INTRODUCTION
Young individuals, including students, are often assumed to be healthy. However, recent years have seen a rise in the prevalence of chronic diseases in this demographic. Estimates suggest that up to 30% of young people may be affected by such health problems [1]. Data from the European Health Interview Survey identify allergies, asthma, and thyroid disorders as the most common chronic health issues among individuals aged 15-29 [2]. Similarly, the National Health Test of Poles revealed a growing incidence of long-term health problems or chronic diseases across all age groups, including young adults. In 2023, 36% of respondents aged 18-24 and 25-34 reported having long-term health problems or chronic diseases, compared to 31% and 35%, respectively, in 2020 [3].
Quality of life (QoL) is defined as “an individual’s perception of their position in life within the context of the culture and value systems in which they live, and in relation to their goals, expectations, and standards” [4]. QoL is closely linked to an individual’s health status, and living with a chronic disease can significantly impair one’s QoL [5]. Several key insights emerged from the experiences of young individuals with chronic illness. First, chronic illness creates a sense of discomfort in both their body and the world. Second, it disrupts their perception of a ‘normal’ life. However, the experience is not wholly negative, as it can also yield unexpected positive outcomes. Moreover, two forms of support are crucial for navigating this experience: external help from others, and personal strategies that the individual develops to cope with the illness [6]. Adolescents with chronic conditions may also experience lower educational outcomes [7], with the intensity of depression in this group further decreasing their quality of life level [8]. These young individuals may become increasingly reliant on their family members, placing considerable demands on caregivers, who must manage complex medical needs, cope with uncertainty, and endure personal sacrifices [9]. Students with chronic illnesses face significantly more academic and social-emotional challenges compared to their healthy peers. They are more likely to repeat a grade, experience academic difficulties, and have increased school absences due to illness. Furthermore, parents of these students report higher emotional distress and lower social confidence in their children. Despite these challenges, students with chronic illnesses often lack additional academic or emotional support, such as tutoring or assistance from school professionals, leaving their needs largely unmet [10]. Medical students, in particular, encounter significant personal difficulties, especially during exam periods. The intense academic demands, coupled with feelings of social isolation, often lead to emotional exhaustion, raising stress levels and negatively impacting their personal lives and overall well-being [11]. Higher stress levels are strongly and negatively correlated with performance on medical school examinations [12]. Additionally, increased concerns about future career prospects and the outcomes of graduation exams further contribute to the deterioration of mental health among medical students [13].
To our knowledge, no prospective cohort study has yet been conducted on the Polish population to examine the occurrence of chronic diseases among medical students concerning their QoL. Further investigation into changes in the occurrence of chronic diseases and QoL throughout medical education, incorporating an analysis of multiple contributing factors, would provide valuable insights.
This study aimed to assess the QoL among medical students, examine its association with the occurrence of diagnosed chronic diseases, and analyze changes over a two-year follow-up period.
MATERIAL AND METHODS
COHORT
The data were collected during a follow-up study called “POLLEK”, in which we studied medical students from the Medical University of Silesia in Katowice (Poland) [14]. Data presented in the current paper were based on questionnaire surveys collected at two time points: during the student’s inaugural year of studies (the academic year 2021/2022, T1), and subsequently during their second year of study (the academic year 2022/2023, T2). Ultimately, the study included 427 first-year (83.7% response rate) and 335 second-year students (83.8% response rate). The dropout rate during the observation period was 21.5%, primarily due to students withdrawing from their studies (n = 87) or not attending on the measurement day (n = 5). Data were collected using a paper-based questionnaire, and written informed consent was obtained from all participants. Each participant was assigned a unique, anonymous identifier (ID), also included in the paper forms distributed to them. The IDs were implemented to enable follow-up assessments at subsequent stages of the study while ensuring complete anonymity. The study was conducted with the approval of the Bioethics Committee of the Medical University of Silesia in Katowice (approval number KNW/0022/KB/217/19; date: 8 November 2019).
MEASUREMENT TOOLS
The QoL, designated as the dependent variable, was assessed with the Polish version of the WHOQOL-BREF questionnaire, a generic tool. This instrument has been validated for the Polish population [15] and was approved by the WHO for use in the “POLLEK” study [Permission request 297756]. The questionnaire contained 26 questions that assessed 4 domains of QoL: Somatic, Psychological, Social (social relationships), and Environmental. The somatic domain (including questions Q3, Q4, Q10, Q15, Q16, Q17, Q18) takes into account satisfaction in terms of daily performance and work capacity, satisfaction with sleep and rest but also the presence of physical pain, and the need for medical treatment. The psychological domain (Q5, Q6, Q7, Q11, Q19, Q26) includes satisfaction with appearance and experiencing negative feelings such as despair, anxiety, or depression (and its frequency), in general – self-satisfaction in everyday life. The social relationships domain (Q20, Q21, Q22) focuses on relationships with others, including social support systems and sexual activity. Questions about financial resources, living conditions, accessibility of social care and health services (as well as their quality), and physical safety are parts of the environmental domain (Q8, Q9, Q12, Q13, Q14, Q23, Q24, Q25). Finally, raw values were calculated based on the respondents’ declaration and then transformed into scores from 0 to 100 points according to the WHO guidelines.
