Factors associated with psychological distress and academic performance among medical students in Palestine: a convergent mixed-methods study

Abstract Background Medical education is associated with substantial psychological stress, and students in Palestine may experience additional strain related to political instability, mobility restrictions, and financial uncertainty. This study assessed psychological distress and self-reported academic performance among Palestinian undergraduate medical students and explored the academic, lifestyle, psychosocial, economic, and political factors associated with these outcomes. Methods A convergent mixed-methods study was conducted from October 2024 to October 2025 across five Palestinian universities. The quantitative component included a cross-sectional survey of 391 undergraduate medical students. Psychological distress was measured using the 12-item General Health Questionnaire (GHQ-12; Likert scoring range 0–36) and categorized into normal/minimal, mild, moderate, and severe distress. Associations were examined using bivariate analyses and multivariable ordinal logistic regression. The qualitative component included semi-structured interviews with 20 students; data were analyzed thematically to contextualize the quantitative findings. Results The mean GHQ-12 score was 15.63 +/- 7.08. Overall, 258 students (66.0%) had some degree of psychological distress, including 86 (22.0%) with mild distress, 78 (19.9%) with moderate distress, and 94 (24.0%) with severe distress. In bivariate analyses, distress level was associated with gender, main household breadwinner, physical inactivity, unhealthy diet, irregular study patterns, lack of moral support, low motivation, absenteeism, class participation, perceived impact of recent political events, financial strain, political anxiety, and impaired concentration. In multivariable ordinal logistic regression, higher distress was independently associated with unhealthy or partially healthy diet, lack of moral support, lower motivation, lower self-rated academic level, living alone, and frequent political anxiety. Self-reported academic performance was associated with living arrangement, study hours, study pattern, class participation, and the perceived academic impact of recent political events. Qualitative themes highlighted family and social support, disrupted routines, academic workload, limited psychological support, career uncertainty, political instability, financial strain, and social media-related comparison as important influences on well-being and academic functioning. Conclusions Psychological distress was highly prevalent among Palestinian medical students and reflected an interaction between academic demands, psychosocial support, lifestyle behaviors, and contextual political and economic stressors. Medical schools should develop multi-level, context-sensitive support systems that integrate accessible mental health services, academic mentoring, flexible educational policies, and strategies to strengthen student engagement and resilience.