Quality of Life (QoL) is defined according to the World Health Organization (WHO) as "an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.”¹ QoL is a broad ranging concept affected in a complex way by the person's physical health, psychological state, personal beliefs, social relationships and environment.¹Medical students represent a unique group of persons at risk of reduced QoL. Several studies have shown increased incidences of anxiety, depression and other psychological disturbances in medical students when compared to the general population.² Medical school also appears to increase the risk of sleep disorders, burnout and substance abuse.³A 2019 study which examined QoL in medical students at the Faculty of Medical Sciences, University of the West Indies, St. Augustine, Campus (FMS-UWI) revealed that QoL was associated with academic performance and programme of study.⁴ The impact of the ongoing COVID-19 pandemic on medical students’ mental wellbeing and concerns has also been documented.⁵There is however a paucity of published data on the QoL construct in medical students during the COVID-19 pandemic. The primary objective of this study was to examine QoL and its associations in FMS-UWI students. The secondary objective was to explore potential impacts of the local COVID-19 pandemic restrictions on QoL in this population.

Setting and sampling strategy

This research was done using a cross-sectional study design on all currently enrolled undergraduate students (n=2164) at FMS-UWI during the period 1^st March 2020 to 30^th June 2020. This represented all the students across all years who were actively enrolled in programmes in the Schools of Medicine (n=1237), Dentistry (n=169), Veterinary Sciences (n=167), Pharmacy (n=229), Nursing (n=271) and Optometry (n=91). The School of Medicine accounted for at least 57% of the total student population at the faculty. Nationwide restrictions due to the pandemic went into effect on 16^th March 2020 after which the survey, being online from inception, was allowed to continue.

Following approval from the Ethics Committee of the University of the West Indies, St. Augustine Campus (CREC-SA.0111/11/2019) an electronic survey form was sent out to all school representatives inviting them to circulate to their respective student bodies through social media. Informed consent was obtained electronically by students’ agreement to continue anonymously with the survey beyond the first page. Up to 3 reminders were sent to the student bodies, with incentives of free coffee shop vouchers for 6 participants at random draw after survey completion.

Sample size

Based on an expected proportion of 30% of students with a reduced QoL and a finite population size of 2180, a minimum of 282 students was required for the survey to estimate proportions with 95% confidence limits and 5% precision.⁶

Instrument development

Primary data was gathered via an online questionnaire which was short and easily interpretable with no technical terms. The questionnaire was based on a validated existing World Health Organization QoL (WHOQOL-BREF) tool which has demonstrated good reliability in medical student surveys.⁷Additionally, demographic data and students’ most recent grade point average (GPA) formed part of the online survey. Before formal testing, the questionnaire was pilot tested in 10 students for feedback and completion time, ease of use and to confirm scoring in compliance with recommendations. Pilot students were also included in the student groups surveyed for final data collection.

Data analysis

The collected data was analyzed using descriptive statistics as well as the Statistical Package for the Social Sciences software for statistical analysis (SPSS version 21.0, IBM Corp, USA). Descriptive data is presented using proportions and means. Comparisons were done using Chi squared testing for categorical and ordinal variables and the t-test was applied for continuous data that was normally distributed. Logistic regression was used for binary outcomes with demographic and student characteristics as independent variables with odds ratios (OR) reported with 95% confidence intervals (CI). A p value <0.05 was deemed statistically significant.

Demographics of the respondents

Table 1 shows the characteristics of the sample of 281 respondents. The response rate for this study was 12.9% (281/2164).

Table 1. Characteristics of the respondents

The majority of the sample was female (78%) with an average ± standard deviation (SD) age of 22±3.9 years. The female preponderance in this study was significantly greater than the 71% expected by enrolment statistics (p=0.01).⁸The predominant ethnicities were East Indian (65.5%), mixed/other (18.9%) and African (15.7%). Almost all respondents were local, with 8% being from a foreign country. Most respondents (88%) were enrolled in the Bachelor of Medicine, Bachelor of Surgery (MBBS) degree with the rest of students from the Schools of Dentistry, Veterinary Medicine and Pharmacy. One third of students were from year 1, another one third from year 2 and the remainder evenly distributed over years 3-5 of their programmes.

