Students' self-perception about their Quality of Life is overestimated: is this the base of their mental troubles? [Version 2]

In this second version, we explained better our third questionnaire regarding self-awareness and the gender discrepancy. We also added the raw numbers followed by percentages in the results. Abstract Purpose: The aim of this study is to investigate the medical student perception about their QoL, in order to become ware of their own probems. Methods: We applied three instruments: a SF36 health questionnaire, a QoL self-perception questionnaire and a questionnaire regarding self-awareness and coping strategies. The questionnaires were sent to all medical students from ﬁrst to fourth year. Results: 203 students answered the questionnaires (64.5% were women and average age was 20 years old). Students self-perception about QoL was overestimated in most of the domains except in physical role functioning (p <0.001). There was a signiﬁcant diﬀerence between genders, and men showed a greater deviation from SF36 to QoL self-perception for mental health domain than women (p=0.04). Regarding the questionnaire about self-awareness, most of them felt that the way they think is consistent with how they act and they are aware of Conclusion: Student self-perception about QoL is mistaken and overestimated.


Introduction
Quality of life (QoL) is a concept that encompasses physical health, psychological state, level of independence, social relationships, personal beliefs, and relationships with factors in the environment, aspects of which may change completely over time (The WHOQOL Group, 1995;Lins and Carvalho, 2016).
A good QoL is known to be fundamental for personal achievement and for an integrated and productive society; it is also crucial to overall health, which is why knowledge on the quality of life of certain populations is very important (Chigerwe, Boudreaux and Ilkiw, 2018). Many methods can be used to evaluate QoL, including a variety of questionnaires available in the literature (Jang et al., 2018). The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), for example, divides QoL into eight domains: physical functioning, general health, pain, social functioning, mental health, role functioning (physical) and role functioning (emotional) - (Makiyama et al., 2004;Lins and Carvalho, 2016;Jang et al., 2018).
In Ireland, more than one third (35%) of physicians experience psychological distress and symptoms of severe depression, anxiety, and stress were found in 7,2%, 6,1%, and 9.5% of respondents, respectively (Hayes, 2017). QoL may be even harder for medical students to achieve. While medical school is often a significant achievement, it is also a place where students experience new difficulties and frustrations, as well as a transition period (Cvejic et al., 2017). A study of medical students in Germany found high rates of depression, as well as of cognitive and emotional burnout; these factors result in significantly lower mental QoL, particularly among women (Burger and Scholz, 2018).
Various studies have also reported differences in stress levels between genders with a greater prevalence of stress among women in a previous study by our team and in studies by other researchers (Botelho et al., 2017;Tempski et al., 2012). This situation is concerning given the increased rate of mental disorders and suicide among medical students as observed in an extensive systematic review and meta-analysis (Rotenstein et al., 2016).
A rarely discussed but important factor in this situation is medical students' perception of their own QoL. This is based on the perception that students make decisions based on the specific situation and its requirements. A study in New Zealand found that, in their self-perception, medical students classified their QoL as better than or the same as that of students from other fields of study using the WHOQOL-BREF scores (Henning et al., 2012). However, this outcome is inconsistent with those of other studies using other questionnaires, which have shown that medical students' QoL is negatively affected by their environment (Tempski et al., 2012;Cvejic et al., 2017).
In a prior pilot study by our team, we found that students' self-perception of QoL was overestimated in most of the domains using SF-36 questionnaire. In the emotional role functioning and mental health domain scores should be considered when evaluating the need for mental health or suicide prevention programs for medical students. We decided to increase sample and sought to understand the reasons for the discrepancy between medical students' selfperceived QoL and the data from their QoL questionnaire.

Methods
This was a cross-sectional, quali-quantitative, descriptive study performed after receiving approval from the institution's ethics committee. Statistical power estimates were performed after the results from the pilot study and the final sample size was 190 students. Those who were married or who had children were excluded, as were students who had transferred into the program less than six months prior to the study, students who were repeating a year after failing, or on academic probation.
Students from the first to fourth year of our medical school were invited to participate in our study and complete three questionnaires: the SF-36, a second in which students gave their subjective opinions on their QoL in the eight domains described in the SF-36 (Table 1), scoring these domains from 1 to 100, and a third questionnaire on selfawareness and coping strategies, with the first part evaluated on a Likert scale addressing self-awareness and the second part on coping methods, with 8 answer options: being alone; seeking help from other people; using drinks or drugs; increased food intake; playing sports; seeking professional help; seeking religious and other help.

Students gave their opinions
The statistical analysis relied on non-parametric evaluation methods for the quantitative questions, with paired ttests, Spearman's correlation test, the Mann-Whitney U test, and chi-square tests.

