A Systematic Review of Psychosocial Interventions for Enhancing Resilience in Medical Sciences Students

Abstract

Background and Aims

Undergraduate medical sciences students experience substantial psychological distress due to demanding academic workloads and early clinical exposure, increasing their vulnerability to anxiety, depression, and burnout. This systematic review evaluates randomized controlled trials (RCTs) examining psychosocial interventions—including mindfulness-based programs, cognitive-behavioral strategies, acceptance-based therapies, and structured stress-management training—designed to enhance resilience among undergraduate medical sciences students.

Methods

A comprehensive search of PubMed, Scopus, ISI Web of Science, ProQuest, Google Scholar, and Semantic Scholar identified studies published between January 2000 and April 2025.

Results

11 RCTs met inclusion criteria. Data extraction included participant characteristics, intervention type and duration, delivery format, and outcome measures. Methodological quality was assessed using the PEDro scale, and risk of bias was evaluated using the Cochrane RoB 2 tool.

Conclusion

Across the included trials, psychosocial interventions demonstrated consistent positive effects on resilience, perceived stress, coping flexibility, and psychological well-being. Mindfulness-based programs—ranging from brief sessions to full 8-week MBSR courses—generally reduced distress, though shorter or peer-led formats produced mixed results. Cognitive-behavioral and stress-management interventions improved coping skills, emotional regulation, and self-efficacy. Acceptance and Commitment Therapy enhanced psychological flexibility, and structured resilience curricula such as the Penn Resilience Program yielded significant gains in resilience scores. Variability in intervention design, duration, and measurement tools limited comparability across studies. Overall, psychosocial interventions appear effective in enhancing resilience among undergraduate medical sciences students. Integrating structured, theory-based approaches into medical education may strengthen students’ psychological health and academic functioning. Future research should prioritize standardized protocols, culturally sensitive adaptations, and long-term follow-up.

Introduction

Undergraduate medical sciences students are exposed to substantial psychological stress due to demanding academic workloads, high performance expectations, and early involvement in emotionally challenging clinical environments. Evidence consistently shows elevated rates of anxiety, depression, and burnout among healthcare students.^1–4 These pressures intensify during the transition from classroom learning to clinical practice, where students must simultaneously acquire foundational scientific knowledge and develop emerging professional competencies.⁵ This combination of academic rigor and early patient-care responsibilities creates a unique vulnerability compared with postgraduate trainees.

Resilience—commonly defined as the capacity to adapt positively to adversity and recover from stress—has been identified as a key protective factor for maintaining mental health and academic functioning in student populations. Contemporary perspectives emphasize that resilience is not a fixed trait but a dynamic process that can be strengthened through targeted training.^6,7 Psychosocial interventions such as cognitive-behavioral therapy (CBT),⁸ mindfulness-based stress reduction (MBSR),⁹ and acceptance and commitment therapy (ACT),¹⁰ which have shown promise in promoting psychological well-being in student populations.^11,12 These approaches strengthen students’ capacity to manage stress and support both mental health and occupational performance.^13–16

Despite growing interest, resilience-building programs for healthcare students remain inconsistent in design, theoretical grounding, and implementation. Many interventions lack standardization, vary widely in duration and content, and are not tailored to the specific stressors faced by undergraduate medical sciences students.^17,18 Cultural and contextual factors also influence intervention effectiveness,^19–23 yet these elements are often insufficiently addressed. A Cochrane review further highlights that resilience training is frequently conflated with other psychosocial approaches, and its effectiveness depends heavily on the targeted outcomes and training environment.²⁴

Given these gaps, a systematic synthesis of randomized controlled trials is needed to clarify which psychosocial strategies effectively enhance resilience in undergraduate medical sciences students. This review evaluates the effectiveness of psychosocial interventions—including mindfulness-based programs, cognitive-behavioral approaches, acceptance-based therapies, and structured stress-management training—and identifies key components associated with improved resilience and psychological well-being in this at-risk population.

Methods

Study Design and Protocol

This systematic review was conducted by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to ensure methodological rigor and transparency. The review aimed to identify and evaluate interventions designed to enhance psychological resilience among medical science students. The protocol for this review was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO).