Quality of life measures

When asked to rate their quality of life the responses were Very Good (19%), Good (55%), Neither Poor nor Good (19%), Poor (5%) and Very Poor (2%). When asked about level of satisfaction with health the respondents reported being either Very Dissatisfied (3%), Dissatisfied (23%), Neutral (23%), Satisfied (42%) or Very Satisfied (9%). Table 2 shows QoL domain scores for the sample. With a maximum QoL score of 100 in any domain, the scores ranged from 55-63.

Table 2. Quality of life domain scores of the respondents

Correlates for quality of life domains

Table 3 shows the associations between QoL domains and students characteristics.

There were no associations between QoL domain scores and age, gender or GPA. However, the social and relationship domain was associated with ethnicity. In post-hoc tests the mean social and relationship score was significantly higher in East Indians compared to Africans (p=0.044). With regards to nationality there was a significantly lower environmental domain score in the foreigners when compared to the locals (p=0.014). Year of enrollment was also associated with the physical QoL domain. In post-hoc tests, year 5 students had the lowest score among all the years, which was significant when compared to year 4 students who had the highest score (p=0.008). QoL domains were also dependent on programme of enrollment. In the physical domain DDS students had significantly lower average scores compared to MBBS students (p<0.001). In the social/relationship QoL domain, DDS students also had significantly lower mean scores compared to MBBS students (p=0.028). With regards to the environmental domain, DDS students also had significantly lower average scores compared to MBBS (p<0.001) and Pharmacy (p=0.002) students.

 Table 3. Associations between quality of life domains and student variables

 

Impact of timing of COVID-19 pandemic restrictions and year

In this survey students either completed the questionnaire before the implementation of the COVID-19 restrictions or during the restrictions. Mean QoL scores for the physical (p=0.002) and environmental (p<0.001) domains were significantly higher during the restrictions compared to before. Comparisons were also performed between this 2020 study’s data and that reported by Chattu et al. for 2019.⁴ Table 4 shows the mean domain scores by year and gender.

 Table 4. Trends in quality of life domains by year and gender

 

 

There were statistically significant decreases in mean psychological and environmental scores in 2020 compared to 2019 for both males and females (p<0.001 for all). Of note there was a significant increase in mean social and relationship QoL scores for females in 2020 compared to 2019 (p<0.001).

Correlates for self-rated quality of life and health status

Table 5 shows the associations between self-rated quality of life and overall satisfaction with health.

 Table 5. Predictors of self-rated quality of life and health status

 

Being a foreigner was associated with a significantly reduced odds of reporting a good QoL (OR: 0.39, 95%CI: 0.16-0.94) compared to locals. Belonging to the dentistry programme was also associated with reduced odds of good QoL when compared to their MBBS counterparts (OR: 0.22, 95%CI: 0.08-0.60). With regards to health status belonging to years 2 (OR: 2.31, 95%CI: 1.26-4.24), 3 (OR: 2.55, 95%CI: 1.08-6.01) or 4 (OR: 2.14, 95%CI: 0.99-4.61) of the respective programmes was associated with increased odds of being satisfied with one’s current health compared to year 1. Similarly, for the programmes of study, respondents from dentistry were less likely to report overall health status satisfaction compared to MBBS students (OR: 0.20, 95%CI: 0.06-0.69). There were no significant associations between age, gender, ethnicity, GPA and these self-rated outcomes. In additional logistic regression analyses, there was no association between satisfaction with health status and when respondents filled the survey (OR: 1.63, 95%CI: 0.95-2.78). When compared to those who filled the survey before the COVID-19 restrictions, there was a positive association for self-rated good QoL in those who completed the survey during the period of nationwide restrictions (OR: 2.32, 95%CI: 1.31-4.11). This association persisted after adjustment for age, gender, ethnicity, and nationality (OR: 2.00, 95%CI: 1.04 - 3.84) and it was also independent, after additional adjustment, for year of study and programme (OR: 2.47, 95%CI: 1.10-5.54).

