Health related quality of life of university students in Lebanon: Lifestyles behaviors and socio-demographic predictors

Ibtissam Sabbah, Hala Sabbah, Rania Khamis, Sanaa Sabbah, Nabil Droubi

Doctoral School of Literature, Humanities & Social Sciences-Lebanese University, Beyrouth, Lebanon.
Faculty of Economic Sciences and Business Administration, Lebanese University, Nabatieh, Lebanon.
Faculty of Public Health, Lebanese University, Saida, Lebanon;.

DOI: 10.4236/health.2013.57A4001                

Abstract

Measuring and monitoring health related quality of life (HRQoL) in youth are important for both researchers and decision makers. During the time that young people are at university, many will encounter a number of academic, as well as social, emotional and psychological difficulties. The aims of this study are to: 1) assess the health related quality of life of youths using SF-36 questionnaire and its factor determinants, and 2) provide an objective basis for a health promotion structure. Methods: This is a cross-sectional study in South Lebanon, in a population of 282 young university students attending a public university which is the largest and most widespread institution of higher education in Lebanon. Socioeconomic and lifestyle behaviors data were collected. Students’ HRQoL was measured using the SF-36 Health Survey. Results: The mean age of the respondents was 18.7 years (SD = 1.16), 80.1% were women, 64.5% were living in rural area. The proportion of current smokers was significantly greater among men than women (26.8% vs. 11.5%, p < 0.01). Water pipe was the main type of smoking. Education of the fathers had negatively influenced HRQoL. Younger age scored higher in Social Functioning and Role-Emotional; the area of residence had no influences on SF-36 scales scores. Females had poorer HRQoL than males especially in mental health scales. Smokers had low Vitality and Mental Health scores. Sedentary lifestyle was linked to a lower score of Physical Functioning (β = -5.16, 95% CI = -7.67 -2.65), and Vitality ( β= -5.85, 95% CI = -10.24 -1.45). The HRQoL of the students studying business and economics was higher than those studying health. Conclusion: Youths’ HRQoL is affected by socio-demographic and behavioral characteristics. Effective health-promoting actions, social support, and counseling services should be implemented in the campus and are a necessary step towards the main goal of improving the overall HRQoL of the university young students in Lebanon.

Keywords

Health Related Quality of Life; Lifestyle Behaviors; SF-36; Health Promotion; Young University Students

1. INTRODUCTION

Measuring and monitoring health related quality of life (HRQoL) in youth continue to increase in importance for both researchers and decision makers [1-13]. World Health Organization (WHO) defines quality of life (QoL) as “an individual’s perceptions of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, and concerns”. This definition of QoL highlights the factors that impact subjective evaluations of life circumstances and may explain the apparent discrepancies sometimes found between an objective evaluation of a person’s life circumstances and his/her own self-evaluation [6,14]. A related concept of healthrelated quality of life is well-being, which involves satisfactory, stable and happy life [1,15,16].

HRQoL is a multidimensional concept which reflects patients’ health both physically and mentally. Health is defined as “a state of complete physical, mental and social wellbeing and not merely the absence of disease and infirmity is an important factor for academic achievement at school, and in higher education [11,17, 18]. In the context of universities, promoting health and well-being means promoting effective learning [17] and human development [19]. Vice versa, education is a strong predictor of lifelong health and quality of life in different populations, settings, and time [17]. Indeed, “efforts to improve school performance that ignore health are ill-conceived, as are health improvement efforts that ignore education” [20].

The majority of students entering university are aged between 18 and 21, a transition age to adulthood characterized by dramatic changes in life. On one hand, the university experience provides the young person with the opportunity to enhance knowledge and perspective, to develop and establish aspects of personal identity and to achieve personal growth. On the other, during that time many will encounter a number of academic as well as social, emotional and psychological difficulties [18,21], financial limitations [11], and a myriad of challenges and stressors [11,22,23]. Young people also seem not to be aware of the effects of unhealthy behaviors [3,24], so they are less likely to engage in health promoting activities [25]. Youth are usually at the stage of life when the future is ahead, and the essential goals are set [16]. Good physical, social, emotional, and psychological health help protect young people against behavioral problems, violence and crime, misuse of drugs and alcohol [26], teenage pregnancy [26], risky sexual behavior [27], suicidal behavior [28], and low academic performance [18,29]. Several factors can negatively predict the Health related quality of life of youth such as gender, socio-economic and demographic status [3,4,11,30-33], parental socio-economic status [2, 16,30,32], overweight and obesity [25,34], alcohol consumption [14], physical activity [25,35-38], and war [36, 39,40].

