Psychology, Health & Medicine

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/cphm20

Quality of life, physical activity and burnout

syndrome during online learning period in
Brazilian university students during the COVID-19
pandemic: a cluster analysis

Diana Vilela Azzi, Júlia Melo, Armindo de Arruda Campos Neto, Paula Midori
Castelo, Eric Francelino Andrade & Luciano José Pereira

To cite this article: Diana Vilela Azzi, Júlia Melo, Armindo de Arruda Campos Neto, Paula
Midori Castelo, Eric Francelino Andrade & Luciano José Pereira (2021): Quality of life, physical
activity and burnout syndrome during online learning period in Brazilian university students
during the COVID-19 pandemic: a cluster analysis, Psychology, Health & Medicine, DOI:
10.1080/13548506.2021.1944656

To link to this article: https://doi.org/10.1080/13548506.2021.1944656

Published online: 30 Jun 2021.

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PSYCHOLOGY, HEALTH & MEDICINE
https://doi.org/10.1080/13548506.2021.1944656

Quality of life, physical activity and burnout syndrome during

online learning period in Brazilian university students during
the COVID-19 pandemic: a cluster analysis
Diana Vilela Azzi , Júlia Melo, Armindo de Arruda Campos Neto ,
Paula Midori Castelo , Eric Francelino Andrade and Luciano José Pereira

ABSTRACT ARTICLE HISTORY

The COVID-19 pandemic caused several changes in the teaching- Received 16 February 2021
learning process, as it abruptly replaced the conventional classes Accepted 11 June 2021
into online classes despite social distancing requirements. Such KEYWORDS
changes may be associated with several mental health problems Burnout syndrome; quality of
and negatively affect the quality of life and academic performance life; online learning; COVID-
of university students. We performed a cluster analysis in a large 19 outbreak
sample of Brazilian undergraduate students, considering sociode­
mographic data, physical activity frequency, study areas, Burnout
Syndrome (BS), Quality of Life (QoL) and perception of online
learning (OL) during COVID-19 pandemic. Seven hundred and
three students (between 17 and 62 years, from 67 higher education
institutions) participated in the study. We identified three different
profiles of students regarding psychological aspects and OL percep­
tion. The first profile, called as the ‘Low QoL’ group was composed
of younger students, mainly females, with higher frequency of
psychological disorders (as evidenced by the self-report of depres­
sion and/or anxiety), in addition to higher Burnout scores, lower
QoL and worse OL perception. The second profile called
‘Intermediate QoL’ comprised participants with an average age of
45 years, with a greater number of men, married, with kids and
working in addition to studying. They presented better OL scores
than the ‘Low QoL’ group. The third profile called ‘Better QoL’
comprised students with higher scores in all domains of QoL and
better OL perception, with greater frequency of physical activity
and lower BS scores. Students from Health courses showed higher
scores for general QoL, and also for the psychological and environ­
mental domains in relation to the other areas. Besides, students of
the Exact Sciences courses showed higher scores on all OL percep­
tion items in comparison to the other courses. Our results provide
insights regarding the mental health profile of undergraduate stu­
dents, allowing educational managers to outline specific coping
strategies to assist students during the pandemic.

Introduction
The global outbreak of Coronavirus disease (COVID-19) has forced educational institu­
tions to interrupt their activities in order to control the spread of the virus. This protocol

CONTACT Luciano José Pereira lucianopereiraufla@gmail.com Health Sciences Department, Universidade

Federal de Lavras, CEP 37200-900, P.O. Box 3037, Lavras, Minas Gerais, Brazil.
© 2021 Informa UK Limited, trading as Taylor & Francis Group
2 D. V. AZZI ET AL.

impacted the academic life of several students worldwide and even caused a massive
disruption of the educational system (Alqahtani & Rajkhan, 2020). Along with the
extension of the pandemic period, many educational institutions implemented online
activities, shortly changing the teaching-learning process (Radha et al., 2020). Such
changes, associated with social distancing during the pandemic could influence student’s
quality of life and even contribute to the worsening of psychological disorders (Cao et al.,
2020; Hasan & Bao, 2020; Silva et al., 2020).
Quality of life (QoL) is defined as the individual’s perception of his/her position in life,
within the context of culture, goals, expectations, references and concerns (WHO, 2014).
Additionally, QoL is closely related to mental health (Ribeiro et al., 2018). Thus, the
deterioration in one component can result in losses in the other one (Damnjanovic et al.,
2011). The QoL perception can also be influenced by the development of occupational
diseases such as Burnout Syndrome (BS) (Paro et al., 2014; Schmidt et al., 2013) which is
a condition characterized by emotional exhaustion, depersonalization and low personal
accomplishment (Miranda-Ackerman et al., 2019). Emotional exhaustion is related to
feelings of tiredness in which the person lacks enough emotional energy, while deperso­
nalization is involved with detachment and lack of empathy with other people (Mazzetti
et al., 2020). Low personal achievement is associated with feelings of productive incapa­
city and low self-esteem in relation to work or performed activities (Treglown et al.,
2016). Generally, BS affects those involved with stressful tasks and/or several hours of
work/study (Almeida et al., 2016).
Studies have investigated the incidence of BS on university students (Almeida et al.,
2016; Montero-Marin et al., 2011). The Burnout Clinical Subtype Questionnaire (BCSQ-
12-SS) is a reliable instrument adapted to assess BS in students considering three
dimensions (‘overload’, ‘lack of development’ and ‘neglect’) (Montero-Marin et al.,
2011). University students are prone to develop BS because they are subjected to several
stressors (Ribeiro et al., 2018). This is more evident in the context of the COVID-19
pandemic, in which students modified their study/work routine due to social distancing
(Bana & Sarfraz, 2020; Hakami et al., 2020) and online classes (Radha et al., 2020).
Moreover, the QoL of students can also be affected by the pandemic due to the loss of
social interaction, leisure deprivation and lower practice of physical activity, contributing
even more to mental health problems (Maugeri et al., 2020).
Some studies have evaluated students’ mental health during the COVID-19 pandemic
(Essadek & Rabeyron, 2020; Wang et al., 2020; Zhai & Du, 2020). However, few studies
have evaluated BS and most of them are restricted to medical or health course students
(Bolatov et al., 2020; Chen et al., 2020; Zis et al., 2021). In one of these studies on a sample
of Medical students, it was observed that the prevalence of BS was higher during the
lockdown compared to the pre-COVID-19 (Zis et al., 2021). In another study, it was
observed that BS decreased during the COVID-19 pandemic in relation to pre-pandemic
results (Bolatov et al., 2020). The authors associated these results with the students’ better
perception of online learning compared to traditional learning (Bolatov et al., 2020). The
discrepancy between these results highlights the importance of a broader evaluation
considering not only the BS symptoms but also the influence of different courses,
cultures, age, sex and physical activity frequency, as made possible by cluster analysis.
To date, studies assessing BS, QoL, physical activity frequency and perception of
online education in university students during the pandemic are scarce. Additionally,
 PSYCHOLOGY, HEALTH & MEDICINE 3

