The relationship between mental health and academic performance amongst undergraduate medical students in low-middle income countries (LMICs): a protocol for a systematic review

¹Department of Clinical Psychology, School of Medicine, Sefako Makgatho Health Sciences, University, Ga-Rankuwa, Pretoria, 0208, Gauteng, South Africa

^&Corresponding author
Antonio Lentoor, Department of Clinical Psychology, School of Medicine, Sefako Makgatho Health Sciences, University, Ga-Rankuwa, Pretoria, 0208, Gauteng, South Africa

Study protocol    

Introduction

Numerous studies acknowledge that medical education is one of the most intellectually and emotionally demanding academic paths. This is particularly the case in the context of medical training, which comes with a high academic workload, including practical and coursework, students mostly prioritize their academics over other aspects of their lives [1]. Furthermore, poor academic performance can lead to dismissal from this course. Studies indicate that worldwide, an estimated number of 31% of university students had been screened positive for a mental health disorder in 2018, with the majority believing them to be typical university stress that does not need intervention [2]. Moreover, in Egypt, a study done by Mansoura Faculty of Medicine reported that 59% of its 900 students suffered more than one mental health illness [3]. Medical students are susceptible to high levels of burnout, anxiety, despair, and stress, which can have a detrimental impact on their general functioning and academic achievement [4]. Additionally, students studying medicine are subjected to stressors such as the pressure of high parental and self-expectations, a demanding academic curriculum that includes lectures, practical simulations, supervised practical training, and mentorship programs; moreover, adapting to new environments [5]. In Low-Middle Income Countries (LMIC´s), these stressors are further aggravated by financial constraints, infrastructural challenges, and limited access to mental health services [6]. Medical students in LMICs are likely to learn in constrained environments, with minimal access to mental health support services on university campuses [7]; consequently, this can negatively impact the academic performance and overall functioning of medical students in LMICs.

Substantial mental health issues such as depression, anxiety, stress, sleep disturbances, and burnout are prevalent amongst undergraduate medical students globally. In LMICs, these issues may be intensified by socio-economic pressures, limited resources, financial stress, access to mental health services, barriers to seeking help, and demanding academic curricula. A study done in South Africa reported poor mental health among medical students as a multifaceted issue influenced by various factors. Firstly, the demanding academic environment places significant pressure on students, with a rigorous curriculum, high workload, and socio-economic pressures [8]. Students´ academic performance, motivation, cognitive functioning, and overall well-being can be negatively impacted by these mental health issues. A study done by Nyun KH [9] on stress and its correlation with academic performance and psychological health reported that chronic stress has been linked to decreased academic performance, psychological problems like anxiety and depression, and burnout.

Most of the studies on this topic come from high-income countries, whereas LMICs are still inadequately represented. The relationship between mental health and academic performance from these high-income contexts [10] may not be fully generalizable to the LMIC, given some of the unique resource-constrained challenges and access to mental health support services. As Akhtar et al. [11] reported, existing studies on the topic in LMICs are small-scale and limited, most of them with variability in study methods and across disciplines, with variable conclusions. This provides an opportunity to look at these small-scale LMIC studies and compile evidence synthesis to gain a deeper understanding of the nature of the relationship between mental health and academic performance of undergraduate medical students in LMICs. Due to the lack of a broader understanding of the nature of the association, the development of targeted policies and interventions designed for improving both academic success and mental health in these vulnerable settings is impeded. One study highlights that practical and evidence-based support systems for mental health problems in medical and other undergraduate students must be developed and implemented [12].

