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Health-Related Quality of Life of Future Physicians at a Medical School in the Philippines: A Cross-Sectional Study

Health-Related Quality of Life of Future Physicians at a Medical School in the Philippines: A... Medical students are trained to maintain the health of patients, but such training may have undesirable effects on medical students’ personal health. This study therefore aimed to assess the health-related quality of life (HRQOL) of medical students and to determine the factors that are associated with the students’ HRQOL. The target population included all students enrolled at the Saint Louis University School of Medicine in Baguio City, Philippines, during school year 2012-2013. The measurements included the 36-Item Short Form Health Survey (SF-36) questionnaire for HRQOL, Beck Depression Inventory, abbreviated Maslach Burnout Inventory, Perceived Stress Scale, Holmes and Rahe Stress Scale, and self-report items for other exposure variables. A total of 527 medical students participated in the study. The mean scores in all of the eight domains of HRQOL ranged from 51.36 to 85.83. The highest mean scores were along the areas of physical functioning (85.83) and bodily pain (69.20), whereas the lowest mean scores were in the areas of vitality (51.72) and role limitations due to emotional problems (51.36). Depression, stress, and burnout were associated with lower scores in most of the domains of HRQOL. Medical students in our school are generally in a satisfactory state of functional health and well-being, but have a lower level of mental health as compared with physical health. Keywords Health-related quality of life, medical students, medical school, medical education As it is multifaceted, HRQOL is in agreement with the defi- Introduction nition of health of the World Health Organization (2013), Medical students are trained to maintain the health of indi- which is “a state of complete physical, mental, and social vidual patients and of populations. Such training is physi- well-being, and not merely the absence of disease or infir- cally and mentally demanding and may have undesirable mity.” HRQOL has been applied to studies of various popu- effects on medical students’ personal health (Dyrbye, lations such as those with chronic diseases or debilitation, as Thomas, & Shanafelt, 2005). According to Weil (n.d.), medi- well as to groups of healthy adults and health professionals. cal schools foster unhealthy lifestyles; medical students suf- A search for published research articles that primarily fer from sleep deprivation, poor nutrition, lack of exercise, assessed the HRQOL of medical students revealed studies and are placed under a considerable amount of stress. In one conducted in Canada (Raj, Simpson, Hopman, & Singer, study, medical students were shown to have a poorer status 2000), Brazil (Paro et al., 2010), and Iran (Jamali et al., of physical and mental health, and more anxiety, depression, 2013), and none in the Philippines. This study therefore and negative lifestyle changes as compared with non- aimed to assess the HRQOL of medical students at the Saint medical students (Al-Dabal, Koura, Rasheed, Al-Souwielem, Louis University in Baguio City, Philippines. Specifically, it & Makki, 2010). Physicians are health professionals who sought to determine the status of the HRQOL of the medical play a vital role in a country’s health care system. It is there- students along the domains of physical functioning, role lim- fore essential that physicians-in-training maintain their own itations due to physical health, bodily pain, general health well-being to better care for their patients in the future. perceptions, vitality, social functioning, role limitations due Assessing the overall health of individuals and popula- to emotional problems, and mental health; it also sought to tions is of public health importance. According to the Center for Disease Control and Prevention (2011), one approach to 1 School of Medicine, Saint Louis University, Baguio City, Philippines this is to make use of an expansive concept known as health- Corresponding Author: related quality of life (HRQOL). It is a multidimensional John Anthony A. Domantay, School of Medicine, Saint Louis University, measure for evaluating physical functioning, psychological Bonifacio Street, Baguio City 2600, Philippines. well-being, and social functioning (Calvert & Skelton, 2008). Email: jad_mdphd@yahoo.com This article is distributed under the terms of the Creative Commons Attribution 3.0 License Creative Commons CC BY: (http://www.creativecommons.org/licenses/by/3.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page (http://www.uk.sagepub.com/aboutus/openaccess.htm). 2 SAGE Open determine factors associated with the medical students’ validity, criterion validity, construct validity, and predictive HRQOL. validity. The various studies on the validity of the SF-36 are cited elsewhere (Ware, 2003). A recent study has shown that the instrument is a valid and reliable tool for measuring the Method health status among Filipinos residing in two cities in the Philippines (Castillo-Carandang et al., 2013). Study Design The SF-36 can be used as a self-administered question- A cross-sectional study design was used. In this design, the naire, or can be administered via a computer or personal or outcome variable, which is the HRQOL, as well as the expo- telephone interview. It takes only 5 to 10 minutes to com- sure variables were assessed at a particular point in time plete. In this study, it was given to the medical students as a using a questionnaire. A descriptive cross-sectional design self-administered questionnaire. was used to determine the status of the medical students’ Scoring of the instrument followed the two-step process HRQOL. An analytical cross-sectional design was used to as recommended by the RAND Corporation (n.d.-b). In the determine the factors that are associated with the medical first step, precoded numeric values were recoded using a students’ HRQOL. scoring key. Each item was scored in a range of 0 to 100. The scores represented the percentage of the total possible score achieved. In the second step, items in the same scale were Study Population averaged together to yield the eight-area (scale) scores. The target population included all students enrolled at the Missing data were not included when computing for the Saint Louis University School of Medicine in Baguio City, scale scores. Philippines, during school year 2012-2013. The total popula- In this study, norm-based interpretation of the SF-36 was tion of the students was 608. As all students were included in used. In this interpretation strategy, 50 is considered as the the study, no sampling techniques were employed. average score or norm. Scores higher than 50 are better than the general population average for all the eight scales, whereas scores lower than 50 are worse (Gandek, 2002). Data Collection Data were gathered using a questionnaire consisting of the Assessment of depression. Depression was assessed using the following parts: Beck Depression Inventory (BDI). This instrument was orig- inally meant to measure depression in patients with mental Assessment of HRQOL. HRQOL was measured using the illness, but it can also be used in a primary care setting. It 36-Item Short Form Health Survey (SF-36) questionnaire. consists of 21 questions, each question having four possible The SF-36 is a multipurpose, short-form health survey con- responses with scores ranging from 0 to 3. The total score of sisting of 36 questions. It measures eight areas of health: the test is a measure of the severity of depression. In a pri- physical functioning, role limitations due to physical health, mary care setting, a score higher than 21 is interpreted as bodily pain, general health perceptions, vitality, social func- having depression. Studies have provided evidence of the tioning, role limitations due to emotional problems, and validity of this tool; it is also considered to have high reli- mental health. The tool produces scores for each of these ability (Encyclopedia of Mental Disorders, n.d.). eight areas. As a generic measure, this questionnaire has The BDI has been validated in some Asian countries such been useful in evaluating the health of general and specific as Indonesia (Ginting, Näring, van der Veld, Srisayekti, & populations as well as assessing HRQOL (Ware, 2003). Becker, 2013), Korea (Yu, Lee, & Lee, 2011), and Japan Thus, it is an appropriate data gathering instrument for this (Kojima, Furukawa, Takahashi, Kawai, & Nagaya, 2002). study. However, a review of the literature did not reveal any valida- The SF-36 was authored by John E. Ware Jr. and was tion studies of the BDI done in the Philippines. developed as a part of the RAND Medical Outcomes Study (MOS): Measures of Quality of Life Core Survey (RAND Measurement of burnout. To measure burnout, an abbreviated Corporation, n.d.