little is known about the profile of students in different areas of knowledge regarding
these variables. Cluster analysis is an unsupervised classification which generates groups
(clusters) of individuals with similar characteristics and dissimilar to individuals in other
clusters (Kaufman & Rousseeuw, 1990). This multivariate exploratory approach may
help investigators to explore data and generate hypotheses (Altman & Krzywinski, 2017),
discovering distinct groups in their populations, and then using this knowledge to
develop target programs or interventions.
Identifying patterns of distress and QoL groups may help providing counseling and
psychological support to students, assisting them to face the challenges of online learning
and isolation and promoting healthier habits and attitudes. Thus, we aimed to perform
a cluster analysis in a large sample of undergraduate students, considering sociodemo­
graphic data, physical activity frequency, study areas, BS, QoL and perception of online
education.

Methods
This study was approved by the Research Ethics Committee (CAAE: 32 185
120.7.0000.5108). All participants provided their informed consent (online) to partici­
pate in the study.

Study design
This cross-sectional study was performed on a large sample of Brazilian students
recruited via convenience sampling online using snowball method. A questionnaire
was prepared on Google Forms (Alphabet, Mountain View, CA, USA) and shared by
e-mail and social networking sites (Facebook®, Instagram® and WhatsApp®) between
August 7th and August 26th. The inclusion criteria were being university student,
performing online education activities during COVID-19 pandemic, age above 18 years-
old, living in Brazil and agree to fill out all the online survey. The instruments for
assessing quality of life (WHOQOL-BREF) and BS (BCSQ-12-SS) used in this study
were chosen because they are considered the gold standard and validated for the Brazilian
population (Demarzo et al., 2020; Fleck et al., 2000).

Measures
Sample characteristics
The following sociodemographic and occupational data were obtained from participants:
age; sex; marital status; kids; state/province; educational institution; course subject;
course semester; extracurricular activities; diagnosis of depression; diagnosis of anxiety;
self-report of anxiety; physical activity and frequency of physical activity.

World health organization quality of life-brief version (WHOQOL-BREF)

QoL was accessed using the Brazilian Portuguese brief version of the World Health
Organization Quality of Life Scale (WHOQOL-BREF; α = 0.91) (Fleck et al., 2000), which
consists of 26 items including two questions related to overall quality of life and general
health and other four domains of functioning (Limbers et al., 2020). Specifically, ‘physical
4 D. V. AZZI ET AL.

health’ has seven items, ‘psychological health’ has six items, ‘social relationships’ has
three items, and ‘environmental health’ has eight items (Limbers et al., 2020).
Participants rated each item considering the last week on a five-point Likert scale,
which varied depending on the domain (Limbers et al., 2020). The scores calculation
for each domain was executed in accordance with the proper guidelines (The WHOQOL
Group, 1996). The questions related to ‘overall quality of life’ and ‘general health
perception’ were assigned to the domain ‘Global Quality of Life’, as proposed by
Pedroso et al. (2010). Additionally, we calculated the ‘Overall Quality of Life’, using the
sum of all WHOQOL-BREF domains (Pedroso et al., 2010). Higher scores represent
better quality of life (Limbers et al., 2020; Pedroso et al., 2010).

Burnout clinical subtype questionnaire students survey (BCSQ-12-SS)

Participants responded to the BCSQ-12-SS (α-values ≥0.74) (Montero-Marin et al.,
2011), which presents 12 items distributed among the dimensions: ‘overload’ (e.g. ‘I
think I invest more than is healthy in my commitment to my studies’), ‘lack of develop­
ment’ (e.g. ‘I would like to study something else that would be more challenging to my
abilities’), and ‘neglect’ (e.g. ‘When the results of my studies are not good at all, I stop
making an effort’). This instrument presents questions within a 7-point-Likert scale
(‘completely disagree’ to ‘completely agree’). Results are presented in scalar scores and
higher domain scores indicate higher BS levels.

Online learning (OL) perception assessment

We applied the adapted version of instrument proposed by Bernard et al. (2004) just like
performed by Adnan and Anwar (2020). To this, we selected two questions with the
highest loading observed for each factor (‘beliefs’, ‘skills’, ‘self-direction’, and ‘interac­
tion’) described in the original instrument (Bernard et al., 2004). The questions were
answered within a five-point Likert scale (‘strongly agree’ to ‘strongly disagree’). Thus, we
attribute the result to the sum of the two questions to represent the score of respective
factor, similarly to the description in the original version of the questionnaire (Bernard
et al., 2004). In addition, we included the item ‘reason for limited internet access’ with the
following answer options: ‘Cost/Too Expensive’, ‘Signals availability/strength Problems’,
‘Don’t know how to use it’, ‘No internet access problem’ and ‘Other’. These adaptations
were performed to reduce the number of questions to guarantee the reliability of the
results.