Search Strategy

A comprehensive search was conducted across PubMed, Scopus, ISI Web of Science, ProQuest, Google Scholar, and Semantic Scholar for studies published from January 2000 to April 2025. This timeframe was selected to capture contemporary psychosocial and resilience-based interventions. Search terms combined Medical Subject Headings (MeSH) and free-text keywords related to resilience, psychosocial interventions, and medical sciences students. Boolean operators (AND, OR) were used to refine the search, and filters were applied to restrict results to peer-reviewed English-language articles.

Inclusion and Exclusion Criteria

The review included randomized controlled trials involving undergraduate medical sciences students. Studies were required to evaluate psychosocial interventions aimed at enhancing resilience, such as mindfulness-based programs, cognitive-behavioral approaches, acceptance-based therapies, or structured stress-management training. Eligible studies compared these interventions with control conditions such as no intervention, standard curriculum, or alternative non-psychosocial activities. Outcomes needed to include resilience, stress, coping, psychological well-being, or related mental-health indicators.

Studies were excluded if they involved postgraduate trainees, non-medical student populations, non-psychosocial interventions, qualitative designs, non-RCT methodologies, or insufficient outcome reporting.

Study Selection Process

Following the removal of duplicates using reference management software (EndNote X9), two reviewers independently screened titles and abstracts against the predefined inclusion and exclusion criteria. Full-text articles of potentially eligible studies were retrieved and independently evaluated by the same reviewers. Discrepancies between reviewers were resolved through discussion, with a third reviewer consulted when consensus could not be reached. The study selection process is summarized in a PRISMA flow diagram (Figure 1).

Figure 1.

PRISMA flowchart for including studies.

Data Extraction

A standardized extraction form was used to collect information on study characteristics (author, year, country), participant demographics, intervention type and duration, delivery format, outcome measures, and key findings (Table 1). Two reviewers independently extracted data, and disagreements were resolved through discussion or adjudication by the corresponding author.

Table 1.