-a). The utilization of the SF-36 has been Maslach Burnout Inventory (aMBI) was used. This inven- cited in more than 4,000 published articles. It has also been tory is the most widely used measure of burnout (Maslach, acknowledged as the most widely evaluated generic patient Jackson, Leiter, Schaufeli, & Schwab, n.d.). The abbreviated assessed health outcome among quality of life measures. It form contains only 12 out of the original 22 questions, but has also been used in the description of more than 200 dis- still assesses the same three domains, namely, emotional eases and conditions. Translations of the instrument have exhaustion, depersonalization, and personal accomplishment been documented in 22 countries (Ware, 2003). The SF-36 (McManus, Smithers, Partridge, Keeling, & Fleming, 2003). has been reported to have high reliability, with coefficients The abbreviated form includes an additional three items exceeding .70 and even .80. There is also evidence of the regarding “satisfaction with medicine,” which makes it an instrument having adequate content validity, concurrent appropriate tool for the present study of medical students. No Domantay 3 validation studies of the aMBI or the Maslach Burnout (unordered categorical), year level (ordered categorical), aca- Inventory in the Philippines were found. demic performance (ordered categorical), pre-medical course (unordered categorical), socioeconomic status (ordered categor- Measurement of perceived stress. Stress was measured using ical), depression (continuous quantitative), burnout (continuous the Perceived Stress Scale (PSS). This is the most commonly quantitative), stress levels (continuous quantitative), and stress- employed questionnaire to gauge an individual’s perception ful life events (continuous quantitative). of stress (Cohen, n.d.). It consists of 14 items which are eas- Prior to actual analysis, the data were checked for missing ily understood and hence can be used in the general popula- values. These were appropriately coded, so that the computer tion. It has been validated in studies, particularly those will recognize them as missing and thus exclude them from dealing with health status. For example, in Asia, it has been the analysis. validated among Chinese cardiac patients who are smokers In the analysis of the data, the following were carried out: (Leung, Lam, & Chan, 2010). It also has good reliability basic descriptive analysis in the form of means and standard (Cohen, Kamarck, & Mermelstein, 1983). deviations of the HRQOL scores along the eight scales; mea- sures of association between the HRQOL scores and the Measurement of stressful life events. Stressful life events were exposure variables, t test, and null hypotheses and p values assessed using the Holmes and Rahe Stress Scale (Mind- for the association between the HRQOL scores and binary Tools, n.d.). This is a list of 43 stressful life events that have variables, that is, sex, one-way ANOVA and null hypotheses, been correlated with illness. Each stressful event corresponds and p values for the association between the HRQOL scores to a value known as a life change unit (LCU), depending on and unordered and ordered categorical variables. In addition, how stressful the event is. The sum of the LCUs yields an Bartlett’s test for inequality of population variances was per- estimate of an individual’s stress level and likelihood of ill- formed. If the p value from Bartlett’s test was less than .05, ness. For this particular study, life events that were most non-parametric tests such as the Mann–Whitney/Wilcoxon likely to apply to medical students in the Philippine setting two-sample test or the Kruskal–Wallis test were used instead were included in the questionnaire. For example, divorce of the t test or ANOVA, respectively. Pearson’s correlation was not included as divorce is not allowed in the Philippines. coefficient and null hypotheses and p values were used to However, no formal validation of this instrument has been determine the association between the HRQOL scores and conducted in the Philippines. quantitative variables, that is, age, depression (BDI score), burnout (aMBI score), stress levels (PSS Score), and stress- Measurement of other variables. The instrument also con- ful life events (Holmes and Rahe Stress Scale score). tained self-report items related to the other exposure vari- ables. These variables were age, sex, civil status, year level, Ethical Considerations academic performance, pre-medical course, and socioeco- nomic status. The research protocol was reviewed and approved by the Institutional Review Board (IRB) of the university prior to the conduct of the study. The review considered both scien- Data Management tific and ethical aspects of the research. The questionnaire The questionnaires were administered personally by the had a cover letter that provided information on the research researcher accompanied by a research assistant. The ques- objectives as well as the significance and importance of the tionnaires were administered at the middle of the second study. Participation in the study was voluntary and it was semester. Questionnaires were administered during regular explained to the students that they had the option not to class days and not during major examination periods. answer the questionnaire. Students were not compensated for To extract the data from the questionnaires, the responses their participation. Complete anonymity of the research par- were coded, using number codes to make the data suitable ticipants was observed as the participants were asked not to for analysis. write their names or any identifying marks on the question- Microsoft Excel was used for data entry. Only one data- naires. Thus, specific information on the questionnaires base was created. The database had one variable for each could not be linked to specific individuals. Access to the data item in the questionnaire and one record for each respondent. was limited only to the researcher and two research Each participant had a unique identifier in the form of an assistants. identification number. The Microsoft Excel file was then exported to Epi Info 7 for data analysis. Results Data Analysis Characteristics of the Study Participants The main outcome variable was the HRQOL scores (continuous A total of 527 medical students participated in the study rep- quantitative). Exposure variables included age (quantitative), resenting a response rate of 86.7%. Most were between the sex (binary), civil status (unordered categorical), ethnicity ages of 19 and 24 years old (78.8%). Most were female 4 SAGE Open Table 1. Demographic Characteristics of the Participants. Table 2. Psychological Characteristics of the Participants. Variable Frequency (n) % Variable Frequency % Age Depression (based on BDI score) 19-24 411 78.9 Without depression 482 91.5 25-29 101 19.4 With depression 45 8.5 30-42 9 1.7 Stress Sex No significant stress 249 47.3 Male 205 38.9 Mild stress 96 18.2 Female 322 61.1 Moderate stress 134 25.4 Year level Major stress 48 9.1 First 160 30.4 Variable M SD Second 112 21.3 Third 137 26.0 Burnout Fourth 118 22.4 Emotional exhaustion 8.20/18 4.70 Civil status Depersonalization 4.24/18 4.16 Single 510 96.8 Personal accomplishment 13.17/18 3.61 Married/legally separated 17 3.2 Satisfaction with medicine 15.23/18 3.37 General weighted average Perceived stress 18.56 (sometimes) 6.17 85 and above 48 9.4 80-84 238 46.8 Note. BDI = Beck Depression Inventory. 79 and below 223 43.8 Pre-medical course example, with depression, the high response rate makes non- BS Biology 113 21.4 response bias less likely. BS Medical laboratory science 65 12.3 In all, 45 students (8.5%) had manifestations of clinical BS Nursing 279 52.9 Others 70 13.3 depression, whereas 182 students (34.5%) had features of Parents’ annual income moderate to major stress. The medical students had a low Less than PhP 100,000 59 14.0 tendency for burnout along the domains of personal accom- 100,000-499,000 171 40.5 plishment and depersonalization, but had a high tendency for 500,000-999,000 117 27.7 burnout along the domain of emotional exhaustion. They 1,000,000 and above 75 17.8 scored relatively high in terms of satisfaction with medicine (Table 2). Note. PhP = Philippine pesos. US$1 is approximately equivalent to 44 PhP. 1 Euro is approximately equivalent to 60 PhP. HRQOL of the Medical Students The mean scores in all of the eight domains were above 50, (61.1%) and single (96.77%). The highest percentage of ranging from 51.36 to 85.83. The highest mean scores were respondents were in first year (30.4%). In terms of academic along the areas of physical functioning (85.83) and bodily performance, the most common grade point average range pain (69.20), whereas the lowest mean scores were in the was 80 to 84. Most of the medical students studied nursing as areas of vitality (51.72) and role limitations due to emotional their pre-medical coursework (55.6%). The most common problems (51.36; Table 3). combined annual income range was between PhP (Philippine pesos) 100,000 and PhP 499,999 (40.5%; Table 1). The response rate in this study was 86.7%. Among the Associations Between HRQOL and the Exposure non-responders, there was an almost equal number of males Variables and females; 40 were males and 41 were females, with a male to female ratio of approximately 1:1. The male to Male students tended to have higher scores than female stu- female ratio in each year of the medical school was as fol- dents along the domains of general health (p = .001), vitality lows: first year—1:1.4, second year—1:1.4, third year— (p = .014), and role limitations due to emotional problems 1:1.6, and fourth year—1:1.5. The overall male to female (p = .004). There were no significant differences in the ratio in the medical school is 1:1.5. Further analysis revealed HRQOL scores among the four year levels except for the that there was no significant difference between the non- area of social functioning, where fourth-year students had responders and responders according to sex (p = .10; see lower scores as compared with the other three year levels (p Table A1 in the appendix). Although it is possible that some < .001). There were also no associations between the HRQOL students who refused to participate were symptomatic, for scores and academic performance, except in the domain of Domantay 5 Table 3. HRQOL of the Medical Students. health, that is, vitality and role limitations due to emotional problems. Depression, stress, and burnout were associated Domain M SD with lower scores in most of the domains of HRQOL, PF 85.83 15.68 whereas sex, pre-medical course, academic performance, RP 52.81 39.72 and year level were associated with fewer of the HRQOL BP 69.20 21.74 domains. GH 62.88 18.91 The lowest scores were in those domains related