Introduction

Education lies at the core of developing a society’s most valuable resource—its human capital1. It is also closely linked to health outcomes. The evidence clearly shows that education greatly impacts people’s well-being2. Higher educational attainment correlates with longer lives, less disease, healthier habits, and overall greater wellness3. The opportunities, jobs, and income made possible through education all influence individual health. Numerous studies emphasize education’s profound lifelong effects on physical and mental health1,2,3,4.

Bangladesh has two main education systems—secular and traditional religious schooling2. Islamic studies, such as memorizing the Quran and other subjects, are typically taught informally through private lessons at places of worship like mosques and formally in madrasas. Madrasa education differs markedly from the country’s formal schooling2. Madrasas, which means “house of learning” in Arabic, are Islamic religious institutions that provide education centered around teachings from the Quran and Hadith. They play an integral role in preserving Muslim cultural heritage and promoting religious learning across generations. Unlike students in Bangladesh’s mainstream schools, those attending madrasas tend to come from less privileged socioeconomic backgrounds with fewer resources available at home for learning. The madrasa model focuses strictly on theological topics rather than subjects like math, science, and English taught in secular schools. This has led to a prevalent perception that madrasa graduates receive a subpar education not aligned with modern needs or national curriculum standards. With some exceptions, the quality of teacher training and infrastructure also tends to be inferior when compared to formal schools2.

Research into the backgrounds of madrasah students in Bangladesh has revealed several notable findings. One study reported that over half of fathers and nearly all mothers of madrasah children had received little to no formal schooling, with most fathers’ highest level of education being primary school at best5. Similarly, another study found that the likelihood of a child to enroll in the madrasah is negatively influenced by their parents level of education6. Additionally, it has been reported that more than half of the madrasa students come from poor families and in some cases the enroll into madrasa simply because they can’t afford general schooling7. These studies also highlighted troubling living conditions and hygiene practices among madrasah residents. Approximately three-quarters of madrasah children lived in cramped, poorly ventilated rooms that were far over capacity. Nearly one-third shared bed linens between multiple students5,8. All these factors and many more markedly impacts the student’s self-esteem and well-being2.

Mental health issues place a significant burden on those experiencing them, their families and communities, as well as society at large9. However, there continues to be discussion around whether psychological difficulties in children and teenagers are truly increasing over time. A growing body of research now suggest a possible rise in mental health issues like depression and anxiety10,11,12. Screening youth for mental health challenges and low life satisfaction is crucial for identifying those at risk of developing problems early or coping with unseen issues13,14. Detecting latent or evident psychological concerns in their initial stages allows for prompt intervention. Screening assessments can pinpoint struggling individuals who may otherwise go unnoticed without support. For children exhibiting distress or impairment, additional evaluation and treatment aiming to remedy suffering and dysfunction are warranted. Furthermore, taking prompt action can prevent such difficulties from becoming chronic or more severe9.

Health-related quality of life (HRQoL) captures an individual’s own perspective and evaluation of how their state of physical and mental health impacts their day-to-day life and well-being15. It is a subjective, multidimensional concept that reflects a person’s perceptions within the context of their unique sociocultural circumstances. The HRQoL assessments aim to understand the extent to which health status may inhibit or promote an individual’s ability to function and engage in daily activities, fulfillment of life roles, level of independence, and overall life satisfaction.

Although perceived quality of life is an important determinant of the mental and physical well-being of the children, the research related to this aspect focusing on informal or madrasa students of Bangladesh is scant. While most previous studies on HRQoL in students focused on school students, it is crucial also to evaluate HRQoL among madrasa students, because HRQoL in school students cannot be adequately understood without such reference data. According to the recent statistics, there are 1.8 million madrasa students in Bangladesh16. It is common for students in Bangladesh to leave home to enroll in a madrasa, losing their first line of protection-their family17. In madrasas, classroom lessons and supervised learning are the main teaching models, and students may have difficulty adjusting to changes in the campus environment and policies18. Meanwhile, madrasa life represents a critical stage for physiological and psychological maturity. Leaving home, facing challenges from peers, managing finances, and managing interpersonal relationships may be difficult experiences for a student. Therefore, special attention should be paid to madrasa students’ physical and mental health. In particular, research on quality of life will help us learn about madrasa students more comprehensively. The HRQoL is intertwined with student well-being, and in the context of madrasa life, this may promote equal opportunities, success, and ensure a better life19.