Medical school is commonly known to be academically and psychologically demanding. Through a wide range of studies, there is a high prevalence of depression, stress, burnout, and anxiety among medical students globally [13]. These mental-health issues ultimately compromise progression and workforce readiness as they not only threaten student mental well-being but also reduce concentration, motivation, and academic performance [14]. Most meta-analyses and systematic reviews conducted highlight mental health in medical students, with evidence done in high-income countries, while there is limited evidence focused specifically on LMICs [15] where financial hardship, limited mental-health support, and resources, which are contextual stressors, can extenuate the impact. Findings in low- and middle-income countries remain fragmented, without consistency, while individual LMIC literature studies highlight an association between poor mental health and poor academic performance [16]. Therefore, in LMICs, a systematic review formulating the relationship between mental health and academic performance among undergraduate medical students is needed to better understand this association by identifying gaps in the literature and inform targeted interventions to support both student success and the future healthcare workforce.

Objectives: this protocol for a systematic review is submitted for publication to synthesize available evidence on the relationship between mental health and academic performance amongst undergraduate medical students in LMICs. The broader goal is that this understanding will enable us to better comprehend the experiences of medical students in LMICs and the fundamental psychosocial factors that can inform strategies for psychosocial support and intervention. In line with PEO criteria, the following research question is asked: what is the link between mental health and academic outcomes among undergraduate medical students in low-and middle-income countries (LMICs)?

Methods

Review questions: 1) main research question: what is the link between mental health and academic outcomes among undergraduate medical students in low-and middle-income countries? 2) sub questions: a) What is the prevalence of mental health conditions among undergraduate medical students in LMICs? b) What factors are associated with mental health challenges in this population? c) How do mental health conditions impact outcomes among undergraduate medical students in LMICs?

Study characteristics

Inclusion criteria: eligibility criteria will be established according to the population, exposure, and outcomes (PEO). This review will consider peer-reviewed journal articles, study design: observational studies, e.g. case-control, cross-sectional, and cohort, will be included. Eligible studies must be published in English between the years 2000 and 2026.

Exclusion criteria: this review will exclude studies focused on non-medical students, postgraduate students, high-income countries, and studies not related to mental health and academic performance, reviews, editorials, commentaries, and conference abstracts.

Population, exposure, and outcomes: P (population): undergraduate medical students (+18 years and older) in LMICs (as World Bank Classification); E (exposure): mental health conditions, e.g., distress, stress, depression, anxiety; O (outcomes): academic performance indicators, e.g., Exam marks, GPA.

Information sources: the literature search will include title, abstract, and keyword fields. The search will be done by the third author. The electronic search of several databases, MEDLINE (Pubmed), Scopus, CINAHL, and Google Scholar, will be conducted for the period January 2000 to December 2026. To ensure this review captures the latest available body of evidence, the publication year will be limited to the past twenty-six years. .

Search strategy: the search strategy will include the identification of main terms based on the PEO framework, with a focus on five primary areas: (“academic performance”), (“mental health”), (“undergraduate medical students”), (“Low-to-middle income countries”). The following Medical Subject Heading (MeSH) search terms will be used in their singular or plural forms in their title, abstract, keywords, and text fields of the articles: (“Academic Performance” OR “Academic Outcome” OR “Academic Achievement” AND “Mental Health” OR “Mental Illness” OR “Mental Disorders” AND “Undergraduate Medical Student” OR “Undergraduate Medical Education” OR “Undergraduate Medical Studies” AND “Low to-middle Income Countries” OR “LMIC´s”). The reference list of all included articles will be screened manually to identify additional studies following a snowball procedure.

Data extraction and management

Data extraction: the literature that was identified through the electronic databases search will be uploaded into Zotero, where all duplicated results based on the title and author will be filtered out and deleted. The remaining results will be imported into Ryyan, which is an online application that is used to support reference selection in systematic reviews and promotes reviewer participation. Selected articles will be stored in a secure cloud-based storage account, with the backup stored in another separate cloud-based storage account. Both will be password-protected, with only the research authors having access to the data.

