Associativism and quality of life among undergraduate students in dentistry

Objective: to analyze the relationship between student participation in associations and the way they perceive their quality of life. Methods: a study of one hundred and sixty students of Federal University of Santa Catarina (UFSC) Dentistry course belonging to the first, fifth, eighth and tenth semesters in Florianopolis, SC, Brazil. The theoretical basis is the Public Health approach, that, under the wider concept of health, considers associations as health promoters. A sociodemographic questionnaire, a questionnaire on associativism and the WHOQOL-Bref were used for data collection. Results: the results indicate that the participation of Dentistry students in associations improves self-evaluation of quality of life, satisfaction in personal relationships and reduces the frequency of negative feelings. Conclusion: students who participate in voluntary associations are associated with a better quality of life, promoting a more adequate professional formation. In this way, the participation of students in associations should be stimulated by the University. This perspective of analysis values social aspects in the perspective of health and can be a pioneering study in a field where there is still much to be studied, and can bring substantial contributions to the field of collective health and health as a whole.


INTRODUCTION
Socialization is an important element of the proper training of future higher-level professionals.The aspect that we discuss here is the quality of life of students observed from one of the fundamental aspects of youth sociability: participation in associations.The objective of this study is to analyze the relationship between participation in associations and how dentistry students perceive their quality of life at the university of origin.The hypothesis is that more participation in associations, be they academic centers, student associations, academic leagues, athletic leagues, political parties, nationalist organizations, or others, fosters a better quality of life for the students and, therefore, better training.
A historic colonization process is observed in Brazil marked by low political participation by the population with little propensity to participate in organizations with common causes.It is estimated that less than 13% of the population has some form of political participation in Brazil.In the USA, Canada, and Europe, such participation is found in 30%-45%.Moreover, social inequality, which tends to foster private relationsfamily or friendships without proper appreciation of public spaces-characterizes the form of sociability in the country 1 .
In the 1980s, the associative practices of Brazilian society began to gain relevance with the mobilization of social movements for rights and citizenship 2 .According to Lüchmann 3 , associations can be defined as autonomous and volunteer organizations, not for profit, and controlled by their members, acting as representatives of social groups according to specific themes and diverse in goals, values, and resources.Thus, associativism impacts the social lives of the people and can be analyzed according to different goals.In this sense, Warren 4 reports the importance of associations and associative life for democratic processes, recognizing their civic virtues.Therefore, the freedom of association becomes fundamental for democracy, allowing diverse interests 5 .
Associations contribute to the promotion of citizenship, strengthening collective bonds and representing less favored or excluded sectors, bringing to the fore demands and enriching political participation [6][7][8][9] .
A literature search showed that few studies evaluate student participation in associations.According to Christófaro 10 , the theme has not been explored in the history of education.According to the author, the most important studies addressed student associations during the Military Dictatorship period.
In the area of public health, Fontes 11 identifies social processes as important spaces for collective actions of different groups; health should not be confined to medical activity but should be understood in its extension into other fields, such as in civil society.
Although associativism is part of the social organization in Brazil, this theme has not studied been studied in dentistry.Given the importance of associations for the construction of democracy and for public health, associativism is an element in this debate.This study describes the participation of this population in associations and verifies the relation of association practices with the quality of life of students.

Health and Quality of Life
Quality of life is a growing concern in society.This is due to the greater appreciation of health parameters, where quality of life has become synonymous with health and even as something broader in which health itself would be another element 12 .
According to Buss 13 , the discussion of the influence of health on quality of life and vice versa has occupied intellectuals and politicians throughout human history.The author points to both as being influenced by issues such as distribution of income, illiteracy, poor education, and poor housing, among others.
Thus, the theme presents many methodologies for its scientific treatment, given its complexity and subjectivity.In this sense, current concepts try to address the multiplicity of cultural and holistic approaches.However, as approaches using a globally accepted concept facilitate analysis, there is a risk of reducing the theme to idealistic concepts 12 .
The concept of quality of life, according to Vieira and Santana 14 , transcends the technological process; is productive, efficient, and scientific; encompasses culture and art; and is a tool for happiness.
In the same sense, associative practices are linked to human values, agents in historical-cultural changes.Thus, associativism has the capacity to raise the selfesteem of those involved in the process, strengthening the bonding of the group 12 .

