Medical schools are known as stressful environments (1). Training in the field of medicine is usually considered as demanding (2,3), providing less time and space for medical students for relaxation or participating in joyful activities (4,5). Many studies in different countries, including Iran (6), have reported high levels of psychological distress (7), for example depression (8–10), anxiety (11,12), stress (12–14), or sleep difficulties (15), among medical students. In addition, the association between poor psychological health with impaired learning ability and poor academic functioning is reviewed in many studies (16,17). Students who are not psychologically fit usually have weaker academic performance (18).
The freshman students are a vulnerable group of students (2) and experience a lot of pressure (19). They need to cope with different role transitions including the second individuation (20) during adolescent development. In Iran, they usually leave the supportive environment of their homes and high schools, and enter the universities and dormitories, as well. Therefore, they face more independent life experiences, more social interactions, and less family support and supervision. Joining a university is often accompany with the first formal interaction with opposite-sex groups. In addition, first-year students usually lose their high-school friendships and should build up new social networks. Therefore, providing different programs for addressing the psychological needs of freshmen may be a priority for educational institutions.
In the present study, we examined the effectiveness of a psychological-educational supportive package on the psychological well-being and the academic performance of freshman medical students of Mashhad University of Medical Sciences (MUMS).
The administrative office of vice-chancellor of education of MUMS divides first-year medical students of every educational year into 2 distinct groups, randomly. The first-year program of one group starts in September (autumn semester), while the other group starts their first-year program in February (winter semester). Therefore, the courses presented for these two groups are different in the winter semester of the first educational year, and the chance of communication between the students of autumn semester and winter semester is very low. The present researchers decided to perform a quasi-experimental study on first -year medical students of MUMS in the academic year of 2018-2019, using the census method. They included all the first-year medical students of autumn semester 2018 as the control group, while the first –year medical students of winter semester 2019 formed the intervention group. Also they described the study to the students in both groups and asked them to participate in the study voluntarily. Finally, 102 students among the control group and 129 students among the intervention group completed the study.
A psychological-educational supportive package was prepared a according to the guidelines published by the Mental Health Office of the Ministry of Health and Education of Iran. By preparing this package, the present researchers aimed to provide a supportive environment for students entering the university, facilitate the transition from high school to medical school, and enhance peer-group interactions. Therefore, the intervention group was divided into 13 groups, each had 8-12 participants, and announced for volunteer facilitators among 2nd/3rd-year medical students. As participants with different personality types may have differences in how to perceive and respond to external stimuli, communicate, and make decisions in different situations (21), the present researchers decided to match the personality types of participants of each group and the facilitator with Myers-Briggs Type Indicator. The volunteer facilitators were trained by expert psychologists affiliated to the Mental Health Office of MUMS. The training courses focused on improving the communication skills of facilitators and how to manage a discussion group. In addition, they were trained to recognise complicated emotional or behavioural problems in order to advise vulnerable students for mental health consultation with an expert. Trained facilitators run 6 weekly collaborative sessions for each group of first-year medical students, followed by face-to-face or virtual (for example via telephone or e-mail) follow-up sessions until the end of the first semester. Table 1 shows the main subjects discussed in each group session. The psychological-educational supportive package more focused on reducing stress related facing the new environment of university (sessions 1 and 2), enhancing coping with problem-solving strategies (sessions 1, 4, 6), increasing emotional intelligence (sessions 3 and 5), and strengthening peer group interactions (session 3 and by selecting facilitators among volunteer medical students).
The Grade Point Average (GPA) of the participants were considered as indicators of academic performance. GPA is calculated by dividing the sum of final grades by the total amount of credits attempted, and commonly used as an indicator of academic performance in different studies (22). The present study used the GPA of the first (post-test) and second semesters (follow-up) in this study. It used the General Health Questionnaire-28 (GHQ-28) to quantify the level of mental health of participants as well. Participants filled the GHQ-28 at the beginning of the first semester (pre-test), at the end of the first semester (post-test), and at the end of the second semester (follow-up).
GHQ-28: The General Health Questionnaire is a self-report psychological assessment tool, originally has 60 questions (23). There are other versions, including the 28-item version (GHQ-28), which is proved to be a valid instrument for research purposes (24). The GHQ-28 has four subscales: somatic symptoms (items 1-7), anxiety and insomnia (items 8-14), social dysfunction (items 15-21), and severe depression (items 22-28). Each item is rated on Likert scale of 0 to 3 (0: “not at all”, 1: “no more than usual”, 2: “rather more than usual”, 3: “much more than usual”) (25). GHQ-28 focuses on the new alterations in the current mental state compared to the usual state of respondents within the last few weeks. Researchers advised not to interpret the four subscales as independent measures. Rather, the use of the total score of GHQ-28 to report the possible psychological disorder of the respondents is recommended (26).