Overview of Included Studies

Number	Study (Year)	Location	Participants	Intervention & Frequency	Outcome Measures	Results
1	Evaluation of a Resilience Intervention to Enhance Coping Strategies and Protective Factors and Decrease Symptomatology 200825	USA	57 (30 experimental, 27 wait-list control) college student	4 two-hour classroom sessions: (1) Transforming Stress Into Resilience, (2) Taking Responsibility, (3) Focusing on Empowering Interpretations, and (4) Creating Meaningful Connections	Dispositional Resilience Scale Connor–Davidson Resilience Scale Brief COPE PSS	Effective coping Stronger protective factors Lower symptomatology
2	Abridged Mindfulness Intervention to Support Wellness in First-Year Medical Students 201426	USA	30 control, 28 intervention group	MBSR intervention for 75 minutes, once per week, for 8 weeks, suggested meditation at home, and a half-day retreat in the last week	PSS RS	Improved engagement or performance Reduced perceived stress levels
3	Application of the Pennsylvania resilience training program on medical students 201427	China	30 control, 30 intervention	Penn Resilience Program (PRP), Ten training sessions, facilitated by group leaders, were conducted every week. Each training session lasted for 90–120 min.	Connor–Davidson Resilience Scale	Improved resilience, heightened positive emotions, and enhanced cognitive appraisal
4	A Peer-Support and Mindfulness Program to Improve the Mental Health of Medical Students 201628	Australia	121 control, 111 intervention	Peer leaders ran weekly peer-taught mindfulness sessions and encouraged the intervention participants to undertake individual mindfulness practice at home supported by the mindfulness CD	GAD-7 RS	Improved mental health
5	Coping with stress in medical students: results of a randomized controlled trial using a mindfulness-based stress prevention training (MediMind) in Germany 201629	Germany	MediMind (n =31), Autogenic Training (n = 32) and control group (n = 17)	Experimental treatment (MediMind), standard treatment (Autogenic Training) and a control group without treatment.	Brief COPE TICS BSI	Significant BSI subscale changes and decreased psychological symptoms
6	A mindfulness-based intervention to increase resilience to stress in university students (the Mindful Student Study): a pragmatic randomised controlled trial 201830	UK	MSS group (n=309) and usual group (n=307)	8 week mindfulness course [MSS] lasted 75–90 min	CORE–OM	Reduced distress scores
7	Acceptance and Commitment Therapy on Cognitive Flexibility on Gorgan University of Medical Sciences Students 201931	Iran	30 students each group n=15	Eight weeks sessions Acceptance and Commitment Therapy	Dennis and Vander Wal	Enhanced adaptability fostering a more versatile learning environment
8	An Intervention Enhances Resilience in Entry-Level Physical Therapy Students: A Preliminary Randomized Controlled Trial 202032	Indianapolis	A resilience curriculum (n = 22) or to a wait-list control group (n = 21),	8-hour resilience curriculum was delivered in 4 consecutive, 2-hour weekly sessions	Connor-Davidson Resilience Scale. PSS CFS	Increased resilience and boosted positive emotions
9	Mindfulness-based resilience training on the psychological well-being of medical students during the COVID-19 pandemic 202333	Iran	30 students in 2 group n=15	Ten sessions of an integrated training program of resilience and mindfulness were conducted for 90 minutes per session for one month for the experimental group	Integrated training program for resilience and mindfulness	Enhanced psychological well‑being as a foundation for fostering resilience and overall happiness
10	Feasibility and effects of mindfulness-based stress reduction (MBSR) for improving resilience, posttraumatic stress disorder symptoms and posttraumatic growth among military medical college students 20249	China	54 students in 2 groups	MBSR intervention once a week, lasting 2 h per session for 8 consecutive weeks.	Connor-Davidson Resilience Scale PTSD Checklist GAD-7	Improved resilience, greater post‑traumatic growth, higher life satisfaction, enhanced mindful attention, and reduced psychological symptoms reflecting enhanced well‑being
11	The effectiveness of stress management training given to first-class health major students in perceiving and coping with stress and developing resilience: A randomized controlled trial (2025)34	Turkey	51 intervention and 51 control	The stress management training seven modules, each lasting 120 min (with a break), on a day determined during the week for 7 weeks.	PSS SCMS BRS	Decreased perceived stress and improved coping and resilience, highlighting enhanced emotional strength and adaptability

Quality Assessment

Methodological quality was evaluated using the PEDro scale, which assesses internal validity, randomization, blinding, and statistical reporting. The scale includes 11 criteria scored as “Yes”, “No”, or “Not specified”, with total scores ranging from 0 to 11. Two reviewers independently rated each study, and inter-rater agreement was calculated using Cohen’s kappa coefficient. Results are presented in Table 2.

Table 2.

Quality Assessment of Included Studies

PEDro Scale	Steinhardt 200825	Erogul 201426	Peng 201427	Moir 201628	Kuhlmann 201629	Galante 201830	Fasihi 201931	Mejia-Downs 202032	Nemati 202333	Yan 20249	Mansuroğlu 202534
1. Eligibility criteria were specified	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
2. Subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated an order in which treatments were received)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
3. Allocation was concealed	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
4. The groups were similar at baseline regarding the most important prognostic indicators	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
5. There was blinding of all subjects	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
6. There was blinding of all therapists who administered the therapy	Ns	Ns	Ns	Ns	Ns	Yes	Ns	Ns	Ns	Ns	No
7. There was blinding of all assessors who measured at least one key outcome	Ns	Ns	Ns	Ns	Ns	Yes	Ns	Ns	Ns	Ns	No
8. Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes
9. All subjects for whom outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analysed by “intention to treat”	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
10. The results of between-group statistical comparisons are reported for at least one key outcome	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
11. The study provides both point measures and measures of variability for at least one key outcome	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Total score	9	9	9	8	9	11	9	9	9	9	9

Risk of Bias Assessment

Risk of bias was assessed using the Cochrane RoB 2 tool, which evaluates five domains: randomization, deviations from intended interventions, missing outcome data, outcome measurement, and selection of reported results (Table 3).

Table 3.