Public Health and Associativism
The construction of the Unified Health System (SUS), which ensured legal universal, equitable, and comprehensive access to health services, has its origins in social movements, being a national public health system fostering disease prevention and health promotion as a right of every citizen and duty of the state 15 .
Thus, for Carneiro Junior and Silveira 15 , although priority groups are defined for local populations based on vulnerability, there are still no real attentional models articulating the demands of the different social groups that share the same space (whether territorial, economic, and/or cultural).
According to Fontes 11 , the importance of social processes is increasing in the everyday world with space for collective actions directed at different groups.It is observed that, although associativism is highlighted as an important democratic tool and an area for action in health, a study by the National Association of Directors of Federal Institutions of Higher Education (ANDIFES) 16 identified low social and political participation among students from federal universities.The same is true for participation in the student movement, in which only 5.8% of students participate.
However, a literature search reveals that there is little data on students in the area of health and their participation in associations.The originality of this research is due to the lack of studies that connect participation in associations with quality of life in students in the area of health.
The motivation for this study was the informal verification through classroom conversations and listening by students and teachers that Federal University of Santa Catarina (UFSC) dentistry students have significant participation in associations.Thus, a question arose: Does this participation have any impact on the quality of life of these students?To answer this question, this study aims to analyze the relationship between the participation of UFSC dentistry students in associations and how they perceive their quality of life.

METHODS
The study was approved by the Ethics Committee for Research with Humans at the UFSC under opinion 14.789/2015, and all who agreed to participate in the study signed an informed consent form.
The study was carried out with students over 18 years old enrolled in the graduate course in dentistry at the UFSC.No census was carried out.As an inclusion criterion, students were considered to be enrolled in the 1st, 5th, 8th, or 10th semester.
The choice of 1st, 5th, 8th, or 10th semester came from the proposal by Spiger 17 , in which the students are classified into the following groups: • Basic Cycle: Period in which the curricula are theoretical or theoretical-practical, being related to the students' adaptation to the course, preceding the pre-clinical stage.In this study, 1st semester.Of these students, all those who answered the questionnaire in full were included.Of 183 students enrolled in the 1st, 5th, 8th, and 10th semesters of dentistry, 160 answered the questionnaire (88.89% response rate).It is worth remembering that, of the 11.11% non-respondents, 9% were not in the room at the time of application of the questionnaire.The non-response rate per cycle was as follows: basic cycle, 8%; pre-clinical stage, 9%; clinical stage, 10%; internship, 14%.The composition of the sample per cycle was as follows: 44 (27.50%) belonged to the basic cycle, 45 (28.13%) to the pre-clinical stage, 34 (21.25%) to the clinical stage, and 37 (23.12%) to the internship.
Data collection took place by means of a printed questionnaire applied individually by the student researcher during the first week of September in 2015, thus preventing the students from knowing the responses of their colleagues.
The in-class approach was standardized to avoid bias.The teachers of the theoretical classes included in the study were contacted by electronic message prior to implementation requesting authorization for the application of the questionnaire.On the scheduled day, students were given guidance, according to a written text that was read in the classroom, explaining the subject of the study and the importance of the reliable completion of the self-explanatory questionnaire.
The questionnaire was composed of three parts: • Sociodemographic questionnaire: Aimed at identifying the sociodemographic profile of the participants (sex, age, current semester, marital status, describing them per phase since they did not present considerable differences, and the grouping increased the statistical robustness.Data were analyzed and interpreted by means of descriptive statistics, the chi-square test, and Student t-test with the aid of the Epi Info program.The significance was set at p = 0.05.

Participation in associations
In this study, as shown in Table 2, a wide variety of types of associations in which students participate became apparent.There was an emphasis on religious associations with membership by half of those who participated in some association followed by participation in associations related to health and public policy councils.The students in the 8th semester reported participating more frequently in associations.
As shown in Table 3, there is an association between participation in associations and self-evaluation of quality of life.Participation in associations stimulates satisfaction with personal relationships and prevents negative states of mind, such as anxiety and depression.

