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. 2022 Dec 22;17(12):e0279446. doi: 10.1371/journal.pone.0279446

Pattern and perceived changes in quality of life of Vietnamese medical and nursing students during the COVID-19 pandemic

Le Dai Minh 1, Hoang Huy Phan 1, Duong Ngoc Le Mai 1, Nguyen Tien Dat 1, Ngo Minh Tri 1, Nguyen Viet Ha 1, Nguyen Huu Tu 2, Kirsty Foster 3, Kim Bao Giang 4, Tung Thanh Pham 5,*
Editor: Elsayed Abdelkreem6
PMCID: PMC9778935  PMID: 36548356

Abstract

Background

The COVID-19 pandemic and governments’ response lead to dramatical change in quality of life worldwide. However, the extent of this change in Vietnamese medical and nursing students has not been documented.

Objectives

The study aims to describe the quality of life and changes in quality of life of medical and nursing students during the COVID-19 pandemic and examine the association of quality of life and changes in quality of life with fear of COVID-19 and other socio-economic and demographic factors.

Methods

The study was a cross-sectional study on all students of Hanoi Medical University from 3 majors: General Medicine, Preventive Medicine, Nursing (3672 invited students); from 7th to 29th of April 2020; using an online questionnaire that included demographic and academic information, the Vietnamese version of the SF-36 Quality of Life questionnaire and the Fear of COVID-19 Scale (FCV-19S). Linear and modified Poisson regression was used to examine the association between quality of life, changes in quality of life and other factors.

Results

The number of participants was 1583 (response rate 43%). Among 8 dimensions of the SF-36 (ranged 0–100), Vitality had the lowest score with a median score of 46. The median physical composite score (PCS) of the sample was 40.6 (IQR:20.8–53.2), 33.5% of the sample had an above-population average PCS score. The median mental composite score (MCS) of the sample was 20.3 (IQR:3.8–31.7), and 98.2% had an MCS score below average. 9.9% (95%CI:8.5%–11.4%) of the population reported a significant negative change in the quality of life. Fear of COVID-19 was not associated with significant changes in quality of life, nor MCS while having some association with PCS (Coef:-5.39;95%CI:-3to-7.8). Perceived reduction in quality of life was also associated with: being on clinical rotation COVID-19 (PR:1.5;95%CI:1.05–2.2), difficulties affording health services (PR:1.4;95%CI:1.02–1.95), obesity (PR:2.38;95%CI:1.08–5.25) and chronic disease (PR:1.92;95%CI:1.23–3), typical symptoms (PR:1.85; 95%CI:1.23–2.78) and atypical symptoms of COVID-19 (PR:2.32;95%CI:1.41–3.81).

Conclusion

The majority of medical and nursing students had below average quality of life, with lower vitality and mental composite health score in the settings of COVID-19. Perceived decrease in quality of life was associated with clinical rotation, difficulties affording healthcare services and was not associated with Fear of COVID-19.

Introduction

The COVID-19 pandemic caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China in December 2019 [1]. Since then, the outbreak had progressed rapidly across the globe with a high death count and devastating impact on multiple aspects of life in many countries, including physical and mental health, politics, economy, and many other social issues [2–8]. Healthcare workers were shown to have a significantly higher risk of COVID-19 infection, compared to the general public, and faced with extraordinary amounts of pressures leading to physical and mental exhaustion [9–14]. Medical and nursing students, especially those that are on clinical rotation, are being exposed to a similar environment and risk for COVID-19 infection.

Medical and nursing students, before the pandemic, were already known to face multiple physical and mental problems including burnout, anxiety, depression, and other mental health issues, with stress, lack of academic motivation, and financial hardship being important risk factors [15–21]. During the COVID-19 pandemic, students at higher education institutions, including medical students, greatly suffer from increased depressive symptoms, anxiety and sleep disturbance [22, 23]. Medical education also changed rapidly in response to the situation, with the replacement of in-person classes with online equivalents and disruption of clinical rotations [24–29]. In Vietnam and many other countries, medical and nursing students also serve in the front line, supporting attempts to control the disease including: contact tracing, providing counseling via telephone hotline, data management, cleaning/disinfecting, and taking test samples from suspected cases [30]. Together with other socio-economic aspects related to the pandemic like lockdown, social distancing, limitation in physical activities, the authors hypothesized that the physical and mental quality of life of medical students could be at high risk and can potentially lead to poorer health outcomes.

Understanding changes in medical students’ quality of life is necessary to implement coping strategies and policies to reduce the burden that medical students are facing in the context of COVID-19. Therefore, the authors conducted this study to (1) describe the quality of life of medical and nursing students during the social distancing period and (2) examine the association between quality of life, fear of COVID-19, and other socio-economics and demographics characteristics.

Methods

Study design and setting

A cross-sectional study is conducted on 1583 students who major in medicine, preventive medicine, and nursing, at Hanoi Medical University (out of total 3672 students), from 7th to 29th of April 2020. This period is within the first 6 months of the COVID-19 pandemic in Vietnam.

Hanoi Medical University is one of the largest and most prestigious public medical schools in Vietnam. Every year, the enrollments for each major are about 400–500 for the general medicine program, 80 for the preventive medicine program and 140 for the nursing program. Students studying medicine and preventive medicine have a 6-year curriculum and are trained in general medicine (for general medicine), in preventive medicine (for preventive medicine) after they graduated, while nursing programs have a 4-year curriculum. Students studying general medicine and preventive medicine start their clinical rotation in the second semester of their third year, whereas nursing student start their rotation in the second semester of their second year. The detailed information on Vietnamese medical and nursing education can be found in other articles [31, 32].

During first 6 months of the COVID-19 pandemic in 2020, Vietnam underwent a temporary shutdown and implemented a social distancing policy [33–37]. The disease was relatively controlled as the number of cases and mortality rate were rather small [33–36, 38]. However, due to the policies, most conventional medical education activities, including clinical rotation were stopped and replaced with online education.

Survey instruments

The questionnaire included questions regarding demographic information, academic information and health information, the Fear of COVID-19 Scale (FCV-19S), and the Quality of life SF-36 version 2.0 (SF-36), and a question asking about the change in the general quality of life before and during the pandemic.

The demographic information included: age, gender (Male/Female), marital status (Married/Single), perceived affordability of healthcare services (No difficulties/Difficulties). The academic information included: major (Doctor of Medicine/Doctor of Preventive Medicine/Nursing), academic year (First year/Second year/Third year/Fourth year/Fifth year/Sixth year), currently being on clinical rotation (Yes/No). Finally, the health information included: BMI (kg/m2), history of chronic disease (Yes/No) and current symptoms of COVID-19 (no symptoms, typical symptoms, atypical symptoms).

In our study, the symptoms of COVID-19 were divided into 3 categories: no symptoms, typical symptoms, atypical symptoms; with typical symptoms being: fever, cough and dyspnea and atypical symptoms being fatigue, muscle aches, sputum, anxiety, headache, sore throat, congestion, chest pain, hemorrhage, nausea and vomiting. At the time of data collection, this categorization was used in Vietnam by the Ministry of Health to screen for COVID-19 [39]. BMI was classified into 4 categories according to the WHO Asian–Pacific cutoff point: underweight (<18.5 kg/m2), normal weight (18.5–22.9 kg/m2), overweight (23–24.9 kg/m2), and obese (≥25 kg/m2) [40].

Fear of COVID-19 was assessed using the FCV-19S questionnaire. The FCV-19S questionnaire was translated into Vietnamese in a previous study by Nguyen and colleague and showed good item-scale convergent validity (mean of Rho = 0.77), discriminant validity and construct validity and high internal consistency (Cronbach’s alpha = 0.90) with the Vietnamese translation [41, 42]. It consisted of 7 items and utilized a 5-point Likert scale with 1 = “strongly disagree”, 2 = “disagree”, 3 = “neutral”, 4 = “agree”, 5 = “strongly agree”. The total score ranged from 7 to 35, with a higher score indicating greater fear of COVID-19. We used a cut-off point of 21 with scores ranging from 7–20 categorized “Low FCV-19S score”, implying lower fear of COVID-19 and scores ranging from 21–35 categorized “High FCV-19S score”, implying higher fear of COVID-19 as we assumed that those who answered neutrally at every question would be having a score of 21.

The quality of life of students during the period was determined using the Vietnamese version of the Quality-of-life SF-36 version 2.0 [43]. The SF-36 determine the quality of life using 8 dimensions: Physical functioning (PF), Role limitations due to physical health (RP), Role limitations due to emotional problems (RE), Vitality (VT), Emotional well-being (MH), Social functioning (SF), Pain (BP), General health (GH). The score for the 8 dimensions of the SF-36 ranged from 0–100 and positively correlate with the state of quality of life. A physical composite score (PCS) and mental composite score (MCS) were calculated from the 8 dimensions using a population-based scoring method [44, 45]. The two summary scores, PCS and MCS, use the sum of the eight dimension z-scores derived from a reference population of Vietnamese people in the study by Watkins in 2000 [43], weighted by factor score coefficients derived from US 1990 general population estimates [44]. A PCS/MCS score of 50 represents the reference population average, and any score below 50 would be considered “Below the population average”. The PCS and MCS scores with z-score derived from USA population averages is also included in the supplemental documents (S8 Table in S1 File). The Vietnamese version of the SF-36 was validated and was shown to provide a valid assessment of self-reported health status among the Vietnamese population, with all but two of the 36 items displayed good discriminant validity and all eight scale had good discriminant validity displayed the internal consistency of the 8 scales: PF (0.82), RP (0.86), BP (0.58), GH (0.66), VT(0.56), SF (0.67), RE (0.70), MH (0.55) [43].