The youth aged between 15 and 29 years represents 28% of the total population in Lebanon [41]. As in certain European countries [11,17], and Canada [22], the available information of HRQoL of this age group remains limited [5,31,42-47]. Assessment of HRQoL should be based on patients’ self-report and should cover the relevant domains of daily functioning (physical, mental, social). The SF-36 measures generic health concepts relevant across age, disease, and treatment groups. It provides a comprehensive, psychometrically sound, and efficient way to measure health from the patient’s point of view by scoring standardized responses to standard questions. The current study aims to: 1) assess the health related quality of life of youths using SF-36 questionnaire and its factor determinants especially gender and residence areas (urban/rural), and 2) establish an evidence-based decision-making for the implementation of a health promotion structure in university setting in Lebanon.

2. METHODS

2.1. Data Collection

From October 2011 to March 2013, a cross-sectional survey was conducted amongst a population of youth university students attending faculties of Economics and Management, and Public Health (Nursing, Midwifery, Physiotherapy, Medico-social Work, Radiology, and Laboratory Sciences), at a public university in South Lebanon. This public university is the largest and most widespread institution of higher education in Lebanon. Classes were chosen randomly. The students were approached after class and asked to participate in the study. Students were informed about the purpose of the study and were assured that their participation would be voluntary, and that if at any point they decided not to complete the questionnaire, they could withdraw from the study. The participants were also informed that the information collected would be anonymous, and that no individual participant could be identified from their data. The students were given a consent form stating the purpose of the study (presented at the beginning of the questionnaire). The sample size would allow us to detect a 5 point difference in SF-36 scores between groups with a fixed norm (a general population), assuming two-sided significance of 5%, with 80% power [48]. This led us to predict that 300 students would be necessary for the survey. Data collection was carried out privately after assuring respondents about confidentiality of the information collected by self-administration. 3 types of Information were collected.

2.1.1. Socio-Economic Status

In order to assess familial socioeconomic status, information about age, marital status as well as mothers and father’s education, profession, social security, number of inhabitants per house, and car ownership was collected. The declared health illness in the family and for students was also collected.

Students’ socio-demographic information was collected such as gender, age, area (urban/rural) and place of residence, marital status, specialization, current occupation, and social security coverage. Self-rated one-item measure of financial status with ratings ranging from 1 (very poor) to 5 (very good) is also collected.

2.1.2. Lifestyle Behaviors’ and Declared Health Illness

Tobacco and alcohol use, physical activities (where the subjects currently exercise over 30 min per session, at least 2 times per week for duration), diet (yes/no) and body weight and height were self-reported by the students. Body mass index (BMI), a universally used and recognized measure in medicine to categorize people’s weight into obese (³30 kg/m²), overweight (25 - 30 kg/m²), normal weight (18.5 - 25 kg/m²), and underweight (<18.5 kg/m²) was used to calculate the participants’ BMI by dividing the individual’s body weight in kilograms by the square of their height. The declared health illness in the family and for students was also collected.

2.1.3. HRQoL

Students’ HRQoL was measured using the SF-36 health survey [48], before the respondent was asked about other health questions and concurrent illnesses, so that any discussion of health problems does not influence the respondent’s answers to the questionnaire. An Arabic copy of SF-36, version 1 which was translated and adapted in Lebanon was used in our study [31]. The SF-36 is a general questionnaire, widely used in various conditions and populations, and was designed to measure health status from the patient’s point of view. The SF-36 consists of 36 questions that are clustered to yield 8 health status scales commonly represented in health surveys: Physical Functioning (PF), Role-Physical (RP), Bodily Pain (BP), General Health (GH), Vitality (VT), Social Functioning (SF), Role-Emotional (RE), Mental Health (MH), and Reported Health Transition (HT). Two summary measures aggregate these status scales, namely the Physical and Mental health summary scales. The SF-36 is suitable for self-administration, computerized administration, or administration by a trained interviewer in person or by telephone, to persons age 14 and older. The health concepts described by the SF-36 range in score from 0 to 100, with higher scores indicating higher levels of function and/or better health status. The subjects’ responses are presented as a profile of scores calculated for each scale. For all domains, each raw scale score is transformed to a 0 to 100 scale using the formula shown below [48]. Transformed scale = {(Actual Raw Score – Lowest Possible Raw Score)/Possible Raw Score Range} × 100. This transformation converts the lowest and highest possible scores to zero and 100, respectively. Scores between these values represent the percentage of the total possible score.

Self-rated one-item measure of quality of life, with ratings ranging from 1, very poor, to 5, very good was also collected [31].