Therefore, the current study aimed to measure the HRQoL of madrasa students using the KIDSCREEN-10 index and the find out the factors influencing it.

Methods

Study design

A cross-sectional study design was used to collect data on exposure and outcome variables from a group of madrasa students in the Mirpur area of Dhaka, Bangladesh between April and May 2022. In Dhaka, there are about a thousand madrasas18. We chose the Mirpur area purposefully because of the number of madrasas in the area, including Maktab, Hafizia, Qawmi and Alia. However, one-third of them, particularly Maktab, Hafizia and Qawmi madrasas, are not fully functional18. In terms of educational programs, environment, and facilities, the madrasas in this area are similar to those in Dhaka city. For this study, six madrasas were randomly selected from a total of 12 madrasas in the area. The data collection process involved the utilization of a structured questionnaire, which was designed using insights from prior research9.

Data collection

One teacher at each madrasa was appointed as a coordinator and given information about the research project and procedures for collecting the data. The coordinator informed the students and their parents about the study before data collection. Following, we used a simple random sampling technique to select participant from each selected madrasa using year of the course. From the register books of the madrasa, we were able to determine the participants’ year of the course. The principal investigator (the first author) and data collectors were present at each marasa when the students filled out the questionnaires. Data collectors stressed informant confidentiality, responded to questions, and read questions aloud for students with reading problems. Written informed consent was obtained from both the madrasa authorities and parents/guardians prior to the survey. In case of boarding and orphan students, madrasa authorities gave the consent on behalf of their guardians. Questionnaires were distributed and returned on the spot. Data collectors checked whether there were any missing items or unclear identification; if there were, the participants were asked to complete the information. A pilot survey was conducted among 20 students to investigate the capacity to comprehend the relevant techniques and potential trouble-some situations during interviews. The eligible study participants included those aged 8 to 18 years old who had been studying at madrasa for at least 6 months. Informed consent was obtained from all the study participants and was informed about the right to free to withdraw or opt out at any point without any penalty. If the students did not consent to data collection, they were not included in the study. The required sample size was 384 at 90% power, 95% confidence level, with anticipated 50% of students had poor HRQoL and margin of error was 5%. We then randomly selected at least 70 students from each of 6 madrasas. A total of 450 students were randomly invited to participate, but 31 students were deemed ineligible, resulting in 419 students receiving the questionnaire, yielding a response rate of 93%. Of them, 24 participants did not continue, leaving 395 participants who filled out the questionnaire. Finally, a total of 373 data were selected for analysis after eliminating incomplete and insufficient quality information of 22 data. The participation in the study was voluntary without any financial compensation. Data selection, identification and inclusion flow diagram process are presented in Supplementary Appendix 1.

Measures

Outcome variable

The quality of life was considered as the primary outcome measure in this study and the quantification of HRQoL was using the KIDSCREEN-10 index which contained 10 items. It is a concise, internationally validated screening tool that can be used to assess vulnerabilities in mental health and subjective well-being among 8- to 18-year-olds. The KIDSCREEN-10 is based on more KIDSCREEN-52 quality of life assessments, but maintains strong psychometric properties while offering an efficient alternative with just 10 items7. Details regarding the index, including its validity can be found elsewhere15. Answer to the first and ninth question had 4 categories: not at all, slightly, moderately, very-extremely. The rest of the questions had 5 categories: never, seldom, quite often, very often, always. Responses were coded so that a higher score indicates better HRQoL. The median score for the participants was 36 (33.0–38.0). Median split was used to categorize the finally summed score as: good (participants at or above the median score of 36) and poor (participants below the median score of 36). The index showed good internal consistency with Cronbach’s alpha of 0.778.

