Post COVID-19 pandemic assessment of quality of life of dental students using the WHOQOL-BREF questionnaire

1Introduction

COVID-19 is a neoteric transpired viral infection that within a minimal stretch of time, became a global pandemic since its initial reporting back in December 2019 in Wuhan, China [1]. It bitterly jolted the lives of masses and created havoc around the world resulting in deaths of millions. COVID-19 not only jeopardized the existence of every individual, but also affected their physical, mental, general health and wellbeing [2, 3]. To curb the situation strict quarantine measures including restricted out-door physical activities, confinement to homes, travel prohibitions, prolonged enforced lockdowns and social isolation measures were imposed to protect the people from this deadly, contagious disease [4, 5]. Extreme measures were taken to overcome the pandemic; however, heightened confusion, insecurity and uncertainty had a negative impact on the mental health as well as quality of life of the already stressed and anxious people [6, 7]. Research conducted by Brooks et al. suggested that the negative effects suffered by the people due to quarantine were akin to symptoms of post-traumatic stress (PTSD), anxiety, and depression [8].

Medical and dental university students when compared with general public experience higher levels of stress, emotional distress and exhaustion which affect their quality of life [9]. A survey conducted on university students, revealed significant increase in stress, depression, anxiety, and PTSD among the students during the COVID-19 crises [10]. Wang et al. surveyed the university students of US and concluded that about 48% students experienced depression, 38% experienced anxiety and 18% had suicidal thoughts during the COVID-19 lockdown which was quite alarming [11]. A study conducted in India by Menon et al. showed that more than three-fourths of medical and dental university students experienced great stress during COVID-19. Uncertainty about the future, academic progress and family health were the major stress factors observed [12]. Another recently conducted study by Agius et al. observed that COVID-19 pandemic evoked fear of tarnishing their manual dexterity skills (due to hospital out-patient-department closures) in students. They were also anxious regarding its consequences on their professional training, and skills [13].

Quality of life (QOL) is a broad, multidimensional concept that comprises physical health, mental health, economic conditions, personal beliefs and interaction with the environment [14, 15]. In other words, quality of life and wellbeing in terms of health involve a combination of various bio-psychosocial factors [16]. The WHO QOL-BREF was developed by a team of WHO QOL to formulate a document that would efficiently address the concept and definition of quality of life and can be applied cross-culturally for assessing QOL. It encompasses the physical health domain which takes into account facets such as mobility, discomforts, laziness/energy and dependency in performing the day-to-day activities of an individual whereas psychological domain consists of cognitive capabilities, perceptions regarding self-esteem, appearance and spirituality. Social domain includes personal, social and sexual relationships and environmental domain takes into account details pertaining to safety/security, freedom, living conditions, pollution and leisure/recreational activities. All of these facets comprehensively measure QOL among the population.

Previous research executed in Pakistan among healthcare professionals (HCP) using WHO QOL-BREF depicted their relatively less satisfaction with physical and environmental domains and considerable satisfaction with the social domains of QOL because HCP have long working hours and stressful jobs but more social interaction with patients in their daily routines [17]. Another study by Al-Shibani [28] reported favorable satisfaction of dental students regarding the environment domain, psychological domain and physical domain of QOL.

Conversely to former research findings, education and learning of undergraduate medical students was greatly affected during COVID-19 and created psychosocial changes which comprised of excessive worrying, restlessness, irritability, body aches and lack of concentration during daily activities among students especially females, during the time of home quarantine effecting their QOL [18, 19]. Research conducted on private medical and dental students of Lahore also identified poor quality of sleep and mental health during the COVID-19 lockdown [20, 21]. Nizam et al. reported alarmingly high levels of perceived stress among medical, dental, pharmacy and allied students from all over Pakistan and emphasized stress management techniques to be implicated for students’ psychological improvement [22].

Although multiple studies have catered to the psychological issues of medical and dental students in Pakistan and around the globe during the COVID-19 lockdown, researches addressing the quality of life after relaxation of COVID-19 restrictions are scarce. None of the research compared the differences in the quality of life between private and public sector dental universities’ students. Hence, the objective of this study was to assess the quality of life of public and private sector college/university of Karachi and compare the findings between the students residing in college accommodation (away from family) or own home (with family and guardian). This research will help determine the measures that are required to be taken in the right direction to overcome the academic stresses of students so that they may perform better during their daily life routines and improve the quality of life amidst the period of ongoing uncertainty.