to mental VT 51.72 16.41 health. This means that medical students have a tendency to SF 61.48 12.89 encounter problems with work or other daily activities as a RE 51.36 44.20 result of emotional problems and that they may experience MH 65.58 17.28 feelings of nervousness and depression (Ware, 2003). These are likely related to the nature of the medical school experi- Note. HRQOL = health-related quality of life; PF = physical functioning; ence, which has been often described as stressful. Medical RP = role-physical; BP = bodily pain; GH = general health; VT = vitality; SF = social functioning; RE = role-emotional; MH = mental health. students have to undergo frequent periods of adjustment, which may affect them emotionally. For instance, first-year students have to adjust to medical school itself, which is role limitations due to physical health where those with more rigorous and intellectually challenging as compared lower weighted averages had lower HRQOL scores than with their pre-medical course. Students in third year have to those with higher weighted averages (p = .015; Table 4). adjust to clinically oriented courses, from the basic science In the Philippines, students admitted to a medical school courses of lower years, not to mention the issue of academic should be holders of a baccalaureate degree, which is termed overload typical of third year. Students in fourth year have to as their pre-medical course. Those who studied nursing as adjust to clinical clerkship, wherein full-time clinical train- their pre-medical course had higher scores in the area of ing in the hospital is an entirely different experience from bodily pain (p = .046), whereas those who studied medical teaching and learning in the classroom setting. Moreover, technology as their pre-medical course had higher scores in this study also showed that psychological conditions such as the area of social functioning (p = .008). No associations depression, stress, and burnout are inversely related to were observed between the HRQOL scores and age, civil sta- HRQOL scores. tus, and parents’ combined annual income (Table 4). There are other issues that might stress medical students. There was a striking association observed between the Although family members are generally supportive, due to HRQOL scores and depression; those who were depressed the cultural norm of close family ties in the Philippines, they had significantly lower scores in seven out of the eight can also be a source of stress, especially for students who domains, as compared with those without depression (p < have family problems, or who are married and/or with chil- .001). In terms of stress, those with moderate to major stress dren, who may be struggling to balance family life and medi- had lower scores in the areas of role limitations due to physi- cal school training. Financial problems can also be a source cal health, general health, and role limitations due to emo- of stress, as medical education is expensive and scholarship tional problems (Table 4). Similar findings were observed in grants for medical education are very limited in the terms of perceived stress, presented in Table 5, where nega- Philippines. tive correlation coefficients in all areas of HRQOL except The findings of the current study are consistent with those bodily pain and social functioning, indicated that higher of Voltmer, Rosta, Aasland, and Spahn (2010) who, as a part stress levels were related to lower HRQOL scores. of their article, studied the HRQOL of medical students in As for burnout, emotional exhaustion and depersonaliza- Germany and discovered that the students had lower scores tion were negatively correlated with HRQOL scores in six in the domain of mental health as compared with physical out of the eight areas. The relationships were stronger for health. The results are also in agreement with those of Dyrbye emotional exhaustion as compared with depersonalization. et al. (2007) who, also as a part of their article, determined There were slightly positive correlations between satisfac- the quality of life of medical students in the United States. tion with medicine and HRQOL in five out of the eight areas Their students also had relatively low mental quality of life (Table 5). scores. However, medical students are able to perform all types of physical activities, even the most vigorous, without limita- Discussion tions due to health, and that they do not experience pain or The results of this study showed that overall, medical stu- there are no limitations due to pain (Ware, 2003). A possible dents had an average to above average HRQOL. It also explanation for this might be that the great majority of medi- revealed that students had a higher HRQOL in the scales cal students are apparently physically fit young adults, as related to physical health, that is, physical functioning and attested by their annual medical-physical examinations. bodily pain, but scored lower in scales related to mental Students have to undergo these physical examinations 6 SAGE Open Table 4. Associations Between HRQOL and Categorical Variables. PF RP BP GH VT SF RE MH Sex Male 85.81 52.80 69.35 66.26 53.93 61.77 58.21 67.16 Female 85.84 52.82 69.10 60.72 50.32 61.30 47.00 64.58 p value Ns ns ns .001 .014 ns .004 ns Year level First 88.13 51.41 71.66 64.98 51.94 62.11 49.17 65.80 Second 87.32 52.90 67.30 63.53 53.81 61.05 49.11 67.07 Third 86.25 50.91 70.84 63.00 51.25 65.51 48.42 66.89 Fourth 80.79 56.85 65.76 59.26 49.97 56.36 59.89 62.31 p value Ns ns ns ns ns <.001 ns ns Average 85+ 86.88 55.72 70.52 59.79 55.07 59.90 50.69 68.50 80-84 87.19 57.18 68.46 64.26 52.59 61.40 54.76 66.97 <80 84.51 46.64 69.92 62.34 50.46 62.33 47.09 63.63 p value Ns .015 ns ns ns ns ns ns Pre-medical course Biology 84.74 55.09 66.28 64.67 50.07 61.28 53.10 64.11 Medical 87.24 50.77 64.54 61.23 51.30 62.69 58.97 67.91 technology Nursing 86.16 52.09 71.44 62.72 52.50 62.37 48.63 65.50 Others 84.22 53.93 69.29 62.16 51.67 57.14 52.38 66.11 p value Ns ns .046 ns ns .008 ns ns Depression (based on BDI score) None 86.58 54.89 68.83 64.45 53.16 61.10 53.67 67.65 Depressed 77.78 30.56 73.17 46.00 36.37 65.56 26.67 43.38 p value <.001 <.001 ns <.001 <.001 .007 <.001 <.001 Stress None 85.73 56.93 70.35 65.52 52.68 60.74 57.30 66.57 Mild 87.43 54.69 68.96 61.08 52.90 62.89 50.69 66.21 Moderate 86.60 48.01 67.52 60.03 50.10 61.85 40.55 62.90 Major 80.93 41.15 68.39 60.73 48.92 61.46 51.08 66.67 p value Ns .029 ns .028 ns ns .005 ns Note. No associations were observed between the HRQOL scores and age, civil status, and parents’ combined annual income. HRQOL = health-related quality of life; PF = physical functioning; RP = role-physical; BP = bodily pain; GH = general health; VT = vitality; SF = social functioning; RE = role- emotional; MH = mental health; ns = not significant; BDI = Beck Depression Inventory. together with basic laboratory tests prior to enrollment. men are supposed to be less emotional than women. Thus, Moreover, chronic diseases which may bring about pain and male medical students in general do not let emotions or emo- physical limitations are uncommon in this age group. tional problems hinder their performance in their studies and Our study also showed that males had significantly higher training. These findings are similar to those of the study of scores than females in the domains of general health and Paro et al. (2010) that female students had lower HRQOL vitality. This means that males have a tendency to evaluate scores than males. Jamali et al. (2013) also established that their personal health as excellent and that they always feel male gender was significantly associated with higher energetic, as compared with females. This is in keeping with HRQOL scores as compared with females. the cultural norm in the Philippines where men are generally Regarding the factors associated with HRQOL, our find- considered to be the stronger sex, thus men perceive them- ings are similar to those of Paro et al. (2010) who found out selves to be so. The present study also revealed that male that female medical students and those with depression had medical students had significantly higher scores in the lower HRQOL scores. Dyrbye et al. (2007) likewise reported domain of role limitations due to emotional problems as that burnout and depression were major factors that influ- compared with female medical students. A higher score enced medical students’ quality of life. In addition, Swami et means that there are less interferences with work or daily al. (2007) observed that in Malaysia, life satisfaction, which activities as a result of emotional problems. This is again is used interchangeably with quality of life, was inversely consistent with the cultural norm in the Philippines where related to depression. Arslan, Ayranci, Unsal, and Arslantas Domantay 7 Table 5. Associations Between HRQOL and Numerical Variables. PF RP BP GH VT SF RE MH Burnout: Personal accomplishment Pearson r −.035 .063 −.04 −.034 −.019 −.06 −.021 −.002 p value ns ns ns ns ns ns ns ns Burnout: Emotional exhaustion Pearson r −.167 −.181 .009 −.273 −.442 .009 −.231 −.444 p value <.001 <.001 ns <.001 <.001 ns <.001 <.001 Burnout: Depersonalization Pearson r −.171 −.104 −.06 −.117 −.185 −.01 −.139 −.275 p value <.001 .017 ns .007 <.001 ns .001 <.001 Burnout: Satisfaction with medicine Pearson r .128 .073 −.03 .139 .185 −.04 .110 .197 p value .003 ns ns .001 <.001 ns .011 <.001 Perceived stress Pearson r −.151 −.241 .073 −.368 −.523 .027 −.326 −.629 p value .001 <.001 ns <.001 <.001 ns <.001 <.001 Note. HRQOL = health-related quality of life; PF = physical functioning; RP = role-physical; BP = bodily pain; GH = general health; VT = vitality; SF = social functioning; RE = role-emotional; MH = mental health; ns = not significant. (2009) also reported that in Turkey, the scores of the SF-36 This study also had a relatively high response rate, which