Independent variables

The study examined several independent variables, including demographic features such as age (in years), gender, orphan status, financial support, fathers’ education, fathers’ occupation, mothers’ education, mothers’ occupation, accommodation, academic year, body mass index [BMI] (BMI > 1SD as ‘overweight/obese’, BMI <  − SD as ‘thinness’ and others are coded as ‘normal’ as per WHO)16, number of family members, and number of siblings. In addition, student’s orphan status, financial guardian, preference for madrasa study, library facility, and opportunity for mobile and computer use was considered independent variables. Furthermore, present illness, visiting doctor and reason for not visiting doctor, feeling safe at madrasa, bullying and place of bullying were independent variables.

Statistical analysis

The study used STATA 17 and jamovi (v 2.4) for data analysis. The normality of continuous variables was tested using the Shapiro–Wilk test. For descriptive statistics, continuous data were presented as mean (Standard Deviation; [SD]) or median (IQR) where applicable. Categorical variables were represented as counts and percentages. For inferential statistics, the authors used the Chi-square test, Fisher’s exact test for testing association between two categorical variables and Mann–Whitney U test for association between categorical and non-normal continuous variable. A logistic regression model with all significant variables identified by bivariate screening was developed to find the strength of association. A p-value < 0.05 was considered statistically significant.

Ethical approval and consent to participate

All procedures performed in studies involving human participants were in accordance with the 1964 Helsinki Declaration. The ethics committee of North South University, Bangladesh approved the study protocol (Ref-NSU/2021/102). For data collection in the madrasas, official permission was obtained from the respective authorities prior to the survey. Participants voluntarily participated in the study and had the right to withdraw from the study without a reason. All methods were carried out in accordance with relevant guidelines and regulations.

Declaration of AI usage

The authors used ChatGPT (version 3.5) during the preparation of this work to enhance the language and readability of the manuscript, as the authors are not native English speakers. After utilizing the tool, the authors thoroughly reviewed and edited the content as necessary and assume full responsibility for the manuscript’s content.

Results

Participant’s background characteristics

A total of 373 students were included in the study. The median age (IQR) for the students were 10.0 (8.0–12.0) years. Most of the students were male (91%) and had normal BMI (63%). Only 5% of students were orphan. Parents paid for most of the students’ study and/or accommodation expenses (95%), while the madrasa authority only covered 5% of students’ expenses. Nearly half (48%) of the students had fathers with formal education, while only 33% had mothers with formal education. The majority of the students’ fathers were informal workers (44%) and mothers were unemployed or housewives (61%). The majority of students were living with parents (55%) and shared their bed (82%). Most madrasa had no library facility (92%). Approximately 41% of students reported history of illness and dental problem was the most common disease (36%). Most students (95%) reported that they felt safe in their institution. Only 13% of students faced bullying with most of the bullying occurring in the playground (40%) (Table 1).

Table 1 Participants' characteristics and their association with HRQoL.
Full size table

The study found significant associations between HRQoL and having library facility (p = 0.036), presence of an illness (p = 0.001), feeling safe (p = 0.004) and bullying (p = 0.021) (Table 1).

Health related quality of life

Among the students, 56% (n=209) had good HRQoL and 44% (n=164) had poor HRQoL (Fig. 1).

Figure 1
figure 1

Distribution of participants by HRQoL.

Full size image

Table 2 shows the result of the logistic regression model. A multivariable logistic regression model was developed to investigate the effects of predictor variables on HRQoL of the participants. Feeling safe in the institution increased the odds of having good HRQoL 3.7 times (95% CI 1.3–10.4; p = 0.016) compared to those who did not feel safe. Furthermore, having a present illness decreased the odds of good HRQoL (AOR 0.6; 95% CI 0.4–0.9; p = 0.010) compared with those without a history of illnesses. However, no significant association was found between HRQoL scores and having library facility in the madrasa and bullying experience (p > 0.05).