Results/Analysis
Two hundred and three first-to fourth-year medical students from FACERES medical School of Medicine (FACERES) in Brazil completed the questionnaires, 131 (64.5%) of whom were women. The mean age of the  A significant difference was found between the genders only in the mental health domain, in which men exhibited a greater discrepancy, with self-perceived QoL higher than their SF-36 (p=0.041) ( Table 3). There were no differences in terms of age or year in the program.
In their responses on the third questionnaire 137 (67.5%) of respondents reported that the way they think is frequently or always consistent with the way they act; 148 (72.9%) reported that they know all or most of what their own needs are, and 150 (73.9%) rated their QoL as good or great. When asked about their coping strategies, 79 (38.9%) of the medical students included herein reported a preference for spending time alone, 85 (41.9%) reported seeking out other people, 26 (12.8%) using drugs or alcohol, 68 (33.5%) increasing their food intake, 22 (10.8%) playing sports, 27 (13.3%) seeking professional help, 23 (11.3%) seeking religious guidance, and 23 (11.3%) reported other methods. When the results from each gender were compared, women increased their food intake more frequently than men (p=0.002). Details are shown in Figure 1. Students' responses to the other coping strategies did not differ by gender.

Discussion
This study demonstrated that medical students' self-perceived QoL was overestimated in almost all domains: physical, social and emotional functioning, general and mental health, Pain, energy/ fatigue. Regarding to role functional capacity, it was underestimated. As aforementioned in the New Zealand study, medical students' selfperceived QoL scores to be high when the students classified their QoL as better than or the same as that of students from other fields of study (Henning et al., 2012). Though their results were focused in different domains and not very clear, it seems to be the only study in the literature to consider self-perception in a similar context. While an optimal level of stress may improve learning ability (Rafidah, 2009), elevated stress levels may cause physical and mental health problems (Niemi and Vainiomäki, 1999), thus affecting students' academic performance.
In our study we observed a great difference between the SF-36 questionnaire and the student´s self-perception in role emotional domain, even when the majority of them reported that the way they think is frequently or always consistent with the way they act, and that they know all or most of what their own needs are, rating their QoL as good or great. This is worrying, as if they are not aware of their difficulties, they won´t be able to motivate themselves to change and look for help.
Another point is coping strategies, that are essential for students handling stress and experiencing better mental health. These strategies included a high value on interpersonal relationships, a good balance between leisure and studies, time set aside for physical activity, a healthy diet, and prioritizing sleep and physical health (Zonta, Robles Neves Ceratti M, da Silva Fucuta P, N.P. Quessada F, Colombelli Pacca F, Cury P MedEdPublish https://doi.org/10.15694/mep.2020.000004.2 Page | 6 andGrosseman, 2006). In our study, medical students used these strategies rarely: in their responses to questions on their coping strategies, few reported playing sports and seeking religious guidance or professional help. Seeking out other people was one of the most common functional strategies used, but some of the students use dysfunctional methods that are ineffective or which have been proven to have no effect, such as spending time alone using drugs or alcohol and increasing food intake. Erchens et al., found a similar findings when studying burnout and coping strategies in medical students (Erchens et al., 2018). However, our finding that women increase food intake more than men was not described in their work or in other studies (Fares et al., 2016;Thompson et al., 2016).
When genders were compared, male students exhibited a significantly greater discrepancy between self-perceived QoL and their SF-36 results in the mental health domain. Previous studies have shown that women may exhibit greater anxiety and distress in stressful situations than men, and that female students have worse perceptions of their academic performance (Paro et al., 2019). If students are more aware of their QoL, they can engage in more productive coping methods.

Strengths
In this study, a clear relationship was found between students' overestimated self-perceived QoL and worse mental health. This was a novel study that found that additional efforts are necessary to make medical education environment more informative and encouraging in order to motivate students to examine their QoL and focus on their mental health, since QoL and mental health have a major influence on students' academic performance, skills, and interactions with patients.

Limitations
One limitation in our study was the inability to collect data from all medical students in the program at roughly the same time (for example, just before final exams). Future studies could investigate associations between QoL scores and factors outside of academic life, such as family relationships and living conditions (whether students live alone or with others) Studies like these could help to eliminate confounding factors like these that could be influencing the overestimated self-perceived QoL scores found in this study.

Conclusion
This study found that medical students' self-perceived quality of life scores are overestimated, given the fact that most of them reported that the way they think is consistent with the way they act and that they know their own needs. These perspectives may prevent them from seeking help or making changes when necessary. Given these findings, more studies on this topic are necessary, as are institutional interventions such as talks, campaigns, and even changes to the medical school curriculum in attempts to motivate students to know themselves better and prioritize their mental health.

Take Home Messages
Medical students' self-perceived quality of life is overestimated, and this is reflected in their worse mental health.
Coping methods, though essential for handling stress and improving mental health, were rarely used. Students must understand their quality of live and concern themselves with their mental health because of the influence these two factors have on their academic careers.