Statistical analysis
Statistical analysis was performed using SPSS version27.0 software by an Applied
Statistics Spec (PMC). Exploratory analysis consisted of means, standard deviation and
percentages. The internal consistency (Cronbach’s Alpha coefficients) of the scales
applied in this study was examined prior to analysis.
Hierarchical cluster analysis using the farthest neighbor method for calculating dis­
tances between clusters was performed to obtain the dendrogram and analyze the
possible range of clusters. Further, K-means analysis was applied to identify the groups
of participants with similar demographic and health-related variables by including the
following variables: age, sex, occupational and marital status, number of kids, physical
 PSYCHOLOGY, HEALTH & MEDICINE 5

activity, internet access, depression and anxiety diagnosis, self-perception of being

anxious, and the perception of QoL, BS and OL questions. The final number of clusters
was based on the interpretability and reliability of the cluster solution, and the differences
between clusters were assessed by F-test for clustering validation and descriptive
purposes.
The graphical analysis, Chi-square, and Analysis of Variance (ANOVA) tests were
used to compare the demographic and health-related outcomes between the groups of
students. The results of the Levene’s equality of variances was evaluated as assumption of
the ANOVA and the effect size (partial Eta squared) and the power of the test were also
obtained for each model. The Bonferroni’s adjustment was applied for multiple compar­
isons and the alpha level was set at 5%.

Results
The study included 703 students aged between 17 and 62 years, being 142 students from
Agrarian Sciences (AGR), 251 from Health Sciences (HS), 152 from Humanities and
Social Sciences (HSS), and 158 from Exact Sciences (ES). The sample comprised parti­
cipants from all five geographical areas of Brazilian territory. The characteristics of
students are described in Table 1.
The internal consistency (Cronbach’s Alpha coefficients) of the scales was examined
prior to analysis. The WHOQOL-BREF and BCSQ-12-SS alpha coefficients obtained in
this sample were 0.92 and 0.87, respectively. For both scales, the correlation coefficients
between items were all positive and the Cronbach’s alpha did not increase when each
item was excluded from the analysis.
By analyzing the dendrogram (Figure 1), three clusters were suggested; thus, K-means
cluster analysis was run to obtain three reliable and meaningful clusters of individuals,
varying significantly according to the demographic and health-related aspects of the
participants. Table 2 shows the final cluster centers and the proposed taxonomy which
defined the three clusters. Cluster 1 (labeled ‘Low QoL’; n = 340) was characterized by
young participants and higher frequencies of depression and anxiety diagnosis, self-
perception of being anxious, and lower scores achieved in the WHOQOL-BREF.
Additionally, the cluster achieved higher scores in the BS domains and lower scores in
the OL questions. The proportion of females was higher compared to the other clus­
ters (76.5%).
Cluster 2 (labeled ‘Intermediate QoL’; n = 37) was characterized by older participants
(mean of 45 years) with higher proportion of males (41%) and married participants than
the other clusters, higher number of kids, and students who also have formal/informal
jobs. Interestingly, they scored higher in OL beliefs, OL self-direction and OL interact
questions.
Cluster 3 (labeled ‘Better QoL’; n = 326) was characterized by young individuals,
higher frequency of participants who practice physical activity and lower frequency of
participants who reported having difficulties accessing the internet. They also scored
higher in the WHOQOL-BREF and OL skills questions.
A higher frequency of anxiety diagnosis was found in students from the Health
Sciences (32%) when compared to the other areas of knowledge (around 20%)
6 D. V. AZZI ET AL.

Table 1. Sample characteristics according to sex, demographic aspects, undergraduate

course, perception of online education and psychological aspects.
Variable Females (n = 503) Males (n = 200)
Age (m/SD)
Years 23.3 (3.7) 24.6 (4.7)
Marital Status (n)
Married/stable relationship 68 21
Single 431 178
Divorced 4 1
Kids (n)
0 470 185
1 16 10
2 18 8
3 or more 8 1
Region (n)
North 23 9
South 100 35
South east 286 122
Northeast 77 26
Midwest 17 8
Educational institution (n)
Private 52 25
Public 451 175
Course Subject (n)
Biology/Biochemistry 25 12
Agrarian Sciences 115 27
Exact and Earth Sciences 34 31
Human Sciences 23 6
Social Sciences 50 18
Engineering 59 34
Arts 39 16
Health 158 56
Course semester
1° to 4º 252 88
5° to 8° 173 73
Up to 9° 78 39
Extracurricular activities (n)
Informal work activity 68 20
Registered work activity 37 22
Extension activities 80 29
Research activities 93 37
None 225 92
Yes 450 138
No 53 62
>5 23 13
Previous diagnosed with depression (n)
Yes 263 154
No 240 46
Previous diagnosed with anxiety (n)
Yes 240 137
No 263 63
Reported itself as ‘anxious’ (n)
Yes 450 138
No 53 62
Physical activity (n)
Yes 261 117
No 242 83
Amount of physical activity – days per week (n)
0–2 318 115
3–5 162 72
>5 23 13
Quality of Live Domain score (m/SD)
Physical health 11.6 (1.4) 11.6 (1.7)
(Continued)
 PSYCHOLOGY, HEALTH & MEDICINE 7

