Psychological distress and preserved academic functioning among medical trainees in Kenya: a convergent mixed-methods cross-sectional study

¹Department of Community Health, School of Public Health, Amref International University, Nairobi, Kenya, ²Department of Educational Studies, Faculty of Education, University of Nairobi, Nairobi, Kenya, ³Department of Pharmacy, Faculty of Health Sciences, Kenya Medical Training College, Nairobi, Kenya

^&Corresponding author
Collins Moses Owuor, Department of Community Health, School of Public Health, Amref International University, Nairobi, Kenya

Introduction    

Background and rationale: psychological distress among health professional trainees has become a major public health, educational, and workforce-development concern. Medical training requires sustained concentration, emotional regulation, professional identity formation, clinical responsibility, and adaptation to repeated academic evaluation. These demands expose trainees to depression, anxiety, sleep disturbance, emotional exhaustion, burnout, substance-related concerns, and suicidal ideation. The consequences extend beyond individual wellbeing because psychological distress may affect learning, progression, professional readiness, and the resilience of future health workers [1-5].

Academic performance is frequently treated as a visible marker of student functioning. This assumption is understandable because psychological distress may impair concentration, working memory, motivation, executive functioning, emotional regulation, decision-making, and academic engagement [6-8]. In many training institutions, unsatisfactory grades, absenteeism, repeat examinations, delayed progression, or discontinuation may therefore become practical triggers for identifying students in difficulty. However, this approach assumes that psychological vulnerability becomes visible through academic decline.

Emerging evidence challenges this assumption [9,10]. The relationship between mental health and academic performance is not always linear [8-10]. Some students with depression, anxiety, sleep disturbance, or other forms of psychological distress continue to maintain satisfactory academic performance, at least in the short term. This may occur through compensatory functioning, where students intensify study effort, suppress emotional distress, rely on peer support, use spirituality, or maintain performance through strong self-regulation and fear of failure [10-12]. Under such circumstances, academic success may conceal rather than exclude psychological vulnerability.

The biopsychosocial model provides a useful framework for understanding this complexity because it conceptualizes mental health as the product of interacting biological, psychological, and social determinants rather than isolated symptoms [13]. Within medical training, these determinants may include sleep disruption, fatigue, illness, financial strain, stigma, family expectations, academic pressure, clinical exposure, social support, and coping capacity. Social cognitive theory complements this explanation by showing how self-efficacy, motivation, outcome expectations, self-regulation, and adaptive coping influence how learners respond to stressors [14]. Together, these frameworks suggest that psychological distress and academic functioning may not deteriorate in parallel.

This issue is particularly important in low- and middle-income countries, where institutional mental health services are often under-resourced, stigma limits help-seeking, and student support systems may be reactive rather than preventive. In Kenya, mental health has gained increasing policy attention, yet routine screening and structured psychosocial support remain inconsistently embedded within tertiary and medical training institutions [15-19]. The evidence gap is more pronounced in middle-level health professional training institutions, where students face simultaneous classroom learning, laboratory practicals, clinical placements, continuous assessments, and financial pressures.

Kenya Medical Training College is central to Kenya's health workforce pipeline. Its students are trained for frontline health service delivery and are exposed to demanding academic and clinical environments. Yet, evidence on whether psychological distress among these trainees is reliably reflected in measurable academic decline remains limited. Most Kenyan studies focus on general university populations or isolated conditions such as depression, anxiety, and stress, rather than multidimensional psychological distress assessed alongside objective academic records [18,19].

Problem statement: psychological distress among medical trainees may remain institutionally invisible when academic decline is treated as its primary signal. This assumption is problematic in medical training environments, where psychological distress may coexist with preserved academic functioning through adaptive or compensatory mechanisms. In Kenya, evidence on this relationship remains limited, particularly within middle-level medical training institutions. This study therefore examined the association between psychological distress and academic functioning among medical trainees at Kenya Medical Training College, Kisumu Campus, with emphasis on concealed psychological vulnerability.

Objectives: this study examined the association between psychological distress and academic functioning among medical trainees at Kenya Medical Training College, Kisumu Campus, by determining the prevalence and pattern of psychological distress, assessing its relationship with academic functioning, and exploring mechanisms underlying preserved academic functioning despite psychological distress.

Methods     

Study design: a convergent mixed-methods cross-sectional design was used to examine the association between psychological distress and academic functioning among medical trainees at Kenya Medical Training College, Kisumu Campus. Quantitative and qualitative data were collected concurrently, analyzed independently, and integrated through triangulation to contextualize observed associations.