Perceived reduction in quality of life was evaluated with a question asking the students “How did your quality of life change compared to before the pandemic?” with the answer either “Worse” “Better” or “No difference”. Students that answered “Worse” were categorized as having their quality of life worsen while other students were categorized as having no change or improvement in their quality of life.

Sample size and data collection

The required sample size was estimated by using the formula for estimating sample mean [46], as follows:

n=Z1−α22*σ2d2=1.962*12.5212=600.25

With, n being the required sample size, Z being the standard error associated with the chosen level of confidence 5%, σ being the standard deviation of the general quality of life score taken from the population used to validate the Vietnamese version of the SF-36 [43].

From April 7th to 29th, 2020, all student (3672 students) from the Doctor of General Medicine, Doctor of Preventive Medicine, and Bachelor of Nursing at Hanoi Medical University were invited to participate in this survey. 1032 students from the Doctor of General Medicine program (2921 invited, response rate 35.3%), 308 from the Doctor of Preventive Medicine program (466 invited, response rate 66.1%), and 243 from the Bachelor of Nursing program (285 invited, response rate 85.3%) agreed to participate in the study and completed the research questionnaire (1583/3672, resulting in a response rate of 43.1%.)

We collected data using a self-reported, online Google Form questionnaire, that included the study instruments. The research staff asked the Office for Student Services to send an official university notice with the questionnaire link to representatives of all invited classes. The class representatives are students that are responsible for major communication between the school administration and the student of the class that they’re in. There is one class representative for each class, and this practice is common for most universities in Vietnam. Each representative then delivered the documents to their class’s social media groups. Through these channels, all students in invited classes could read the information regarding the study and decide whether to participate and complete the survey. The research staff also checked the responses and sent a reminder to classes with low response rate every week. At the end of April 2020, we closed the questionnaire link and extracted the data to an Excel file, which was then converted into a Stata data file.

Data analysis

Stata 15.1 was used to analyze data. The Chi-squared, Fisher exact, t-test, and Kruskal-Wallis test were used to compare the difference between groups of students regarding demographic characteristics, quality of life and changes in quality of life of participants. We consider a p -value < 0.05 as statistically significant for all statistical tests [47, 48].

Linear regression was used to determine the association between PCS and MCS score with demographic characteristics and fear of COVID-19 in students. Residual plots were used to check for linear model assumptions. The prevalence of people with changes in quality of life was high, thus, using logistic regression analysis to determine the association between the decrease in quality of life and independent variables may result in an overestimation of the relationship [49, 50]. Therefore, we used a modified Poisson regression model with a robust error variance with binary data to directly calculate the Prevalence ratio (PR) as an appropriate alternative [49, 50].

Ethical issue

Our survey was approved by the Institutional Review Board of Hanoi Universities of Public Health and the administrative board of Hanoi Medical University (IRB No. 133/2020/YTCC-HD3). The online questionnaire provided participants with comprehensive information about the study. All participants gave informed consent by clicking “I agree to participate” box on the informed consent page. This consent procedure was approved by the IRB. Moreover, the participants could stop participating and close the Google Form at any time during the survey.

Results

Sample characteristics

The response rate for the study was 43% (1583/3672). The cohort characteristics are presented in Table 1. Of the 1583 participants, 65% were studying General Medicine, 19.5% were studying Preventive Medicine and 15.4% majored in Nursing. The proportion of participants currently on clinical rotation was 65.4%. There are several differences among the three cohorts regarding gender, age, affordability of healthcare services, BMI, as well as the prevalence of symptoms of COVID-19 and FCV-19S scores. The proportion of females was greater among Nursing (96.7%) and Preventive Medicine (75%) students than General Medicine (50.9%) students (p<0.001). Among nursing students, typical symptoms of COVID-19 were more prevalent at around 17.7% (p<0.001), compared to 10.7% in general medicine and 15.9% in preventive medicine. Additionally, nursing major students also had higher scores in the FCV-19S (Median: 19.00; IQR: 15.00–21.00; p<0.01), and had more students scored “High” on FCV-19S categories (44.4%, p<0.01), compared to students from other majors.

Table 1. Sample characteristics.

Columns by: Academic majors General Medicine Preventive Medicine Nursing Total P-value
n (%) 1032 (65.2) 308 (19.5) 243 (15.4) 1583 (100.0)  
Age, mean (sd) 21.74 (1.95) 22.53 (1.83) 20.10 (1.47) 21.64 (2.00) <0.01
Gender, n (%)          
    Female, n (%) 525 (50.9) 231 (75.0) 235 (96.7) 991 (62.6)  
    Male, n (%) 507 (49.1) 77 (25.0) 8 (3.3) 592 (37.4) <0.01
Academic years, n (%)          
    First year, n (%) 147 (14.2) 38 (12.3) 97 (39.9) 282 (17.8)  
    Second year, n (%) 247 (23.9) 19 (6.2) 79 (32.5) 345 (21.8)  
    Third year, n (%) 153 (14.8) 36 (11.7) 37 (15.2) 226 (14.3)  
    Fourth year, n (%) 103 (10.0) 54 (17.5) 30 (12.3) 187 (11.8)  
    Fifth year, n (%) 122 (11.8) 74 (24.0) 0 (0.0) 196 (12.4)  
    Sixth year, n (%) 260 (25.2) 87 (28.2) 0 (0.0) 347 (21.9) <0.01
Currently on clinical rotation, n (%)          
    No, n (%) 394 (38.2) 57 (18.5) 97 (39.9) 548 (34.6)  
    Yes, n (%) 638 (61.8) 251 (81.5) 146 (60.1) 1035 (65.4) <0.01
Marital status, n (%)          
    Single, n (%) 1026 (99.4) 304 (98.7) 242 (99.6) 1572 (99.3)  
    Married, n (%) 6 (0.6) 4 (1.3) 1 (0.4) 11 (0.7) 0.35
Affordability of healthcare services, n (%)          
    No Difficulties, n (%) 543 (52.6) 179 (58.1) 101 (41.6) 823 (52.0)  
    Difficulties, n (%) 489 (47.4) 129 (41.9) 142 (58.4) 760 (48.0) <0.01
BMI categories, n (%)          
    Underweight, n (%) 168 (16.3) 75 (24.4) 79 (32.5) 322 (20.3)  
    Normal, n (%) 682 (66.1) 191 (62.0) 154 (63.4) 1027 (64.9)  
    Overweight, n (%) 163 (15.8) 38 (12.3) 8 (3.3) 209 (13.2)  
    Obese, n (%) 19 (1.8) 4 (1.3) 2 (0.8) 25 (1.6) <0.01
Having chronic disease, n (%)          
    No, n (%) 961 (93.1) 281 (91.2) 226 (93.0) 1468 (92.7)  
    Yes, n (%) 71 (6.9) 27 (8.8) 17 (7.0) 115 (7.3) 0.53
Symptoms of COVID-19, n (%)          
    No symptoms, n (%) 866 (83.9) 244 (79.2) 172 (70.8) 1282 (81.0)  
    Typical Symptoms, n (%) 110 (10.7) 49 (15.9) 43 (17.7) 202 (12.8)  
    Atypical Symptoms, n (%) 56 (5.4) 15 (4.9) 28 (11.5) 99 (6.3) <0.01
FCV-19S score categories, n (%)          
    Low, n (%) 756 (73.3) 221 (71.8) 135 (55.6) 1112 (70.2)  
    High, n (%) 276 (26.7) 87 (28.2) 108 (44.4) 471 (29.8) <0.01
FCV-19S score, median (iqi) 16.00 (13.00; 21.00) 16.00 (12.25; 21.00) 19.00 (15.00; 21.00) 16.00 (13.00; 21.00) <0.01
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Statistical comparison Statistical comparison using Chi-square test for categorical variable—display as n(%);T test for continuous-normally distributed variable—display as mean(sd); Wilcoxon rank-sum test for continuous-skewed variable—display as median(iqi); The bold p-value indicated statistical significance (p<0.05).

Description of the SF-36 scores

Table 2 describe the median (IQR) the scoring on PCS, MCS and 8 dimensions of the SF-36 in different groups.

Table 2. PCS, MCS, and scoring of the 8 dimensions of the SF-36.