2Materials and methods

3Results

A total number of 402 proformas of participating students were found accurate and incorporated in the study after a thorough assessment for incomplete and faulty filled proformas. Out of the 402 students, 85.3% (n = 343) were females, while male constituted about 14.7% (n = 50) of the study population. The mean age of the participants was 20.87 years. Bahria University Dental College representing the private sector comprised of about 45.3% participants, whereas 54.7% participants belonged to Dow University of Health Sciences, which represented the government/public sector. Most of the participating students (30.8%) belonged to 3rd year of Bachelor of Dental Surgery program (BDS) followed by 24.9% from 1st year. Students/participants residing in hostel facilities to pursue their degrees were about 32.3% while 67.6% participants were non-hostelites living with families or relatives (Table 1).

The mean scores of WHOQOL-BREF domains, rate of quality of life and satisfaction with health along with the Cronbach’s alpha coefficient were assessed. The participants rated their quality of life to be good during the post COVID-19 period (3.99±0.93), while satisfaction with health was neutral to satisfactory (3.77±0.87) where 1 represented very poor/very dissatisfaction while 5 depicted very good and very satisfied. Cronbach’s alpha showed that the reliability and internal consistency between the 4 domains was good with a mean value > 0.8 stipulating good internal uniformity among the domains (Table 2).

Comparison between the four domains of WHOQOL revealed a statistically significant difference between the students of both public and private sector institutions with respect to physical health domains (p = 0.019*) and social relationship domains (p = 0.047*).

The psychological and environmental domains, however, showed non-significant difference. Meanwhile statistically significant differences were observed for all the 4 domains among the students living the life of a hostelite versus the students who were living with their own families or close relatives (non-hostelites) (Table 3).

Pearson’s correlation coefficient demonstrated a significantly higher and positive correlation between the mental health and environmental domains with the students’ personal satisfaction with health whereas a moderate association with the physical and social domain (p < 0.001*). However, a moderately positive and significant association was observed with physical, mental, social and environmental health and students’ rate of quality of life (p < 0.001*) (Table 4).

Multiple linear regression model shows that gender was statistically associated with Psychological domain (B = –0.027, 95% CI = –0.049 to –0.005, standardized β= –0.210, p = 0.017) and Social domains (B = 0.19, 95% CI = 0.005 to 0.034, standardized β= 0.165, p = 0.009) of quality of life. Public/private sector institute also significantly influenced the Physical domain (B = 0.042, 95% CI = –0.015 to –0.070, standardized β= 0.245, p = 0.003*), Social domain (B = 0.0271, 95% CI = 0.001 to –0.042, standardized β= 0.130, p = 0.040*) and Environmental domains (B = –0.023, 95% CI = –0.045 to –0.001, standardized β= –0.173, p = 0.037*) whereas the residency (hostelite/non-hostelite) of the students was significantly associated with only the Social domain (B = 0.036, 95% CI = 0.017 to 0.055, standardized β= 0.234, p < 0.001*). Year of education did not show any significant association with any of the 4 domains of quality of life (Table 5).

4Discussion

The COVID-19 pandemic left unprecedented impact and deleteriously burdened the lives of millions of children and adolescents in every part of the world, affecting their health and quality of life causing mental health issues and heightened anxiety [24]. This study is the first in Pakistan, aimed to assess the level of quality of life of dental students according to different domains of quality of life and explore its comparison between students studying in public and private sector universities and residing in personal or rented residential spaces (hostelite/non–hostelite) during the post COVID-19 phase.

Female students predominated forming 85.3% of the study population. Similar higher female predominance was also observed by Huseyin (74.5%) in Turkey and Zhang (62%) in China [6, 10]. Contrasting male predominance of 52% as compared to 48% females was however reported in a study conducted in Saudi Arabia [18]. The reason for contrasting male dominance may be due to differences in cultural norms since educational opportunities for males are more in Saudi Arabia as compared to females.

Quality of life (QOL) is a broad term that evaluates people’s health [25]. The WHO defines quality of life as “an individual’s perception of their position in life, in the context of culture and value system in which they live and in relation to their goals, expectations, standards and concerns” [26]. It concentrates on the proper physical, psychological and social functioning of the human body in their environment. WHOQOL-BREF, a brief version of WHOQOL-100, that is employed in this study to determine the QOL under the 4 important domains that represent the physical, psychological, social and environmental domains [27].