Table 2 Multivariable logistic regression.
Full size table

Discussion

The current study examined the HRQoL of madrasa students in Dhaka, Bangladesh and its association with various factors. The study findings show the overall HRQoL of the students were mostly good (56%). The median score for the KIDSCREEN-10 index was 36.0 (33.0–38.0). On literature review, studies conducted on the overall quality of life among Bangladesh Madrasa students were scarce. Hence, findings of this study can provide valuable and critical insights on this often-neglected part of the student population in Bangladesh.

The most important finding of the study is the majority of students’ good HRQoL. Although, no direct relationship has been established by the available literature between being a madrasa student and HRQoL, there may be a compound relationship. Studies have shown that positive coping mechanisms can improve the overall quality of life21,22 and religious believes was significantly associated with life satisfaction among Southeast Asian students23. Also, a study in Kosovo suggests that madrasa education can make it easier to cope with challenge24. Keeping all this compounding relationship and effects of their interaction in mind, it can be said that the feeling of belonging (due to the residential nature of the madrasas) and believing a higher cause among madrasa students may increase their perception of HRQoL.

The median age of the participants of the study was 10 which was almost similar to another study conducted in Bangladesh where the mean age was 11.24 years8. Also, an overwhelming majority were male (91%) which is also similar to the Bangladeshi study (92%)8. However, this could be due to absence of female-only madrasas in our chosen study place. Moreover, concordant to the previous study, we found that a handful of participants were orphans8.

One significant finding of the study is that participants who had present illnesses showed 0.6 times lower odds of reporting good HRQoL than those without any illness. Studies have reported that HRQoL is greatly influenced by the presence of a disease and especially among patients with chronic illness25. Hence, the association found in the current study is easily explainable.

Almost all the participants (95%) reported feeling safe. It was also found that those who feel safe had 3.7 times higher odds of having good HRQoL. The study also reports that bullied participants had 0.5 times lower odds of having good HRQoL than those who were never bullied. It is well-known that the feeling of stress (which may result from lack of safety, bullying etc.) can negatively affect the HRQoL of the children26. A study conducted using KIDSCREEN-27 questionnaire found that stress had the largest indirect effect on HRQoL27.

What can be done by parents, madrasa authorities and the government to improve HRQoL among madrasa students in Bangladesh? Students residing in boarding houses require proper attention and care, especially as many are orphans. Regularly monitoring their health status and providing them with proper care is essential for better HRQoL. This study argues in favour of a direct approach to influencing the future place of madrasas in Bangladesh as places without bullying or mobbing for better HRQoL. The authors suggest establishing a library and computer lab with appropriate competency in the madrasa when no such facility existed in the madrasa. The current study had several strengths. It was conducted using two-stage stratified random sampling increasing the strength of the sampling. Also, there is very limited research conducted on the health-related quality of life of the madrasa students. As such, findings and insights of the current study can help in illuminating the current situation. However, the study also had some limitations. Firstly, the cross-sectional nature can also establish an association, not any causal relationship. Secondly, the current study only focused on madrasas of Dhaka city, which is the capital of the country, leaving the need for research to be conducted on madrasas from rural areas.

Conclusion

The overall findings of this study provide valuable insights into the HRQoL of madrasa students in Bangladesh. The key results show that the majority reported a good HRQoL. Several factors were found to be associated with HRQoL. Feeling safe, and not being bullied were positively associated with good HRQoL. The presence of illness was negatively associated. These relationships align with existing literature on how physical, psychological, and social factors impact children’s well-being. Future longitudinal and comparative rural research is recommended to deepen understanding. Key implications include promoting students’ physical, mental and social welfare through health education, anti-bullying initiatives, regular screening, and multi-sectoral involvement. A rights-based approach prioritizing holistic development may help madrasa students optimize their overall quality of life.