  Physical Composite Score (PCS) Mental Composite Score (MCS) Physical functioning (PF) Role limitations due to physical health (RP) Role limitations due to emotional problems (RE) Vitality (VT) Emotional well-being (MH) Social functioning (SF) Pain (BP) General health (GH)
Total 40.6 (20.8–53.2) 20.3 (3.8–31.7) 90 (70–100) 100 (50–100) 100 (33.3–100) 46 (36–56) 64 (52–76) 75 (62.5–87.5) 100 (80–100) 71.3 (58.8–77.5)
    Academic majors
General Medicine 43.2 (22.7–53.8) 20.1 (3.3–31.3) 90 (70–100) 100 (50–100) 100 (33.3–100) 46 (36–56) 64 (52–76) 75 (62.5–87.5) 100 (80–100) 71.3 (58.8–77.5)
Preventive Medicine 39.9 (21.3–52.5) 22.5 (8–34.4) 90 (70–100) 100 (50–100) 100 (33.3–100) 46 (36.3–56.3) 64 (52–76) 75 (62.5–100) 100 (80–100) 71.3 (58.8–81.3)
Nursing 29.3 (12.5–48.6) 17.3 (2.8–29.9) 85 (60–95) 75 (25–100) 100 (33.3–100) 46 (36–56) 60 (52–72) 62.5 (50–87.5) 100 (80–100) 71.3 (58.8–77.5)
    P value <0.001 0.009 0.001 <0.001 0.026 0.474 0.004 <0.001 0.007 0.417
    Gender
Female 38.8 (20.8–51.9) 19.8 (3.7–31.4) 90 (70–100) 100 (50–100) 100 (33.3–100) 46 (36–56) 64 (52–72) 75 (62.5–87.5) 100 (80–100) 71.3 (58.8–77.5)
Male 45.1 (21.2–54.2) 21.1 (4.3–32.2) 95 (65–100) 100 (50–100) 100 (66.7–100) 46 (38.5–56.3) 64 (52–76) 75 (62.5–87.5) 100 (80–100) 71.3 (58.8–81.3)
    P value 0.005 0.288 0.004 0.031 0.077 0.105 0.250 0.375 0.004 0.417
    Academic years*
First year 27.8 (11.1–44.1) 16.6 (0.7–32.5) 80 (55–95) 75 (25–100) 66.7 (33.3–100) 46.3 (36–56) 64 (52–72) 62.5 (50–87.5) 100 (80–100) 71.3 (58.8–77.5)
Second year 39.3 (18.1–51.5) 20.3 (5.5–31.8) 90 (65–100) 100 (50–100) 100 (66.7–100) 46 (36.3–51.5) 60 (52–72) 75 (62.5–87.5) 100 (80–100) 71.3 (58.8–77.5)
Third year 39.5 (20.7–53.2) 19.9 (3.2–29) 90 (70–100) 100 (50–100) 100 (66.7–100) 45.8 (36–51) 60 (52–68) 75 (62.5–87.5) 100 (80–100) 65 (52.5–77.5)
Fourth year 47.6 (30.2–54.3) 21.5 (6.8–32.4) 95 (85–100) 100 (75–100) 100 (66.7–100) 46 (36–56.3) 60 (52–76) 75 (62.5–87.5) 100 (90–100) 65 (58.8–77.5)
Fifth year 46.7 (31.3–55.7) 23 (8.7–32.3) 95 (80–100) 100 (100–100) 100 (66.7–100) 46 (40.8–56.3) 68 (52–76) 75 (62.5–100) 100 (80–100) 71.3 (58.8–83.8)
Sixth year 44.8 (25–54.2) 20.6 (0.3–33.2) 95 (75–100) 100 (50–100) 100 (33.3–100) 50.3 (36–56.3) 68 (56–80) 75 (62.5–87.5) 100 (90–100) 71.3 (58.8–83.8)
    P value <0.001 0.247 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
    Currently on clinical rotation
No 32.4 (13.6–49.4) 18.4 (2.8–31.8) 85 (55–95) 87.5 (25–100) 100 (33.3–100) 46 (36–56) 60 (52–72) 75 (62.5–87.5) 100 (80–100) 71.3 (58.8–77.5)
Yes 44.5 (24.1–54.1) 21 (5.2–31.6) 95 (75–100) 100 (50–100) 100 (33.3–100) 46 (36–56) 64 (52–76) 75 (62.5–87.5) 100 (80–100) 71.3 (58.8–81.3)
    P value <0.001 0.316 <0.001 <0.001 <0.001 0.295 0.029 <0.001 0.001 0.692
    Marital status
Single 40.6 (20.8–53.2) 20.3 (4–31.7) 90 (70–100) 100 (50–100) 100 (33.3–100) 46 (36–56) 64 (52–76) 75 (62.5–87.5) 100 (80–100) 71.3 (58.8–77.5)
Married 49.9 (23.1–52.7) 13.8 (-1.9–37.7) 95 (75–100) 100 (50–100) 100 (33.3–100) 51 (35.8–56.3) 72 (60–84) 75 (62.5–75) 100 (100–100) 77.5 (58.8–77.5)
    P value 0.514 0.735 0.343 0.978 0.841 0.867 0.207 0.837 0.227 0.632
    Affordability of healthcare services
No Difficulties 44.1 (25.7–53.9) 23.5 (8.3–33.7) 90 (75–100) 100 (75–100) 100 (66.7–100) 50.3 (40.8–56.3) 68 (56–76) 75 (62.5–87.5) 100 (80–100) 71.3 (58.8–83.8)
Difficulties 36.4 (15.3–52.1) 17.1 (-0.7–29.5) 85 (65–100) 100 (25–100) 100 (33.3–100) 45.5 (36–51.3) 60 (52–72) 75 (50–87.5) 100 (80–100) 65 (52.5–77.5)
    P value <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
    BMI categories
Underweight 36.4 (16.5–50.7) 18.7 (2.3–29.9) 85 (65–100) 100 (50–100) 100 (33.3–100) 45.5 (36–51.3) 60 (52–72) 75 (62.5–87.5) 100 (80–100) 65 (52.5–77.5)
Normal 41.6 (21.6–53.8) 20.7 (4.9–32) 90 (70–100) 100 (50–100) 100 (33.3–100) 46 (36.3–56) 64 (52–76) 75 (62.5–87.5) 100 (80–100) 71.3 (58.8–83.8)
Overweight 44 (25.4–53.5) 21.3 (3.2–32.9) 90 (70–100) 100 (75–100) 100 (66.7–100) 46.3 (40.5–56.3) 64 (56–76) 75 (62.5–87.5) 100 (90–100) 71.3 (58.8–81.3)
Obese 39.3 (21.9–51.3) 18.2 (1.6–36.6) 90 (80–95) 100 (25–100) 100 (33.3–100) 46 (36–56.3) 72 (56–84) 62.5 (50–87.5) 100 (80–100) 71.3 (58.8–77.5)
    P value 0.007 0.471 0.053 0.117 0.270 0.005 0.001 0.719 0.054 <0.001
    Symptoms of COVID-19
No symptoms 43.2 (22.6–53.9) 21 (5.8–32.2) 90 (70–100) 100 (50–100) 100 (33.3–100) 46 (36.3–56.3) 64 (52–76) 75 (62.5–87.5) 100 (80–100) 71.3 (58.8–81.3)
Atypical symptoms 23.1 (6.1–42.1) 10.9 (-7-27) 85 (60–95) 75 (25–100) 66.7 (0–100) 40.8 (36–46.3) 56 (48–68) 62.5 (50–75) 80 (60–100) 58.8 (46.3–71.3)
Typical symptoms 35.3 (17.2–49) 17.6 (-1-30.9) 90 (70–95) 75 (25–100) 100 (33.3–100) 45.8 (36–55.5) 64 (52–76) 75 (62.5–87.5) 100 (80–100) 68.1 (58.8–77.5)
    P value <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
    Having chronic disease
No 40.7 (20.9–53.2) 20.7 (5.1–31.9) 90 (70–100) 100 (50–100) 100 (33.3–100) 46 (36–56) 64 (52–76) 75 (62.5–87.5) 100 (80–100) 71.3 (58.8–81.3)
Yes 40.3 (19.6–51) 14.5 (-4.5–27.8) 90 (70–100) 100 (50–100) 66.7 (0–100) 46 (36–51.5) 64 (52–72) 75 (62.5–87.5) 100 (70–100) 65 (52.5–77.5)
    P value 0.457 0.007 0.621 0.257 0.001 0.111 0.312 0.484 0.021 0.011
    FCV-19S score categories
Low 43.6 (23.5–53.9) 21.2 (3.9–32.9) 90 (75–100) 100 (50–100) 100 (33.3–100) 46.3 (40.8–56.3) 68 (56–76) 75 (62.5–87.5) 100 (80–100) 71.3 (58.8–83.8)
High 31.7 (11.2–49.8) 18.6 (3.8–29) 85 (55–100) 100 (25–100) 100 (33.3–100) 41 (36–51.3) 56 (52–68) 75 (62.5–87.5) 100 (80–100) 65 (52.5–77.5)
    P value <0.001 <0.001 <0.001 0.023 0.663 <0.001 <0.001 0.001 <0.001 <0.001
    How have your quality of life changed compare to before the pandemic
Not Worsen 41.9 (22.5–53.3) 21.5 (7.4–32.5) 90 (70–100) 100 (50–100) 100 (66.7–100) 46 (36.3–56.3) 64 (52–76) 75 (62.5–87.5) 100 (80–100) 71.3 (58.8–81.3)
Worsen 23.9 (3.5–45.4) -3.5 (-14.3–17.7) 85 (55–95) 37.5 (0–100) 33.3 (0–66.7) 36.3 (31.3–46) 58 (48–70) 62.5 (50–75) 90 (70–100) 58.8 (52.5–71.3)
    P value <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
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All data was presented as median (IQI). Statistical comparison using:

Wilcoxon rank-sum test for continuous-skewed variable—display as median(iqr) for comparison between 2 groups

Kruskal-Wallis test for continuous-skewed variables—display as median (iqr) for comparison between 3 or more groups

Bold p-value indicated statistical significance (p<0.05).

*Fifth and sixth year students are only from General Medicine and Preventive Medicine major

Eight dimensions of the SF-36

The median score for the dimension of the SF-36 were PF = 90, RP = 100, RE = 100, VT = 46, MH = 64, SF = 75, BP = 100, and GH = 71.3 with Table 2 described the 8 dimensions of SF-36 score by major. There was no difference in VT, GH between majors and gender. However, nursing students have lower PF, RP, RE, MH, SF, BP scores compared to Preventive Medicine and General Medicine students (p<0.001). Females have lower physical functioning (PF), more role limitation due to physical functioning (RP) and bodily pain (BP) compared to males.