2.2. Statistical Analysis

Analyses were carried out through frequencies, mean and standard deviation (SD). Individual SF-36 items were recorded, summed and transformed, with missing values imputed as recommended [48]. Subjects with missing scale scores were excluded listwise from the analysis. The mean and standard deviation (SD), percentiles for responses to each scale of the SF-36 were calculated. The percentage of people with scores at the ceiling (percentage of subjects with a score of 100) and floor (lowest level) were calculated for each scale.

The Chi-square statistics (χ²) and t-test statistics independent sample were used for categorical and continuous variables respectively to analyze the significance of differences. One-way analysis of variance (ANOVA) was performed for demographic dimensions with more than two categories. As the HRQoL may differ between males and females, and according to area of residence (urban/rural) we do stratify the analyses for gender and residency.

A multivariate analysis was performed to analyze the combined effect of predictors (independent variables), on SF-36 dimensions (dependent variables). The adjustments were performed by generalized linear model. The confusion variables taken into account were the following: age (included in the model as a continuous variable), gender areas of residence, marital status, financial status perception, global quality of life perception, health illness, mother’s and father’s education, and mother’s and father’s job.

The SPSS 16 package was used in the analysis of the data. All tests of significance were two-tailed. p < 0.05 was taken as the critical level of significance.

3. RESULTS

A sample of 300 young university students was recruited. A total of 282 self-reported questionnaires were returned (that is, approximately 94% response rate).

3.1. Household’s Characteristics

The mean age of mothers and fathers was respectively 50.7 (SD = 5.6) years, and 45.7 (SD = 5.0) years. 5% of the parents were widowed or divorced. The mean number of inhabitants per house was 5.77 (SD = 1.5; median 6; minimum = 2, maximum = 11). 18.4% of fathers have university education and higher, 19.1% were educated to primary level or lower and only 1.4% were illiterate. The proportion of mothers with university and higher education was 14.2% and there was a significant difference between rural and urban environment: 26.1% in rural vs. 15.5% in urban areas have primary level and lower, and 10.1% in rural vs. 16.4% in urban areas have university level of education and higher (p < 0.05). Regarding employment status, 13.1% of the mothers were employed; 52% of fathers were independent workers, with non difference between urban and rural areas in this regard. Concerning car possession, 7.1% of families didn’t have a car, 45.7% had one car and 47.2% had 2 cars and more. 45.0% of the families were not registered with the social security, with no statistically difference between urban and rural area. 38.8% of the families reported having experienced a disease during the last 12 months in the family.

3.2. Socio-Demographic Characteristics, Lifestyle Behaviors, and Self-Reported Illnesses

Table 1 summarizes the socio-demographic characteristics and lifestyle of the people interviewed, stratified by gender, and urban and rural settings. A majority (80.1%) of the respondents were women, living in rural area (64.5%). 41.5% live in Nabatieh, 46.8% in South Lebanon, and 11.7% in Mount Lebanon Department. 18.8% have moved after their birth from urban (41.5%), rural (37.7%) or abroad (20.8%). The students’ age span was from 16 to 24 years and the mean, and median age of the respondents was 18.7 (SD = 1.16), and 18 years respectively. Most of the respondents were single (92.2%). Concerning the marital status we observed more married and fiancée in rural area (10.4% vs. 3.0%; p ≤ 0.05), and in female (9.7% vs. 0.0%; p ≤ 0.05); 77.3% studied in public health faculty. 98.9% of students were affiliated to social security (all had non Lebanese nationality). Regarding employment status, 20 (7.1%) of the students indicated that they were employed. The males reported worse financial status than the females where 8.9% vs. 2.2%; p ≤ 0.05 declared their financial status was very poor and poor. The largest proportion assessed their quality of life as good and very good (59.9%) or fair (37.6 %), with much smaller percentages for poor or very poor (2.5%), but the students living in urban areas reported bad quality of life (6.0% vs. 0.5%; p ≤ 0.05). The proportion of current smokers was significantly greater among men than women (26.8% vs. 11.5%; p ≤ 0.01). The water pipe was the main type of smoking (60.0% of men vs. 96.2% of women; p ≤ 0.01). Alcohol consumption was declared by 2.5% of respondents without statistically significant difference between men and women, and according to area of residence. A higher rate of physical activity was reported by male students (87.5% vs. 49.6%; p ≤ 0.001). Indeed, 58.4% of the samples do the regular walking or jogging or running, and 41.6% of students declared doing physical activities including playing football or any other games, weight lifting, swimming, karate, horse riding, aerobics, and dancing. Higher rate of women declared that they are on diet (11.9% vs. 1.8%; p ≤ 0.05). Self-reported diseases and symptoms, employing a recall period of 12 months, were numerous, declared by 39.4% of young students. 11.2% were underweight, and 1.4% were obese.

Conflicts of Interest

The authors declare no conflicts of interest.

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