scale were lower for those with depression as compared with could have minimized selection bias. To the best of our those without depression. knowledge, this is the first study on the HRQOL of medical However, the results of the current study differ from those students in the Philippines. of Naseem and Iqbal’s (2010) study. Among Pakistani medi- However, this study also had certain limitations. As in cal students, physical functioning, general health perception, other studies employing questionnaires, recall bias is a pos- vitality, and social functioning for second-year students were sibility. In determining the factors associated with HRQOL, significantly less than the other classes. In the present study, confounding was not assessed as the main objective of the social functioning was highest among third-year students study was to describe the status of the medical students’ and lowest among fourth-year students. This is because stu- HRQOL. Furthermore, the present study only involved stu- dents in the third year have already adjusted to life in medical dents from just one medical school in the Philippines. This school and have already established friendships among limits the study’s generalizability. The results may not neces- classmates. Thus, they are able to interact with each other sarily be extrapolated to students from other medical schools and socialize on weekends. However, fourth-year students in the country or to those from other countries. It is important are in clinical clerkship wherein they spend most of their to bear in mind that medical schools vary in terms of the time in the hospital. There is little time for socialization with nature of their curricula, for instance, traditional versus prob- friends and after work they would rather rest and sleep in lem-based learning, duration of the medical course, as well preparation for the next hospital duty the following day. This as school and hospital atmosphere and environment. Medical is similar to the findings of Paro et al. (2010) and Jamali et al. students from different schools may also vary according to (2013) where students in the highest year level had lower sociodemographic characteristics such as age and sex distri- HRQOL scores as compared with lower year levels. bution, and other personality characteristics. All these may It is interesting to note that 45 medical students (8.5%) influence their HRQOL. had depression based on the BDI score. Further analysis of In conclusion, medical students in our school are gener- Item Number 9 on the BDI, which assesses suicidal thoughts, ally in a satisfactory state of functional health and well- revealed that 54 students checked the response “I have being, but have a lower level of mental health as compared thoughts of killing myself, but I would not carry them out”; with physical health. Depression, stress, and burnout reduce 3 students responded that “I would like to kill myself”; and 2 the medical students’ state of health. The results of this study students responded that “I would kill myself if I had the have implications for medical educators in our school. It chance.” This has implications for counseling services in a could provide a basis for the development of student well- medical school. Such services are available at our universi- ness programs and activities. It is imperative that counseling ty’s Guidance Center, and the head of the center personally services and mentoring programs for medical students be attends to medical students who seek consultation. However, strengthened and enhanced. Improving the well-being of very few medical students avail of these services, most prob- future physicians will hopefully translate to better quality of ably due to lack of time owing to their heavy class schedule care for the patients they are meant to serve. and busy hospital rotations. Future research on the HRQOL of medical students is The strength of this study is that it made use of well- needed. This study may be replicated by other medical schools established and validated data gathering instruments such as in the country. Further investigations could utilize a longitudi- the SF-36, BDI, aMBI, PSS, and Holmes and Rahe Stress nal design rather than a cross-sectional design to trace changes Scale. The use of such tools minimized information bias. in the students’ health and well-being over time. 8 SAGE Open nicity, and medical student well-being in the United States. Appendix Archives of Internal Medicine, 167, 2103-2109. doi:10.1001/ archinte.167.19.2103 Table A1. Differences Between Non-Responders and Dyrbye, L. N., Thomas, M. R., & Shanafelt, T. D. (2005). Medical Responders According to Sex. student distress: Causes, consequences, and proposed solu- Sex Non-responders Responders Total tions. Mayo Clinic Proceedings, 80, 1613-1622. Encyclopedia of Mental Disorders. (n.d.). Beck Depression Male 40 205 245 Inventory. Retrieved from http://www.minddisorders.com/ Female 41 322 363 A-Br/Beck-Depression-Inventory.html Total 81 527 608 Gandek, B. (2002). Interpreting the SF-36 Health Survey. Winnipeg, Manitoba: Canadian Association of Cardiac Rehabilitation. Note. Fisher’s exact test p value = .10 (not significant). Ginting, H., Näring, G., van der Veld, W. M., Srisayekti, W., & Becker, E. S. (2013). Validating the Beck Depression Inventory-II in Indonesia’s general population and coronary Acknowledgment heart disease patients. International Journal of Clinical Health & Psychology, 13, 235-242. The author would like to thank Carl Froilan D. Leochico, MD, for Jamali, A., Tofangchiha, S., Jamali, R., Nedjat, S., Jan, D., Narimani, his invaluable assistance in data collection, data management, and A., & Montazeri, A. (2013). Medical students’ health-related data analysis; and to Joshua H. Gaboy, MD, and Rodel J. quality of life: Roles of social and behavioural factors. Medical Banggiacan, MD, for their help with data management. Education, 47, 1001-1012. doi:10.1111/medu.12247 Kojima, M., Furukawa, T. A., Takahashi, H., Kawai, M., & Declaration of Conflicting Interests Nagaya, T. T. S. (2002). Cross-cultural validation of the Beck The author declared no potential conflicts of interest with respect to Depression Inventory-II in Japan. Psychiatry Research, 110, the research, authorship, and/or publication of this article. 291-299. Leung, D. Y. P., Lam, T., & Chan, S. S. C. (2010). Three versions Funding of Perceived Stress Scale: Validation in a sample of Chinese cardiac patients who smoke. BMC Public Health, 10, Article The author disclosed receipt of the following financial support for the research and/or authorship of this article: This study was funded Maslach, C., Jackson, S. E., Leiter, M. P., Schaufeli, W. B., & through a University Research Grant (URG No.12.3.SoM.1) from Schwab, R. L. (n.d.). Maslach Burnout Inventory. Mind Saint Louis University, Baguio City, Philippines. Garden. Retrieved from http://www.mindgarden.com/pro- ducts/mbi.htm References McManus, I. C., Smithers, E., Partridge, P., Keeling, A., & Fleming, Al-Dabal, B. K., Koura, M. R., Rasheed, P., Al-Souwielem, L., & P. R. (2003). A levels and intelligence as predictors of medi- Makki, S. M. (2010). A comparative study of perceived stress cal careers in UK doctors: 20 year prospective study. British among female medical and non-medical university students in Medical Journal, 327, 139-142. doi:10.1136/bmj.327.7407.139 Dammam, Saudi Arabia. Sultan Qaboos University Medical MindTools. (n.d.). The Holmes and Rahe Stress Scale (Stress man- Journal, 10, 231-240. agement). Retrieved from http://www.mindtools.com/pages/ Arslan, G., Ayranci, U., Unsal, A., & Arslantas, D. (2009). article/newTCS_82.htm Prevalence of depression, its correlates among students, and Naseem, K., & Iqbal, M. (2010). Health related quality of life in its effect on health-related quality of life in a Turkish uni- a Pakistani medical school. Rawal Medical Journal, 35, 234- versity. Upsala Journal of Medical Sciences, 114, 170-177. 237. Retrieved from http://www.scopemed.org/?mno=3811 doi:10.1080/03009730903174339 Paro, H. B. M. S., Morales, N. M. O., Silva, C. H. M., Rezende, Calvert, M. J., & Skelton, J. R. (2008). The need for education C. H. A., Pinto, R. M. C., Morales, R. R., . . .Prado, M. M. on health related-quality of life. BMC Medical Education, 8, (2010). Health-related quality of life of medical students. Article 2. doi:10.1186/1472-6920-8-2 Medical Education, 44, 227-235. doi:10.1111/j.1365- Castillo-Carandang, N. T., Sison, O. T., Grefal, M. L., Sy, R. G., 2923.2009.03587.x Alix, O. C., Llanes, E. J. B., . . .Wee, H.-L. (2013). A com- Raj, S. R., Simpson, C. S., Hopman, W. M., & Singer, M. A. munity-based validation study of the short-form 36 version 2 (2000). Health-related quality of life among final-year medi- Philippines (Tagalog) in two cities in the Philippines. PLoS cal students. Canadian Medical Association Journal, 162, ONE, 8, e83794. doi:10.1371/journal.pone.0083794 509-510. Centers for Disease Control and Prevention (n.d.). Health-Related RAND Corporation. (n.d.-a). 36-item Short Form Survey from the Quality of Life. Retrieved from http://www.cdc.gov/hrqol RAND medical outcomes study. Retrieved from http://www. Cohen, S. (n.d.). Perceived Stress Scale. Mind Garden. Retrieved rand.org/health/surveys_tools/mos/mos_core_36item.html from http://www.mindgarden.com/products/pss.htm RAND Corporation. (n.d.-b). 36-item Short Form Survey scoring Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global mea- instructions. Retrieved from http://www.rand.org/health/sur- sure of perceived stress. Journal of Health and Social Behavior, veys_tools/mos/mos_core_36item_scoring.html 24, 385-396. Swami, V., Chamorro-Premuzic, T., Sinniah, D., Maniam, T., Dyrbye, L. N., Thomas, M. R., Eacker, A., Harper, W., Massie, Kannan, K., Stanistreet, D., & Furnham, A. (2007). General F. S., Power, D. V., . . .Shanafelt, T. D. (2007). Race, eth- health mediates the relationship between loneliness, life Domantay 9 satisfaction and depression: A study with Malaysian medical Yu, B.-K., Lee, H.-K., & Lee, K.-S. (2011). Validation and factor students. Social Psychiatry & Psychiatric Epidemiology, 42, structure of Korean version of the Beck Depression Inventory 161-166. doi:10.1007/s00127-006-0140-5 Second Edition (BDI-II): In a university student sample. Voltmer, E., Rosta, J., Aasland, O. G., & Spahn, C. (2010). Study- Journal of the Korean Society of Biological Psychiatry, 18, related health and behavior patterns of medical students: A lon- 126-133. gitudinal study. Medical Teacher, 32, e422-e428. doi:10.3109/ 0142159X.2010.496008 Author Biography Ware, J. E. (2003). The SF community—SF-36® Health Survey Dr. John Anthony A. Domantay is the Dean of the School of update. Retrieved from http://www.sf-36.org/tools/sf36.shtml Medicine, Saint Louis University, Baguio City, Philippines. He Weil, A. (n.d.). A healthy doctor. Retrieved from http://www. holds a Ph.D. in Educational Management from the same university drweil.com/drw/u/id/ART02019 World Health Organization (n.d.). Health. Retrieved from http:// and an M.Sc. in Epidemiology from the London School of Hygiene www.who.int/trade/glossary/story046/en/ and Tropical Medicine, University of London, United Kingdom. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png SAGE Open SAGE