In addition to the WHOQOL-BREF questionnaire, the following independent variables were also identified: sociodemographic data (age, sex, marital status, current financial situation, current place of residence during medical studies), lifestyle aspects (current traditional or electronic cigarette smoking, the prevalence of hazardous alcohol use, and selected eating behaviors, and frequency of physical activity). Health indicators refer to self-rated health, the occurrence of chronic disease previously diagnosed by a physician, body weight, and height, which were used to calculate body mass index (BMI).
The prevalence of hazardous alcohol use among medical students was evaluated using the Polish version of the Alcohol Use Disorder Identification Test (AUDIT), a 10-item screening tool developed by the World Health Organization (WHO). The AUDIT assesses three main areas: recent alcohol consumption, symptoms of alcohol dependence, and alcohol-related mental and physical issues. Each item is scored from 0 to 4, with a maximum total score of 40. Students scoring 8 or more were classified as engaging in hazardous alcohol drinking [16].
STATISTICAL ANALYSIS
Statistical analyses were conducted using the Statistica 13.3 package (TIBCO Software Inc., Palo Alto, CA, USA). Categorical variables are presented as the number of observations and percentages. Additionally, the relationships between categorical variables were analyzed using the chi-squared test. The mean values and standard deviations were applied in the statistical description of particular QoL domains. Due to the non-normal distribution of quantitative variables (the Shapiro-Wilk test), non-parametric tests were used to assess group differences (Mann-Whitney U or Kruskal-Wallis test). Finally, multivariable linear regression models were used to evaluate the determinants of QoL in the T1 and T2 periods, separately for groups defined by the occurrence of previously diagnosed chronic diseases (DCD – declared chronic disease group: a group of students with declared chronic diseases; NDCD – no declared chronic disease group: a group of students without chronic diseases). Four separate models were computed, each utilizing the sample with follow-up data. A p-value < 0.05 was considered statistically significant in all analyses. The missing values limiting the calculation of regression models were automatically removed from the analysis.
RESULTS
The study was conducted with the participation of 427 first-year (289 females, 138 males) and 335 second-year students (226 females, 109 males). The results indicated that, during the first year of observation, 23.7% (n = 101) of respondents reported having at least one chronic disease, with 4.2% experiencing multimorbidity. Among these, 90.1% (n = 91) were under treatment. In the second year, there was a slight increase, with 28.3% (n = 95) of respondents reporting at least one chronic disease, while the proportion experiencing multimorbidity remained constant at 4.2%. Among these, 73.7% (n = 70) were under treatment. Endocrinopathies, allergies, and mental disorders dominated among the declared diseases both in the first (T1) and second year of studies (T2). The prevalence of mental disorders increased from 2.6% in the first year to 5.1% in the second year.
Table 1 presents sociodemographic characteristics, lifestyle factors, and self-rated health status of the studied groups, along with a comparison between the first and second-year observations. In both years, students with DCD more frequently reported a worse financial situation and were more likely to be tobacco smokers compared to students without chronic diseases. However, the differences were not statistically significant. Additionally, students with chronic diseases were significantly more likely to report worse health status (p < 0.001).
Table 2 presents the WHOQOL-BREF domain scores among medical students during the T1 and T2 periods, categorized by the occurrence of a previously diagnosed chronic disease. In the first year (T1), students with chronic diseases reported significantly lower QoL scores in the overall (p < 0.001), somatic (p < 0.001), and psychological (p = 0.028) domains compared to those without chronic diseases. In the second year (T2), these students continued to report lower QoL scores, particularly in the overall (p < 0.001) and environmental domains (p = 0.018).
In the next stage, a multivariable analysis was conducted to assess the relationship between the QoL and various explanatory variables among students with and without chronic diseases, during both the first (T1) and second (T2) year of observation. In the first year (T1), the lower QoL scores in most domains for students with chronic diseases (DCD group) were associated with worse self-rated health and less frequent physical activity. Additionally, lower scores in the environmental domain were linked to a worse financial situation, while in the somatic domain, tobacco use was also a significant factor. Among students without chronic diseases (NDCD group), worse self-reported health status was similarly associated with lower scores in overall QoL domains. In the somatic and psychological domains, female students reported lower scores, and in the social relations domain, lower scores were common among single students. The detailed results are presented in Table 3.
