Impact of Family Illness on Psychological Status and Academic Performance Among Medical Students, at 21 September University for Medical and Applied Sciences, Sana'a, Yemen – 2024

Technical Summary: Impact of Family Illness on Psychological Status and Academic Performance Among Medical Students

Problem Statement
Medical students globally face significant psychological distress due to the rigorous demands of their training, including high-stakes examinations and exposure to patient suffering. While the prevalence of burnout, anxiety, and depression in this population is well-documented, there is a scarcity of focused research regarding how specific personal stressors—particularly the concurrent illness of a family member—intersect with academic pressures. This gap is especially pronounced in Low- and Middle-Income Countries (LMICs) and Arabic-speaking contexts, where cultural norms regarding familial caregiving obligations may differ significantly from Western settings. In Yemen, where protracted conflict and limited healthcare access exacerbate family health crises, medical students often assume dual roles as trainees and primary caregivers, creating a unique burden that may exceed individual coping capacities. This study investigates the prevalence, psychological impact, and academic consequences of family illness among medical students at 21 September University for Medical and Applied Sciences (21UMAS) in Sana'a, Yemen.

Methodology
The study employed a descriptive analytical cross-sectional design conducted between November 2023 and April 2024.

• Population and Sampling: The target population included all full-time medical students (Years 1 through Internship) at 21UMAS. A simple random sampling method was used to recruit 374 participants, calculated based on a 95% confidence level, 5% margin of error, and an estimated 50% prevalence of distress.
• Instruments: Data were collected via a structured, self-administered questionnaire comprising:
  • Sociodemographics and Family Illness Characteristics: Including relationship to the ill member, diagnosis, duration, and severity.
  • Perceived Stress Scale (PSS-14): A validated Arabic version (Cronbach's α = 0.876) measuring stress over the past month (score range 0–56).
  • General Health Questionnaire (GHQ-12): A validated Arabic version (Cronbach's α = 0.734) assessing psychological distress (score range 0–36).
  • Modified Brief-COPE: A 10-item adaptation of the Brief Coping Orientation to Problems Experienced scale (Cronbach's α = 0.921) to assess coping strategies.
  • Academic Performance: Self-reported Grade Point Average (GPA) and perceived changes in performance.
• Statistical Analysis: Data were analyzed using IBM SPSS Statistics (v25). Descriptive statistics were computed for all variables. Between-group comparisons utilized independent-samples t-tests, one-way ANOVA, Mann-Whitney U, and Kruskal-Wallis tests depending on data distribution. Spearman's rank correlation coefficient (ρ) was used to assess associations between stress, distress, coping, and academic ratings. Significance was set at p < 0.05.
• Ethical Considerations: The study received approval from the 21UMAS Institutional Review Committee (IRC-FM-21UMAS-2023). Written informed consent was obtained from all participants, adhering to the Declaration of Helsinki.

Key Results

• Prevalence of Family Illness: A striking 86.96% (n=325) of the participating students reported a concurrent family member illness, a rate substantially higher than typical Western estimates (19–25%).
• Psychological Distress:
  • The mean PSS score for students with family illness was 38.74, placing them in the "high stress" category.
  • Students with family illness had significantly higher GHQ-12 scores (mean 11.37) compared to those without (mean 9.67; p = 0.013).
  • Gender Differences: Female students consistently reported higher levels of stress (mean PSS 39.29 vs. 38.08) and psychological distress (mean GHQ-12 11.76 vs. 10.42) than males.
  • Severity and Relationship: Illness severity was the strongest predictor of stress, showing a clear dose-response gradient (PSS rising from 35.29 for mild to 43.28 for extremely severe illness). Students with an ill parent reported the highest stress levels (mean PSS 40.02).
• Academic Performance:
  • There was a strong negative correlation between perceived stress and academic self-rating (ρ = −0.38, p < 0.001).
  • Students who perceived their academic performance as "significantly worse" had the highest PSS (44.75) and GHQ-12 (13.59) scores.
  • A significant association was found between psychological distress and academic underperformance (p < 0.00001).
• Coping Strategies:
  • Religious/spiritual coping was the most frequently employed strategy (mean 3.74/4.00), followed by information seeking (3.49).
  • Substance use was the least utilized strategy (mean 1.82).
  • While overall coping scores (CMS) did not differ significantly by gender or illness severity, a trend suggested that students facing the highest burdens (extremely severe illness and significantly worsened grades) utilized coping mechanisms less effectively.
• Correlations: Significant positive correlations were found between PSS and GHQ-12 (ρ = 0.42). Both stress and distress were negatively correlated with academic self-rating and coping effectiveness.

Significance and Claims
The authors claim this study provides the first systematic empirical evidence from Yemen regarding the intersection of family illness, psychological distress, and academic performance in medical education. The paper asserts that:

1. Family illness is a potent, independent stressor: It significantly elevates psychological distress beyond baseline academic stress, with illness severity acting as a primary driver.
2. Contextual Relevance: The exceptionally high prevalence of family illness (87%) reflects the compounding effects of Yemen's humanitarian crisis and cultural caregiving norms, highlighting the need for locally grounded evidence rather than reliance on Western data.
3. Gender Sensitivity: The consistent finding of higher distress among female students suggests that institutional support systems must incorporate gender-sensitive components.
4. Academic Impact: High perceived stress directly correlates with academic underperformance, suggesting that mental health interventions could serve as an indirect strategy to preserve academic outcomes.
5. Cultural Coping: The dominance of religious/spiritual coping underscores the importance of integrating culturally specific frameworks into support mechanisms, rather than viewing them as passive.

Limitations
The authors acknowledge several limitations: the cross-sectional design precludes causal inference; reliance on self-reported GPA introduces potential recall bias; the use of a modified 10-item Brief-COPE (though highly consistent) may lack the granularity of the full 28-item scale; the single-university setting limits generalizability; and the exclusion of students with prior mental health diagnoses means the most vulnerable subgroup is not represented. Additionally, the ongoing conflict in Yemen may have elevated baseline stress levels, affecting the generalizability of findings to non-conflict settings.

Recommendations
Based on these findings, the paper recommends that medical institutions:

• Establish dedicated, accessible mental health services with rapid-access pathways.
• Implement systematic mental health screening (e.g., GHQ-12) with triage protocols.
• Develop "Family Illness Disclosure Policies" to allow confidential notification of crises, triggering academic accommodations (extensions, reduced loads) without stigma.
• Integrate Problem-Based Learning (PBL) to reduce emotional exhaustion.
• Offer flexible learning schedules for students with caregiving responsibilities.
• Provide psychoeducational workshops tailored to cultural and religious coping frameworks.