Associativism and Quality of Life
Table 3 presents the distribution of the aspects of quality of life among the dentistry students in the 1st, 5th, 8th, and 10th semesters of the UFSC who do or do not participate in associations.and declared family income).Prepared by the authors themselves.
• Questionnaire of associativism: Aimed at identifying the participation of the study population in Latin American Public Opinion Project 18 associations.
• Quality of life questionnaire: The WHOQOL-BREF questionnaire, a short version of the WHO Quality of Life questionnaire, developed in 1998 and validated in Brazil by Fleck 19 , which evaluates physical, psychic, social, and environmental aspects through 26 questions, was applied.This study aimed to identify aspects of the students' quality of life based on the WHOQOL-BREF questionnaire, which selected some questions related to the students' community participation: self-assessment of quality of life; personal satisfaction with health; satisfaction with personal relationships with friends, family, acquaintances, and colleagues; satisfaction with the support received from friends; and reported frequency of negative states of mind.The other information regarding quality of life will be used in other studies.The questions were answered on a scale from 1 to 5 according to the abbreviated WHO Quality of Life Questionnaire.For satisfaction issues regarding quality of life, health, personal relationships, and support of friends, the scale presents 1 as Very Poor, 2 as Poor, 3 as Neither Poor nor Good, 4 as Good, and 5 as Very Good.
For the frequency of negative states of mind, the order is inverted: 1 represents Never, 2 Sometimes, 3 Quite often, 4 Very often, and 5 Always.It is worth mentioning that, to facilitate this analysis, data on participation in associations have been converted into "participation" or "non-participation."Therefore, the refinement is lost in relation to simultaneous participation in more than one association.This choice was made due to the small number of participants.The quality of life data were grouped without Figure 1 shows a direct relationship between participation in associations and self-assessment of health, although there is no statistical significance.This does not disqualify this conclusion, since the sample in the study is small, which impedes a more robust statistical analysis.
Figure 2 shows the distribution of aspects of quality of life, according to students' participation or non-participation in associations.

DISCUSSION
The present study aimed to analyze the relations between participation by UFSC dentistry students in associations and aspects of their self-perceived quality of life.To this end, we used the literature to discuss associated aspects with the findings of the study, because this relationship, in itself, is unprecedented, which can be an aspect that restricts the discussions but innovates from a democratic and citizenship perspective and in the refusal of individualism in favor of collective action.
The quality of student life is a topic that has stimulated the interest of several researchers in health and education.The ANDIFES 16 evaluated the quality of life of students through their use of health services, preventive habits, frequency of visits to the dentist, and practice of physical activities in addition to mental health.It was observed that students widely use the public network with only 1.44% reporting not having used any service.Approximately one-third of students reported not performing physical activities in addition to worrying values with respect to mental health issues, such as the importance of stressors, emotional crises, and the consumption of psychoactive substances: 14% of the students frequently consumed alcoholic beverages, 15% were smokers, and 6% used illicit substances.
With regard to the perception of students regarding quality of life in relation to the participation or non-participation in associations, as shown in Figure 2, one can observe that involvement with voluntary associations is associated statistically with a better self-perception of quality of life.This is the most important finding of this study that needs to be perceived broadly, given that the sociability of concrete interaction between participants produces good results in quality of life.
What also draws attention is that the rise of student participation in the health councils, which can be explained by their service in units of the SUS (via internship) in that semester, is a generating element of citizenship and quality of life.In that semester, students are encouraged to participate in the meetings of the municipal and local health councils of Florianópolis, but student participation on the councils is voluntary.
These findings are similar, in terms of quality of life alone, to published findings.Bampi and colleagues 20,21 observed that 71.5% of medical students and 85.40% of nurses felt satisfied or very satisfied with their  22 reported that 60.70% of dentistry students in the State of Ceará indicated a good quality of life.Nursing students, for example, displayed impairment in important aspects of quality of life, such as ability to concentrate and sleep, degree of energy, ability to perform day-to-day activities, and so on.A similar situation can be observed in other health courses, such as medicine and nutrition [23][24][25][26][27][28][29][30][31][32][33][34] .
In general, there is a tendency for the dentistry students studied to respond positively about their quality of life, which can reduce the sensitivity of the assessment of the impact of associations on student quality of life.
Associations are linked to humans and participate in historical and cultural changes, and their relevance is in actual and unconditional creation and implementation where there is exposure of social attitudes of communities in various areas.Thus, associativism has the capacity to raise the self-esteem of those involved in the process, strengthening the bonds of a group, where actions can support improvement in quality of life 14 .
Even with the importance of associativism in the current scenario, there are no studies that address how the process of social participation and associativism among health students occurs, even considering the training focused on the SUS and the relevance of associations for public health.
Although associativism is touted as an important tool of democracy and a working area for health, a study conducted at the national level by the ANDIFES 16 has identified low social, artistic, cultural, and political participation among students of federal universities.The same can be observed regarding participation in the student movements themselves, in which only 5.8% of Brazilian students are involved.Other movements, such as the ecological movements, have even lower values with only 4.5% of students participating.
What we can affirm without a shadow of a doubt, based on the study, is that the participation of students in associations improves their self-assessment of quality of life, satisfaction with their health, and satisfaction regarding personal relationships and regarding the support of friends and significantly reduces the frequency of negative states of mind, such as anxiety and depression.It is important to give due weight to these findings and discuss them in light of the social theories that facilitate understanding of the phenomenon.Therefore, it seems obvious that participation in associations has benefits for participants and the community.However, when one thinks about these potential health impacts, the exercise seems to become more complex and difficult.But why? Health is still observed by most professionals and researchers in health and public health as a mirror of the biological, clinical, and biomedical factors in relationship with the social element.This view that puts the social only in relation lowers its importance in the discussion of health.The proposal is to perceive health as a mirror of the social to perceive the well-being and quality of human life in the complexity that it demands.