Health-Related Quality of Life of Future Physicians at a Medical School in the Philippines: A Cross-Sectional Study

SAGE Open , Volume 4 (3): 1 – Aug 4, 2014

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Abstract

Medical students are trained to maintain the health of patients, but such training may have undesirable effects on medical students’ personal health. This study therefore aimed to assess the health-related quality of life (HRQOL) of medical students and to determine the factors that are associated with the students’ HRQOL. The target population included all students enrolled at the Saint Louis University School of Medicine in Baguio City, Philippines, during school year 2012-2013. The measurements included the 36-Item Short Form Health Survey (SF-36) questionnaire for HRQOL, Beck Depression Inventory, abbreviated Maslach Burnout Inventory, Perceived Stress Scale, Holmes and Rahe Stress Scale, and self-report items for other exposure variables. A total of 527 medical students participated in the study. The mean scores in all of the eight domains of HRQOL ranged from 51.36 to 85.83. The highest mean scores were along the areas of physical functioning (85.83) and bodily pain (69.20), whereas the lowest mean scores were in the areas of vitality (51.72) and role limitations due to emotional problems (51.36). Depression, stress, and burnout were associated with lower scores in most of the domains of HRQOL. Medical students in our school are generally in a satisfactory state of functional health and well-being, but have a lower level of mental health as compared with physical health. Keywords Health-related quality of life, medical students, medical school, medical education As it is multifaceted, HRQOL is in agreement with the defi- Introduction nition of health of the World Health Organization (2013), Medical students are trained to maintain the health of indi- which is “a state of complete physical, mental, and social vidual patients and of populations. Such training is physi- well-being, and not merely the absence of disease or infir- cally and mentally demanding and may have undesirable mity.” HRQOL has been applied to studies of various popu- effects on medical students’ personal health (Dyrbye, lations such as those with chronic diseases or debilitation, as Thomas, & Shanafelt, 2005). According to Weil (n.d.), medi- well as to groups of healthy adults and health professionals. cal schools foster unhealthy lifestyles; medical students suf- A search for published research articles that primarily fer from sleep deprivation, poor nutrition, lack of exercise, assessed the HRQOL of medical students revealed studies and are placed under a considerable amount of stress. In one conducted in Canada (Raj, Simpson, Hopman, & Singer, study, medical students were shown to have a poorer status 2000), Brazil (Paro et al., 2010), and Iran (Jamali et al., of physical and mental health, and more anxiety, depression, 2013), and none in the Philippines. This study therefore and negative lifestyle changes as compared with non- aimed to assess the HRQOL of medical students at the Saint medical students (Al-Dabal, Koura, Rasheed, Al-Souwielem, Louis University in Baguio City, Philippines. Specifically, it & Makki, 2010). Physicians are health professionals who sought to determine the status of the HRQOL of the medical play a vital role in a country’s health care system. It is there- students along the domains of physical functioning, role lim- fore essential that physicians-in-training maintain their own itations due to physical health, bodily pain, general health well-being to better care for their patients in the future. perceptions, vitality, social functioning, role limitations due Assessing the overall health of individuals and popula- to emotional problems, and mental health; it also sought to tions is of public health importance. According to the Center for Disease Control and Prevention (2011), one approach to 1 School of Medicine, Saint Louis University, Baguio City, Philippines this is to make use of an expansive concept known as health- Corresponding Author: related quality of life (HRQOL). It is a multidimensional John Anthony A. Domantay, School of Medicine, Saint Louis University, measure for evaluating physical functioning, psychological Bonifacio Street, Baguio City 2600, Philippines. well-being, and social functioning (Calvert & Skelton, 2008). Email: jad_mdphd@yahoo.com This article is distributed under the terms of the Creative Commons Attribution 3.0 License Creative Commons CC BY: (http://www.creativecommons.org/licenses/by/3.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page (http://www.uk.sagepub.com/aboutus/openaccess.htm). 2 SAGE Open determine factors associated with the medical students’ validity, criterion validity, construct validity, and predictive HRQOL. validity. The various studies on the validity of the SF-36 are cited elsewhere (Ware, 2003). A recent study has shown that the instrument is a valid and reliable tool for measuring the Method health status among Filipinos residing in two cities in the Philippines (Castillo-Carandang et al., 2013). Study Design The SF-36 can be used as a self-administered question- A cross-sectional study design was used. In this design, the naire, or can be administered via a computer or personal or outcome variable, which is the HRQOL, as well as the expo- telephone interview. It takes only 5 to 10 minutes to com- sure variables were assessed at a particular point in time plete. In this study, it was given to the medical students as a using a questionnaire. A descriptive cross-sectional design self-administered questionnaire. was used to determine the status of the medical students’ Scoring of the instrument followed the two-step process HRQOL. An analytical cross-sectional design was used to as recommended by the RAND Corporation (n.d.-b). In the determine the factors that are associated with the medical first step, precoded numeric values were recoded using a students’ HRQOL. scoring key. Each item was scored in a range of 0 to 100. The scores represented the percentage of the total possible score achieved. In the second step, items in the same scale were Study Population averaged together to yield the eight-area (scale) scores. The target population included all students enrolled at the Missing data were not included when computing for the Saint Louis University School of Medicine in Baguio City, scale scores. Philippines, during school year 2012-2013. The total popula- In this study, norm-based interpretation of the SF-36 was tion of the students was 608. As all students were included in used. In this interpretation strategy, 50 is considered as the the study, no sampling techniques were employed. average score or norm. Scores higher than 50 are better than the general population average for all the eight scales, whereas scores lower than 50 are worse (Gandek, 2002). Data Collection Data were gathered using a questionnaire consisting of the Assessment of depression. Depression was assessed using the following parts: Beck Depression Inventory (BDI). This instrument was orig- inally meant to measure depression in patients with mental Assessment of HRQOL. HRQOL was measured using the illness, but it can also be used in a primary care setting. It 36-Item Short Form Health Survey (SF-36) questionnaire. consists of 21 questions, each question having four possible The SF-36 is a multipurpose, short-form health survey con- responses with scores ranging from 0 to 3. The total score of sisting of 36 questions. It measures eight areas of health: the test is a measure of the severity of depression. In a pri- physical functioning, role limitations due to physical health, mary care setting, a score higher than 21 is interpreted as bodily pain, general health perceptions, vitality, social func- having depression. Studies have provided evidence of the tioning, role limitations due to emotional problems, and validity of this tool; it is also considered to have high reli- mental health. The tool produces scores for each of these ability (Encyclopedia of Mental Disorders, n.d.). eight areas. As a generic measure, this questionnaire has The BDI has been validated in some Asian countries such been useful in evaluating the health of general and specific as Indonesia (Ginting, Näring, van der Veld, Srisayekti, & populations as well as assessing HRQOL (Ware, 2003). Becker, 2013), Korea (Yu, Lee, & Lee, 2011), and Japan Thus, it is an appropriate data gathering instrument for this (Kojima, Furukawa, Takahashi, Kawai, & Nagaya, 2002). study. However, a review of the literature did not reveal any valida- The SF-36 was authored by John E. Ware Jr. and was tion studies of the BDI done in the Philippines. developed as a part of the RAND Medical Outcomes Study (MOS): Measures of Quality of Life Core Survey (RAND Measurement of burnout. To measure burnout, an abbreviated Corporation, n.d.