=0.006), with emotional stress as the mediating variable (Table 2). Higher levels of stress were associated with lower physical activity (p=0.005) and greater sedentary behavior (p<0.001) (Figure 1).
In sex-stratified analysis, a significant direct effect of social support on sedentary behavior was observed among males (?=0.12, 95% CI: 0.01, 0.22) (Table 2 and Figure 2). The indirect effect of social support on sedentary behavior, mediated by emotional stress, was statistically significant for both males (? = -0.09, 95% CI: -0.13, -0.04) and females (? = -0.07, 95% CI: -0.10, -0.04) (Table 2 and Figures 2 and 3). Among females, an additional indirect effect of social support on physical activity mediated by stress was also observed (? = 0.03, 95% CI: 0.01, 0.07) (Table 2 and Figure 3). Unstandardized coefficients for all analysis are available as Supplementary Material (Figures 1S, 2S and 3S), accessible through the following link: https://drive.google.com/file/d/13mIe59yOEudHbgStxIdqV4chqBsp1aoO/view?usp=sharing.
Discussion
We investigated the effects of social support on physical activity and sedentary behavior mediated by perceived stress in healthcare college students. No association with physical activity was found while a direct and positive effect of social support on sedentary behavior was observed. Nevertheless, as hypothesized, we ascertained an indirect effect of social support on physical activity and sedentary behavior mediated by emotional stress.
Different from our findings, systematic reviews demonstrated a positive association between greater social support and physical activity and a greater probability of physical activity 28, 44. A possible explanation is that we used a broad measure of social support 32, not a specific scale on social support related to physical activity. At the same time, a general measurement of social support focused on emotional support and social interaction, as MSPSS, could not capture the instrumental support that greater influence physical activity.
In our study, the greater the perception of social support, the longer the sedentary behavior time, which conflicts with findings reported in studies with school-age children and young people 45, female 46, and young students 47. However, lower social support was generally associated with reduced access to instrumental resources, which could contribute to lower levels of engagement in physical activity 48 and increased sedentary behavior time 49, in addition to behavioral modeling, pressure, and network norms 50.
It is important to note that the direct effect of social support on physical activity is mainly due to the association found among men, as our gender-stratified analyses revealed that the same cannot be said for women. Men may be simultaneously physically more active and receive greater social support from parents and friends while tending to be more exposed to sedentary behavior than women 20,36-38. We hypothesize that greater instrumental social support offered for men may enable easy access to social media (television, video games, mobile phone, and computer) in an academic environment, favoring increased time spent in sedentary behavior, and, at the same time, in physical activity. It is also important to highlight that the double workload often experienced by women, encompassing both domestic and academic responsibilities, may limit their available time for sedentary behavior, leisure, and physical activities. Thus, even though women tend to perceive that they receive more emotional social support than men in our study, it can be argued that this does not always translate into sufficient instrumental help to cope with the double burden of work in a society grounded in female informal care labor 51.
Additionally, we found an indirect effect between social support and physical activity and sedentary behavior time, mediated by perceived stress. For a college student sample, social support led to a lower stress level, which is associated with a higher level of physical activity practice (among women) and shorter sedentary behavior time. In this sense, a systematic review pointed out associations between reduced physical activity and increased sedentary behavior time with poor mental health among adults 52. Another study with 1910 Brazilian adult workers also found that reduced leisure time of moderate to vigorous physical activity and more sedentariness were associated with increased perceived stress 53.
Once again, analysis by gender shed light on more nuanced results. Our findings suggest that physical activity among women may be a behavior more susceptible to supportive social interactions in the context of stressful situations than it is for men. This may be explained by the fact that women, who often carry a greater burden of unpaid domestic and caregiving responsibilities, are simultaneously more vulnerable to stress 51 and have less time and motivation to engage in physical activity. In contrast, among men, emotional social support in times of stress may occur in social contexts that promote sedentary behaviors, often combined with avoidant coping strategies (e.g., playing video games, watching sports on TV, drinking alcohol with friends, or spending long hours on social media or online forums) 54.
Our findings reinforce that gender should be understood as a structural factor that simultaneously influences perceived social support, psychological well-being, and opportunities for physical activity 55. Therefore, future studies should more thoroughly investigate the role of gender in shaping the relationships between social support, physical activity, and sedentary behavior.
Some implications of our findings emerge for public policies and health promotion initiatives in university settings. Strategies aimed at encouraging physical activity among students should account for the complex interplay between perceived stress, social support, and gender. Given that emotional support may not translate into adequate instrumental support—particularly for women—programs should prioritize actions that reduce structural barriers to physical activity, such as flexible schedules, access to on-campus childcare, and educational initiatives that promotes gender equality. Furthermore, considering that men may experience social support in settings that reinforce sedentary behaviors, interventions targeting this group could promote healthier alternatives for stress management and leisure.
Considering the cross-sectional design, our results should be interpreted cautiously. Reverse causality cannot be excluded. Social support could be a resource to cope with stressful situations across the university period 9, and physical activity can be a coping strategy. It also can provide a way to rear or expand the students` social network and strengthen social cohesion 56. In this sense, it could be argued that physical activity may provide a lower level of stress 57, as well as low stress favoring a greater practice of physical activity 9. Longitudinal studies could explore these relationships across time and identify optimal intervention periods.
Furthermore, our data were collected from a private university, where students are generally from wealthier economic classes, and can have specific patterns of health behavior and access to leisure activities. Even though, our findings are based on a large and representative sample of university students from the Brazilian Midwest got through rigorous and standardized procedures for data collection and using validated measures for the target variables. In addition, the structural equation model showed acceptable adjustment to the data, and the method provides a lower measurement error that favors the exploration of the interrelationship between multiple variables, as well as the use of more than one outcome. Future studies are required to expand the findings to diverse populations.

Conclusions
Our findings offer insights into the interplay between social support, perceived stress, physical activity, and sedentary behavior among healthcare university students. The study revealed a direct effect of social support on sedentary behavior among male students, and the higher the perception of social support, the longer the sedentary behavior time. It suggests that social interactions often occur in sedentary contexts, especially for young men. Moreover, an indirect effect of social support on sedentary behavior mediated by emotional stress was observed, as well as on physical activity among women. Thus, the findings suggest a mediating role of stress in the relationship between social support and level of physical activity, and sedentary behavior time, with a nuanced figure by gender.
The results have critical implications for the field of public health, particularly in designing and implementing interventions aimed at promoting healthier lifestyles within academic environments. University policies should incorporate psychosocial and physical health objectives by redesigning spaces to foster active behaviors during social interactions, promoting peer-supported physical activity programs, and integrating mental health resources with physical activity initiatives, considering the gender differences. Beyond the university setting, these findings provide valuable insights for workplace and community health programs, highlighting the importance of reducing stress, enhancing social support, and encouraging active lifestyles. Finally, public health promotion policies should adopt holistic approaches that address the interplay between social support, stress, behavior and gender to promote sustainable and equitable improvements in both physical and emotional well-being.

Acknowledgments
None.

Funding
No funding was received to conducting this study.

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