CONCLUSION
This article concludes that voluntary participation by UFSC dentistry students in associations is related to better quality of life, which promotes more appropriate training.
As a major contribution to the field of public health, this study proposes the study of health from a social perspective, using quality of life as an outcome measure.This approach is intended to be a new way of analyzing people's health and perhaps that of populations from a broad understanding and facing the collective organization of life in individual contexts.After all, denying individualism and acting with and for the collective out of values of solidarity, cooperation, and democracy, in the associative perspective, are important aspects to building a better society, and the public health field must take this into account.
As a limitation of this study, one should consider the currently poor depth of the study of the relationship between associativism and quality of life, which requires further study and discussion to allow the understanding of the phenomenon with an emphasis on quantitative and qualitative studies.
Considering the limitations, one can affirm that the stimulation of the associations can have benefits for the quality of life of the students, having a potential for reducing psychosocial problems and improving interpersonal relations, enabling better conditions in the teaching-learning relation, a fundamental aspect in the adequate training of dentists.
Based on the data collected, it is also possible to affirm that the inclusion of students in the SUS in their spaces of social participation, such as the health councils, can yield good results.It is also perceived that this ensues only when the student is, in fact, an intern in the health units and plunges into the community as a health professional and citizen, embracing the defense of public health.Thus, one of the recommendations of this study is the early insertion of students into the community, in the health units, and in the political life of the community.To become a professional member of the SUS, it is necessary that students be politically engaged and aware of their rights, duties, and possibilities; moreover, it is necessary to break with the culture of individualism and cultivate a culture of collective action.
Thus, both the UFSC and the dentistry course should stimulate the creation of voluntary, democratic associations with a social purpose, rejecting those that act merely for the defense of private interests or groups of power.These associations include academic centers, student associations, national student unions, leagues, athletics, movements, and political parties, among many other forms of association, with the aim of contributing to the promotion of citizenship, strengthening collective bonds, and enriching participation and democratic political representation in the university and in society.

Figure 1 .
Figure 1.Satisfaction of the dentistry students of the 1st, 5th, 8th, and 10th semesters of the UFSC in relation to their health according to participation in associations.Florianópolis, 2016

Figure 2 .
Figure 2. Perception of the dentistry students from the 1st, 5th, 8th, and 10th semesters of the UFSC in relation to quality of life according to participation in associations in relative frequency (%).Florianópolis, 2016

• Pre-clinical stage:
Involves the 3rd to 5th semester, where work is progressively developed with pre-clinical and laboratory curricula, although there are no clinical activities with patients.In this study, 5th semester.•Clinical stage: From the 6th to the 8th semester, where clinical learning is provided, with attendance to the population.Represented by the 8th semester.
• Professional internship: Last year of the course, predominance of internships.In this study, represented by the 10th semester.

Table 1
presents the distribution of the participants in this study according to sex, age, marital status, and family income.

Table 1 .
Distribution of dental students from 1st, 5th, 8th, and 10th semesters of the university of origin according to the variables: Sex, Age, Marital status, Family income, and Semester as Absolute (n) and Relative (%) frequency.Florianópolis, 2016

Table 2 .
Participation of dentistry students of the 1st, 5th, 8th, and 10th semesters of the university of origin in different associations, according to semester enrolled, in absolute frequency (n) and relative frequency of the total number of respondents of each group (%).

Table 3 .
Distribution of aspects of quality of life among the dentistry students of the 1st, 5th, 8th, and 10th semesters of the UFSC participating and not participating in associations, displayed as mean, standard deviation, and correlation between the variables (independent t-test).Florianópolis, 2016