Cochrane Risk of Bias

Cochrane RoB	Steinhardt 200825	Erogul 201426	Peng 201427	Moir 201628	Kuhlmann 201629	Galante 201830	Fasihi 201931	Mejia-Downs 202032	Nemati 202333	Yan 20249	Mansuroğlu 202534
Domain 1	Low	Low	Some concerns	Some concerns	Low	Low	Low	Low	Low	Low	Low
Domain 2	Low	Low	Low	Some concerns	Low	Low	Low	Low	Some concerns	Low	Low
Domain 3	Low	Low	Low	Low	Low	Low	Some concerns	Low	Low	Low	Low
Domain 4	Low	Low	Low	Low	Low	Low	Low	Low	Low	Low	Low
Domain 5	Low	Low	Low	Low	Low	Low	Low	Low	Low	Low	Low
Overall risk of bias	Low	Low	Low	Low	Low	Low	Low	Low	Low	Low	Low

Ethical Considerations

This study was approved by the Ethics Committee of Shiraz University of Medical Sciences, Iran (Ethics Approval Code: IR.SUMS.REHAB.REC.1404.002). As this review synthesized published data, informed consent was not required.

Data Synthesis

Due to anticipated heterogeneity in intervention types and outcome measures, a narrative synthesis was planned. Where appropriate, random-effects meta-analyses will be conducted to pool effect sizes for resilience outcomes. Heterogeneity will be assessed using the I² statistic, and subgroup analyses will explore moderators such as intervention type and duration.

Results

Study Characteristics and Quality Assessment

The final review included 11 randomized controlled trials evaluating psychosocial interventions aimed at enhancing resilience among undergraduate medical sciences students (Table 1). These studies spanned diverse health-related disciplines, including medicine, nursing, physical therapy, and allied health fields. Sample sizes ranged from small cohorts of 21–60 participants to large university-wide trials, which enrolled more than 600 students.^28,30

Methodological quality, assessed using the PEDro scale, demonstrated overall moderate to high rigor. Nine studies were rated moderate to high quality, and two were moderate. Risk-of-bias evaluation using the Cochrane RoB 2 tool indicated common challenges typical of psychosocial trials, including limited blinding and reliance on self-report measures.

Intervention Characteristics

Interventions varied substantially in duration, content, and delivery format. Programs were delivered individually or in groups and commonly incorporated psychoeducation, role-play, guided discussions, homework, and practical exercises.

Mindfulness-Based Interventions

Mindfulness-based approaches were the most frequently implemented, appearing in most of the studies.^{9,26,28–30,33} These ranged from brief two-session formats to full eight-week MBSR courses with weekly 75–120-minute sessions and home practice. Most studies reported reductions in perceived stress and improvements in well-being,^26,30,33 although shorter or peer-led formats produced mixed or nonsignificant results.^28,29

Acceptance and Commitment Therapy (ACT)

One study implemented an eight-session ACT protocol and reported significant improvements in psychological flexibility, supporting ACT’s relevance for adaptive coping in student populations.³¹

Cognitive-Behavioral and Stress-Management Approaches

CBT-based and stress-management interventions were evaluated in 3 studies.^25,27,34 These programs included multicomponent curricula addressing communication skills, crisis management, anger regulation, cognitive reframing, and coping strategies delivered over 7–10 weeks. Findings consistently demonstrated improvements in coping skills, emotional regulation, and self-efficacy.

Structured Resilience-Training Programs

Three studies implemented structured resilience curricula: Penn Resilience Program,²⁷ Stop Running on Empty! (26 sessions)³² and Transforming Lives Through Resilience Education.²⁵ All three reported significant increases in resilience scores, suggesting that multisession, theory-driven programs may yield more robust outcomes than brief workshops.

Outcome Measures

Resilience and stress outcomes were assessed using validated instruments. The Perceived Stress Scale (PSS) demonstrated significant reductions in stress in several studies.^26,30 The Connor-Davidson Resilience Scale (CD-RISC-10) was frequently used to evaluate resilience.^9,33 Additional measures included the Resilience Scale (RS), Brief Resilience Scale (BRS), Dispositional Resilience Scale (DRS), Brief COPE, Cognitive Flexibility Inventory, Coping Flexibility Scale, DASS-21, GAD-7, TICS, SSCS, BSI, CORE-OM, and PTSD Checklist.