Physical composite score

The median PCS score of the sample was 40.6 (IQR: 20.8–53.2). There was a significant difference in the PCS score between the 3 majors (p<0.001). The PCS score of general medicine, preventive medicine and nursing students were 43.2 (IQR: 22.7–53.8), 39.9 (IQR: 21.3–52.5) and 29.3 (IQR: 12.5–48.6) respectively. PCS score was also higher in males than females (p = 0.005), in students in later years of the program (from 4th year) than those in earlier years (p<0.001), in students on clinical rotation than those not on rotation (p<0.001), and in students who had no difficulties affording healthcare services than those with difficulties (p<0.001). The PCS score was significantly lower in those who had symptoms of COVID-19 (p <0.001) and those who have significant fear of COVID-19 (p <0.001), compared to those who didn’t. There was no difference in PCS scores regarding chronic diseases status. Overall, 66.5% (95% CI: 64.1%– 68.8%) of the sample had PCS score below the reference population average. Nursing major has the highest number of students who had a below average score (77.4%; p <0.01) (S1 and S2 Tables in S1 File).

Mental composite score

The median MCS score of the sample was 20.3 (IQR: 3.8–31.7). Similar to the PCS score, there was a difference between 3 majors (p<0.001) with the MCS score of 20.1 (IQR: 3.3–31.3) for general medicine, 22.5 (IQR: 8–34.4) for preventive medicine and 17.3 (IQR: 2.8–29.9) for nursing. The MCS score was also higher in students who had no difficulties affording healthcare services than those with such difficulties (p<0.001), in those who did not have symptoms of COVID-19 than those with symptoms (p<0.001), and in those who had insignificant fear of COVID-19 than those with significant fear (p<0.001). Students having chronic disease also had a lower MCS score, compared to those who did not (p = 0.007). On the other hand, there was no difference in the MCS score regarding gender, academic year, clinical rotation. Compared to the reference population average, 98.2% (97.5–98.8) of the sample have a lower MCS score (S1 and S2 Tables in S1 File).

Regression analysis of PCS and MCS scores

We noticed no specific pattern in the residual analysis of the two linear regression models of PCS and MCS score (S3, S4 Figs in S1 File).

In Table 3, there was no difference in PCS scores between gender after accounting for other socio-demographic and academic characteristics, the FCV-19S scale, and symptoms of COVID-19. Chronic disease was also not associated with PCS score. Lower PCS score was associated with: majoring in Preventive Medicine (Coef: -3.3; 95% CI: -6.2 to -0.43) or Nursing (Coef: -5.67; 95% CI: -9 to -2.4), significant fear of COVID-19 (Coef: -5.39; 95% CI: -3 to -7.8) and typical (Coef: -4.96; 95% CI: -8.2 to -1.7) and atypical (Coef: -11.52; 95% CI: -16 to -7) symptoms of COVID-19, difficulties affording healthcare services were associated with PCS (Coef: -6.32; 95% C: -8.5 to -4.1). Higher PCS score was associated with being on clinical rotation (Coef: 8.89; 95% CI: 6.6 to 11). The factors with the highest influence on PCS score was being on clinical rotation (Coef: 8.89; 95% CI: 6.6 to 11) and having atypical symptoms (Coef: -11.52; 95% CI: -16 to -7). An identical pattern of association was also found in our quantile regression analysis with same dependent and independent variables (S5 Table in S1 File), with the only difference being that Preventive Medicine major was not statistically significant associated with lower PCS score (Coef: -3.00; 95% CI: -6.8 to 0.79).

Table 3. Linear regression of PCS score.

Physical Composite Score
Coef. p-value 95% CI
Academic Major
General Medicine ref.
Preventive Medicine -3.31 0.024 -6.2 -0.43
Nursing -5.67 0.001 -9 -2.4
Gender
Female ref.
Male -0.62 0.629 -3.1 1.9
Currently on Clinical Rotation
No ref.
Yes 8.89 <0.001 6.6 11
Marital Status
Single ref.
Married 3.35 0.612 -9.6 16
Affordabilities of Healthcare Services
No Difficulties ref.
Difficulties -6.32 <0.001 -8.5 -4.1
BMI Category
Underweight ref.
Normal 2.28 0.108 -0.5 5.1
Overweight 3.44 0.095 -0.59 7.5
Obese -1 0.828 -10 8
Having Chronic Disease
No ref.
Yes -0.35 0.868 -4.5 3.8
Symptoms of COVID-19
No symptoms ref.
Typical Symptoms -4.96 0.003 -8.2 -1.7
Atypical Symptoms -11.52 <0.001 -16 -7
Fear of COVID-19 Scale score categories
Low ref.
High -5.39 <0.001 -7.8 -3
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In Table 4, there was also no difference in MCS scores between gender. Significant fear of COVID-19 and being on clinical rotation had no statistically significant effect on MCS score. Regarding academic characteristics, majoring in Preventive Medicine result in higher MCS score (Coef: 2.97; 95% CI: 0.33 to 5.6) compared to those who were majoring in general medicine. Lower MCS score was associated with: having chronic disease (Coef: -9.5; 95% CI: -1.7 to -5.6), having atypical symptoms of COVID-19 (Coef: -7.59; 95% CI: -12 to -3.4), difficulties affording healthcare services (Coef: -5.20; 95% CI: -7.2 to -3.2). The association of having atypical symptoms and affordability of healthcare services with MCS score was also consistent with our quantile regression analysis. However, in the quantile regression analysis with the same variables (S6 Table in S1 File), there were no association between the Preventive Medicine major (p = 0.064), chronic disease and MCS (p = 0.073), but being on clinical rotation was associated with a higher MCS score (Coef: 3.239; 95% CI: 0.71 to 5.8).

Table 4. Linear regression of MCS score.

Mental Composite Score
Coef. p-value 95% CI
Academic Major
General Medicine ref.
Preventive Medicine 2.99 0.028 0.33 5.6
Nursing 0.34 0.827 -2.7 3.4
Gender
Female ref.
Male 0.53 0.651 -1.8 2.9
Currently on Clinical Rotation
No ref.
Yes 1.29 0.238 -0.85 3.4
Marital Status
Single ref.
Married -1.06 0.862 -13 11
Affordabilities of Healthcare Services
No Difficulties ref.
Difficulties -5.2 <0.001 -7.2 -3.2
BMI Category
Underweight ref.
Normal 0.64 0.622 -1.9 3.2
Overweight 1.1 0.563 -2.6 4.8
Obese 1.71 0.687 -6.6 10
Having Chronic Disease
No ref.
Yes -5.6 0.004 -9.5 -1.7
Symptoms of COVID-19
No symptoms ref.
Typical Symptoms -2.38 0.125 -5.4 0.66
Atypical Symptoms -7.59 <0.001 -12 -3.4
Fear of COVID-19 Scale score categories
Low ref.
High -0.95 0.4 -3.2 1.3
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Perceived negative changes in quality of life

Overall, 9.9% (95% CI: 8.5%– 11.4%) of the study population reported a significant negative change in quality of life. 20.2% of 6th-year medical students reported having a reduction in quality of life, a prevalence much higher than that of their junior (<10%) (p<0.01). Also, students that were on clinical rotation reported a negative change in quality of life was higher (11.4%) compared to the who weren’t (6.9%) (p<0.01). A significant portion of those who were obese (28%) or having chronic disease (20.9%) perceived a decrease in the quality of life, while this decrease is much less prevalent in students with normal BMI (9.8%) or those without chronic disease (9.0%) (p<0.05). There were no significant differences among genders (p = 0.25), marital status (p = 0.35), academic majors, and FCV-19S score (p = 0.08). (S7 Table in S1 File)

Table 5 shows the modified Poisson regression analysis of perceived negative changes in the quality of life of medical students. Results showed that being on clinical rotation was associated with more deterioration in quality of life during COVID-19 (PR: 1.5; 95% CI: 1.05–2.2). Additionally, students that had difficulties affording health services were more susceptible to these negative changes compared to those who don’t (PR: 1.4; 95% CI: 1.02–1.95). Obesity (PR: 2.38; 95% CI: 1.08–5.25), having chronic disease (PR: 1.92; 95% CI: 1.23–3), and typical symptoms (PR: 1.85; 95% CI: 1.23–2.78), atypical symptoms of COVID-19 (PR: 2.32; 95% CI: 1.41–3.81) were also associated with the reduction in quality of life of the sample.

Table 5. Poisson regression analysis of negative changes in quality of life.
Changes in Quality of Life
PR p-value 95% CI
Academic Major
General Medicine ref.
Preventive Medicine 1.10 0.631 0.74 1.65
Nursing 0.92 0.742 0.55 1.53
Gender
Female ref.
Male 1.22 0.282 0.85 1.76
Currently on Clinical Rotation
No ref.
Yes 1.52 0.028 1.05 2.22
Marital Status
Single ref.
Married 1.57 0.529 0.39 6.42
Affordabilities of Healthcare Services
No Difficulties ref.
Difficulties 1.41 0.037 1.02 1.95
BMI Category
Underweight 0.82 0.371 0.54 1.26
Normal ref.
Overweight 0.85 0.522 0.52 1.40
Obese 2.38 0.032 1.08 5.25
Having Chronic Disease
No ref.
Yes 1.92 0.004 1.23 3.00
Symptoms of COVID-19
No symptoms ref.
Typical Symptoms 1.85 0.003 1.23 2.78
Atypical Symptoms 2.32 0.001 1.41 3.81
FCV-19S score categories
Low ref.
High 0.71 0.078 0.49 1.04
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Discussion

From our study, it can be seen that there is a similar pattern in quality of life between different groups of students: a lower score in vitality (VIT = 46), emotional functioning (MH = 64) and social functioning (SF = 75) with vitality being the lowest. This pattern is similar to a pattern from other studies on medical students using the SF-36 instruments, outside of the pandemic [51, 52]. A study on Italian medical students from 2005–2015 showed a similar pattern of lower VIT (Mean: 59.4; SD: 16.1), MH (Mean: 68.65; SD: 16.3) compared to other dimensions and reference Italian population [52]. Compared to the general population, medical students were already suffering from burnout, stress and multiple mental issues, as mentioned in previous studies in other countries [15–18]. Combined with sudden changes in the context of the pandemic, students are having symptoms of depression, anxiety, sleep disturbances [22, 23, 25, 53]. Low vitality, fatigue, extensive feelings of sleepiness and increased daily nap time were recorded in multiple studies [53–55].

