In general, our participants scored lower than their fellows at Andhra Medical College in the overall (QoL) and general health [16] but had a better overall (QoL) than those in the clinical internship at Tabriz University of Medical Sciences [17]. Our findings are higher than those scored by medical students of Hadramout University in the psychological health, physical health and social relationships but lower in the environment [15]. Asian and European medical students at New Zealand University had higher domain mean scores than our participants, except in the social relationships, where Asian participants scored slightly lower than ours [18]. Furthermore, our participants had relatively better scores in the social relationships than those at Tabriz University of Medical Sciences in Iran [17] and China Medical University [2]. It is obvious that the (QoL) of medical students at the clinical levels at Sana’a University is neither bad nor good, and the lowest scores are in the environment and psychological health domains. This could be attributed to inappropriate and inadequate clinical training, traditional unrevised curricula, level-mismatched exams and increasing financial requirements with transition to clinical training. For the advanced levels and interns, thinking of postgraduate studies, future careers and providing for their parents and starting their own families could be possible causes. This is aggravated by the miserable condition of the country and the consecutive economic recessions along with prohibitive expensiveness and poverty together with lack of safety and nutritional security.
According to the literature reviewed, we gathered and added several sociodemographic factors that could have an important impact on the (QoL) of medical students at the clinical levels directly or indirectly. These included age, gender, marital status, educational level, tuition fees payment, employment either medical or nonmedical and part or full-time, residency, inhabit and (PA) and (LAs).
Age was found to be significant in the environment, being best for young ages and worst for advanced ages. Our findings are in accordance with those at Al-Imam Muhammad Ibn Saud Islamic University [19]. This could be due to higher levels of stress, future expectations and more responsibilities carried by individuals with the advancement of age.
The mean scores regarding gender are significant in the overall (QoL) and environment, where female students scored better in both. This is completely consistent with that found at Hadramout University [15], Andhra Medical College in the overall (QoL) [16], Tehran University of Medical Sciences [20] and China Medical University in the environment [2]. This variation in scores could be due to extra responsibilities imposed on males in the context of daily life.
Being married is a favorable factor that was found to improve social relationships. There were no significant score differences or P-values in other domains. Married students at King Faisal University had better scores in all domains [14], and those at Tabriz University of Medical Sciences had a better overall (QoL) [17].
Regarding educational level, only in the physical health domain did the results reveal a significant relationship between educational level and (QoL), where level 4 beginners scored the lowest, followed by students at level 5. Despite being insignificant, the overall (QoL) was best for level 6 beginners, followed by level 6 graduates, and worst for level 4 beginners, followed by those short of the final exams for the same level. Other than the overall (QoL) and physical health, the lowest scores were in the environment: minimum for level 4 beginners and maximum level 6 beginners, followed by psychological health: minimum for level 5 and maximum for level 6 graduates. Intermediate scores are found in the social relationships, being lowest for level 6 graduates and highest for level 6 beginners. Except for the environment, clinical students at Sana’a University scored higher than their fellows at Hadramout University [15]. In addition, except for the environment and psychological health being much lower, they scored very closely to their peers in a multicenter study involving 22 Brazilian medical schools [21]. Our findings for the 4th and 5th levels are relatively higher in the physical health than of corresponding levels at Al-Imam Muhammad Ibn Saud Islamic University but slightly lower than those scored in the environment with no significant variation in the psychological health and social relationships [19]. We also found that our participants at the 4th and 5th levels scored lower than Asian students in the physical health and environment and lower than European students in all domains at New Zealand University [18]. The findings for level 6 exhibited better scores in the physical health but lower scores in the psychological health and environment in comparison to those found at King Abdulaziz University [22]. However, our participants scored lower in the four domains as well as the overall (QoL) and general health, contrary to their fellows at Andhra Medical College [16]. Our interns scored higher than the interns of Tabriz University of Medical Sciences in the overall (QoL) and similarly in the social relationships but lower in the physical health, psychological health and environment [17]. The results, either significant or not, revealed that level 6 beginners and graduates are superior to the others in the (QoL), and level 4 and 5 students are inferior in order. This could be explained by the fact that level 4 students do not get the appropriate orientation either academically or clinically on starting the clinical education that they keep learning from the difficulties they face and try to cope with. Furthermore, when transiting level 5, they have to cover many lectures they were supposed to have at level 4 in addition to the lectures of level 5 itself along with the clinical training. Moreover, all the theoretical lectures must be completed at level 5, so it is a year with a very heavy academic workload. The results for level 6 beginners seem favorable but are not. These findings are explained and justified as follows: the 6th academic year is left for training only and unfortunately is mostly unsupervised in most courses such that students either do not receive proper training and orientation or underestimate the training in this period and advocate their time preparing for the final exams. The final bachelor’s exam period is the most stressful time for (MBBS) students, but unfortunately, the timing of data collection occurred relatively far from this period. Interns represent the lowest percentage (10%) in the study population, while the minimum percentage among the other levels is 14%. This is possibly because they may have postponed the internship and started working in other cities to provide as much as possible for their families. Those who are still performing their internship at their training hospital in Sana’a city obtained moderate overall (QoL), and probably some of them are employed. Their choice for a city to work in depends on the monthly income they are going to get.