Afterward, the determinants of QoL were examined during the second year of observation (T2) for students both with and without chronic disease (Table 4). The analysis among the group of students with DCD revealed that the overall QoL, along with scores in the somatic and psychological domains, was significantly associated with higher BMI values. Additionally, lower QoL in the somatic and environmental domains was linked to a poor financial situation. It is also worth noting that worse self-rated health was associated with lower overall QoL scores, particularly in the environmental domain. Moreover, the analysis conducted on the NDCD group revealed that the lower scores in all QoL domains were particularly associated with worse self-rated health. A significant factor contributing to reduced overall QoL, as well as declines in the somatic and environmental domains, was the infrequent engagement in physical activity.
DISCUSSION
The primary objective of this study was to assess the quality of life among medical students and investigate its association with self-reported chronic diseases, while also analyzing changes observed over a two-year observation period. To our knowledge, no previous research has concurrently examined these dimensions within the cohorts of medical students in the Polish population. Published data indicate that medical students report up to 11% lower quality of life than their non-medical peers [17]. This group is particularly vulnerable to psychological distress, academic challenges related to frequent examinations, work overload, and insufficient rest [18, 19]. Additionally, there is evidence that quality of life deteriorates in successive years of medical education. Martins et al.’s meta-analysis found that students in their 5th and 6th years experience lower quality of life scores in the psychological and social domains compared to those in the pre-clinical years, attributing this decline to factors such as exposure to human suffering and educational debt [20]. In our study, scores in the psychological and social domains were notably higher in the first year compared to the second. Nevertheless, overall quality of life was slightly higher in the second year (68.6 ± 17.9 vs. 69.0 ± 17.0, respectively).
Our findings also revealed a modest increase in the occurrence of chronic diseases within the study cohort, rising from 23.7% (n = 95) at T1 to 28.3 (n = 101) at T2. In this instance, the variables incorporated in the study do not provide sufficient means to directly explain the underlying causes of this trend. However, our previous analysis in the same cohort revealed a significant increase in BMI values, and higher blood pressure, as well as a slight rise in cigarette smoking and hazardous alcohol consumption between the first and second years of observation [21]. These factors may contribute to the observed increase in chronic disease prevalence, suggesting a potential link between lifestyle changes and health outcomes. Further research is needed to explore the interplay between these variables and their direct impact on chronic disease development. Additionally, incorporating a broader range of health indicators and behavioral factors in future studies could provide a more comprehensive understanding of the mechanisms driving this trend.
Furthermore, the occurrence of chronic diseases among medical students in our study was associated with a decline in overall quality of life, as well as in specific domains, throughout the cohort’s observation period. Particularly, during the first year of medical studies, students with chronic diseases diagnosed by a physician reported deterioration in QoL across multiple domains, including somatic, psychological, and environmental well-being. Available research highlights a broad spectrum of effects that chronic diseases have on young people, including their school attendance, engagement, academic performance, social-emotional development, and overall well-being [22]. During the early stages of their studies, they consistently experienced stress. Specifically, the first-year medical students demonstrated lower scores in the somatic and environmental domain of QoL compared to the third-year students [23]. First-year medical students report that the shift from high school to university brings substantial personal challenges, especially when it comes to living alone for the first time [24]. Notably, first-year medical students experiencing numerous challenges exhibit increased consumption of antidepressants and anxiolytics. In contrast, during the second year, there is a marked rise in the use of recreational drugs for various reasons. These findings suggest that the initial two years of medical school significantly contribute to the deterioration of students’ mental health [25]. It is reasonable to conclude that the deterioration in students’ quality of life can be attributed to the cumulative effect of the rigorous academic demands of the first year, compounded by the challenges imposed by their underlying chronic illnesses. Academic pressures are likely intensified by the added difficulties of dealing with chronic diseases, such as managing ongoing symptoms, adhering to treatment regimens, and coping with the psychological stress associated with both the medical condition and the academic environment. Consequently, the interaction between these academic and health- related stressors may affect the student’s overall well- being, highlighting the need for targeted support systems to address their educational and health-related needs during this critical period.