Selection process: four reviewers will perform the selection procedure while considering the previously defined inclusion and exclusion criteria from the review team. The titles and abstracts of all retrieved search results will be independently reviewed by the reviewers, who will then classify them as included, excluded, or possible. The full text of the articles marked as included and/or possible will then be retrieved and evaluated in both scenarios. The fifth author from the review team will be consulted in cases where consensus cannot be reached after discussion and resolution of all documents generating any hesitations or disagreements.

Data collection process: to ensure that all the relevant data is obtained and to reduce any possible bias, the four authors will independently extract the key information (e.g., authors, year of publication, country economy status, design questions, etc.) from all qualifying studies. The descriptive data for each study will be logged using the same standard extracted data form. The extracted data will be verified by the researchers, and conflicts will be settled through discussion and reference to information in primary articles. The fifth author will evaluate and validate the extracted data.

Data items/measurable outcomes: Table 1 represents data items to be extracted from the selected articles.

Data synthesis: a systematic narrative synthesis of study findings will be included and presented in written text and summaries to explain the findings of the synthesis [17]. A narrative synthesis process is suitable for linking different types of evidence and exploring relationships between and within studies. This methodology exposes the context and attributes of each study, allowing for a comparative analysis of their similarities and contrasts. Our narrative synthesis methodology will be informed by the techniques defined by [18], which involves three steps: coding of text, developing descriptive themes, and generating analytical themes.

This study follows the narrative thematic synthesis method [19] and will synthesize transparently. The reviewers will extract the data verbatim for the analytical process. Data analysis will be conducted using the NVivo program. NVivo offers researchers a comprehensive set of features to manage and analyze various types of unstructured data, such as text documents, interview transcripts, audio and video recordings, images, etc [19]. The findings will be illustrated and supported by direct quotes, which will be developed into meaningful themes and presented in a narrative format. The synthesized findings will be subjected to confidence evaluation using the ConQual approach in line with the JBI criteria of qualitative synthesis output [20]. This will ensure trustworthiness, dependability, and credibility of the analytical and interpretative findings among the different reviewers.

Risk of bias: according to the PRISMA 2000 recommendations, the methodology of the retrieved articles will be critically appraised. The quality appraisal will be conducted with relevant appraisal tools. For this review, the Joanna Briggs Institute (JBI) Critical Appraisal Tool Studies will be used. The JBI Randomized Controlled Trials Checklist, the JBI checklist for Quasi-experimental Studies, and the JBI Critical Appraisal Checklist for Analytical Cross-Sectional Studies Tool will be used. The checklists consist of numerous items with the response options “yes”, “no”, “unclear”, or “not applicable”. To summarize the overall quality of the articles, a complete risk of bias judgment will be made. The four reviewers will independently complete the appraisal tools. The ratings of each reviewer will be compared using inter-rater agreement (Cohen´s kappa), and any conflict, and any conflicted decisions will be resolved through discussion during a consensus meeting. The fifth reviewer will be consulted if we fail to meet consensus.

Trial registration number: this protocol is registered on PROSPERO with registration CRD42025116261.

Ethics and dissemination: this study is a systematic review of previously published studies; therefore, ethical approval is not necessary as it will not involve any human participants. The protocol was submitted to the School Research Ethics Council (SREC) and Sefako Makgatho Health Sciences University Research Ethics Council (SMUREC) for ethics waiver, and is approved with the study ID SMUREC/M/59/2026: UG. Any modifications to the systematic review process will be evaluated and approved using the PROSPERO registry, and the specifications of those modifications will be included in the study´s final report. Dissemination for this study will be through peer-reviewed publications, national and international conferences, and interdepartmental webinars.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Aphiwe Gumede, Mudzunga Tendamudzimu, Kenewang Ramoroka, and Nokwenele Buthelezi were responsible for conceptualizing and designing the study as well as drafting the revision of the protocol. While Sello Mantse, Richard Mphago, and Antonio Lentoor simultaneously oversaw the process. The final protocol manuscript was read and approved by all the authors.

Table     

Table 1: data items to be extracted from the selected articles

References