This study was a cross-sectional study that examined medical students one year after a similar survey. The significantly greater female representation in this study however was higher than the proportion expected based on enrolment. This female preponderance in filling online surveys has been documented with differences in female and male values operating in a gendered online environment as a plausible reason.⁹Despite the disparity between males and female participation in our study however, gender was not found to be a significant predictor of QoL scores. While some studies, including the local 2019 survey, suggest academic stress and burnout is worse in females, others have found better QoL domain scores in females or no difference between genders.^4,10 Age in this study was also independent of QoL across all domains. While this was in keeping with other studies, the associations were also inconsistent across various surveys that examined similar subjects.^4,11,12 The poor response rates from schools, other than that of the school of medicine, meant this survey focused mostly on medical (MBBS) students. A likely reason for this was the way participants were recruited. The absence of access to a mailing list for all students, for purposes of filling surveys, meant the authors had to resort to use of snowball sampling methods through use of personal student emails and social media. The pandemic nationwide restrictions also meant schools including the university were closed making face-to-face interviews unrealistic.

Comparison of QoL with other studies

The means scores of the WHOQOL-BREF QoL domains ranged between 54.9- 62.7. These scores were similar to students in the Chinese setting where average scores ranged from 54.9-64.9.¹³ Our study's highest mean score was in the physical domain and lowest mean score was in the psychological domain. In the Chinese study, the highest score was also in the physical domain, but their lowest mean score was in the environmental domain.¹³ However, we compared the results to a study conducted on medical students in Malaysia, which also utilized the WHOQOL-BREF tool. The domain scores ranged from 66.07-70.58; these results showed that the overall QoL at this Malaysian school was higher in all four domains.¹⁴

Comparisons with previous local survey

This study began data collection on 1^stMarch 2020. COVID-19 was declared a pandemic on 11^th March 2020 with the first confirmed case of COVID-19 locally on 12^th March 2020.¹⁵Nationwide restrictions including closure of all teaching institutions and closure of borders were enforced from 16^thMarch 2020.¹⁵ These restrictions resulted in students having to stay home as all face-to-face and clinical teachings were cancelled. Compared to the 2019 local study, social/relationship QoL domain scores were higher in females while psychological and environmental scores were lower in both genders. This may have been due to several factors. The decreases in psychological and environmental scores can be explained by the COVID-19 restrictions, which were maintained for most of the 4-month period of data collection. The negative consequences of the pandemic on medical students have been well documented. Anxiety surrounding contracting COVID-19, stress, interruptions in clinical training and inadequate supervision are some of these effects.¹⁶The improvement in female social/relationship scores in this study compared to 2019 may reflect differences in coping with the above reductions in QoL domains between the genders. Studies have found that females, despite having higher reported stress, tend to have a larger support networks and report greater quality in their social support.¹⁷

Effects of the COVID-19 pandemic

From the 2020 data collected in this survey, participants experienced higher QoL scores in the physical and environmental domains after the COVID-19 quarantine, compared to those who filled out the survey prior to COVID-19 restrictions. This suggests a positive impact of the pandemic on the QoL of students. During the first wave of COVID-19 in Trinidad and Tobago, there was low incidence and mortality in cases when compared to other countries.¹⁵ All of the early positive cases were hospitalized regardless of symptomology. Combined with measures that were not stringent during the early restriction period, students may have been able to maintain physical freedom and participate in regular recreational and leisure activities. Additionally, availability of online classes would have afforded students more free time for other activities of daily living. Furthermore, resources such as financial aid cheques and electronic devices provided by the government and university may have alleviated financial difficulties that students faced at the time. These factors may have resulted in an increased physical and environmental QoL score in our study. These positive effects contrast with a Spanish study which highlighted negative mental effects of the COVID-19 pandemic on university students.¹⁸ Student follow up beyond the end of this study’s data collection period, after 3 months of restrictions, may have resulted in different findings.

Foreign students and QoL

This study showed foreign students had lower mean scores across all domains of the WHOQOL-BREF survey, particularly in the environmental domain. Other authors have reported on the association between acculturative stress and reduced QoL in international students in various settings.¹⁹ Lack of social support, which is key to QoL, may be a main factor. Sojourning students often miss out on this social support from their family and friends at home. Discrimination has also been proposed as a negative contributor to QoL in international students, and it has been reported that international students may perceive prejudice and discrimination during their interactions with host nationals, increasing their vulnerability to discriminatory practices and likelihood of facing negative psychological consequences.²⁰ Financial strain, substance abuse and gambling have also been associated with international students, which may be contributing factors to their reduced QoL.²¹