An extremely low level of mental quality of life was recorded as 98.2% of students have a lower MCS score (Median: 20.3 IQR: 3.8–31.7) than that of the reference population (MCS: 50) The extreme number could be partially explained due to the reference Vietnamese population being young with an average age of 27 and had a high quality of life, and the below-average medical students quality of life suggested in multiple studies outside of the pandemic [51, 52]. However, the median MCS score was still exceptionally low and thus, the overall mental status of the students should be critically alarming. In our study, mental quality of life was found to be associated with academic major (Coef: 2.97; 95% CI: 0.33 to 5.6), affordability of healthcare services (Coef: -5.20; 95% CI: -7.2 to -3.2), chronic disease (Coef: -9.5; 95% CI: -1.7 to -5.6), and atypical symptoms of COVID-19 (Coef: -7.59; 95% CI: -12 to -3.4), while not being associated with gender. The association of financial difficulties and quality of life is rather similar to the findings of a study on depression on 4th, 5th and 6th-year students of Hanoi Medical University before the pandemic, in 2019 [18]. However, a study by Vo on medical students in southern Vietnam, in the same year 2019, shows that female has a lower mental and physical quality of life [56]. This variation in results could be explained by the difference in environmental exposure between the two cohorts as there are major differences in the curriculum and academic environments, as some southern medical schools used an organ-based and modular curriculum for general medicine program, while Hanoi Medical University still used a traditional discipline-based curriculum for general medicine program at the time of this survey.

Regarding physical health, the PCS score of the sample has a median score of 40.6 with 66.5% below the population average. The low level of physical health is likely to be related to the low level of mental health, vitality and increased fatigue reduced physical activities during the lockdown [55, 57–59]. There have been mixed findings regarding gender and physical-related quality of life around the world and Vietnam [56, 60, 61]. Similar to mental quality of life., physical quality of life was lower in females in a study on southern medical students of Vietnam [56]. However, this association was also not observed in our study. On the other hand, difficulties affording healthcare services (Coef: -6.32; 95% C: -8.5 to -4.1), fear of COVID-19 (Coef: -5.39; 95% CI: -3 to -7.8), and symptoms of COVID-19: typical (Coef: -4.96; 95% CI: -8.2 to -1.7) and atypical (Coef: -11.52; 95% CI: -16 to -7) were found to be correlated with reduced physical health. In addition, academic major and clinical rotation also associated with physical health, as preventive medicine (Coef: -3.3; 95% CI: -6.2 to -0.43) and nursing students (Coef: -5.67; 95% CI: -9 to -2.4) have lower PCS scores and students being on clinical rotation have better physical health (Coef: 8.89; 95% CI: 6.6 to 11).

There was no relationship between genders and reduction in quality of life in our study, consistent with findings on PCS and MCS scores. Significant perceived negative changes in quality of life were associated with being on clinical rotation (PR: 1.5; 95% CI: 1.05–2.2), difficulties affording healthcare services (PR: 1.41; 95% CI: 1.02–1.95), obesity (PR: 2.38; 95% CI: 1.08–5.25), having chronic diseases (PR: 1.92; 95% CI: 1.23–3), and having symptoms of COVID-19: typical symptoms (PR: 1.85; 95% CI: 1.23–2.78), atypical symptoms of COVID-19 (PR: 2.32; 95% CI: 1.41–3.81). Despite having higher PCS and relatively the same MCS score, students on clinical rotation are more likely to perceive negative changes in their quality of life (PR: 1.5; 95% CI: 1.05–2.2), which is probably due to visible disruption in clinical rotation and medical rotation and concerns for their career development, which was explored in prior studies [23, 25]. Students who have difficulties affording healthcare services are 1.41 times (PR: 1.41; 95% CI: 1.02–1.95) more likely to feel that their quality of life has worsened. Affordability of healthcare services consistently correlated with changes in quality of life and quality of life of students during the pandemic, as it could place an invisible pressure on the person should they get infected. According to our study, students who have obesity and/or chronic disease are more vulnerable to deterioration in their quality of life. Compared to a person with a normal BMI, an obese person is 2.38 times (PR: 2.38; 95% CI: 1.08–5.25) more likely to have worse quality of life in the pandemic, while having chronic diseases increases the prevalence 1.92 times (PR: 1.92; 95% CI: 1.23–3). An interesting finding of our study is that atypical symptoms had an impact on MCS scores (Coef: -7.59; 95% CI: -12 to -3.4) while typical symptoms did not. The impact of atypical symptoms on mental quality of life could be due to the physical impairment it brings and the uncertainty in making the decision to get a COVID-19 test [62]. However, there was no association between Fear of COVID-19 and reduction in quality of life (PR: 0.71; 95% CI: 0.49–1.04). Therefore, we hypothesized that the symptoms of COVID-19 mostly affected medical students via physical impairment, rather than fear and anxiety because Fear of COVID-19 was not found to be associated with mental quality of life but had some relation to the physical quality of life. This result could be explained by the restrictions of physical activities during the lockdown, while the pandemic was relatively controlled. Therefore, Fear of COVID-19 could have a lesser impact than expected on medical students’ mental health and anxiety during the pandemic, as the change was primarily due to previously mentioned factors.

Strength and limitations

The strength of our study is that our representative sample frame included all students from 3 majors: General Medicine, Preventive Medicine, and Nursing. Moreover, the main instrument—the Vietnamese version of the SF-36 was validated and was shown to provide a valid assessment of self-reported health status among the Vietnamese population and allowed for both compound and specific evaluation of quality life. Finally, the survey was conducted after the first wave of COVID hit Vietnam—after Bach Mai hospital, a major teaching hospital of Hanoi Medical University, was locked down after a case series COVID-19 on March 28th, 2020. Therefore, we believe that the result captures the changes in quality of life of the students during the early stage of the pandemic. However, this study used an online, anonymous data collection scheme, which lead to a low response rate of only about 43%, and potential sampling errors, and selection bias. The difference in response rate between academic majors could be due to clinical rotation’s scheduling, the willingness and interest of the class representatives, or miscommunications between the Office for Student Services and the class representatives. Due to the anonymous feature of the survey, we were not able to pinpoint the exact reasons for the difference in response rate and will look into this issue in future studies. Moreover, there was no available data on medical students’ quality of life using the same instruments prior the pandemic, so a direct comparison was not possible. The use of a cross-sectional study design also limited our interpretation of the results to association, rather than causation. This design was also unable to examine the changes in quality of life of the students in other waves of COVID-19 and their adaptation going further into the pandemic. Also, the translation into Vietnamese of the SF-36, FCV-19S might affect the validity of these questionnaire. Furthermore, the SF-36 tools scoring used population-based scoring methods, however, there was no Vietnamese population-derived weighting coefficient for 8 dimensions of SF-36 when calculating PCS and MCS score, thus we had to use the coefficient from the original USA population, which can cause a slight alteration in the results, as the weight for each population is slightly different [44]. Additionally, since we only use a single direct question to examine the reduction in quality of life, it is difficult to accurately determine the specific changes in quality of life of healthcare students in the pandemic.

Conclusion

The physical and mental quality of life of the medical and nursing students was lower than that of the general population. Vitality, mental health, and social functioning dimensions showed the lowest score among the 8 dimensions. Lower PCS score was associated with academic majors, chronic disease, not being on clinical rotation, difficulties affording healthcare services, and Fear of COVID-19. Lower MCS score was associated with academic major, difficulties affording healthcare services, and chronic disease. Perceived reduction in quality of life was associated with being on clinical rotation, difficulties affording healthcare services, having chronic disease, obesity, and having symptoms of COVID-19. Future studies could be done to explore further the specific impact of COVID-19 on students of different major in regard to their curriculum, risk, and exposure in the pandemic.

Supporting information

S1 File

(DOCX)

Click here for additional data file. (174.8KB, docx)

Data Availability

According to our application to the Institutional Review Board (IRB) of Hanoi University of Public Health, the data cannot be shared publicly because of ethical restrictions to protect the confidentiality of the participants imposed by the IRB. A de-identified dataset is available for researchers who meet the criteria for access to confidential data. Requests for data should be submitted to Institutional Review Board of Hanoi University of Public Health (irb@huph.edu.vn) and the corresponding author, Dr. Pham Thanh Tung (phamthanhtung@hmu.edu.vn).

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Christmal Dela Christmals

8 Jul 2022

PONE-D-22-14424Pattern and perceived changes in quality of life of Vietnamese medical and nursing students during the COVID-19 pandemicPLOS ONE

Dear Dr. Pham,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Three reviewers have engaged with your study. All the reviewers see your study relevant and with the potential for publication subject to some revisions. Please critically engage with the reviewer comments and resubmit for reconsideration.

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[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: PONE D 22 14424

COMMENTS

The manuscript is technically sound and the data support all the conclusions made

L26- L 61 Credentials – some authors do not have Orcid numbers. It will be beneficial to generate an Orcid number

L 64 ABSTRACT- abstract is concise and succinct.