The mean scores of WHOQOL-BREF scale’s domains among the present study population were found favorable and similar to a study by Al-Shibani [28] (Table 2). In this study, the mean physical health scores and psychological domain scores (12.97 and 14.20) was reported to be less when compared with the findings of a similar study (19.77 and 17.64) [28]. Decreased physical health domain (D1) scores are reflected by the reduced psychological domain (D2) scores and signify that lack of physical activity tends to influence mental health. In short they have a directly proportional response to each. Environmental domain score was found to be highest in the present study. Comparable highest scores in environmental domains were observed in studies by Malibary et al. in Saudi Arabia and Naseem et al. in Pakistan [29, 30]. These observations underpin the influence that COVID-19 lockdown measures had, both on the physical and mental health of the students, the after-effects of which are still taking time to recover and normalize. Lower mean scores in psychological (12.71), social (13.65) and environmental domains (12.25) were also reported in Italian students by Epifanio et al. in comparison to our students [31]. The lower scores in the aforementioned domains may be due to the fact that Italian population was severely affected by the wraths of COVID-19 and this badly affected their quality of life as represented by the QOL scale’s score. Higher physical composite score was however found to be associated with higher mental comparative scores in collegiate students by Snedden in the USA [32]. The proposed reason for these results may be because the study was conducted in 2018, a time when the world was free from any global pandemic threats and implications of lockdown measures did not exist to halt the propagation of the deadly COVID-19 virus.

An Iranian study by Shahrestanaki et al. conducted on medical science students using the WHOQOL-BREF questionnaire found higher domain scores (physical domain = 24.50, psychological domain = 20.53, environment = 25.96), and higher overall quality of life scores (7.26) as compared to the present study [30]. These contrasting findings with the present study, promotes that QOL of students was better and satisfactory in the pre-COVID than the post-COVID period. A recent study carried out in Jordan also reported lower mental and physical health related quality of life among the health care students that was influenced by academic as well as lifestyle related factors [31]. Salman et al. also observed adverse impact on the mental health of 4 major university students of Pakistan and emphasized that mental health of students was affected as a result of COVID-19 and should not be ignored [35].

University life is an important period of an individual’s life, where they acquire knowledge, new skills, gain experiences, and develop and expand their social networks. However, for many students, especially hostelites, this can be stressful since they must manage life on their own, away from their families, worry about financial constraints, and lead an independent lifestyle [36]. The present study observed a statistically significant difference in all the 4 domains of quality of life between hostelites (students living away from family) and non-hostelites students (living with their family). Alsubaie et al. reported that quality of life of university students who had family/friends and social support had a better quality of life which was evident by better psychological domain (21.37±3.60) and social relationship (11.0±2.49) scores and no depression [36]. These findings underpin the essential influence that presence of family/friends or near and dear ones have on one’s mental health and wellbeing. These findings support the statistically significant and contrasting results in all the quality of life domains between hostelites and non-hostelites reported in our study. (Table 3) A longitudinal study on medical students in Korea revealed that friends and family constitute an individual’s support system and had a statistically significant and positive influence on all the sub-domain scores of quality of life [9]. Abdullah et al. found out that mental and social QOL was affected in students of a public medical university during the pandemic when they were compared with general population norms and participants who had greater family and friends support. A higher QOL score was also seen in these students in correlation to those living away from family [37].

Statistically significant difference was also reported in the physical domain (p = 0.019*) and social relation domain (p = 0.047*) among the public sector and private sector students with no difference in psychological and environmental domains of QOL during the post-COVID period. The difference may be observed due to lifestyle changes and better privileges available to private sector students in comparison to public sector students. These findings are comparable to a similar study in Pakistan [30]. Statistically significant and moderately positive correlation existed between the dental students’ QOL domain scores and their personal rating of satisfaction with health. Hence in view of the findings it is imperative to note that the COVID-19 pandemic did affect the quality of life of students studying in health care facilities. Thus, by facilitating our students with stress relieving measures, and incorporation of friendly conducive learning environment, will help them overcome their physical, psychological and social deficiencies and normalize their lives again.

Strengths of this study are that it was a comparative, multi-centric research executed to assess the impact which COVID-19 had on the quality of life via a validated WHOQOL-BREF questionnaire on dental students who were already stressed due to the educational uncertainty posed by the COVID-19 pandemic. Evaluation of QOL of our students will help us devise policies whereby efforts will be directed towards reducing the mental and environmental stresses imposed on the students due to academic burden as well as COVID-19 lockdown measures, so that they may be able to perform better and further improve their quality of lives.

5Conclusion

WHOQOL-BREF was found to be a validated, reliable and effective tool for assessing the quality of life of dental students during the post-COVID-19 period. Overall students rated their QOL to be good and were satisfied with their health. However, statistically significant difference was observed in the mean QOL domains’ score among the students residing in own homes with the students utilizing college accommodation, while the difference between public and private sector students was observed in physical health and social domains only. Psychological and environmental domains were similar in both the sector students signifying that COVID-19 had similar impact on the mental and physical environment of every student.

Ethical approval

Institutional ethical approval (ERC 76/2021) was obtained prior to commencement of research.

Informed consent

Informed consent was obtained from all participants.

Conflict of interest

The authors have no conflict of interest to declare.