Introduction

As defined by the WHO, well-being is ‘a positive state experienced by individuals and societies’.1 Welfare can be considered a component of well-being, however, it also indicates a type of external support intended to ensure members of a group are meeting their basic needs. Welfare includes the broader society, policy and interventions in place to ensure appropriate support for individuals.2 Where welfare needs are unmet, greater well-being cannot be achieved. It provides a foundation for the support of personal and societal well-being, yet welfare provision alone is not sufficient to guarantee well-being can be achieved: further opportunities to develop life satisfaction are needed for its fulfilment.2 Such definitions remain, however, limited compared with their broader uses in practice and in the literature.1 3 For instance, the concept of well-being has been reported as not only indicating a state of feelings of happiness and content but also including the idea of resilience, that is, the ability of recovering from setbacks.4 Adding onto this, well-being has also often been described in terms of burn-out in the literature.5 The problem with this lies in the fact that burn-out is a pathological state, whereas well-being is a concept that holds a positive connotation6; measuring well-being in terms of lack of ability to thrive has been described as a limitation.3 Positive functioning is at the core of well-being and should be at the core of its definition; comprehensive research and measurements of such should go beyond transient moods in order to measure human developments in a holistic manner, taking into account the plethora of features which characterise the state of well-being: social, psychological, cognitive and spiritual domains.

From the aforementioned evidence, it follows that a universal definition of what well-being is is currently lacking, something that complicates research around the topic.5 7 In the context of medical education, the concepts of well-being and welfare have gained increasing levels of attention in recent years, particularly following the COVID-19 pandemic.3 As interest in well-being research has been growing, so has the understanding that medical students report the highest levels of mental health morbidity when compared with other students enrolled in university-level education.8 Statistics on medical students’ well-being and welfare are concerning not only because of a higher risk of mental ill health and its complications, but because they represent the future workforce of doctors, a category that is itself at increased risks of psychiatric morbidity.9 A number of medical students from different countries were interviewed and the results illustrated a concerning prevalence of burn-out, with an average of 78% of respondents reporting exhaustion and 81% reporting disengagement; substance misuse and mental ill health were also highlighted.10 11 Furthermore, around 25% of medics meet the criteria for clinical depression12 along with 87% experiencing constant exhaustion.13 Such statistics become particularly concerning when considering that increased burn-out negatively impacts empathy and professionalism.14 The importance of the topic lies, indeed, in the latter point, meaning that poor well-being not only affects students and doctors but also negatively impacts patients; it was shown that the consequence of a workforce of healthcare professionals that suffer from poor well-being leads to poor patient outcomes as a consequence.15

Despite an increased level of interest towards the issue, rates of psychiatric comorbidities have been on the rise, with an increase of up to 30% in prevalence following the COVID-19 pandemic.16 As students progress upwards to senior doctors, such statistics are only estimated to keep worsening due to the demands of the job. Indeed, increasing levels of physician suicide and psychiatric comorbidities have been reported in recent years,17 and rates of difficulties in these groups are well reported in the literature.18

There are known stressors that apply to student doctors, both academic and not. Academics is heavily associated with increased levels of burn-out across students.19 20 Furthermore, the higher expectations from medical schools lead to a lack of work–life balance, reduced leisure time and poor interpersonal relationships.20 A perceived lack of support tends to further exacerbate the situation; a lack of faculty support has been known to cause increased levels of uncertainty and stress. Indeed, it has been reported medical students often feel mistreated or let down by faculty, which correlates with increased levels of burn-out.21 This includes teaching during clinical years, which is often unstructured and student-driven with difficult interactions with hospital staff which may potentially perpetuate a lack of well-being.9 Programmes to enhance well-being by medical schools also drastically range in effectiveness and are often not well perceived by students.12 Lastly, fear of stigmatisation and loss of future work perspectives often stop medical students and doctors from asking for support altogether.22 This was shown to be only exacerbated during the COVID-19 pandemic when additional fear of adding strains on the healthcare system also came into play.23

Therefore, further attention to medical students’ well-being is paramount to ameliorate future doctors’ mental health, prevent psychiatric complications and discontent within the profession. Students’ attitudes towards well-being and well-being promoting interventions remain largely under-reported in the literature, and therefore, warrant further interest towards the issue. As this is the first systematic review exploring the reported medical students’ attitudes towards well-being and welfare, this will provide a baseline to understand the matter. This will lead to better and targeted approaches for future welfare-enhancing interventions, addressing what the most common opinions that students hold are, making it easier knowing where action is needed to improve their well-being. Additionally, this systematic review will identify key points and gaps in the current literature, prompting where further research may be needed in the future.