L67 add nursing to medical students

L 101 add s to student

Introduction – well explained and purpose of the study well explained

Methods

The test and sample size are appropriate

The language used is clear, correct, and unambiguous

Setting – well explained

Survey instrument – questionnaire items well explained

Sample size

L221 - remove full stop after percentage of nursing students

L223 – Replace “an” with a in “A self-reported…”

L225 – Who are these representatives?

Data analysis

L235 – Separate the ap-value to read a p-value. Data analysis procedure explained well

Ethical issues are well explained by authors

Results

Results well explained

Table concise

L291 – What does normal students mean? Try another word to describe them as this does not sound good

Discussion

Discussion covered the main findings in the study and exposed challenges face by health students on clinical rotation during the Covid -19 pandemic.

Strengths and limitations

Strengths and limitations well explained in the study

Conclusion

Replace sample on L471 with group names of participants

Reviewer #2: The manuscript is well written, with few grammatic errors. See attached document with comments.

Reviewer #3: The experiments and the statistical analysis seem to have been conducted rigorously. Data underlying the findings is not made fully available. The authors in the manuscript indicated the following in this regards: "According to our application to I have no competing interests, the data cannot be shared publicly because of ethical restrictions to protect the confidentiality of the participants. A de-identified dataset is available for researchers who meet the criteria for access to confidential data." The reviewer understands and respect that the Institutional Review Board of Hanoi University of Public Health wants to protect the confidentiality of participants in this way. The reviewer in this regard wants to suggest that the authors should consider omitting the name of the University to not only further protect the confidentiality of the participants but also of the University.

In rule 136-138 the authors mentioned that the cross-sectional study was conducted in the first six months of the COVID-19 pandemic and then go further to state the dates on which the study was conducted namely 7-29 April of 2020. The sentence could cause confusion as it could sound as if the study was conducted over a period of six months.

In the discussion of the limitations of the study, the authors seem to contradict themselves with regards to utilizing a translated version of the SF-36 and of the FCV-19S. The authors first mentioned that the main instrument of the study namely the Vietnamese version of the SF-36 was validated and as a result provided a valid assessment of self-reported health status among the Vietnamese population. It further allowed for both compound and specific evaluation of quality life. Then in the discussion of the limitation of the study, the authors indicated that the translation of the SF-36 and the FCV-19S into Vietnamese might have affected the validity of these questionnaires.

The reviewer wonders whether the research was not conducted too hastily which resulted in preventing the authors to conduct a pilot study beforehand in order to rule out the possible limitations that the translation of the documents in the end brought about.

The reviewer wants to suggest that if the manuscript is to be published that the authors add information pertaining to what was put into place to support participants who, as a result of the study, needed psychological treatment/assistance. From the discussion of the results it is for instance mentioned that the quality of life for some of the participants changed as a result of the COVID-19 pandemic. By participating in the study could have created a specific awareness amongst some of the participants about these changes which potentially could for instance have contributed to further stress and anxious feelings. The authors in Rules 374-375 for instance refer to what the mental state of medical students could be as a result of the sudden changes in the context of the pandemic.

The reviewer is of the opinion that the results of the specific topic lends itself to causation interpretation. The authors stated that the use of a cross-sectional study design however limited their interpretation of the results to association, rather than causation. The interpretation of the conclusions therefore seems to be very linearly done. The authors do not draw adequate connections between the outcome of the study and the quality of life of the different groups that participated.

The formulation and construction of sentence for instance need attention (Refer to Rules 196 and 197: Should the formulation of the last part of the sentence not read: and any score below 50 was considered to be "Below the population average". etc). In certain sentences words such as ‘the’ and ‘a’ are missing (Refer to Rule 171: The word "the" should be added between the words "to" and WHO"s etc). COVID-19 is sometimes indicated as Covid-19 (Refer to Rules 101, 137, 156, 174 etc). Other examples where attention needs to be paid to the editing of the manuscript involves the following: Rule 3: it should be students and not just "student" as it currently stands; Rule 136: the "who" needs to be added between the words "student" and "major".

It is strongly suggested that the manuscript should be language edited if it is to be reviewed again.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

**********

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Attachment

Submitted filename: 08 June SZ PLOS ONE 2022.docx

Click here for additional data file. (162.2KB, docx)
PLoS One. 2022 Dec 22;17(12):e0279446. doi: 10.1371/journal.pone.0279446.r003

Author response to Decision Letter 0

25 Aug 2022

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Thank you for your comments, we checked and revised the manuscript to meet the PLOS ONE's style requirements.

2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

Once you have amended this/these statement(s) in the Methods section of the manuscript, please add the same text to the “Ethics Statement” field of the submission form (via “Edit Submission”).

Thank you for your comments, all participants received comprehensive information about the survey and so were fully informed before giving consent (by clicking “I agree to participate” button on the informed consent page of the questionnaire). We added this information on the “Ethical issue” section as you requested (Line 251)

For additional information about PLOS ONE ethical requirements for human subjects research, please refer to http://journals.plos.org/plosone/s/submission-guidelines#loc-human-subjects-research.

3. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

According to our application to the Institutional Review Board (IRB) of Hanoi University of Public Health, the data cannot be shared publicly because of ethical restrictions to protect the confidentiality of the participants imposed by the IRB. A de-identified dataset is available for researchers who meet the criteria for access to confidential data. Requests for data should be submitted to Institutional Review Board of Hanoi University of Public Health

(irb@huph.edu.vn) and the corresponding author, Dr. Pham Thanh Tung (phamthanhtung@hmu.edu.vn)

4. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 3 an 4 in your text; if accepted, production will need this reference to link the reader to the Table.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer 1 Comments

Thank you for your very insightful comments. These comments greatly helped us complete and improve our manuscript. We will be replying to every specific comment down below.

Comment:

The manuscript is technically sound and the data support all the conclusions made

L26- L 61 Credentials – some authors do not have Orcid numbers. It will be beneficial to generate an Orcid number

L 64 ABSTRACT- abstract is concise and succinct.

Answer: Thank you for your comments. We will ask all of our co-authors to include this information

Comment: L67 add nursing to medical students

Answer: we have fixed the sentence as recommended in the manuscript

Comment: L 101 add s to student

Answer: we have added “s” to student in the keyword section as recommended

Comment:

Introduction – well explained and purpose of the study well explained

Methods

The test and sample size are appropriate

The language used is clear, correct, and unambiguous

Setting – well explained

Survey instrument – questionnaire items well explained

Answer: Thank you for your comments

Sample size

Comment: L221 - remove full stop after percentage of nursing students

Answer: Thank you for your comments. We have removed the full stop in the sentence

Comment: L223 – Replace “an” with a in “A self-reported…”

Answer: Thank you for your comments. We have replaced the “an” with “a” in the sentence.

Comment: L225 – Who are these representatives?

Answer: Thank you for your comments. We added the following information on line 228

“The class representatives are students that are responsible for major communication between the school administration and the student of the class that they’re in. There is one class representative for each class, and this practice is common for most universities in Vietnam”

Data analysis

Comment: L235 – Separate the ap-value to read a p-value. Data analysis procedure explained well

Answer: Thank you for your comments. we have fixed the sentence as recommended.

Comment:

Ethical issues are well explained by authors

Results

Results well explained

Table concise

Answer: Thank you for your comments

Comment: L291 – What does normal students mean? Try another word to describe them as this does not sound good

Answer: Thank you for your comments. We have rephrased the sentence as below on line 297

“The PCS score was significantly lower in those who had symptoms of COVID-19 (p <0.001) and those who have significant fear of COVID-19 (p <0.001), compared to those who didn’t.”

Comment:

Discussion

Discussion covered the main findings in the study and exposed challenges face by health students on clinical rotation during the Covid -19 pandemic.

Strengths and limitations

Strengths and limitations well explained in the study

Answer: Thank you for your comments

Conclusion

Comment: Replace sample on L471 with group names of participants

Answer: Thank you for your comments. We have rephrased the sentence as below on line 477

“The physical and mental quality of life of the medical and nursing students was lower than that of the general population”

 

Reviewer 2 Comments

Thank you for your very insightful comments. These comments greatly helped us complete and improve our manuscript. We will be replying to every specific comment down below.

Comment: How many is all?

Answer: Thank you for your comments. The total number of participants was 3672 students. We revised line 75-76 as follows:

“The study was a cross-sectional study on all students of Hanoi Medical University from 3 majors: General Medicine, Preventive Medicine, Nursing (3672 invited students)”

Comment: The response rate seems low

Answer: Thank you for your comments. Due to using online questionnaires to collect data, the response rate is usually low. This was acknowledged in our limitation section in the full text on line 459:

“However, this study used an online, anonymous data collection scheme, which lead to a low response rate of only about 43%, and potential sampling errors, and selection bias.”

Comment: Would be good to highlight, what leads to the previous mental problem faced by the students for the reader to follow the progression of the risk factors.

Answer: Thank you for your comments. We revised it as follows on line 116

“Medical and nursing students, before the pandemic, were already known to face multiple physical and mental problems including burnout, anxiety, depression, and other mental health issues, with stress, lack of academic motivation, and financial hardship being important risk factors [13–16]”

Comment: Please include literature, that address what in quality life in a life of Medical and Nursing student, and how it affects them so as to link the following sentence that address the solution which is the study aim.