Despite a thorough review of the literature, we could not find previous works that considered tuition fees payment. We did not find a significant relationship in this regard (P-value > 0.05), yet those who paid obtained lower scores in the overall (QoL), general health, psychological health and social relationships. It is observed that the majority of those who pay suffer more and harder that they take loans, deal with difficult access to do their exams and get their results obscured rather than the other needs such as snacks, books and transportation.
The second most significant relationship to the (QoL) is found in correlation with the family income in the overall (QoL), general health, physical health, psychological health and environment; maximum scores for sufficient income and minimum scores for insufficient income. Previous studies have shown that family/individual income is an important predictor of the (QoL) among medical students [14] [17] [23]. Unfortunately, Yemen is a low-income country and, moreover, is under siege and in civil war with repetitive financial crises, thus aggravating the miserable condition of the general population as a whole and medical students in particular owing to the higher financial demands of medical education itself.
In terms of employment, only psychological health is statistically significant, being best for nonmedical employees, followed by medical employees. The other aspects, regardless of being statistically insignificant (P-value > 0.05), showed higher scores for the employees. Only 3 students worked full-time in comparison to 59 students working part-time, making it difficult for us to correlate such a comparison to the (QoL). Our findings are against those found at Tabriz University of Medical Sciences [17]. We think that it is a source of income that improves the (QoL) and helps for daily needs all required for our students rather than the work itself during studying. It is no doubt that employed individuals probably have lower academic performance than unemployed individuals, yet it was very difficult to obtain such academic records.
Regarding residency, a significant relationship emerged in the environment best for those living with their own families, followed by those with host families, and worst for those living in dormitories, followed by those living alone. Those living with family scored slightly better than those living alone or in dormitories in the other aspects of (QoL), although the difference was statistically insignificant. Our findings, despite being relatively lower, are consistent with those exhibited at Hadramout University [15] and Al-Imam Muhammad Ibn Saud Islamic University [19]. This could be related to unavailability and/or poor quality services in the dorms and for those living alone.
Only 84 of 336 medical students came from rural origins and scored lower than their urban colleagues in the environment. The scores in the other domains are closely related although lower for rural participants and are statically insignificant. This is in agreement with findings at China Medical University, where rural students scored lower than urban students in the psychological health and social relationships [2], but in disagreement with those at Andhra Medical College in the same domains [16]. This may be explained by the belief that rural students live away from their families in dorms or alone where they, to some extent, have unfavorable environment for living.
The prevalence of (PA) among the participants for a minimum of 3 times a week for 30 minutes each was 26.2%. (PA) appeared to be an important factor in the psychological health in favor of those engaging in (PA). (PA) also showed better scores in the other domains regardless of being statistically insignificant. On the other hand, while 40% of the participants have a moderate to good opportunity for (LAs) 60% do not. A strong positive and significant relationship exists between (LAs) and the four domains. The finding of (PA) is in general agreement with that at China Medical University, [2] and general disagreement with that at Andhra Medical College [16]. The finding of (LAs) agrees with that noticed at 22 Brazilian medical schools in the psychological health and environment [13]. While (PA) and (LAs) seem to improve the (QoL) of medical students, only a few students perform (PA) and have good opportunity for (LAs), and this could be due to the study overload, inadequate clinical training and exam stress that make them advocate all their time for studying. In addition, a lack of time management and accessible places for performing (PA) contribute greatly.
The reliability of the WHOQoL-BREF was expressed by Cronbach’s alpha coefficient. We found that the WHOQoL‑BREF preserves acceptable reliability in assessing the (QoL) among medical students.
A potential limitation of our study is its, cross-sectional design, which cannot detect the causal relationships between variables. Our study was limited to one medical school, eliminating the possibility of comparing results with other college students. The relatively small sample size was also one of the limitations of our study that could affect some of the characteristics with low prevalence, including being married, employed, rural and living alone or in dorms. An important limitation is that our results may not be informative regarding the last clinical level students (Level 6), as they were not exposed to the expected academic stress at the time of data collection, and the WHOQoL-BREF limits the participants’ answers to the last two weeks only. However, the bachelor’s exams at the end of clinical training are believed to negatively impact all aspects of the (QoL) of (MBBS) students at Sana’a University. Future research with a longitudinal design can be conducted to trace changes in medical students’ (QoL) over time. Multi-institutional studies with larger sample sizes are needed.