Methods

A systematic literature search will be carried out according to the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) recommendations.24 Here, the seven steps described by Eggar, Davey and Altman have been followed to develop a thorough systematic review protocol to follow.25

Development of a review question.

Definition of inclusion and exclusion criteria.

Development of a search strategy.

Study selection.

Quality of studies assessment.

Data extraction.

Data synthesis.

The protocol was registered with PROSPERO and the registration number is CRD42023471022. Significant differences or changes to the protocol will be highlighted in the final manuscript.

Review questions

The primary aim will be to describe medical students’ attitudes towards well-being, and what trends can be identified.

The secondary aim will be to describe medical students’ reported attitudes towards welfare-promoting programmes. Additionally, how such parameters compare across countries, and how these have changed during the COVID-19 time frame, will be reported.

Search strategy

The literature search will be based on Scopus, MEDLINE and Embase databases. The search strategy was developed between 25 January 2023 and 15 March 2023 and will be re-run during the screening process to ensure all the most recent studies available will be included. All relevant synonyms of the terms: “medical students” AND “wellbeing” AND “perceptions” were searched on said databases (the full search strategy is available in online supplemental file 1). The search strategies have been discussed and finalised with the help of a medical librarian. Additionally, we will search the bibliography of relevant identified systematic reviews and meta-analyses for additional papers. To identify grey literature, we will search OpenGrey (www.opengrey.eu), and contact authors for unpublished and ongoing studies that could be included.

Assessment and screening

All peer-reviewed papers available in the English language will be assessed based on inclusion and exclusion criteria. This was decided due to language constraints within the team, hindering the usage of studies in other languages at this stage.

The Sample, Phenomenon of Interest, Design, Evaluation and Research type framework was used to aid in the assessment of the included studies (table 1).26

Table 1

SPIDER framework applied to this systematic review

The number of results after the initial search will be reported. Duplicates will be removed through EndNote.27 Papers that remain after deduplication will be added to the Rayyan tool28 for screening according to appropriate inclusion and exclusion criteria. Two reviewers will be assigned screening of all studies independently, with a third reviewer being assigned to resolve conflicts. Full-text screening and data synthesis will follow a similar framework, with two reviewers assigned for full-text screening, and a third reviewer for conflict resolution.

Inclusion and exclusion criteria

The identified papers will be assessed against predetermined inclusion and exclusion criteria. All included texts will need to be original research that included medical students, and focused on their perceptions towards well-being and/or welfare. We will include papers based on any country. Texts must be available in English.

Papers based on animal studies, those that are not relevant to the review, or those based only on healthcare professionals or other healthcare students will be excluded. Reviews and papers not available in English will also be excluded (table 2).

Table 2

Inclusion and exclusion criteria with explanations of reasoning

Quality assessment and risk of bias

The Mixed Method Appraisal Tool (MMAT) will be used for quality and risk of bias assessment of the included studies. MMAT is a critical appraisal tool that is designed for the appraisal stage of systematic mixed studies reviews, that is, reviews that include qualitative, quantitative and mixed-methods studies. It allows to appraise the quality of five categories of studies, that is, qualitative, quantitative, randomised trials, non-randomised trials and mixed-method studies. This tool is validated and considered appropriate for the appraisals of the mentioned study designs.29

Data extraction

Data will be extracted and collected independently through Microsoft Excel (Microsoft Corporation, Redwood, VA) after full-text screening and checked by two other reviewers to ensure adequate completion. All data will be summarised narratively in tabular forms (online supplemental tables 1S–5S) and will be further described in the results section.

Online supplemental table 1S will include the paper’s characteristics, these being year of publication, country of publication (ie, country the study population is from), level of included evidence, journal of publication and summary of findings. The country of publication will be further summarised according to developing or developed groups using the World Economic Situation and Prospects classification system in order to gather a map of countries which have published data on this matter.

Additional students’ characteristics will be included in online supplemental tables 2S. Here, data on their mean age, known comorbidities and additional reported demographic information (ie, sex, ethnicity, religious beliefs, marital status, financial background and deprivation) will be added if available.