Answer: Thank you for your comments. This sentence was intended as our hypothesis rather than information from the literature. We revised it as follows on line 126

“Together with other socio-economic aspects related to the pandemic like lockdown, social distancing, limitation in physical activities, the authors hypothesized that the physical and mental quality of life of medical students could be at high risk and can potentially lead to poorer health outcomes.”

Comment: The authors, instead of we.

Answer: Thank you for your comments. We revised the sentence as you suggested

Comment: Would be good to add the overall medical and nursing students that were enrolled in that period for the reader to see the sample size you got for the study.

Answer: Thank you for your comments. We revised the sentence as you suggested on line 138.

“A cross-sectional study was conducted on 1583 students who major in medicine, preventive medicine, and nursing, at Hanoi Medical University (out of total 3672 students), from 7th to 29th of April 2020. This period is within the first 6 months of the covid-19 pandemic in Vietnam”

Comment: Ensure consistency. Second or 2nd ?

Answer: Thank you for your comments. We have fixed the typing error (from 2nd to second) to ensure consistency

Comment: Is the instrument developed, adapted or edited by the authors and is the permission ranted if it was adapted ?

Answer: Thank you for your comments. We included detailed information on these questionnaires in our method section. No adaptation or edition was made by the authors as we simply used the Vietnamese version (adapted, translated, tested, and sometimes validated in previous studies)

Line 176 “The FCV-19S questionnaire was translated into Vietnamese in a previous study and showed good item-scale convergent validity (mean of Rho = 0.77), discriminant validity and construct validity and high internal consistency (Cronbach’s alpha = 0.90) with the Vietnamese translation [33,34]”. The information on this questionnaire was available online from previous paper and could be considered resource on public domain, which could be reused by other researchers.

Line 187 “The quality of life of students during the period was determined using the Vietnamese version of the Quality-of-life SF-36 version 2.0 [35]”. The information on this questionnaire was available online from previous paper and could be considered resource on public domain, which could be reused by other researchers.

The license for this questionnaire was also fully granted by RAND: https://www.rand.org/health-care/surveys_tools/mos/36-item-short-form/terms.html

Comment: Acknowledge the source, since it is adapted please

Answer: Thank you for your comments. We included the name of the author of the article in the source and cited accordingly on line 177

“Fear of Covid-19 was assessed using the FCV-19S questionnaire. The FCV-19S questionnaire was translated into Vietnamese in a previous study by Nguyen and colleague and showed good item-scale convergent validity (mean of Rho = 0.77), discriminant validity and construct validity and high internal consistency (Cronbach’s alpha = 0.90) with the Vietnamese translation [33,34].”

Comment: Suggested a usage of nor instead of or

Answer: Thank you for your comments. We have changed it to “neutral” as in the original English version

https://www.nlm.nih.gov/dr2/Fear_of_Covid-19_Scale_2020.pdf

Line 180: “It consisted of 7 items and utilized a 5-point Likert scale with 1 = “strongly disagree”, 2 = “disagree”, 3 = “neutral”, 4 = “agree”, 5 = “strongly agree””

Comment: What informed then number of invited participants. It needs be scientifically justifiable

Answer: Thank you for your comments. The total number of invited students was collected using record from the administration. As for the scientifical justification, we invited ALL students in Doctor of General Medicine, Doctor of Preventive Medicine, and Bachelor of Nursing tracks (3672 students) rather than using random sampling. Inviting all individuals from the target population to participate is always the best sampling method if resources are available.

We also provided information on sample size calculations on line 211:

“Sample size and data collection

The required sample size was estimated by using the formula for estimating sample mean [38], as follows:

n=(Z_(1-α/2)^2 〖*σ〗^2)/d^2 =(〖1.96〗^2*〖12.5〗^2)/1^2 =600.25

With, n being the required sample size, Z being the standard error associated with the chosen level of confidence 5%, σ being the standard deviation of the general quality of life score taken from the population used to validate the Vietnamese version of the SF-36 [35].”

Comment: Clarify the ap to the reader

Answer: Thank you for your comments. It is a typo, we changed it to:

Line 241: “We consider a p -value < 0.05 as statistically significant for all statistical tests”

Comment: Add a source to reference this, it is significant but elaborate as to according to who

Answer: Thank you for your comments. We included citation on paper tracking and discussing the origin of this threshold. We understand this threshold is not perfect; therefore, we always try to provide full p-value rather than using cut-off and also use 95%CI when possible.

Comment: Provide value to the reader

Answer: Thank you for your comments. We used general medicine was used as a reference in the regression model for the independent variable of major, so the coefficient for general medicine was 0 while the coefficient for nursing was not significantly different from the reference, but the table did include this information. The coefficient could be understood as the difference among groups when comparing the score.

We also added detailed values in the following sentence on line 337:

“Regarding academic characteristics, majoring in Preventive Medicine result in higher MCS score (Coef: 2.97; 95% CI: 0.33 to 5.6) compared to those who were majoring in general medicine. Lower MCS score was associated with: having chronic disease (Coef: -9.5; 95% CI: -1.7 to -5.6), having atypical symptoms of COVID-19 (Coef: -7.59; 95% CI: -12 to -3.4), difficulties affording healthcare services (Coef: -5.20; 95% CI: -7.2 to -3.2). The association of having atypical symptoms and affordability of healthcare services with MCS score was also consistent with our quantile regression analysis. However, in the quantile regression analysis with the same variables (S6 Table), there were no association between the Preventive Medicine major (p=0.064), chronic disease and MCS (p=0.073), but being on clinical rotation was associated with a higher MCS score (Coef: 3.239; 95% CI: 0.71 to 5.8).”

Comment: Delete douplicate

Answer: Thank you for your comments we deleted the duplicate

Comment: This affirms the earlier suggestion, that if the tool is amended. Its reliability and validity must be ensured in the current context

Answer: Thank you for your comments. All questionnaires in languages other than English usually involve translation. Although these questionnaires may be validated rigorously. The reliability and validity will never be 100% as the original version in the original language. Even a sensitivity and specificity of 99% is not 100%. Therefore, in this sentence, we want to clearly state this fact even though previous studies may have already validated these tools rigorously in Vietnamese population. 

Reviewer 3 Comments

Thank you for your very insightful comments. These comments greatly helped us complete and improve our manuscript. We will be replying to every specific comment down below.

Comment: The experiments and the statistical analysis seem to have been conducted rigorously. Data underlying the findings is not made fully available. The authors in the manuscript indicated the following in this regards: "According to our application to I have no competing interests, the data cannot be shared publicly because of ethical restrictions to protect the confidentiality of the participants. A de-identified dataset is available for researchers who meet the criteria for access to confidential data." The reviewer understands and respect that the Institutional Review Board of Hanoi University of Public Health wants to protect the confidentiality of participants in this way. The reviewer in this regard wants to suggest that the authors should consider omitting the name of the University to not only further protect the confidentiality of the participants but also of the University.

Answer: Thank you for your comments. The dataset of this paper was collected at only one university, and the IRB did not prohibit us from reporting the name of the university from this data as there is no sensitive data regarding the university. We think that reporting group level data like table and figure are good enough to protect the confidentiality of participants

Comment: In rule 136-138 the authors mentioned that the cross-sectional study was conducted in the first six months of the COVID-19 pandemic and then go further to state the dates on which the study was conducted namely 7-29 April of 2020. The sentence could cause confusion as it could sound as if the study was conducted over a period of six months.

Answer: Thank you for your comments. We have adjusted the sentence in the manuscript as follows, in order to clear the confusion.

Line 138: “A cross-sectional study was conducted on 1583 students major in medicine, preventive medicine, and nursing, at Hanoi Medical University (out of total 3672 students), from 7th to 29th of April 2020. This period is within the first 6 months of the covid-19 pandemic in Vietnam.”

Comment: In the discussion of the limitations of the study, the authors seem to contradict themselves with regards to utilizing a translated version of the SF-36 and of the FCV-19S. The authors first mentioned that the main instrument of the study namely the Vietnamese version of the SF-36 was validated and as a result provided a valid assessment of self-reported health status among the Vietnamese population. It further allowed for both compound and specific evaluation of quality life. Then in the discussion of the limitation of the study, the authors indicated that the translation of the SF-36 and the FCV-19S into Vietnamese might have affected the validity of these questionnaires.

The reviewer wonders whether the research was not conducted too hastily which resulted in preventing the authors to conduct a pilot study beforehand in order to rule out the possible limitations that the translation of the documents in the end brought about.

Answer: Thank you for your comments. All questionnaires in languages other than English usually involve translation. Although these questionnaires may be validated rigorously. The reliability and validity will never be 100% as the original version in the original language. Even a sensitivity and a specificity of 99% is not 100%.

Therefore, in this sentence, we want to clearly state this limitation even though previous studies may have already validated these tools rigorously in Vietnamese population.

Comment: The reviewer wants to suggest that if the manuscript is to be published that the authors add information pertaining to what was put into place to support participants who, as a result of the study, needed psychological treatment/assistance. From the discussion of the results, it is for instance mentioned that the quality of life for some of the participants changed as a result of the COVID-19 pandemic. By participating in the study could have created a specific awareness amongst some of the participants about these changes which potentially could for instance have contributed to further stress and anxious feelings. The authors in Rules 374-375 for instance refer to what the mental state of medical students could be as a result of the sudden changes in the context of the pandemic.

Answer: Thank you for your comments. The questionnaire was anonymous, so we could not refer student to a clinician. This anonymous procedure was put in place to protect the participants’ identity and encourage them to participate in the study as many students with mental health issue don’t want to reveal this information. The IRB also agreed and approved this anonymous procedure.

