Assessment of quality of life and associated factors in nursing students

ABSTRACT Objective: To assess the quality of life of nursing undergraduate students and factors associated with socioeconomic variables and internship field. Methods: A cross-sectional study was conducted in an educational institution located in the northern region of the state of Ceará, Brazil, involving 309 nursing undergraduates from the 1st to the 10th semester. The WHOQOL-bref instrument was used to evaluate the quality of life. Each domain and total score of the instrument were considered as outcome variables. Results: 69.3% of the individuals were women, the mean age of the sample was 28 years, and 67.7% defined their quality of life as “good” or “very good.” Undergraduates who consumed well water and those with lower income had a higher chance of presenting lower scores in the physical domain and environmental domain of quality of life, respectively (p < 0.05), and of having a lower total quality of life score. Conclusion: The students considered their quality of life to be good/very good, and sociodemographic factors influenced the lower quality of life score.


INTRODUCTION
The World Health Organization (WHO) defines quality of life as an individual's perception of their position in society in relation to culture and value systems, including expectations and concerns [1].Evidence suggests that the low quality of life among students in the health field is closely related to various factors such as sleep quality, level of physical exercise, post-exercise state, roommate relationships, and family satisfaction [2].
Given this, assessing the level of quality of life in a population of university students is of paramount importance, as these individuals, during their university-level studies, are exposed to a multitude of complex factors in their lives [3].The day-to-day routine of a student pursuing higher education triggers sensations and experiences that generate both positive and negative perceptions about well-being and quality of life [4].However, when the institution fails to successfully support the student during the adaptation phase, a series of changes occur, which can result in various problems and adversities in their studies, leading to potential emotional discomforts that affect well-being [5].The constant exposure to pressure situations and the pursuit of results do not always come with sufficient resources and suitable conditions for carrying out activities [6].
Internships aim to develop the ability to question practice, work routines, professional practice, and the personal dimension of student training [7].Various situations, such as daily hustle, pressure for results, and competitiveness, are experienced by many university undergraduates.The new generations have high expectations and do not cope well with frustrations and additional responsibilities, which contributes to an imbalance in their well-being, affecting their health [8].Considering this context, the aim of this study was to assess the quality of life of nursing undergraduate students and the factors associated with socioeconomic variables and internship field.

Study type
This is an analytical cross-sectional study that followed the STROBE recommendations.

Study location
The study was conducted at a private educational institution with a total of 1089 students enrolled in the nursing undergraduate program.The institution is in the northern region of the state of Ceará, Brazil, within a population of 205.529 inhabitants.The institution possesses a faculty and infrastructure that are coordinated with existing courses, both at the undergraduate and postgraduate levels.

Participants
The sample size calculation was performed using the EpiInfo program.The sample of 309 nursing undergraduates (from the 1st to the 10th semester) provided a test power of 0.80, with a confidence level of 95%, to detect an odds ratio (OR) of 2.0.The exposed to non-exposed ratio was set to one, and the response rate in the non-exposed group was assumed to be 50%.

Data collection
The study was submitted to the Ethics and Research Committee (CEP) of the Faculty of Dentistry of Piracicaba FOP/UNICAMP (CAAE 08685018.0.0000.5418).A meeting was initially conducted with representatives from each class (1st to 10th semesters) to introduce the study and explain the participation process.Data collection was carried out online using Google Forms, where participants had access to the Informed Consent Form (ICF).Upon agreeing to participate, participants were directed to a page with the study questionnaires.The researcher visited all classrooms in all three shifts, emphasizing the study's importance and the correct completion of instruments on the platform.

Instruments
For data collection, the validated WHOQOL-bref instrument was used.It consists of 26 questions, with the first question concerning overall quality of life and the second related to satisfaction with one's own health.The remaining 24 questions are divided into the domains: physical, psychological, social relationships, and environment.Responses are provided on a Likert scale with five response options (1 to 5), which are then transformed into final scores ranging from 0 (high QoL) to 100 (low QoL).Additionally, sociodemographic variables (gender, age, income, family size, parents' education level, housing, water consumption type, head of household profession, and birthplace) were collected, along with variables related to the internship field (semester, immersion in the internship field, participation in internships, and, if applicable, the type -practical experiences or supervised internships).