Online supplemental table 3S will include the summarised data on the reported attitudes towards aspects of well-being. This will be created on the basis of previous research that analysed and described the dimensions of well-being. The six key domains which will be included, therefore, are mental, social, physical, spiritual well-being, activities and functioning, personal circumstances.7 Further explanations of the domains are included in table 3.

Table 3

Adapted from Linton et al, description of the six domains of well-being7

Online supplemental table 4S will include data regarding attitudes towards welfare-promoting interventions. This will include study authors, location and medical school (where available). Reported intervention and respective students’ opinions will be added here. All available data will then be synthesised.

Online supplemental table 5S will include data specific to the COVID-19 period (ie, the time between May 2020 and March 2023, where studies were published or carried out in this time frame; additionally those aimed at targeting the ‘COVID-19’ time frame as part of their methodology will be included), by summarising details as described in the above points.

Data synthesis

A descriptive synthesis approach will be used to identify and describe the medical students’ attitudes towards well-being and welfare. The synthesis of attitudes towards well-being parameters and welfare will be represented in a tabular form as described in the ‘Data extraction’ section. Examples of the empty summary tables can be found ine online supplemental file S2.

In addition to this, we will conduct a descriptive subgroup analysis on demographics and COVID-19-specific data. Demographics regarding which countries have looked into this will be of particular interest, in order to highlight any relationship between location and findings. Data regarding the COVID-19 period may also reveal differences in students’ attitudes specific to this time and different from previous years. Given that COVID-19 has been an exceptional period of time, studies describing this should be examined separately. Therefore, we will separate studies from this period and narratively synthesise our findings compared with other included periods.

Quantitative analysis will not be carried out, as a meta-analysis of the results is unlikely to be possible due to the varied nature of the studies that are predicted to be included. Available data will be summarised in text, and percentages will be implemented to depict the distribution of students’ gender, ideology, comorbidities and attitudes. The same will be done for the COVID-19 time frame and regional areas included.

Patient and public involvement

Patients or the public were not involved in the development of this protocol and will not need to be recruited for the completion of the project.

Discussion

This systematic review is the first to look at studies conducted on medical students’ attitudes towards well-being and welfare. The evidence gathered will be relevant to direct attention towards what students’ perceptions are, in order to develop adequate and ad-hoc interventions based on students’ specific perspectives rather than generalised approaches to well-being promotion.

The primary outcome of this systematic review is to describe the reported medical students’ attitudes towards well-being. Further attitudes towards welfare-promoting interventions will also be reported, and particular attention will be directed towards the COVID-19 pandemic time frame, by commenting on this dataset separately. This approach will be fundamental to elucidate the attitudes of medical students towards well-being promoting interventions, understanding whether these are targeting students’ true needs, and leading to further research and policies to address their concerns. A country-wise approach will aid in understanding which countries have put more attention towards addressing this issue; additionally, this will provide an outlook on whether or not differences exist between countries and cultures, which may be used in the creation of better-suited tools depending on the location of the institutions. As culture has a key role in guiding how well-being is perceived, but also how this is accepted within societies, such an approach would provide a novel way of looking at welfare-promoting interventions for medical students globally.

This systematic review will also be used to guide further studies in the area of medical students’ well-being and welfare, providing a targeted approach to an issue that is only starting to receive further attention.

Strengths and limitations

Strengths of this review include following the well-established PRISMA-P recommendations, as well as a systematic review process that will ensure adequate coverage of all the available data at this time, which included consultation with a medical librarian to discuss the appropriateness of the search strategy. This review, additionally, will establish if attitudes have changed through the COVID-19 pandemic, and by how much. By looking at all countries, we will be able to conduct subgroup analysis by region, if the data allow and provide greater insights on local and global levels.

Potential limitations could include a variety of study designs, which will be addressed by the implementation of the MMAT, and that should indicate whether any bias was present in the available data. As mentioned in the introduction, a definition of well-being is not fully established, which is something that could also include a high degree of variability in our analysis. However, we believe it is relevant to conduct such a review, and this could be a further step in gaining a precise definition of what well-being is and guide future research endeavours. Further limitations include the potential bias in establishing inclusion and exclusion criteria, which can restrict the applicability of the findings to specific populations or interventions. Finally, the only language included is English, which is something that may limit the variety of countries included in this study.