Comment: The reviewer is of the opinion that the results of the specific topic lends itself to causation interpretation. The authors stated that the use of a cross-sectional study design however limited their interpretation of the results to association, rather than causation. The interpretation of the conclusions therefore seems to be very linearly done. The authors do not draw adequate connections between the outcome of the study and the quality of life of the different groups that participated.

Answer: Thank you for your comments. The connection between quality of life and associated factors was discussed with regards to the data collected. There are many factors that need to be considered to use causation interpretation in this case. We have a low response rate, many unmeasured/residual confounders, and weak temporarily relationship in this study. All of these factors could completely change the results: student with low quality of life don’t want to participate, a strong unmeasured confounder like academic motivation distorted the relationship, the relationship is not causal as low quality of life lead to the risk factor (not the other way).

Therefore, we are not confidence to put forward a causal interpretation and would only report association.

Comment: The formulation and construction of sentence for instance need attention (Refer to Rules 196 and 197: Should the formulation of the last part of the sentence not read: and any score below 50 was considered to be "Below the population average". etc).

Answer: Thank you for your comments. We have rephrased the sentence accordingly.

Line 198: “A PCS/MCS score of 50 represents the reference population average, and any score below 50 would be considered “Below the population average””

Comment: In certain sentences words such as ‘the’ and ‘a’ are missing (Refer to Rule 171: The word "the" should be added between the words "to" and WHO"s etc).

Answer: Thank you for your comments. We have rephrased the sentence accordingly.

Line 174: “BMI was classified into 4 categories according to the WHO Asian – Pacific cutoff point: underweight (<18.5 kg/m2), normal weight (18.5–22.9 kg/m2), overweight (23–24.9 kg/m2), and obese (≥25 kg/m2) [32]”

Comment: COVID-19 is sometimes indicated as Covid-19 (Refer to Rules 101, 137, 156, 174 etc).

Answer: Thank you for your comments. We have adjusted the sentences according to the recommendation to ensure consistency.

Comment: Other examples where attention needs to be paid to the editing of the manuscript involves the following: Rule 3: it should be students and not just "student" as it currently stands; Rule 136: the "who" needs to be added between the words "student" and "major".

It is strongly suggested that the manuscript should be language edited if it is to be reviewed again.

Answer: Thank you for your comments. We have rewritten sections of the manuscript and hope that this complies with the reviewer’ remarks

Attachment

Submitted filename: Answer to reviewers comment_TP.docx

Click here for additional data file. (38.3KB, docx)

Decision Letter 1

Christmal Dela Christmals

2 Oct 2022

PONE-D-22-14424R1Pattern and perceived changes in quality of life of Vietnamese medical and nursing students during the COVID-19 pandemicPLOS ONE

Dear Dr. Pham,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The reviewers have engaged with your study and recommended some minor comments. Please address them as soon as you can.

Please submit your revised manuscript by Nov 16 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

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Christmal Dela Christmals, PhD, MSc, BSc, RN

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: No

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: REVIEW COMMENTS

Pattern and perceived changes in quality of life of Vietnamese medical and nursing students during the COVID-19 pandemic

SUMMARY OF RESEARCH AND IMPRESSION

This study looked at the patterns and perceptions of changes in quality of care of medical and nursing students during Covid -19 pandemic. This study is really timely to identify issues that students face and how institutions can support them during training. This can also serve as a guide for replication of this study in other contexts. I recommend that the manuscript be accepted and published.

ABSTRACT

Abstract is well explained, and major findings highlighted

INTRODUCTION

Introduction has more information on medical students than nursing students although the study covers both specialties. I suggest you consider more informing pertaining to nurses.

METHODS

L140 – Check the sentence on this line use “was” instead of “is”

L152 – delete being from the sentence

Data collection instruments well explained

L211 – not having no change – correct the two negative words

L222 – can you provide a brief explanation the low response rate among the general Medicine students?

Statistical analysis well explained

RESULTS

Results well explained with required statistical methods

Tables are well labelled

DISCUSSION

Discussion covered the main findings of the study

Reviewer #3: Thank you for attending to the previous comments and recommendations that were made. There are however still a few places where COVID-19 is still referred to as Covid-19 or even covid-19. Refer to Lines 134; 140; 152 and 159. Line 233 starts with the word "Thorough" and it should be "Through". In Line 320 is should be Table 3 and not table 3. The same goes for Line 337 where it should be Table 4 and not table 4. The reason for the last two comments is because the Table elsewhere is written with a capital letter.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #3: No

**********

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PLoS One. 2022 Dec 22;17(12):e0279446. doi: 10.1371/journal.pone.0279446.r005

Author response to Decision Letter 1

10 Oct 2022

Dear Editors and Reviewers,

Sincerest thanks for the previous editor’s and reviewers’ comments on our manuscript.

We hope that a revised version of the manuscript will still be considered by PLOS One. We have modified the paper in response to the extensive and insightful reviewers’ comments.

Furthermore, we have rewritten sections of the manuscript and hope that this complies with the reviewers’ remarks. We will respond to the comments point by point.

All the line number mentioned in this document were based on the marked-up copy (the revised manuscript with track changes).

Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: REVIEW COMMENTS

Pattern and perceived changes in quality of life of Vietnamese medical and nursing students during the COVID-19 pandemic

SUMMARY OF RESEARCH AND IMPRESSION

This study looked at the patterns and perceptions of changes in quality of care of medical and nursing students during Covid -19 pandemic. This study is really timely to identify issues that students face and how institutions can support them during training. This can also serve as a guide for replication of this study in other contexts. I recommend that the manuscript be accepted and published.

Thank you for your comments!

ABSTRACT

Abstract is well explained, and major findings highlighted

Thank you for your comments!

INTRODUCTION

Introduction has more information on medical students than nursing students although the study covers both specialties. I suggest you consider more informing pertaining to nurses.

Thank you for your comments! We added several references according to your suggestion

“Healthcare workers were shown to have a significantly higher risk of COVID-19 infection, compared to the general public, and faced with extraordinary amounts of pressures leading to physical and mental exhaustion [9–14]” => We added 2 studies that look specifically at nurses in the front-line of COVID-19

“Medical and nursing students, before the pandemic, were already known to face multiple physical and mental problems including burnout, anxiety, depression, and other mental health issues, with stress, lack of academic motivation, and financial hardship being important risk factors [15–21]” => We added 2 studies that look specifically at nursing students

“Medical education also changed rapidly in response to the situation, with the replacement of in-person classes with online equivalents and disruption of clinical rotations [24–29]” => We added 2 studies that look specifically at nursing students and how their education was affected by COVID-19

METHODS

L140 – Check the sentence on this line use “was” instead of “is”

Thank you for your comments! We changed it to “is”

L152 – delete being from the sentence

Thank you for your comments! We deleted the word “being”

Data collection instruments well explained

Thank you for your comments!

L211 – not having no change – correct the two negative words

Thank you for your comments! We changed it to “having no change or improvement in their quality of life”

L222 – can you provide a brief explanation the low response rate among the general Medicine students?

Thank you for your comments! We added the explanation for this in line 462 in the limitation section

“The difference in response rate between academic majors could be due to clinical rotation’s scheduling, the willingness and interest of the class representatives, or miscommunications between the Office for Student Services and the class representatives. Due to the anonymous feature of the survey, we were not able to pinpoint the exact reasons for the difference in response rate and will look into this issue in future studies”

Statistical analysis well explained

Thank you for your comments!

RESULTS

Results well explained with required statistical methods

Tables are well labelled

Thank you for your comments!

DISCUSSION

Discussion covered the main findings of the study

Thank you for your comments!

Reviewer #3: Thank you for attending to the previous comments and recommendations that were made. There are however still a few places where COVID-19 is still referred to as Covid-19 or even covid-19. Refer to Lines 134; 140; 152 and 159.

Thank you for your comments! We did a search for all inconsistencies in wording of COVID-19 and changed it as you suggested

Line 233 starts with the word "Thorough" and it should be "Through".

Thank you for your comments! We changed it to "Through" as you pointed out

In Line 320 is should be Table 3 and not table 3. The same goes for Line 337 where it should be Table 4 and not table 4. The reason for the last two comments is because the Table elsewhere is written with a capital letter.

Thank you for your comments! We changed it to Table 3 and Table 4 as you pointed out

Attachment

Submitted filename: Answer to reviewers comment_TP.docx

Click here for additional data file. (19.4KB, docx)

Decision Letter 2

Elsayed Abdelkreem

7 Dec 2022

Pattern and perceived changes in quality of life of Vietnamese medical and nursing students during the COVID-19 pandemic

PONE-D-22-14424R2

Dear Dr. Pham,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Elsayed Abdelkreem, MD, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: ALL THE CORRECTIONS ARE SUFFUCIENTLY DONE AND I AM OF THE OPINION THAT IF THE EDITORS ARE OF THE OPINION THAT THE ARTICLE CAN BE PUBLISHED, THAT IT SHOULD BE PUBLIED

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

**********

Acceptance letter

Elsayed Abdelkreem

14 Dec 2022

PONE-D-22-14424R2

Pattern and perceived changes in quality of life of Vietnamese medical and nursing students during the COVID-19 pandemic

Dear Dr. Pham:

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Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

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    Data Availability Statement

    According to our application to the Institutional Review Board (IRB) of Hanoi University of Public Health, the data cannot be shared publicly because of ethical restrictions to protect the confidentiality of the participants imposed by the IRB. A de-identified dataset is available for researchers who meet the criteria for access to confidential data. Requests for data should be submitted to Institutional Review Board of Hanoi University of Public Health (irb@huph.edu.vn) and the corresponding author, Dr. Pham Thanh Tung (phamthanhtung@hmu.edu.vn).

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