Study setting: the study was conducted at Kenya Medical Training College, Kisumu Campus, a public health training institution in western Kenya. The institution provides an academically and clinically demanding training environment relevant to the study objectives. Data were collected during the approved study period.

Participants and sampling procedures: registered medical trainees at Kenya Medical Training College, Kisumu Campus were eligible if aged ≥18 years, had completed at least one examinable semester, and provided written informed consent; those on academic leave, suspension, discontinuation, or without complete academic records were excluded. Proportionate stratified random sampling ensured representation across academic programmes and study levels. Of 271 eligible trainees approached, 266 were included in the final analysis (response rate 98.2%) after exclusion of two incomplete questionnaires. For the qualitative component, purposive sampling recruited information-rich participants across programme and performance categories through one focus group discussion (n = 10) and five key informant interviews, with recruitment continuing until thematic saturation.

Study variables: the primary outcome variable was academic functioning, measured using official end-semester academic records. The primary exposure variable was psychological distress, assessed using the Global Mental Health Assessment Tool-Primary Care version (GMHAT/PC) across multiple mental health domains [20]. Potential confounders included sociodemographic, biophysical, and psychosocial factors.

Data sources and measurement: quantitative data were collected using a structured questionnaire capturing sociodemographic, biophysical, psychospiritual, and mental health characteristics. Psychological distress was assessed using the validated GMHAT/PC [20], a standardized multidimensional instrument administered under uniform supervision to ensure measurement consistency. Academic performance data were extracted from official institutional consolidated mark sheets to provide objective outcome measurement. Qualitative data were collected through semi-structured focus group discussions and key informant interviews, audio-recorded, and transcribed verbatim for thematic analysis.

Bias and quality control: selection and information bias were minimized through stratified sampling, validated assessment tools, and objective academic records. Social desirability bias in sensitive domains was mitigated through confidential data collection, although residual confounding could not be fully excluded. Study rigor was strengthened through tool piloting, routine data quality checks, investigator triangulation, independent coding, and audit trail maintenance.

Study size: sample size was estimated using Cochran's formula at 95% confidence, 5% precision, and a conservative prevalence estimate of 50%, with finite population correction and adjustment for anticipated non-response, yielding a minimum required sample of 266 participants. The final analytic sample met this requirement and was adequate for prevalence estimation and multivariable regression.

Quantitative variables: academic functioning was analyzed as a binary outcome using KMTC institutional grading criteria, with aggregate scores ≥50% classified as satisfactory academic performance and scores <50% as unsatisfactory academic performance. Psychological distress severity was measured using GMHAT/PC and categorized as none, mild, moderate, or severe according to standard scoring criteria. Continuous and categorical covariates were analyzed in their original or grouped forms as appropriate for descriptive and regression analyses.

Statistical analysis: quantitative data were coded, cleaned, and analyzed using IBM SPSS Statistics version 26. Descriptive statistics summarized continuous variables using means (SD) or medians (IQR), and categorical variables using frequencies and percentages. Bivariate associations with academic functioning were assessed using Chi-square or Fisher's exact tests, as appropriate. Variables with p < 0.20 at bivariate analysis, together with theoretically relevant covariates, were entered into multivariable logistic regression to estimate adjusted odds ratios (AORs) with 95% confidence intervals. Model fit and multicollinearity were assessed using the Hosmer-Lemeshow test and variance inflation factors, respectively. Statistical significance was set at p < 0.05. Missing data were handled using complete-case analysis; no subgroup, interaction, or sensitivity analyses were performed.

Qualitative data analysis: qualitative data from focus group discussions and key informant interviews were transcribed verbatim and analyzed using thematic analysis [21]. Transcripts underwent iterative familiarization, inductive coding, and constant comparative analysis to develop higher-order themes related to psychological distress, coping, and academic functioning. Analytical rigor was enhanced through investigator triangulation, independent coding, consensus-based theme refinement, and audit trail maintenance.

Ethical considerations: ethical approval was obtained from the Amref International University Ethics and Scientific Review Committee (ESRC) (Approval No. ESRC P1834/2025) prior to data collection. Research authorization was granted by the National Commission for Science, Technology and Innovation (NACOSTI) (License No. 967901), while institutional permission was obtained from Kenya Medical Training College and Kisumu Campus leadership. Written informed consent was obtained from all participants. Participation was voluntary, with the right to withdraw at any stage without adverse consequences. Confidentiality was ensured through anonymized identifiers, restricted access to study data, and secure data storage. Participants identified with severe psychological distress or suicidal risk were referred for counselling and mental health care.