GHQ-28 is a valid questionnaire in different cultures and samples (27). It was used to evaluate the psychological well-being of medical students (28). The Persian translation of GHQ-28 has been frequently used in different studies in Iran, too (29).
Statistical analysis: In the present study the Kolmogorov-Smirnov test was used to assess the normality of data distribution. The normally distributed data compared with Independent-Samples T-test and Paired-Samples T-test. Non-normally distributed data compared with Mann-Whitney test. Categorical variables compared with Chi-Square test. The SPSS-16 was utilized for statistical analysis. Level of significance was defined as P<0.05.
A total number of 231 first-year medical students voluntarily participated in the present study, 129 students in the intervention group and 102 in the control group. Table 2 shows the baseline characteristics of them.
Tables 3 and 4 show the outcome measures (GHQ-28 and GPA) of the participants in the intervention and control groups. The mean baseline GHQ-28 scores (pre-test) were different between intervention and control groups (Table 2). Therefore, we compared the mean difference in GHQ-28 scores (pre-test and post-test, post-test and follow-up) between the intervention and control groups (Table 3). The results showed that the difference in consecutive GHQ-28 scores had a significant difference between the intervention and control groups. The mean GHQ-28 changes were significantly higher in the intervention group compared to the control group (pre-test/post-test: P= 0.013, post-test/follow-up: P<0.0001). Comparing the GPA of the first and second semesters showed that in the intervention group, GPA was significantly higher than the control group (P=0.016, P<0.0001, respectively; Table 4). In addition, in the second semester, the GPA of the intervention group increased significantly compared to the first semester, while it decreased significantly in the control group (P<0.0001, P=0.003; Table 4).
In the present study, we assessed the effects of a psychological-educational supportive package on the psychological well-being and academic performance of 129 freshman medical students in Mashhad, Iran. A group of first-year medical students received the supportive package during the first semester. The present researchers found out that in this group of first-year medical students the GHQ-28 scores decreased at the end of the first and second semesters compared to the baseline assessment at the beginning of the first semester. In addition, the GPA of this group of students was higher at the end of the first and second semesters compared to the other first-year medical students.
Many studies have described the association between the psychological well-being and academic performance in medical students. Poor psychological health negatively affects the learning ability of the students, while students with lower anxiety and depression usually have more academic achievements (30). The present study showed similar results on the association between psychological well-being and academic performance, too. Poor psychological health may impair the cognitive ability of the individual. The association between the depression, sleep problems, burnout, excessive anxiety and stress with impaired cognitive ability discussed earlier in different studies (5,22,31).
In 2013, Chew et al. reported that medical students with higher levels of emotional intelligence have better academic achievements (32). This finding was later reported in the broader population of undergraduate students (33). Emotional intelligence is defined as the ability to recognize and manage the emotions of self (self-awareness) and others (empathy) (33). Both skills of empathy and self-awareness were included in our supportive package (sessions 3 and 5, respectively). In addition, emotional intelligence is positively correlated with psychological well-being in different studies (34,35). The positive effects of higher emotional intelligence on academic performance and psychological well-being may partly explain the results of the present study.
The effects of peer group on psychological well-being of university students have been reviewed in different studies (36,37). It seems that students' perception of peer group support does not interfere with the sense of independence during the socialization process (38). Peer group interactions could increase knowledge on the psychological health and coping mechanisms among university students, resulting in higher mental well-being (39). Also, participating in a group of students expands the sense of trust among them; so, increases their psychological well-being (40). Most researchers showed a positive effect of peer group support on academic performance, too (37,41,42). Peer group support, for example support from classmates or senior students, could enhance the academic motivation, engagement, and initiatives (43); therefore it helps university students better adjust to the new academic demands and deal more effectively with their academic challenges (40). Although some studies have focused on how peer support could affect academic performance on adolescents, the results could be generated to the university students, too (44).
Psychological-educational intervention was effective in promoting mental health and academic performance of freshman medical students. Promoting both psychological well-being and academic performance of first-year medical students is an important responsibility of medical schools (45). Generally, medical students experience higher levels of psychological distress than non-medical students (5). Besides, freshmen struggle with higher levels of stress compared to senior students, and may need more support, particularly from their peers (46).
To the best knowledge of the present researchers, this was the first study on the effectiveness of intervention on the peer group interactions targeting both educational and psychological needs of freshman medical students in Iran. However, this study had some limitations. Students in autumn and winter semesters had different baseline characteristics, particularly different mean baseline GHQ-28 scores. Some of the students did not participate in the study, specifically among the autumn semester group (control group). We did not include some baseline demographic characteristics of participants in the study, for example the academic level before admission at the university, the history of any mental health problems, new mental health problems during the study period, and the socio-economic status. Therefore, we recommend further research on the efficacy of supportive interventions on the mental well-being and academic achievements of medical students.
Ethical issues including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc. have been completely observed by the authors. The ethics committee of Mashhad University of Medical Sciences approved this research, ethics code IR.MUMS.REC.1395.471.