Data analysis
The study's outcome variables were scores in the domains of the WHOQOL-bref questionnaire (physical, psychological, social relationships, and environment) and the overall score.Other variables such as monthly family income, family size, head of household education, housing, water consumption type, participation in internships, and type of internship were considered independent variables.Descriptive analyses were conducted, providing frequencies, percentages, mean, standard deviation, median, minimum, and maximum values.Logistic regression models were estimated for each independent variable and outcome.Variables with p < 0.20 were explored in multiple logistic regression models, with the final model including variables that remained with p ≤ 0.05.The strength of associations was expressed as odds ratios (OR) with a 95% confidence interval.Analyses were conducted using R software [10].

RESULTS
The sample consisted of 309 Nursing undergraduates, with 69.3% being female and 30.7% being male.The mean age was 28.2 years, with a standard deviation of 6.4 years, a minimum of 19, and a maximum of 43 years.
In table 1, it can be observed that 4.8% of the sample defined their quality of life as "poor," while 67.7% defined it as "good" or "very good."Additionally, 11.0% considered their health as "very poor" or "poor," while 57.3% considered it "good" or "very good." Please review the translation for accuracy and coherence in the context of your article before using it for publication.
Table 2 descriptive analysis results of total quality of life (WHOQOL-bref) scores and by domain.Table 3 presents the frequency distributions of quality-of-life scores evaluated by WHOQOL-bref, along with demographic, socioeconomic, and immersion variables in the internship field.It is observed that 54.0% of the surveyed nursing undergraduates are conducting internships.Furthermore, it is noteworthy that 36.2% are engaged in supervised internships, while 63.8% have practical experiences.
In the analysed sample, 4.5% declared consuming well water, and it was observed that students who mostly consume well water are more likely (OR=5.36,95% CI: 1.18-24.49)to present lower scores in the physical domain of quality of life (p<0.05).
The results of the association analyses with the psychological domain score of quality of life are presented, and no significant association was found with any of the analysed variables (p>0.05).Similarly, the quality-of-life score in the social relationships' domain did not exhibit a significant association with the analysed variables (p>0.05)(table 3).Table 4 displays the analyses of associations between quality of life scores assessed by the WHOQOL-bref and demographic, socioeconomic, and immersion variables in the internship field.Undergraduates from families with lower income (up to R$ 1.510.00)have a higher likelihood (OR=2.11,95% CI: 1.33-3.33) of presenting lower quality of life scores in the environmental domain (p<0.05).Furthermore, it is observed that undergraduates who predominantly consume well water are more likely (OR=3.96,95% CI: 1.08-14.57)to exhibit lower total quality of life scores (p<0.05)(table 4).