Results     

Participant characteristics: of 271 eligible medical trainees, 266 were included in the final analysis (response rate 98.2%). Participants were predominantly young adults aged 21-25 years, male, single, and enrolled in diploma-level programmes. Based on institutional grading criteria, 207 participants (77.8%) had satisfactory academic performance and 59 (22.2%) had unsatisfactory academic performance. Detailed participant characteristics are presented in Table 1.

Prevalence and pattern of psychological distress: psychological distress was highly prevalent, with 226 of 266 participants (85.0%) reporting symptoms in at least one GMHAT/PC domain. Symptom burden was multidimensional, spanning affective, cognitive, behavioural, and functional domains, with concentration difficulties, anxiety-related symptoms, and depressive symptoms predominating. Although most symptoms were mild to moderate, severe symptoms-including depression, sleep disturbance, alcohol-related symptoms, and suicidal ideation-were also observed. These findings reflect overall symptom burden rather than formal psychiatric diagnoses. Detailed distributions are presented in Table 2.

Factors associated with academic functioning: bivariate analysis identified significant associations between academic functioning and current depressive symptoms (p = 0.038), adolescent onset of psychological difficulties (p = 0.029), and perceived genetic predisposition to mental illness (p = 0.011). However, none remained significant after multivariable adjustment, including depressive symptoms (AOR = 0.770; 95% CI: 0.532-1.114; p = 0.166), adolescent onset of psychological difficulties (AOR = 0.985; 95% CI: 0.703-1.380; p = 0.929), motivation and satisfaction with learning (AOR = 1.035; 95% CI: 0.778-1.376; p = 0.814), and perceived genetic predisposition (AOR = 0.874; 95% CI: 0.659-1.158; p = 0.348). No subgroup, interaction, or sensitivity analyses were performed. Detailed regression findings are presented in Table 3.

Qualitative findings: qualitative findings contextualized the coexistence of psychological distress and preserved academic functioning through four interrelated themes: concealed psychological burden, persistent academic and psychosocial stressors, adaptive coping and functional preservation, and reactive institutional support (Table 4). Participants described substantial hidden psychological distress despite continued academic functioning, largely driven by cumulative academic, clinical, and financial pressures. Adaptive coping strategies-including structured routines, peer support, spirituality, self-discipline, and achievement motivation-appeared to buffer functional deterioration and sustain academic performance despite distress. However, institutional mental health support was perceived as limited and largely reactive, with intervention often occurring only after visible functional decline. Collectively, these findings suggest that adaptive coping may temporarily preserve academic functioning while masking underlying psychological vulnerability.

Discussion     

Key results: three principal findings emerged. Psychological distress was highly prevalent and multidimensional, spanning affective, cognitive, behavioural, and functional domains. Although selected distress-related variables showed crude associations with academic functioning, these associations were attenuated after multivariable adjustment, indicating the absence of an independent linear relationship. Qualitative findings further showed that adaptive coping mechanisms-including resilience, self-regulation, peer support, and spirituality-may preserve academic functioning despite substantial psychological burden. Collectively, these findings reveal a clinically important paradox: psychological distress may coexist with preserved academic functioning, consistent with concealed psychological vulnerability.

Interpretation: the high prevalence and multidimensional nature of psychological distress observed in this study are consistent with global evidence demonstrating substantial psychological morbidity among medical and health professional trainees [1-5]. Rather than reflecting isolated symptom clusters, the observed distress burden spanned affective, cognitive, behavioural, and functional domains, indicating that psychological distress in medical training is better understood as a systemic educational and public health concern rather than solely an individual clinical problem.

A central finding of this study was the coexistence of substantial psychological distress with preserved academic functioning, with nearly four-fifths of participants maintaining satisfactory academic performance despite significant psychological burden. This challenges the conventional assumption that psychological vulnerability becomes clinically or institutionally visible through academic decline. Although prior studies have linked psychological distress to poor academic outcomes [6-8,10], the present findings suggest that academic performance may function poorly as a standalone proxy for psychological well-bein.

The observed association between depressive symptoms and academic functioning suggests that psychological distress may not affect academic performance uniformly across severity levels. Moderate distress may coexist with preserved functioning, whereas severe distress appears more likely to impair performance. This pattern supports a non-linear relationship between psychological distress and academic functioning, potentially moderated by resilience, coping capacity, motivation, and environmental support [8,10-12].