Table 1. (Continued).
Variable Females (n = 503) Males (n = 200)
Psychological health 12.3 (1.7) 12.4 (1.9)
Social relationships 12.9 (2.8) 12.7 (3.1)
Environment 13.2 (2.1) 13.5 (2.3)
Global quality of life 13.7 (2.7) 13.6 (2.9)
Overall Quality of Life 12.6 (1.5) 12.7 (1.7)
Burnout Domain score (m/SD)
Overload 13.0 (4.2) 10.9 (4.3)
Lack of development 9.1 (5.0) 8.1 (4.9)
Neglect 9.0 (3.8) 9.7 (4.9)
Reason for limited Internet access (n)
Cost/Too Expensive 31 5
Signals availability/strength Problems 129 44
Don’t know how to use it 1 2
No internet access problem 322 145
Other 20 4
Online Learning (OL)
Achievement scores (m/SD)
Skills Questionsa 6.5 (1.1) 7.0 (1.2)
Beliefs Questionsb 3.2 (1.2) 3.3 (1.4)
Self-direction Questionsc 5.3 (1.2) 5.5 (1.2)
Interaction Questionsd 7.6 (1.0) 7.6 (1.1)
a
‘I am comfortable communicating electronically’ and ‘I possess sufficient computer skills for doing online
work’. b ‘Learning is the same in class and at home on the Internet’ and ‘I believe that learning on the
Internet outside of class is more motivating than a regular course’. c ‘In my online studies, I am self-
disciplined and find it easy to set aside reading and homework time’ and ‘In online learning, I am able to
manage my study time effectively and easily complete assignments on time’. d I can work in a group during
online activities” and ‘I can collaborate with other students during online activities outside of class’.

(X2 = 8.2; p = 0.042); on the other hand, the diagnosis of depression and the self-report of
being anxious did not differ (p = 0.155 and 0.291, respectively).
Figure 2 shows the scores achieved in the WHOQOL-BREF (Overall Quality of Life)
according to the area of knowledge; students from the HS scored higher than students
from agrarian and humanities and social sciences (p < 0.05), although the size of the
difference was small (eta partial squared = 0.02; power = 87%). The domains that
contributed to such difference were the physical, psychological and environmental
domains, with HS students scoring higher than the students from the other areas of
knowledge (Table 3).
Table 3 also shows the scores achieved by the students in the questions related to BS
and OL. When comparing the answers to the burnout questions, no significant
difference was found according to the area of knowledge (p > 0.05). However, a better
perception of the OL was found among students from the Exact Sciences in all aspects
examined when compared to agrarian, health and humanities sciences, as described in
Table 3.

Discussion
Our findings reveal three different profiles of students regarding psychological aspects
and OL perception during the COVID-19 pandemic. The ‘Low QoL group’ was com­
posed by young students, mainly females, with higher frequency of self-reported psy­
chological disorders (depression and/or anxiety), in addition to higher Burnout scores
and lower QoL scores and worse OL perception. The ‘Intermediate QoL’ group
8 D. V. AZZI ET AL.

Figure 1. Dendrogram used to examine the number of generated clusters (hierarchical method;
Euclidean distance). The horizontal line (red) indicates a suitable number of clusters.
 PSYCHOLOGY, HEALTH & MEDICINE 9

Table 2. Final cluster centers (means) of the demographic and health-related variables. (important
differences which identify the clusters are colored).
Low QoL Intermediate QoL Better QoL F test p-value
Number of participants 340 37 326
Age 22.80 45.08 22.31 576.0 <0.001
Sex .76 .59 .68 4.5 0.011
Marital status .13 .49 .09 25.8 <0.001
Number of kids .08 1.05 .04 106.0 <0.001
Occupational status .20 .51 .18 11.5 <0.001
Diagnosis of depression .35 .30 .22 7.2 0.001
Diagnosis of anxiety .52 .43 .40 4.9 0.008
Self-perception of being anxious .91 .78 .77 12.0 <0.001
Physical activity .48 .54 .60 4.8 0.009
Internet access .38 .46 .28 5.4 0.005
QoL Physical Domain 10.79 12.94 12.47 87.1 <0.001
QoL Psychological Domain 11.32 13.14 13.49 109.3 <0.001
QoL Social Relationships Domain 11.54 13.44 14.19 51.2 <0.001
QoL Environmental Domain 12.35 13.68 14.32 51.1 <0.001
Overall QoL 12.24 13.68 15.26 79.2 <0.001
Burnout Overload 16.01 9.43 9.12 270.0 <0.001
Burnout Lack of Development 13.52 5.68 4.39 407.0 <0.001
Burnout Neglect 11.36 8.54 7.22 66.8 <0.001
OL Skills Questionsa 6.46 6.76 6.90 7.7 <0.001
OL Beliefs Questionsb 3.11 4.00 3.31 5.4 0.005
OL Self-direction Questionsc 5.08 5.95 5.74 17.0 <0.001
OL Interaction Questionsd 5.19 6.14 5.97 22.9 <0.001
a
‘I am comfortable communicating electronically’ and ‘I possess sufficient computer skills for doing online work’. b
‘Learning is the same in class and at home on the Internet’ and ‘I believe that learning on the Internet outside of class is
more motivating than a regular course’. c ‘In my online studies, I am self-disciplined and find it easy to set aside reading
and homework time’ and ‘In online learning, I am able to manage my study time effectively and easily complete
assignments on time’. d I can work in a group during online activities” and ‘I can collaborate with other students during
online activities outside of class’.

Figure 2. Means (SD) of the scores achieved in the WHOQOL-BREF (Overall Quality of Life) according to
the area of knowledge (AGR, agrarian sciences; HS, health sciences; HSS, humanities and social
sciences, ES, exact sciences) (HS≠AGR, HS≠HSS; p < 0.05, power = 87%, eta partial squared = 0.02;
One-way ANOVA and Bonferroni’s post-test).
10 D. V. AZZI ET AL.