Comparison among various schools within FMS

Significant differences were recorded following comparison of QoL scores in all domains between students studying in the various schools of FMS-UWI. One finding of particular interest was the reduced QoL scores of dental (DDS) compared to medical students (MBBS) in all 4 QoL domains. These findings are consistent with an Indian study that found dental students scored consistently lower in all domains particularly the physical and environmental domains.²² That study attributed the marked difference in the physical domain to the greater physical exertion that is associated with the dental profession compared to medicine. The local 2019 study also found that dental students had lower physical and environmental domain QoL scores than medical students but conversely had higher social and psychological domain QoL scores. Final year (5^th year) students in this survey also experienced reduced QoL scores in the physical domain. The stresses and pressures on final year medical students have been well highlighted.²³ The pandemic restrictions may have exacerbated these effects, especially as students faced many uncertainties with cancellations in clinical training and changes in modes of examinations.

Next steps

Seeing that foreign students had the lowest quality of life in the environmental domain, programmes such as festivals to welcome foreign students to the culture and practices of the host country may boost their QoL. Furthermore, it is noteworthy that many foreign students stay in halls of residence provided by UWI. Provision of recreational and support services at these facilities may further improve the wellbeing of international students. The dedicated center for student psychological support and counselling at UWI continued their services remotely during the pandemic. Improved awareness and access to such services can ensure students with low QoL have the necessary support and the best learning experience. Screening for QoL outcomes may also identify at-risk students who may benefit from intervention. As the COVID-19 pandemic evolves, advances in curriculum delivery, use of emerging technologies and student engagement, also has the potential to improve QoL.^22,24,25 Constant contact throughout their course of study can improve the relationship between students and faculty, who can advise and mentor students during this vulnerable period of their career.

Strengths and limitations

This study attempted to document the QoL in a group of medical students 1 year after an initial study, providing some interesting comparisons. It also provided key data on medical students QoL during the COVID-19 pandemic using a well validated tool that has been utilized in many other medical student surveys. Responses were collected using an online form which allowed researchers to maintain social distancing, obey restrictions and gather important data. This was however a convenience sample which may have resulted in selection bias and lack of generalizability. The biggest limitation of this study was the small number of respondents from the other schools of pharmacy, veterinary medicine, nursing, and optometry. This means the findings presented may not have been representative of those student populations. The influence of the ongoing COVID-19 pandemic may have also prevented those most negatively impacted, from filling an online survey.

In conclusion, dental, foreign, and final year students emerged as high-risk groups for reduced QoL scores in this study. The ongoing COVID-19 pandemic also may have had significant impacts on medical students’ QoL. Follow up studies should be done to monitor the QoL at this faculty as the pandemic is ongoing. There is also need for appropriate supportive interventions for young medical professionals who are identified as having reduced QoL.

1. World Health Organization. WHOQOL: measuring quality of life. Accessed on: 05 October 2020. Available at: https://www.who.int/healthinfo/survey/whoqol-qualityoflife/en/.

2. Hope V, Henderson M. Medical student depression, anxiety and distress outside North America: a systematic review. Med Educ. 2014;48:963-79.

https://doi.org/10.1111/medu.12512

3. Ribeiro Í, Pereira R, Freire IV, Oliveira BG de, Casotti CA, Boery EN. Stress and quality of life among university students: A systematic literature review. Health Prof Educ. 2017;4:70-7.

https://doi.org/10.1016/j.hpe.2017.03.002

4. Chattu VK, Sahu PK, Seedial N, et al. An exploratory study of quality of life and its relationship with academic performance among students in medical and other health professions. Med Sci (Basel). 2020;8:23.

https://doi.org/10.3390/medsci8020023

5. Lyons Z, Wilcox H, Leung L, Dearsley O. COVID-19 and the mental well-being of Australian medical students: impact, concerns and coping strategies used. Australas Psychiatry. 2020;28:649-52.

https://doi.org/10.1177/1039856220947945

6. Ramos-Dias JC, Libardi MC, Zillo CM, Igarashi MH, Senger MH. Quality of life among 100 medical students at the Catholic University in Sorocaba, São Paulo. Rev Bras Educ Med. 2010;34:116-23.

https://doi.org/10.1590/S0100-55022010000100014

7. Ilić I, Šipetić S, Grujičić J, Mačužić IŽ, Kocić S, Ilić M. Psychometric properties of the World Health Organization's quality of life (WHOQOL-BREF) questionnaire in medical students. Medicina (Kaunas). 2019;55:772. https://doi.org/10.3390/medicina55120772

8. The University of the West Indies St. Augustine Campus. Student Statistical Digest 2014/2015 – 2018/2019. Campus Office of Planning and Institutional Research. 2019. Accessed on: 06 February 2021. Available at: https://sta.uwi.edu/resources/documents/statistics/Student_Statistics_14_15-18_19.pdf.