-a). The utilization of the SF-36 has been Maslach Burnout Inventory (aMBI) was used. This inven- cited in more than 4,000 published articles. It has also been tory is the most widely used measure of burnout (Maslach, acknowledged as the most widely evaluated generic patient Jackson, Leiter, Schaufeli, & Schwab, n.d.). The abbreviated assessed health outcome among quality of life measures. It form contains only 12 out of the original 22 questions, but has also been used in the description of more than 200 dis- still assesses the same three domains, namely, emotional eases and conditions. Translations of the instrument have exhaustion, depersonalization, and personal accomplishment been documented in 22 countries (Ware, 2003). The SF-36 (McManus, Smithers, Partridge, Keeling, & Fleming, 2003). has been reported to have high reliability, with coefficients The abbreviated form includes an additional three items exceeding .70 and even .80. There is also evidence of the regarding “satisfaction with medicine,” which makes it an instrument having adequate content validity, concurrent appropriate tool for the present study of medical students. No Domantay 3 validation studies of the aMBI or the Maslach Burnout (unordered categorical), year level (ordered categorical), aca- Inventory in the Philippines were found. demic performance (ordered categorical), pre-medical course (unordered categorical), socioeconomic status (ordered categor- Measurement of perceived stress. Stress was measured using ical), depression (continuous quantitative), burnout (continuous the Perceived Stress Scale (PSS). This is the most commonly quantitative), stress levels (continuous quantitative), and stress- employed questionnaire to gauge an individual’s perception ful life events (continuous quantitative). of stress (Cohen, n.d.). It consists of 14 items which are eas- Prior to actual analysis, the data were checked for missing ily understood and hence can be used in the general popula- values. These were appropriately coded, so that the computer tion. It has been validated in studies, particularly those will recognize them as missing and thus exclude them from dealing with health status. For example, in Asia, it has been the analysis. validated among Chinese cardiac patients who are smokers In the analysis of the data, the following were carried out: (Leung, Lam, & Chan, 2010). It also has good reliability basic descriptive analysis in the form of means and standard (Cohen, Kamarck, & Mermelstein, 1983). deviations of the HRQOL scores along the eight scales; mea- sures of association between the HRQOL scores and the Measurement of stressful life events. Stressful life events were exposure variables, t test, and null hypotheses and p values assessed using the Holmes and Rahe Stress Scale (Mind- for the association between the HRQOL scores and binary Tools, n.d.). This is a list of 43 stressful life events that have variables, that is, sex, one-way ANOVA and null hypotheses, been correlated with illness. Each stressful event corresponds and p values for the association between the HRQOL scores to a value known as a life change unit (LCU), depending on and unordered and ordered categorical variables. In addition, how stressful the event is. The sum of the LCUs yields an Bartlett’s test for inequality of population variances was per- estimate of an individual’s stress level and likelihood of ill- formed. If the p value from Bartlett’s test was less than .05, ness. For this particular study, life events that were most non-parametric tests such as the Mann–Whitney/Wilcoxon likely to apply to medical students in the Philippine setting two-sample test or the Kruskal–Wallis test were used instead were included in the questionnaire. For example, divorce of the t test or ANOVA, respectively. Pearson’s correlation was not included as divorce is not allowed in the Philippines. coefficient and null hypotheses and p values were used to However, no formal validation of this instrument has been determine the association between the HRQOL scores and conducted in the Philippines. quantitative variables, that is, age, depression (BDI score), burnout (aMBI score), stress levels (PSS Score), and stress- Measurement of other variables. The instrument also con- ful life events (Holmes and Rahe Stress Scale score). tained self-report items related to the other exposure vari- ables. These variables were age, sex, civil status, year level, Ethical Considerations academic performance, pre-medical course, and socioeco- nomic status. The research protocol was reviewed and approved by the Institutional Review Board (IRB) of the university prior to the conduct of the study. The review considered both scien- Data Management tific and ethical aspects of the research. The questionnaire The questionnaires were administered personally by the had a cover letter that provided information on the research researcher accompanied by a research assistant. The ques- objectives as well as the significance and importance of the tionnaires were administered at the middle of the second study. Participation in the study was voluntary and it was semester. Questionnaires were administered during regular explained to the students that they had the option not to class days and not during major examination periods. answer the questionnaire. Students were not compensated for To extract the data from the questionnaires, the responses their participation. Complete anonymity of the research par- were coded, using number codes to make the data suitable ticipants was observed as the participants were asked not to for analysis. write their names or any identifying marks on the question- Microsoft Excel was used for data entry. Only one data- naires. Thus, specific information on the questionnaires base was created. The database had one variable for each could not be linked to specific individuals. Access to the data item in the questionnaire and one record for each respondent. was limited only to the researcher and two research Each participant had a unique identifier in the form of an assistants. identification number. The Microsoft Excel file was then exported to Epi Info 7 for data analysis. Results Data Analysis Characteristics of the Study Participants The main outcome variable was the HRQOL scores (continuous A total of 527 medical students participated in the study rep- quantitative). Exposure variables included age (quantitative), resenting a response rate of 86.7%. Most were between the sex (binary), civil status (unordered categorical), ethnicity ages of 19 and 24 years old (78.8%). Most were female 4 SAGE Open Table 1. Demographic Characteristics of the Participants. Table 2. Psychological Characteristics of the Participants. Variable Frequency (n) % Variable Frequency % Age Depression (based on BDI score) 19-24 411 78.9 Without depression 482 91.5 25-29 101 19.4 With depression 45 8.5 30-42 9 1.7 Stress Sex No significant stress 249 47.3 Male 205 38.9 Mild stress 96 18.2 Female 322 61.1 Moderate stress 134 25.4 Year level Major stress 48 9.1 First 160 30.4 Variable M SD Second 112 21.3 Third 137 26.0 Burnout Fourth 118 22.4 Emotional exhaustion 8.20/18 4.70 Civil status Depersonalization 4.24/18 4.16 Single 510 96.8 Personal accomplishment 13.17/18 3.61 Married/legally separated 17 3.2 Satisfaction with medicine 15.23/18 3.37 General weighted average Perceived stress 18.56 (sometimes) 6.17 85 and above 48 9.4 80-84 238 46.8 Note. BDI = Beck Depression Inventory. 79 and below 223 43.8 Pre-medical course example, with depression, the high response rate makes non- BS Biology 113 21.4 response bias less likely. BS Medical laboratory science 65 12.3 In all, 45 students (8.5%) had manifestations of clinical BS Nursing 279 52.9 Others 70 13.3 depression, whereas 182 students (34.5%) had features of Parents’ annual income moderate to major stress. The medical students had a low Less than PhP 100,000 59 14.0 tendency for burnout along the domains of personal accom- 100,000-499,000 171 40.5 plishment and depersonalization, but had a high tendency for 500,000-999,000 117 27.7 burnout along the domain of emotional exhaustion. They 1,000,000 and above 75 17.8 scored relatively high in terms of satisfaction with medicine (Table 2). Note. PhP = Philippine pesos. US$1 is approximately equivalent to 44 PhP. 1 Euro is approximately equivalent to 60 PhP. HRQOL of the Medical Students The mean scores in all of the eight domains were above 50, (61.1%) and single (96.77%). The highest percentage of ranging from 51.36 to 85.83. The highest mean scores were respondents were in first year (30.4%). In terms of academic along the areas of physical functioning (85.83) and bodily performance, the most common grade point average range pain (69.20), whereas the lowest mean scores were in the was 80 to 84. Most of the medical students studied nursing as areas of vitality (51.72) and role limitations due to emotional their pre-medical coursework (55.6%). The most common problems (51.36; Table 3). combined annual income range was between PhP (Philippine pesos) 100,000 and PhP 499,999 (40.5%; Table 1). The response rate in this study was 86.7%. Among the Associations Between HRQOL and the Exposure non-responders, there was an almost equal number of males Variables and females; 40 were males and 41 were females, with a male to female ratio of approximately 1:1. The male to Male students tended to have higher scores than female stu- female ratio in each year