Table 3. Means (SD) of the scores achieved in the perception of quality of life, burnout symptoms and
online learning.
Agrarian Health Humanities and Exact Partial eta
Sciences Sciences Social Sciences Sciences p-value squared Power
Number of students 142 251 152 158
QoL Physical Domain 11.7 (2.0) 11.8 (2.0) 11.6 (2.0) 11.6 (1.9) 0.734 0.002 0.136
QoL Psychological 12.0B (2.4) 12.7A (2.1) 12.3AB (2.1) 12.5AB (2.2) 0.012 0.016 0.802
Domain
QoL Social 12.7 (3.9) 13.2 (3.5) 12.2 (3.8) 13.1 (3.4) 0.059 0.011 0.618
Relationship
Domain
QoL Environmental 13.0B (2.7) 13.8A (2.7) 12.8B (2.7) 13.4AB (2.6) <0.001 0.025 0.960
Domain
Global QoL 13.5 (3.5) 14.1 (3.4) 13.3 (3.5) 13.7 (3.3) 0.094 0.009 0.547
Overall QoL 12.4B (2.0) 13.0A (1.9) 12.3B (2.0) 12.7AB (1.9) 0.005 0.018 0.873
Burnout Overload 12.0 (5.3) 13.2 (5.0) 12.3 (5.3) 11.8 (5.2) 0.036 0.012 0.688
Burnout Lack of 8.2 (5.9) 9.2 (6.3) 9.8 (6.6) 8.0 (5.6) 0.032 0.012 0.700
Development
Burnout Neglect 8.9 (4.6) 9.4 (5.2) 9.1 (5.0) 9.6 (5.2) 0.598 0.003 0.182
OL Skillsa 6.6AB (1.4) 6.7AB (1.4) 6.4B (1.5) 7.0A (1.5) 0.004 0.019 0.876
OL Beliefsb 3.1B (1.6) 3.2B (1.5) 3.1B (1.6) 3.7A (1.8) 0.003 0.020 0.897
OL Self-directionc 5.4B (1.6) 5.2B (1.5) 5.4B (1.7) 5.9A (1.6) <0.001 0.025 0.959
OL Interactiond 5.6AB (1.7) 5.6AB (1.7) 5.3B (1.6) 6.0A (1.4) 0.001 0.023 0.935
A ≠ B (One-way ANOVA and Bonferroni’s post-test). Significant differences and higher means are in bold.
a
‘I am comfortable communicating electronically’ and ‘I possess sufficient computer skills for doing online work’. b
‘Learning is the same in class and at home on the Internet’ and ‘I believe that learning on the Internet outside of class is
more motivating than a regular course’. c ‘In my online studies, I am self-disciplined and find it easy to set aside reading
and homework time’ and ‘In online learning, I am able to manage my study time effectively and easily complete
assignments on time’. d I can work in a group during online activities” and ‘I can collaborate with other students during
online activities outside of class’.

comprised participants with an average age of 45 years, with a greater number of male
participants, married and with children and working in addition to studying. They
presented better OL scores than ‘Low QoL’ group. The group ‘Better QoL’ presented
students with higher scores in all domains of QoL and better OL skills, with greater
frequency of physical activity and lower BS scores.
Although this study was conducted only during the COVID-19 pandemic, some
characteristics observed were still similar to the pattern found by Lyndon et al. (2017)
in a sample of medical students using cluster analysis. These authors also identified three
clusters. One group had high BS scores and low QoL scores while the second group
presented moderate burnout and moderate QoL (Lyndon et al., 2017). The third group
was identified with low BS scores and high QoL scores (Lyndon et al., 2017). Thus, our
results endorse the link between QoL and BS highlighted by Lyndon et al. (2017).
Considering the first cluster observed in our study, women are more prone to stress,
and consequently, to some disorders, such as anxiety and depression (Andrade et al.,
2020; Maeng & Milad, 2015). This was well evidenced in medical students, where women
presented higher scores for emotional exhaustion (Paro et al., 2014). In addition, women
had a lower perception of physical and psychological QoL as well as a greater tendency to
empathic concern, disposition to anguish and anxiety (Paro et al., 2014). The higher
frequency of these disorders associated with the higher BS scores may contribute to the
lower QoL scores observed in this group (Lyndon et al., 2017; Vinter, 2021). Regarding
QoL during the COVID-19 pandemic, it was reported that nursing students who had
online experience and felt well prepared for online learning had better scores in each QoL
 PSYCHOLOGY, HEALTH & MEDICINE 11

domain (Keener et al., 2020). This relationship can be observed in our results, since the
‘Better QoL’ cluster had a higher OL skills score. Additionally, in Brazilian dentistry
students, the performance of online activities during the pandemic was related to better
QoL scores (Silva et al., 2020). This relationship can be confirmed by the fact that the
‘Better QoL’ group had the lowest BS scores. Academic burnout is characterized by
feelings of exhaustion due to the high academic demand, the experience of feeling
helplessness, negative attitude, low efficiency and lack of interest in the tasks (Mohebbi
et al., 2019). Besides, the fact that the ‘Intermediate QoL’ group had better results for
anxiety, depression and BS compared to the ‘Low QoL’ group may be related to resilient
behaviors and coping strategies that, commonly, could be developed with aging (Brice,
2001; Le Maistre & Paré, 2010). Also, older participants who declared to work concur­
rently with studying can benefit from the psychosocial well-being of the work (e.g., sense
of purpose, increased feelings of self-worth, opportunities for socialization) that helps the
individual to cope with the changes brought by the pandemic (Koch et al., 2021). Thus, it
is possible that older and more experienced individuals are more able to deal with the
factors that promote BS.
We speculate that the ‘Better QoL’ group, possibly presented better socioeconomic level.
In our study, the socioeconomic status of the participants was not directly assessed.
However, the lower frequency of individuals who reported not carrying out work activities
besides studying, may be related to better financial status. Additionally, we observed that
this group had higher levels of physical activity. Exercise is recognized as an effective
coping strategy for anxiety, depression and BS (Toker & Biron, 2012) because modulates
the release of neurotransmitters and hormones that act on the central nervous system and
promote a feeling of well-being (Escames et al., 2012; Kandola et al., 2018; Phillips, 2017).
We also observed that Health Sciences students had higher scores for general QoL,
psychological and environmental domains. Health Sciences students are generally heal­
thier and have better lifestyle habits than those of students from other branches of
knowledge (de-Mateo-Silleras et al., 2019; Gutiérrez-Salmeán et al., 2013).
On the other hand, we observed that students of the Exact Sciences area had higher
scores on all OL questions. Possibly, these students already have greater interaction with
online resources. A previous study reported that Exact Sciences students have a higher
frequency of access to website courses than other areas (Nachmias & Segev, 2003).
At our knowledge, this is the first study that evaluates the OL perception, BS and QoL
in a large sample of university students during the COVID-19 pandemic. Our results can
provide insights regarding the mental health profile of students, allowing educational
managers to outline specific strategies to assist students’ coping strategies. Future studies
should evaluate the same variables considering the perspective of vaccination and return
to face-to-face activities.