Within our study cohort, we conducted further analyses to examine the factors influencing the quality of life among medical students, both with and without chronic diseases. The determinants of quality of life exhibited variability depending on the observation period (T1 vs. T2) and the cohort of students examined (those with chronic diseases [DCD] vs. those without chronic diseases [NDCD]). It is particularly noteworthy that during the second year of observation (T2), the analysis among the cohort of students with diagnosed chronic disease (DCD) indicated that the deterioration of overall QoL, as well as in the somatic and psychological domains, was significantly linked with higher values of BMI. The relationship between longitudinal BMI changes and the occurrence of chronic diseases remains unclear. Studies on clinical outcomes in patients with chronic obstructive pulmonary disease (COPD) have shown that, following COPD diagnosis, BMI decreased in 5% of patients, remained stable in 69.2%, and increased in 5%. Furthermore, an increase in BMI was associated with an elevated mortality risk, but only in obese patients with COPD [26]. Conversely, findings from the Hokkaido COPD cohort study demonstrated that annual body weight loss constituted an independent risk factor for all-cause mortality [27]. Similarly, research has established a correlation between increases in body mass index and the prevalence of chronic kidney disease (CKD) [28], with evidence indicating that transitioning from normal weight to obesity and maintaining obesity throughout adulthood significantly raises the risk of developing CKD [29]. Existing longitudinal analyses also concluded that higher levels of overweight are correlated with an increased likelihood of developing or having asthma [30]. Additionally, longitudinal studies of patients with chronic liver diseases (CLD) revealed that reductions in BMI may lead to a deterioration in mental health [31]. Nonetheless, obesity is widely recognized as a major risk factor for non-communicable diseases, with individuals who remained consistently obese over time demonstrating the highest risk for developing at least one chronic disease in later life [32]. The results of our study showed that 13.1% of the first year medical students (T1) were overweight or obese, while 15.8% of the second-year students (T2) fell into the same category. Simultaneously, as previously demonstrated, an increase in the occurrence of chronic diseases between T1 and T2 (23.7% vs. 28.3%) was observed. Students with chronic diseases are more likely to be overweight or obese compared to their peers without chronic conditions (18.3% vs. 14.8%). Among the surveyed students, overweight and obesity could be considered not only as risk factors for chronic disease but also as potential outcomes. However, identifying the direction of the relationship requires long-term observation.
It is also important to consider additional conservative risk factors of chronic diseases, as well as overweight and obesity, within the study group, alongside the interrelationships among these factors. Regarding the sociodemographic and lifestyle characteristics of students in our study at T2, chronic diseases were slightly more prevalent among females (30.5% vs. 23.8% in males), students who were single (30.6% vs. 27.4% of students in a relationship), and those who reported a poor financial situation (38.6% vs. 24.4% of students reporting a good financial situation). Moreover, students with chronic diseases exhibited a higher prevalence of tobacco smoking (32.6% vs. 25.5% in students without chronic diseases) and hazardous alcohol consumption (41.6% vs. 27.9 in students without chronic diseases). In conclusion, the observed decline in QoL among students with chronic diseases, as also evidenced by multivariable models, underscores the significance of body mass index (BMI), hazardous alcohol consumption, and specific dietary patterns as modifiable risk factors [33].
Our findings suggest that obesity and lifestyle management are crucial factors in protecting the quality of life and health of medical students with diagnosed chronic diseases. Published data have shown that students with excess body weight exhibit poorer health outcomes and are more likely to engage in less favorable health behaviors compared to students with healthy weight [34]. It is therefore important to prioritize the maintenance of healthy body weight through comprehensive dietary and lifestyle modifications [28]. Moreover, studies conducted among medical students with chronic diseases from Morocco have highlighted a significant association between chronic disease occurrence and stress [35]. For students who are overweight or obese, stress increases health risks, making it especially important to focus on stress management strategies, including regular physical activity, as these interventions play a fundamental role in mitigating the negative impact of stress on their overall health and well-being [35, 36]. Effective stress management interventions may also include workshops aimed at enhancing medical students’ understanding of the effects of stress, as well as equipping them with coping mechanisms and resilience-building strategies [37, 38]. Mindfulness-Based Stress Reduction (MBSR) programs, which focus on developing mindfulness skills, such as breathing, relaxation exercises, body scanning, and yoga-inspired physical activities, have also demonstrated promising outcomes in promoting the overall well-being of medical students [39].
The main strength of the present study is that it focuses on its high response rate, exceeding 80% for both observation periods, which included medical students in their first and second years of study. High participation enhances the reliability of longitudinal analyses, allowing for the identification of temporal trends in the occurrence of chronic diseases. Furthermore, the study facilitates the examination of the relationships between students’ QoL and a broad range of determinants, providing valuable insights into the factors influencing QoL over time. The primary limitations concern the declarative nature of identifying chronic diseases among medical students as examined in the POLLEK study. Additionally, the relatively small sample size and the concentration of participants from a single educational institution limit the generalizability of the findings. Consequently, the results and conclusions presented cannot be extrapolated to the entire population of medical students in Poland.
CONCLUSIONS
The results of the present study confirmed a slight increase in the occurrence of chronic diseases among medical students over a two-year observation period with accompanying deterioration of their QoL. Notably, during the first year of medical studies, students with chronic diseases diagnosed by a physician reported a decline in QoL across several domains, including somatic, psychological, and overall well-being. The findings of our study underline the necessity of developing and implementing programs and strategies aimed at promoting a healthy lifestyle, with a particular focus on the prevention of overweight and obesity. These initiatives should also account for the specific needs of students with chronic diseases.
DISCLOSURE
The authors report no conflict of interest.
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