of the medical school was as fol- dents along the domains of general health (p = .001), vitality lows: first year—1:1.4, second year—1:1.4, third year— (p = .014), and role limitations due to emotional problems 1:1.6, and fourth year—1:1.5. The overall male to female (p = .004). There were no significant differences in the ratio in the medical school is 1:1.5. Further analysis revealed HRQOL scores among the four year levels except for the that there was no significant difference between the non- area of social functioning, where fourth-year students had responders and responders according to sex (p = .10; see lower scores as compared with the other three year levels (p Table A1 in the appendix). Although it is possible that some < .001). There were also no associations between the HRQOL students who refused to participate were symptomatic, for scores and academic performance, except in the domain of Domantay 5 Table 3. HRQOL of the Medical Students. health, that is, vitality and role limitations due to emotional problems. Depression, stress, and burnout were associated Domain M SD with lower scores in most of the domains of HRQOL, PF 85.83 15.68 whereas sex, pre-medical course, academic performance, RP 52.81 39.72 and year level were associated with fewer of the HRQOL BP 69.20 21.74 domains. GH 62.88 18.91 The lowest scores were in those domains related to mental VT 51.72 16.41 health. This means that medical students have a tendency to SF 61.48 12.89 encounter problems with work or other daily activities as a RE 51.36 44.20 result of emotional problems and that they may experience MH 65.58 17.28 feelings of nervousness and depression (Ware, 2003). These are likely related to the nature of the medical school experi- Note. HRQOL = health-related quality of life; PF = physical functioning; ence, which has been often described as stressful. Medical RP = role-physical; BP = bodily pain; GH = general health; VT = vitality; SF = social functioning; RE = role-emotional; MH = mental health. students have to undergo frequent periods of adjustment, which may affect them emotionally. For instance, first-year students have to adjust to medical school itself, which is role limitations due to physical health where those with more rigorous and intellectually challenging as compared lower weighted averages had lower HRQOL scores than with their pre-medical course. Students in third year have to those with higher weighted averages (p = .015; Table 4). adjust to clinically oriented courses, from the basic science In the Philippines, students admitted to a medical school courses of lower years, not to mention the issue of academic should be holders of a baccalaureate degree, which is termed overload typical of third year. Students in fourth year have to as their pre-medical course. Those who studied nursing as adjust to clinical clerkship, wherein full-time clinical train- their pre-medical course had higher scores in the area of ing in the hospital is an entirely different experience from bodily pain (p = .046), whereas those who studied medical teaching and learning in the classroom setting. Moreover, technology as their pre-medical course had higher scores in this study also showed that psychological conditions such as the area of social functioning (p = .008). No associations depression, stress, and burnout are inversely related to were observed between the HRQOL scores and age, civil sta- HRQOL scores. tus, and parents’ combined annual income (Table 4). There are other issues that might stress medical students. There was a striking association observed between the Although family members are generally supportive, due to HRQOL scores and depression; those who were depressed the cultural norm of close family ties in the Philippines, they had significantly lower scores in seven out of the eight can also be a source of stress, especially for students who domains, as compared with those without depression (p < have family problems, or who are married and/or with chil- .001). In terms of stress, those with moderate to major stress dren, who may be struggling to balance family life and medi- had lower scores in the areas of role limitations due to physi- cal school training. Financial problems can also be a source cal health, general health, and role limitations due to emo- of stress, as medical education is expensive and scholarship tional problems (Table 4). Similar findings were observed in grants for medical education are very limited in the terms of perceived stress, presented in Table 5, where nega- Philippines. tive correlation coefficients in all areas of HRQOL except The findings of the current study are consistent with those bodily pain and social functioning, indicated that higher of Voltmer, Rosta, Aasland, and Spahn (2010) who, as a part stress levels were related to lower HRQOL scores. of their article, studied the HRQOL of medical students in As for burnout, emotional exhaustion and depersonaliza- Germany and discovered that the students had lower scores tion were negatively correlated with HRQOL scores in six in the domain of mental health as compared with physical out of the eight areas. The relationships were stronger for health. The results are also in agreement with those of Dyrbye emotional exhaustion as compared with depersonalization. et al. (2007) who, also as a part of their article, determined There were slightly positive correlations between satisfac- the quality of life of medical students in the United States. tion with medicine and HRQOL in five out of the eight areas Their students also had relatively low mental quality of life (Table 5). scores. However, medical students are able to perform all types of physical activities, even the most vigorous, without limita- Discussion tions due to health, and that they do not experience pain or The results of this study showed that overall, medical stu- there are no limitations due to pain (Ware, 2003). A possible dents had an average to above average HRQOL. It also explanation for this might be that the great majority of medi- revealed that students had a higher HRQOL in the scales cal students are apparently physically fit young adults, as related to physical health, that is, physical functioning and attested by their annual medical-physical examinations. bodily pain, but scored lower in scales related to mental Students have to undergo these physical examinations 6 SAGE Open Table 4. Associations Between HRQOL and Categorical Variables. PF RP BP GH VT SF RE MH Sex Male 85.81 52.80 69.35 66.26 53.93 61.77 58.21 67.16 Female 85.84 52.82 69.10 60.72 50.32 61.30 47.00 64.58 p value Ns ns ns .001 .014 ns .004 ns Year level First 88.13 51.41 71.66 64.98 51.94 62.11 49.17 65.80 Second 87.32 52.90 67.30 63.53 53.81 61.05 49.11 67.07 Third 86.25 50.91 70.84 63.00 51.25 65.51 48.42 66.89 Fourth 80.79 56.85 65.76 59.26 49.97 56.36 59.89 62.31 p value Ns ns ns ns ns <.001 ns ns Average 85+ 86.88 55.72 70.52 59.79 55.07 59.90 50.69 68.50 80-84 87.19 57.18 68.46 64.26 52.59 61.40 54.76 66.97 <80 84.51 46.64 69.92 62.34 50.46 62.33 47.09 63.63 p value Ns .015 ns ns ns ns ns ns Pre-medical course Biology 84.74 55.09 66.28 64.67 50.07 61.28 53.10 64.11 Medical 87.24 50.77 64.54 61.23 51.30 62.69 58.97 67.91 technology Nursing 86.16 52.09 71.44 62.72 52.50 62.37 48.63 65.50 Others 84.22 53.93 69.29 62.16 51.67 57.14 52.38 66.11 p value Ns ns .046 ns ns .008 ns ns Depression (based on BDI score) None 86.58 54.89 68.83 64.45 53.16 61.10 53.67 67.65 Depressed 77.78 30.56 73.17 46.00 36.37 65.56 26.67 43.38 p value <.001 <.001 ns <.001 <.001 .007 <.001 <.001 Stress None 85.73 56.93 70.35 65.52 52.68 60.74 57.30 66.57 Mild 87.43 54.69 68.96 61.08 52.90 62.89 50.69 66.21 Moderate 86.60 48.01 67.52 60.03 50.10 61.85 40.55 62.90 Major 80.93 41.15 68.39 60.73 48.92 61.46 51.08 66.67 p value Ns .029 ns .028 ns ns .005 ns Note. No associations were observed between the HRQOL scores and age, civil status, and parents’ combined annual income. HRQOL = health-related quality of life; PF = physical functioning; RP = role-physical; BP = bodily pain; GH = general health; VT = vitality; SF = social functioning; RE = role- emotional; MH = mental health; ns = not significant; BDI = Beck Depression Inventory. together with basic laboratory tests prior to enrollment. men are supposed to be less emotional than women. Thus, Moreover, chronic diseases which may bring about pain and male medical students in general do not let emotions or emo- physical limitations are uncommon in this age group. tional problems hinder their performance in their studies and Our study also showed that males had significantly higher training. These findings are similar to those of the study of scores than females in the domains of general health and Paro et al. (2010) that female students had lower HRQOL vitality. This means that males have a tendency to evaluate scores than males. Jamali et al. (2013) also established that their personal health as excellent and that they always feel male gender was significantly associated with higher energetic, as compared with females. This is in keeping with HRQOL scores as compared with females. the cultural norm in the Philippines where men are generally Regarding the factors associated with HRQOL, our find- considered to be the stronger sex, thus men perceive them- ings are similar to those of Paro et al. (2010) who found out selves to be so. The present study also revealed that male that female medical students and those with depression had medical students had significantly higher scores in the lower HRQOL scores. Dyrbye et al. (2007) likewise reported domain of role limitations due to emotional problems as that burnout and depression were major factors that influ- compared with female medical students. A higher score enced medical students’ quality of life. In addition, Swami et means that there are less interferences with work or daily al. (2007) observed