Acknowledgments
This study was supported by the Coordination for the Improvement of Higher Education
Personnel - Brazil (CAPES) - Finance Code 001. Authors thank to the Fundação de Amparo à
Pesquisa do Estado de São Paulo (FAPESP grant n. 2017/26 400-6).
12 D. V. AZZI ET AL.

Disclosure statement
Authors declare no competing interests.

Funding
This work was supported by the Fundação de Amparo à Pesquisa do Estado de São Paulo [2017/
26400-6].

ORCID
Diana Vilela Azzi http://orcid.org/0000-0003-0468-5855
Armindo de Arruda Campos Neto http://orcid.org/0000-0003-4922-6150
Paula Midori Castelo http://orcid.org/0000-0001-8703-2272
Eric Francelino Andrade http://orcid.org/0000-0002-9253-3108
Luciano José Pereira http://orcid.org/0000-0002-0502-2554

References
Adnan, M., & Anwar, K. (2020). Online learning amid the COVID-19 pandemic: Students’
perspectives. Journal of Pedagogical Sociology and Psychology, 2(1), 45–51. https://doi.org/10.
33902/JPSP
Almeida, G., Souza, H. R. D., Almeida, P. C. D., Almeida, B. D. C., & Almeida, G. H.. (2016). The
prevalence of burnout syndrome in medical students. Archives of Clinical Psychiatry (São
Paulo), 43(1), 6–10. https://doi.org/10.1590/0101-60830000000072
Alqahtani, A. Y., & Rajkhan, A. A. (2020). E-learning critical success factors during the COVID-19
pandemic: A comprehensive analysis of E-learning managerial perspectives. Education Sciences,
10(9), 216. https://doi.org/10.3390/educsci10090216
Altman, N., & Krzywinski, M. (2017). Points of significance: Clustering. Nature Methods, 14(6),
545–546. https://doi.org/10.1038/nmeth.4299
Andrade, E. F., Pereira, L. J., de Oliveira, A. P. L., Orlando, D. R., Alves, D. A. G., De
Guilarducci, J. S., & Castelo, P. M. (2020). Perceived fear of COVID-19 infection according to
sex, age and occupational risk using the Brazilian version of the Fear of COVID-19 Scale. Death
Studies, Ahead to P, 1–10. 10.1080/07481187.2020.1809786
Bana, K. F., & Sarfraz, S. (2020). Impact on mental health of undergraduates and the ways to cope
stress during COVID-19 pandemic. Pakistan Armed Forces Medical Journal, 70(5), 1453–1459.
https://mail.pafmj.org/index.php/PAFMJ/article/view/5584
Bernard, R. M., Brauer, A., Abrami, P. C., & Surkes, M. (2004). The development of
a questionnaire for predicting online learning achievement. International Journal of
Phytoremediation, 25(1), 31–47. https://doi.org/10.1080/0158791042000212440
Bolatov, A. K., Seisembekov, T. Z., Askarova, A. Z., Baikanova, R. K., Smailova, D. S., & Fabbro, E.
(2020). Online-learning due to COVID-19 improved mental health among medical students.
Medical Science Educator, 31(2020), 1–10. https://doi.org/10.1007/s40670-020-01165-y
Brice, H. E. (2001). Working with adults with enduring mental illness: Emotional demands
experienced by occupational therapists and the coping strategies they employ. British Journal
of Occupational Therapy, 64(4), 175–183. https://doi.org/10.1177/030802260106400404
Cao, W., Fang, Z., Hou, G., Han, M., Xu, X., Dong, J., & Zheng, J. (2020). The psychological impact
of the COVID-19 epidemic on college students in China. Psychiatry Research, 287, 112934.
https://doi.org/10.1016/j.psychres.2020.112934
Chen, E., Kaczmarek, K., & Ohyama, H. (2020). Student perceptions of distance learning strategies
during COVID-19. Journal of Dental Education, 1–2. Online ahead of print. https://doi.org/10.
1002/jdd.12339
 PSYCHOLOGY, HEALTH & MEDICINE 13