Overall Synthesis of Effects

Across the 11 included RCTs, psychosocial interventions consistently demonstrated positive effects on resilience, perceived stress, coping flexibility, and psychological well-being.

• Mindfulness-based interventions showed strong evidence for reducing stress and distress, though effectiveness varied by duration and delivery format.

• ACT improved psychological flexibility.

• CBT-based and stress-management programs enhanced coping, emotional regulation, and self-efficacy.

• Structured resilience curricula produced reliable improvements in resilience scores.

Overall, interventions grounded in established theoretical frameworks—mindfulness, CBT, ACT—yielded more consistent outcomes than brief or single-component workshops. Longer, repeated-practice programs were associated with stronger and more sustained effects (Table 4).

Table 4.

Summary of Intervention Categories, Frameworks, and Effectiveness

Intervention Category	Theoretical Framework	Delivery Format & Duration	Outcome Measures	Effectiveness Summary
Mindfulness-Based Interventions	Attention regulation; emotional regulation	Weekly sessions (75–120 min), 2–8 weeks; home practice; peer-led or instructor-led formats	PSS, RS, CORE-OM, GAD-7	Significant reductions in stress and distress; no significant change in peer-led or brief formats
Cognitive-Behavioral / Stress-Management Training	Cognitive restructuring; coping skills; emotional regulation	Multi-component programs (7–10 weeks); group workshops	VAS, Brief COPE, SCMS, DASS-21	Improved coping, self-efficacy, and emotional regulation
Acceptance and Commitment Therapy (ACT)	Psychological flexibility; values-based action	Eight weekly sessions	Cognitive Flexibility Inventory	Increased psychological flexibility
Structured Resilience-Training Programs	Multi-component resilience frameworks; problem-solving; empowerment	4–26 sessions; 2-hour modules	CD-RISC, PSS, CFS	Consistent improvements in resilience; strongest effects in multi-session curricula

Discussion

This systematic review synthesizes evidence from eleven randomized controlled trials evaluating psychosocial interventions designed to enhance resilience among undergraduate medical sciences students. Across these studies, interventions such as mindfulness-based programs, cognitive-behavioral approaches, acceptance and commitment therapy (ACT), and structured resilience-training curricula demonstrated varying degrees of effectiveness in improving stress, coping, psychological flexibility, and resilience. However, interpretation of these findings requires caution due to substantial heterogeneity in intervention design, delivery, and measurement approaches.

Mindfulness-based interventions were the most frequently implemented.^{25,26,28–30,33} These programs ranged from brief peer-led sessions to full eight-week MBSR courses. Several studies reported reductions in perceived stress and improvements in well-being,^9,26 while others—particularly shorter or peer-led formats—showed no significant changes.^28,29 These mixed results suggest that mindfulness effectiveness may depend on program fidelity, duration, participant engagement, and contextual factors such as academic pressure and cultural expectations.

Beyond mindfulness, ACT demonstrated positive outcomes in improving psychological flexibility,³¹ highlighting the value of acceptance-based approaches for enhancing adaptive functioning. Cognitive-behavioral and stress-management interventions also contributed to resilience enhancement. Mansuroğlu (2025) reported improvements in coping and emotional regulation following a multi-component CBT-based program,³⁴ while Peng (2014) and Mejia-Downs (2020) demonstrated consistent gains in resilience through structured resilience-training curricula such as the Penn Resilience Program and Stop Running on Empty!^25,27,32 Yan (2024) further supported the effectiveness of structured resilience education in improving students’ adaptive capacities.⁹

Despite these encouraging findings, methodological limitations across studies constrain the strength of conclusions. Many trials employed small sample sizes, reducing statistical power and increasing the likelihood of Type II error. Most relied heavily on self-reported outcomes—including the PSS, CD-RISC, DASS-21, and coping inventories—which are subject to response bias and may not fully capture objective changes in resilience or stress. Blinding was not feasible in psychosocial interventions, increasing the risk of performance and detection bias. Additionally, follow-up periods were generally short or absent, limiting understanding of long-term intervention effects.