DISCUSSION
The present study holds its significance in the exploration of variables that might interfere with this perception, as well as in suggesting pathways toward students' quality of life during their period in the educational institution.Considering this, the results of this study identified a low percentage of students who perceived their quality of life as poor or very poor (11%), while the majority reported a good or very good perception (67.7%).On the other hand, other studies categorized overall quality of life as moderate [11,12], and reported that most students evaluated their overall quality of life as positive, moderate, good, or very good.Interestingly, it was highlighted that the negative impact was more prevalent among senior students [12].
It was observed that family income was associated with lower quality of life.This phenomenon could be linked to depressive symptoms, as described in a study conducted at the School of Nursing at UFRGS [13], which observed an association between depression, at a moderate or severe level, and family income lower than 1 minimum wage per capita.This emphasizes that income can be one of the factors significantly associated with depressive symptoms.
The relationship between quality of life and consumption of potable water was identified in the study.This explanation is attributed to the fact that access to clean water and proper sanitation is an essential human right for the full enjoyment of life [14].A study carried out in a private university in São Paulo revealed student dissatisfaction in the domain related to the environment [15], reinforcing the significance the environment has on quality of life, especially concerning inadequate sanitation conditions that are responsible for many waterborne diseases [16].
When identifying the direct relationship between income and quality of life, the present study not only corroborates the findings of other authors [17,18] but also prompts us to reflect.The affirmative policies that took place in Brazil from the mid-21st century onwards, responsible for the inclusion of thousands of low-income Brazilian youths or individuals from less privileged social strata, were of paramount importance in combating the country's historical inequalities.They represent a duty of the Brazilian state towards historically marginalized and oppressed populations and ethnicities.These policies have been and continue to be essential.However, it is necessary to recognize that they must go beyond merely facilitating access to higher education for these individuals.It is imperative that they provide concrete conditions for social well-being -in other words, ensuring dignified and comfortable circumstances that enable students to engage in their studies and develop in academia with social justice and thus, quality of life.
Furthermore, the findings of this study identified that academic internships did not affect the quality of life.Probably, the expectation of a rapid inclusion in the job market by the interns -supported by statistics showing that 40 to 60% of interns are hired after their internship [19] -may contribute to the fact that internships do not negatively impact the students' quality of life.Certainly, such an expectation would motivate the students.And motivation, as is known, can positively influence people's spirits and well-being.Moreover, the acquisition of experience also has a positive impact on one's qualifications and consequently, on self-perception.
The results obtained in this study emphasize the need to pay attention to the environmental and socioeconomic aspects of university students.In addition, there is a call for the adoption of measures that directly focus on quality of life, aiming to promote the integrity and academic success of university students.Insufficient levels of quality of life can negatively impact health and create difficulties in academic life [20].Beyond graduation, it is essential to enhance strategies that provide quality of life for the individuals we seek to educate [21].

CONCLUSION
Nursing students perceived their quality of life as good/very good, and sociodemographic factors influenced lower quality of life scores.Therefore, the need for adopting social measures that directly focus on quality of life is emphasized, aiming to promote integrity and academic success among university students.Since an insufficient level of quality of life can negatively impact their health and create difficulties in academic life, this calls for immediate attention.
The study contributed to highlighting vulnerabilities related to social and environmental domains, underscoring the need for a comprehensive perspective for students entering higher education in Brazil.The association between course development and available resources can influence the learning process and contribute to lower quality of life.It is important to emphasize the necessity for further research, investigating a wider range of variables related to students' understanding of quality of life.This can yield results that influence the creation and execution of effective actions to address this demand.
A limitation of this study lies in its cross-sectional design, preventing the establishment of causal relationships.This makes it challenging to determine whether the associations presented precede or follow the occurrence of the outcome.Despite employing a reliable and valid quality of life assessment instrument that ensures data confidentiality, it's important to acknowledge the possibility of information bias, given that some instrument questions were subjective and dependent on participants' memory.

Table 1 .
Descriptive analysis of self-perceived quality of life and health satisfaction among nursing undergraduates (n=309).

Table 3 .
Frequency distribution of quality-of-life scores assessed by the WHOQOL-bref, along with demographic, socioeconomic, and immersion variables in the internship field, among nursing undergraduates (n=309).

Table 3 .
Frequency distribution of quality-of-life scores assessed by the WHOQOL-bref, along with demographic, socioeconomic, and immersion variables in the internship field, among nursing undergraduates (n=309).

Table 3 .
Frequency distribution of quality-of-life scores assessed by the WHOQOL-bref, along with demographic, socioeconomic, and immersion variables in the internship field, among nursing undergraduates (n=309).

Table 3 .
Frequency distribution of quality-of-life scores assessed by the WHOQOL-bref, along with demographic, socioeconomic, and immersion variables in the internship field, among nursing undergraduates (n=309).

Table 4 .
An analysis of the associations between the scores of quality of life assessed by the WHOQOL-bref and the demographic and socioeconomic variables and immersion in the field of internship, for nursing undergraduates (n=309).

Table 4 .
An analysis of the associations between the scores of quality of life assessed by the WHOQOL-bref and the demographic and socioeconomic variables and immersion in the field of internship, for nursing undergraduates (n=309).

Table 4 .
An analysis of the associations between the scores of quality of life assessed by the WHOQOL-bref and the demographic and socioeconomic variables and immersion in the field of internship, for nursing undergraduates (n=309).