Damnjanovic, M., Lakic, A., Stevanovic, D., & Jovanovic, A. (2011). Effects of mental health on
quality of life in children and adolescents living in residential and foster care: A cross-sectional
study. Epidemiology and Psychiatric Sciences, 20(3), 257–262. https://doi.org/10.1017/
S2045796011000291
Demarzo, M., García-Campayo, J., Martínez-Rubio, D., Pérez-Aranda, A., Miraglia, J. L.,
Hirayama, M. S., De Salvo, V. M. A., Cicuto, K., Favarato, M. L., Terra, V., de Oliveira, M. B.,
García-Toro, M., Modrego-Alarcón, M., & Montero-Marín, J. (2020). Frenetic, under-
challenged, and worn-out burnout subtypes among brazilian primary care personnel:
Validation of the Brazilian “burnout clinical subtype questionnaire” (BCSQ-36/BCSQ-12).
International Journal of Environmental Research and Public Health, 17(3), 1081. https://doi.
org/10.3390/ijerph17031081
de-Mateo-Silleras, B., Camina-Martín, M. A., Cartujo-Redondo, A., Carreño-Enciso, L., De-la-
cruz-marcos, S., & Redondo-del-Río, P. (2019). Health perception according to the lifestyle of
university students. Journal of Community Health, 44(1), 74–80. https://doi.org/10.1007/
s10900-018-0555-4
Escames, G., Ozturk, G., Baño-Otálora, B., Pozo, M. J., Madrid, J. A., Reiter, R. J., Serrano, E.,
Concepción, M., & Acuña-Castroviejo, D. (2012). Exercise and melatonin in humans:
Reciprocal benefits. Journal of Pineal Research, 52(1), 1–11. https://doi.org/10.1111/j.1600-
079X.2011.00924.x
Essadek, A., & Rabeyron, T. (2020). Mental health of French students during the Covid-19
pandemic. Journal of Affective Disorders, 277(2020), 392–393. https://doi.org/10.1016/j.jad.
2020.08.042
Fleck, M. P. A., Louzada, S., Xavier, M., Chachamovich, E., Vieira, G., Santos, L., & Pinzon, V.
(2000). Application of the Portuguese version of the abbreviated instrument of quality life
WHOQOL-bref. Revista de Saude Publica, 34(2), 178–183. https://doi.org/10.1590/s0034-
89102000000200012
Gutiérrez-Salmeán, G., Meaney, A., Esther Ocharán, M., Araujo, J. M., Ramírez-Sánchez, I.,
Olivares-Corichi, I. M., García-Sánchez, R., Castillo, G., Méndez-Bolaina, E., Meaney, E., &
Ceballos, G. (2013). Anthropometric traits, blood pressure, and dietary and physical exercise
habits in health sciences students; the Obesity Observatory Project. Nutricion Hospitalaria, 28
(1), 194–201. https://doi.org/10.3305/nh.2013.28.1.6185
Hakami, Z., Khanagar, S. B., Vishwanathaiah, S., Hakami, A., Bokhari, A. M., Jabali, A. H.,
Alasmari, D., & Aldrees, A. M. (2020). Psychological impact of the coronavirus disease 2019
(COVID-19) pandemic on dental students: A nationwide study. Journal of Dental Education, 85
(4), jdd.12470. https://doi.org/10.1002/jdd.12470
Hasan, N., & Bao, Y. (2020). Impact of “e-Learning crack-up” perception on psychological distress
among college students during COVID-19 pandemic: A mediating role of “fear of
academic year loss”. Children and Youth Services Review, 118(2020), 105355. https://doi.org/
10.1016/j.childyouth.2020.105355
Kandola, A., Vancampfort, D., Herring, M., Rebar, A., Hallgren, M., Firth, J., & Stubbs, B. (2018).
Moving to beat anxiety: Epidemiology and therapeutic issues with physical activity for anxiety.
Current Psychiatry Reports, 20(8), 1–9. https://doi.org/10.1007/s11920-018-0923-x
Kaufman, L., & Rousseeuw, P. J. (1990). Finding groups in data. John Wiley & Sons, Inc. https://
doi.org/10.1002/9780470316801
Keener, T. A., Hall, K., Wang, K., Hulsey, T., & Piamjariyakul, U. (2020). Quality of life, resilience,
and related factors of nursing students during the COVID-19 pandemic. Nurse Educator, 46
(3):143–148. https://doi.org/10.1097/NNE.0000000000000969
Koch, L. C., Rumrill, P. D., & Chan, F. (2021). Multiple sclerosis in the COVID-19 Era: Vocational
rehabilitation strategies to meet the needs of a growing and immune-vulnerable clientele.
Journal of Vocational Rehabilitation, 54(2), 175–183. https://doi.org/10.3233/JVR-201128
Le Maistre, C., & Paré, A. (2010). Whatever it takes: How beginning teachers learn to survive.
Teaching and Teacher Education, 26(3), 559–564. https://doi.org/10.1016/j.tate.2009.06.016
Limbers, C. A., McCollum, C., & Greenwood, E. (2020). Physical activity moderates the association
between parenting stress and quality of life in working mothers during the COVID-19
14 D. V. AZZI ET AL.

pandemic. Mental Health and Physical Activity, 19(2000), 100358. https://doi.org/10.1016/j.