Loss of statistical significance after multivariable adjustment suggests that academic functioning is shaped less by isolated psychological symptoms than by dynamic interactions among psychological, behavioural, social, and contextual determinants. This interpretation aligns with the study's theoretical framework, in which the biopsychosocial model explains distress generation through interacting vulnerabilities, while social cognitive theory explains functional preservation through self-efficacy, self-regulation, and adaptive coping [13,14].

Qualitative findings provided explanatory depth to the quantitative results. Participants described persistent academic and psychosocial stressors alongside adaptive coping mechanisms, including structured study routines, peer support, spirituality, resilience, and achievement motivation. Integrated analysis suggests that psychological distress may compromise emotional wellbeing before measurably affecting academic performance, with functioning remaining preserved until adaptive coping mechanisms are overwhelmed [10,14].

A central contribution of this study is the identification of concealed psychological vulnerability, wherein students remain academically functional despite substantial psychological burden. This has important institutional implications, as reliance on academic decline for case detection may leave psychologically vulnerable students unidentified. Delayed recognition may permit progression to burnout, maladaptive coping, discontinuation, impaired professional development, or future clinical errors [2,11,17]. Academic performance should therefore not be considered a reliable standalone indicator of psychological wellbeing.

These findings support a shift from reactive, performance-based support systems toward proactive mental health models independent of academic performance indicators. In resource-constrained settings, routine screening, early identification, confidential counselling, and structured support pathways are critical to overcoming delayed help-seeking driven by stigma and limited mental health service access [11,15-19].

Limitations: interpretation of these findings is limited by the cross-sectional design, which precludes causal inference, and the single-campus setting, which may constrain generalizability. Self-reported responses in sensitive domains may have introduced reporting bias, while dichotomization of academic performance may have reduced sensitivity to subtle academic variation and biased associations toward the null. Residual confounding and potential underrepresentation of students absent or discontinued during data collection may have further underestimated severe psychological distress. The relatively small number of participants with unsatisfactory academic performance may have reduced statistical power to detect modest independent associations in multivariable analysis. These limitations were partly mitigated by objective academic records, multidimensional mental health assessment, high response rate, and mixed-methods triangulation.

Generalizability and future research: these findings are most applicable to medical and health professional training institutions operating in similarly resource-constrained and academically demanding environments. Future multicenter longitudinal studies are needed to clarify temporal pathways between psychological distress and academic functioning and to examine mediating mechanisms such as resilience, coping strategies, self-efficacy, social support, and economic stress.

Conclusion     

Psychological distress was highly prevalent among medical trainees despite largely preserved academic functioning. Academic performance and psychological wellbeing do not necessarily deteriorate in parallel. Students may therefore remain academically successful while experiencing substantial psychological burden, creating concealed psychological vulnerability that may remain institutionally invisible. Strengthening mental health support for medical trainees is also relevant to primary healthcare systems, as psychologically healthy trainees are essential for safe, resilient, and effective frontline service delivery. Medical training institutions should adopt proactive, system-level mental health strategies that identify distress before academic deterioration becomes visible.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

All authors fulfilled the authorship criteria under ICMJE guidelines; Collins Moses Owuor contributed to study conceptualization, design, data collection, analysis, interpretation, and manuscript drafting; Augustine Mwangi Gatotoh and Ruth Mumo Omungo provided academic supervision, methodological oversight, interpretation, and critical manuscript review; Grace Achieng Otieno contributed to data collection, manuscript review, and intellectual input in interpretation. All the authors read and approved the final version of this manuscript.

Acknowledgments     

The authors acknowledge Kenya Medical Training College, Kisumu Campus, for institutional support, participating students for their valuable contribution, and faculty, key informants, and the School of Public Health at Amref International University for academic support and guidance. The authors remain responsible for the originality, accuracy, and integrity of this manuscript, including content refined using artificial intelligence tools.

Tables     

Table 1: sociodemographic characteristics and academic functioning of medical trainees at the Kenya Medical Training College, Kisumu Campus, Kenya (n=266)

Table 2: prevalence and severity of major psychological distress symptom domains assessed using global mental health assessment tool - primary care version (GMHAT/PC) among medical trainees at the Kenya Medical Training College, Kisumu Campus, Kenya (N=266)

Table 3: bivariate and multivariable association between psychological distress variables and academic functioning among medical trainees at the Kenya Medical Training College, Kisumu Campus, Kenya (N=266)

Table 4: qualitative themes, sub-themes, interpretive meanings, and integration with quantitative findings on psychological distress and academic functioning among medical trainees at the Kenya Medical Training College, Kisumu Campus, Kenya

References