Generalizability of the findings is also limited. The included studies were conducted across diverse healthcare disciplines (medicine, nursing, physical therapy, occupational therapy) and cultural contexts (eg, Iran, Turkey, Germany, the United States). Cultural norms, academic pressures, and institutional resources may influence both stress experiences and responsiveness to psychosocial interventions.^19–23 A Cochrane review further noted that resilience training is often not clearly distinguished from other psychosocial approaches and that effectiveness depends heavily on specific outcomes and training environments.²⁴ These contextual differences underscore the need for culturally sensitive, discipline-specific adaptation of resilience-building programs.

Occupational Therapy Perspective on Resilience

Occupational therapy concepts provide a complementary lens for understanding resilience in healthcare students. Within occupational therapy, resilience is closely tied to flexible engagement in daily occupations—such as self-care, education, rest, social participation, and leisure—which collectively support health and well-being.^35,36 Occupational resilience refers to an individual’s ability to navigate stressors by modifying patterns of occupational participation and adapting daily routines.³⁷ These principles help explain why activity-based strategies—such as mindfulness practice, goal-setting, and problem-solving—may enhance resilience. They also suggest potential avenues for future intervention development, particularly in designing programs that integrate meaningful occupations and activity-oriented coping strategies into medical curricula.

Overall Interpretation

Taken together, the evidence suggests that psychosocial interventions can enhance resilience and mental well-being among undergraduate medical sciences students. However, the considerable heterogeneity across studies, methodological limitations, and contextual variability indicate that no single approach can be universally recommended. Future research should prioritize multisite randomized trials, standardized outcome measures, culturally sensitive program design, and long-term follow-up to clarify which strategies most effectively strengthen resilience in this at-risk population.

Limitations

This review has several limitations. Restricted access to the full text of some relevant studies limited the depth of analysis. Many resilience interventions also focus on generally healthy student populations rather than individuals experiencing adversity, which is central to resilience theory. Additionally, most included trials relied heavily on self-reported outcomes and often lacked adequate baseline mental-health data, reducing the precision and interpretability of findings.

Future Directions for Occupational Therapy

Future work should prioritize occupational therapy–led, student-focused research to develop standardized resilience interventions grounded in OT principles. Technology-based supports, such as mental-health applications, may enhance accessibility and engagement. Occupational therapists can play a key role in integrating early resilience training into healthcare curricula through workshops and interdisciplinary collaborations aimed at reducing burnout. By incorporating CBT, MBSR, and ACT within occupation-centered frameworks, OT practitioners can help students manage academic and professional challenges. Future initiatives should emphasize objective outcome measures, diverse cultural contexts, and tailored intervention designs.

Stress Management Theory underscores the importance of identifying stressors, applying strategies such as relaxation, exercise, and time management, and adjusting these techniques over time with support from strong social networks.³⁸ These principles can guide educational workshops for occupational therapists and inform evaluations of intervention effectiveness among students and healthcare professionals across different cultural settings. Embedding resilience training and wellness programs within medical curricula may strengthen coping skills and support overall student well-being.

Conclusion

Across the eleven included trials, psychosocial interventions—mindfulness-based programs, cognitive-behavioral and stress-management approaches, acceptance and commitment therapy, and structured resilience-training curricula—show potential to improve resilience and psychological well-being in undergraduate medical sciences students. However, substantial heterogeneity in intervention design, populations, and outcome measures requires cautious interpretation. Small samples, reliance on self-report, limited blinding, and short follow-up periods further constrain the strength of the evidence. Occupational therapy concepts offer a complementary theoretical perspective, though direct empirical support within the included studies is limited. Overall, psychosocial interventions appear promising, but more rigorous, standardized, and context-sensitive research is needed to determine which approaches most effectively enhance resilience in this student population.

Funding Statement

This study was funded by the Research Deputy of Shiraz University of Medical Sciences.

Data Sharing Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. The protocol for this review was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) [https://www.crd.york.ac.uk/PROSPERO/view/CRD420251049236].

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work. All authors have read and approved the final version of the manuscript. Sara Zamiran had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis. Sahar Ghanbari (first author) and Sara Zamiran (corresponding author) affirm that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

Disclosure

The authors declared no conflict of interest.