mhpa.2020.100358
Lyndon, M. P., Henning, M. A., Alyami, H., Krishna, S., Zeng, I., Yu, T. C., & Hill, A. G. (2017).
Burnout, quality of life, motivation, and academic achievement among medical students: A
person-oriented approach. Perspectives on Medical Education, 6(2), 108–114. https://doi.org/10.
1007/s40037-017-0340-6
Maeng, L. Y., & Milad, M. R. (2015). Sex differences in anxiety disorders: Interactions between
fear, stress, and gonadal hormones. Hormones and Behavior, 76(2015), 106–117. https://doi.org/
10.1016/j.yhbeh.2015.04.002
Maugeri, G., Castrogiovanni, P., Battaglia, G., Pippi, R., D’Agata, V., Palma, A., Di Rosa, M., &
Musumeci, G. (2020). The impact of physical activity on psychological health during Covid-19
pandemic in Italy. Heliyon, 6(6), e04315. https://doi.org/10.1016/j.heliyon.2020.e04315
Mazzetti, G., Guglielmi, D., & Topa, G. (2020). Hard enough to manage my emotions: How
hardiness moderates the relationship between emotional demands and exhaustion. Frontiers in
Psychology, 11(2020), 1194. https://doi.org/10.3389/fpsyg.2020.01194
Miranda-Ackerman, R. C., Barbosa-Camacho, F. J., Sander-Möller, M. J., Buenrostro-Jiménez,
A. D., Mares-País, R., Cortes-Flores, A. O., Morgan-Villela, G., Zuloaga-Fernández del
Valle, C. J., Solano-Genesta, M., Fuentes-Orozco, C., Cervantes-Cardona, G. A., Cervantes-
Guevara, G., & González-Ojeda, A.. (2019). Burnout syndrome prevalence during internship in
public and private hospitals: A survey study in Mexico. Medical Education Online, 24(1),
1593785. https://doi.org/10.1080/10872981.2019.1593785
Mohebbi, S. Z., Yazdani, R., Talebi, M., Pakdaman, A., Heft, M. W., & Bahramian, H. (2019). Burn
out among Iranian dental students: Psychometric properties of burnout clinical subtype ques­
tionnaire (BCSQ-12-SS) and its correlates. BMC Medical Education, 19(1), 388. https://doi.org/
10.1186/s12909-019-1808-3
Montero-Marin, J., Monticelli, F., Casas, M., Roman, A., Tomas, I., Gili, M., & Garcia-Campayo, J.
(2011). Burnout syndrome among dental students: A short version of the “burnout Clinical
Subtype Questionnaire” adapted for students (BCSQ-12-SS). BMC Medical Education, 11(1),
103. https://doi.org/10.1186/1472-6920-11-103
Nachmias, R., & Segev, L. (2003). Students’ use of content in Web-supported academic courses.
Internet and Higher Education, 6(2), 145–157. https://doi.org/10.1016/S1096-7516(03)00021-
6
Paro, H. B. M. S., Silveira, P. S. P., Perotta, B., Gannam, S., Enns, S. C., Giaxa, R. R. B., Bonito, R. F.,
Martins, M. A., & Tempski, P. Z. (2014). Empathy among medical students: Is there a relation
with quality of life and burnout? PLoS ONE, 9(4), e94133. https://doi.org/10.1371/journal.pone.
0094133
Pedroso, B., Pilatti, L. A., Gutierrez, G. L., & Picinin, C. T. (2010). Calculation of scores and
descriptive statistics of WHOQOL-bref through Microsoft Excel. Revista Brasileira De
Qualidade De Vida, 2(1), 31–36. https://doi.org/10.3895/s2175-08582010000100004
Phillips, C. (2017). Physical activity modulates common neuroplasticity substrates in major
depressive and bipolar disorder. Neural Plasticity, 2017(2017), 7014146. https://doi.org/10.
1155/2017/7014146
Radha, R., Mahalakshmi, K., Kumar, V. S., & Saravanakumar, A. R. (2020). E-Learning during
lockdown of Covid-19 pandemic: A global perspective. International Journal of Control and
Automation, 13(4), 1088–1099. http://sersc.org/journals/index.php/IJCA/article/view/26035
Ribeiro, Í. J. S., Pereira, R., Freire, I. V., de Oliveira, B. G., Casotti, C. A., & Boery, E. N. (2018).
Stress and quality of life among university students: A systematic literature review. Health
Professions Education, 4(2), 70–77. https://doi.org/10.1016/j.hpe.2017.03.002
Schmidt, D. R. C., Paladini, M., Biato, C., Pais, J. D., & Oliveira, A. R. (2013). Quality of working
life and burnout among nursing staff in Intensive Care Units. Revista Brasileira De Enfermagem,
66(1), 13–17. https://doi.org/10.1590/s0034-71672013000100002
Silva, P., de Oliveira, C. A. L., Borges, M. M. F., Moreira, D. M., Alencar, P. N. B., Avelar, R. L., Bitu
Sousa, R. M. R., & Sousa, F. B.. (2020). Distance learning during social seclusion by COVID-19:
 PSYCHOLOGY, HEALTH & MEDICINE 15

Improving the quality of life of undergraduate dentistry students. European Journal of Dental
Education, 25(1), eje.12583. https://doi.org/10.1111/eje.12583
Toker, S., & Biron, M. (2012). Job burnout and depression: Unraveling their temporal relationship
and considering the role of physical activity. Journal of Applied Psychology, 97(3), 699–710.
https://doi.org/10.1037/a0026914
Treglown, L., Palaiou, K., Zarola, A., & Furnham, A. (2016). The dark side of resilience and
Burnout: A moderation-mediation model. PLOS ONE, 11(6), e0156279. https://doi.org/10.
1371/journal.pone.0156279
Vinter, K. (2021). Examining academic burnout: Profiles and coping patterns among Estonian
middle school students. Educational Studies, 47(1), 1–18. https://doi.org/10.1080/03055698.
2019.1702510
Wang, X., Hegde, S., Son, C., Keller, B., Smith, A., & Sasangohar, F. (2020). Investigating mental
health of US college students during the COVID-19 pandemic: Cross-sectional survey study.
Journal of Medical Internet Research, 22(9), e22817. https://doi.org/10.2196/22817
WHO. (2014). WHO | WHOQOL: Measuring Quality of Life. http://www.who.int/healthinfo/
survey/whoqol-qualityoflife/en/index2.html
The WHOQOL Group. (1996). WHOQOL-BREF Introduction, Administration, Scoring and
Generic Version of the Assessment. https://www.who.int/mental_health/media/en/76.pdf
Zhai, Y., & Du, X. (2020). Mental health care for international Chinese students affected by the
COVID-19 outbreak. The Lancet Psychiatry, 7(4), e22. https://doi.org/10.1016/S2215-0366(20)
30089-4
Zis, P., Artemiadis, A., Bargiotas, P., Nteveros, A., & Hadjigeorgiou, G. M. (2021). Medical studies
during the COVID-19 pandemic: The impact of digital learning on medical students’ Burnout
and mental health. International Journal of Environmental Research and Public Health, 18(1),
349. https://doi.org/10.3390/ijerph18010349