that in Malaysia, life satisfaction, which activities as a result of emotional problems. This is again is used interchangeably with quality of life, was inversely consistent with the cultural norm in the Philippines where related to depression. Arslan, Ayranci, Unsal, and Arslantas Domantay 7 Table 5. Associations Between HRQOL and Numerical Variables. PF RP BP GH VT SF RE MH Burnout: Personal accomplishment Pearson r −.035 .063 −.04 −.034 −.019 −.06 −.021 −.002 p value ns ns ns ns ns ns ns ns Burnout: Emotional exhaustion Pearson r −.167 −.181 .009 −.273 −.442 .009 −.231 −.444 p value <.001 <.001 ns <.001 <.001 ns <.001 <.001 Burnout: Depersonalization Pearson r −.171 −.104 −.06 −.117 −.185 −.01 −.139 −.275 p value <.001 .017 ns .007 <.001 ns .001 <.001 Burnout: Satisfaction with medicine Pearson r .128 .073 −.03 .139 .185 −.04 .110 .197 p value .003 ns ns .001 <.001 ns .011 <.001 Perceived stress Pearson r −.151 −.241 .073 −.368 −.523 .027 −.326 −.629 p value .001 <.001 ns <.001 <.001 ns <.001 <.001 Note. HRQOL = health-related quality of life; PF = physical functioning; RP = role-physical; BP = bodily pain; GH = general health; VT = vitality; SF = social functioning; RE = role-emotional; MH = mental health; ns = not significant. (2009) also reported that in Turkey, the scores of the SF-36 This study also had a relatively high response rate, which scale were lower for those with depression as compared with could have minimized selection bias. To the best of our those without depression. knowledge, this is the first study on the HRQOL of medical However, the results of the current study differ from those students in the Philippines. of Naseem and Iqbal’s (2010) study. Among Pakistani medi- However, this study also had certain limitations. As in cal students, physical functioning, general health perception, other studies employing questionnaires, recall bias is a pos- vitality, and social functioning for second-year students were sibility. In determining the factors associated with HRQOL, significantly less than the other classes. In the present study, confounding was not assessed as the main objective of the social functioning was highest among third-year students study was to describe the status of the medical students’ and lowest among fourth-year students. This is because stu- HRQOL. Furthermore, the present study only involved stu- dents in the third year have already adjusted to life in medical dents from just one medical school in the Philippines. This school and have already established friendships among limits the study’s generalizability. The results may not neces- classmates. Thus, they are able to interact with each other sarily be extrapolated to students from other medical schools and socialize on weekends. However, fourth-year students in the country or to those from other countries. It is important are in clinical clerkship wherein they spend most of their to bear in mind that medical schools vary in terms of the time in the hospital. There is little time for socialization with nature of their curricula, for instance, traditional versus prob- friends and after work they would rather rest and sleep in lem-based learning, duration of the medical course, as well preparation for the next hospital duty the following day. This as school and hospital atmosphere and environment. Medical is similar to the findings of Paro et al. (2010) and Jamali et al. students from different schools may also vary according to (2013) where students in the highest year level had lower sociodemographic characteristics such as age and sex distri- HRQOL scores as compared with lower year levels. bution, and other personality characteristics. All these may It is interesting to note that 45 medical students (8.5%) influence their HRQOL. had depression based on the BDI score. Further analysis of In conclusion, medical students in our school are gener- Item Number 9 on the BDI, which assesses suicidal thoughts, ally in a satisfactory state of functional health and well- revealed that 54 students checked the response “I have being, but have a lower level of mental health as compared thoughts of killing myself, but I would not carry them out”; with physical health. Depression, stress, and burnout reduce 3 students responded that “I would like to kill myself”; and 2 the medical students’ state of health. The results of this study students responded that “I would kill myself if I had the have implications for medical educators in our school. It chance.” This has implications for counseling services in a could provide a basis for the development of student well- medical school. Such services are available at our universi- ness programs and activities. It is imperative that counseling ty’s Guidance Center, and the head of the center personally services and mentoring programs for medical students be attends to medical students who seek consultation. However, strengthened and enhanced. Improving the well-being of very few medical students avail of these services, most prob- future physicians will hopefully translate to better quality of ably due to lack of time owing to their heavy class schedule care for the patients they are meant to serve. and busy hospital rotations. Future research on the HRQOL of medical students is The strength of this study is that it made use of well- needed. This study may be replicated by other medical schools established and validated data gathering instruments such as in the country. Further investigations could utilize a longitudi- the SF-36, BDI, aMBI, PSS, and Holmes and Rahe Stress nal design rather than a cross-sectional design to trace changes Scale. The use of such tools minimized information bias. in the students’ health and well-being over time. 8 SAGE Open nicity, and medical student well-being in the United States. Appendix Archives of Internal Medicine, 167, 2103-2109. doi:10.1001/ archinte.167.19.2103 Table A1. Differences Between Non-Responders and Dyrbye, L. N., Thomas, M. R., & Shanafelt, T. D. (2005). Medical Responders According to Sex. student distress: Causes, consequences, and proposed solu- Sex Non-responders Responders Total tions. Mayo Clinic Proceedings, 80, 1613-1622. Encyclopedia of Mental Disorders. (n.d.). Beck Depression Male 40 205 245 Inventory. Retrieved from http://www.minddisorders.com/ Female 41 322 363 A-Br/Beck-Depression-Inventory.html Total 81 527 608 Gandek, B. (2002). Interpreting the SF-36 Health Survey. Winnipeg, Manitoba: Canadian Association of Cardiac Rehabilitation. Note. Fisher’s exact test p value = .10 (not significant). Ginting, H., Näring, G., van der Veld, W. M., Srisayekti, W., & Becker, E. S. (2013). Validating the Beck Depression Inventory-II in Indonesia’s general population and coronary Acknowledgment heart disease patients. International Journal of Clinical Health & Psychology, 13, 235-242. The author would like to thank Carl Froilan D. Leochico, MD, for Jamali, A., Tofangchiha, S., Jamali, R., Nedjat, S., Jan, D., Narimani, his invaluable assistance in data collection, data management, and A., & Montazeri, A. (2013). Medical students’ health-related data analysis; and to Joshua H. Gaboy, MD, and Rodel J. quality of life: Roles of social and behavioural factors. Medical Banggiacan, MD, for their help with data management. Education, 47, 1001-1012. doi:10.1111/medu.12247 Kojima, M., Furukawa, T. A., Takahashi, H., Kawai, M., & Declaration of Conflicting Interests Nagaya, T. T. S. (2002). Cross-cultural validation of the Beck The author declared no potential conflicts of interest with respect to Depression Inventory-II in Japan. Psychiatry Research, 110, the research, authorship, and/or publication of this article. 291-299. Leung, D. Y. P., Lam, T., & Chan, S. S. C. (2010). Three versions Funding of Perceived Stress Scale: Validation in a sample of Chinese cardiac patients who smoke. BMC Public Health, 10, Article The author disclosed receipt of the following financial support for the research and/or authorship of this article: This study was funded Maslach, C., Jackson, S. E., Leiter, M. P., Schaufeli, W. B., & through a University Research Grant (URG No.12.3.SoM.1) from Schwab, R. L. (n.d.). Maslach Burnout Inventory. Mind Saint Louis University, Baguio City, Philippines. Garden. Retrieved from http://www.mindgarden.com/pro- ducts/mbi.htm References McManus, I. C., Smithers, E., Partridge, P., Keeling, A., & Fleming, Al-Dabal, B. K., Koura, M. R., Rasheed, P., Al-Souwielem, L., & P. R. (2003). A levels and intelligence as predictors of medi- Makki, S. M. (2010). 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Validation and factor students. Social Psychiatry & Psychiatric Epidemiology, 42, structure of Korean version of the Beck Depression Inventory 161-166. doi:10.1007/s00127-006-0140-5 Second Edition (BDI-II): In a university student sample. Voltmer, E., Rosta, J., Aasland, O. G., & Spahn, C. (2010). Study- Journal of the Korean Society of Biological Psychiatry, 18, related health and behavior patterns of medical students: A lon- 126-133. gitudinal study. Medical Teacher, 32, e422-e428. doi:10.3109/ 0142159X.2010.496008 Author Biography Ware, J. E. (2003). The SF community—SF-36® Health Survey Dr. John Anthony A. Domantay is the Dean of the School of update. Retrieved from http://www.sf-36.org/tools/sf36.shtml Medicine, Saint Louis University, Baguio City, Philippines. He Weil, A. (n.d.). A healthy doctor. Retrieved from http://www. holds a Ph.D. in Educational Management from the same university drweil.com/drw/u/id/ART02019 World Health Organization (n.d.). Health. Retrieved from http:// and an M.Sc. in Epidemiology from the London School of Hygiene www.who.int/trade/glossary/story046/en/ and Tropical Medicine, University of London, United Kingdom.

Journal

SAGE OpenSAGE

Published: Aug 4, 2014

Keywords: Health-related quality of life; medical students; medical school; medical education

References