9. Smith WG. Does gender influence online survey participation? A record-linkage analysis of university faculty online survey response behavior. 2008. Accessed on: 05 October 2020. Available at: https://eric.ed.gov/?id=ED501717.

10. Qiu Y, Yao M, Guo Y, et al. Health-related quality of life of medical students in a Chinese university: a cross-sectional study. Int J Environ Res Public Health. 2019;16:5165. https://doi.org/10.3390/ijerph16245165

11. Mahmoud MA, Fareed M. Assessment of quality of life among medical students in Saudi Arabia: a study based on WHO-QOL-BREF Protocol. Int J Med Res Health Sci. 2018;7:1-11.

12. Alkatheri AM, Bustami RT, Albekairy AM, et al. Quality of life and stress level among health professions students. Health Prof Educ. 2020;6:201-10.

https://doi.org/10.1016/j.hpe.2019.11.004

13. Zhu Y, Hu B, Bai X, Qu B. The quality of life and its influencing factors among medical students. J China Med Univ. 2015;44:714-6.

14. Gan GG, Yuen Ling H. Anxiety, depression and quality of life of medical students in Malaysia. Med J Malaysia. 2019;74:57-61.

15. Ministry of Health, Trinidad and Tobago. COVID19 Releases Archives. Accessed on: 31 August 2020. Available at: http://www.health.gov.tt/sitepages/default.aspx?id=293.

16. Lasheras I, Gracia-García P, Lipnicki DM, et al. Prevalence of anxiety in medical students during the COVID-19 pandemic: a rapid systematic review with meta-analysis. Int J Environ Res Public Health. 2020;17.

https://doi.org/10.3390/ijerph17186603

17. Kneavel M. Relationship between gender, stress, and quality of social support. Psychol Rep. 2020:33294120939844.

https://doi.org/10.1177/0033294120939844

18. Odriozola-González P, Planchuelo-Gómez Á, Irurtia MJ, de Luis-García R. Psychological effects of the COVID-19 outbreak and lockdown among students and workers of a Spanish university. Psychiatry Res. 2020;290:113108.

https://doi.org/10.1016/j.psychres.2020.113108

19. Yu B, Chen X, Li S, Liu Y, Jacques-Tiura AJ, Yan H. Acculturative stress and influential factors among international students in China: a structural dynamic perspective. PloS One. 2014;9:e96322.

https://doi.org/10.1371/journal.pone.0096322

20. Williams DR, Lawrence JA, Davis BA, Vu C. Understanding how discrimination can affect health. Health Serv Res. 2019;54 Suppl 2:1374-88.

https://doi.org/10.1111/1475-6773.13222

21. Moore SM, Thomas AC, Kalé S, et al. Problem gambling among international and domestic university students in Australia: who is at risk? J Gambl Stud. 2013;29:217-30. https://doi.org/10.1007/s10899-012-9309-x

22. Cherkil S, Gardens SJ, Ks D. Perceived stressors as determinants of quality of life among the undergraduates in medical education. Int J Indian Psychol. 2019;7:519-28.

23. Shelke Umesh S, Kunkulol Rahul R, Narwane Sandeep P. Level of stress in final year MBBS students at Rural Medical College: A cross-sectional study. Int J Med Res Health Sci. 2014;3:886-91.

https://doi.org/10.5958/2319-5886.2014.00020.4

24. Samarasekera DD, Goh DLM, Lau TC. Medical school approach to manage the current COVID-19 crisis. Acad Med. 2020;95(8):1126-7.

https://doi.org/10.1097/ACM.0000000000003425

25. Goh PS, Sandars J. A vision of the use of technology in medical education after the COVID-19 pandemic. MedEdPublish. 2020;9:49.

https://doi.org/10.15694/mep.2020.000049.1