Peer-Led Mentoring Intervention for Test Anxiety Reduction among Medical Students: Development, Implementation, and Prospective Evaluation

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Peer led interventions offer a promising alternative, but evidence in medical education is limited. This study was aimed to develop a validated mental health intervention module and evaluate the impact of peer-led mentoring program on test anxiety among undergraduate MBBS students in India. Methods: A structured, evidence-based peer-led mentoring module was developed using ADDIE model and validated by experts (Content Validity Index > 0.78). A prospective pre-and post-intervention cohort study involved 100 second-year MBBS students of a public medical college. Peer mentors, trained using a validated module, provided group and individual mentoring before high-stakes examinations (Mock Boards). The primary outcome was test anxiety scores measured using Westside Test Anxiety (WTA) Scale. Secondary outcomes included academic performance and qualitative assessments of acceptability and feasibility through focus group discussions. Results: At baseline, 40% of students had test anxiety (WTA ≥ 3) (32% moderate-high, 8% severe), with a median WTA score of 2.7 (IQR: 2.25-3.25). Post-intervention, median WTA scores significantly decreased to 2.35 (difference: -0.35; 95% CI: -0.5 to -0.2; P < 0.001). The proportion of students with normal/high-normal anxiety (WTA score <3) increased from 60% to 79%, and no students had severe anxiety post-intervention (P = 0.002). Students with moderate-high anxiety showed ~22% reduction, while those with severe anxiety showed ~30% reduction in median WTA scores. Academic performance showed no significant differences among anxiety groups. Students reported high satisfaction (median score: 7/10), and the intervention was deemed highly acceptable and feasible. Conclusions: The peer-led mentoring program effectively reduced test anxiety among medical students during high stakes examination. While academic performance did not significantly improve, integration of such programs into formal support systems could enhance sustainability and impact in medical education settings. Figures Figure 1 Figure 2 Introduction Test anxiety is a common experience among students related to examinations in higher education [ 1 ]. However, medical students experience higher levels of test anxiety compared to their age-matched peers in other disciplines [ 2 , 3 , 4 ]. This heightened anxiety stems from the unique challenges they face, including daunting academic landscape, rigorous professional examinations and demanding cognitive workloads inherent to medical education [ 3 , 5 , 6 ]. Test or exam anxiety affects between 27–65% of medical students and is characterized by negative behavioral, physiological, or emotional responses that may hinder both learning and academic performance [ 7 – 9 ]. In India, studies also report high test anxiety prevalence among MBBS students [ 10 , 11 ]. Unfortunately, this phenomenon is often normalized and overlooked by teachers, parents, and students, leading to a lack of support [ 4 ]. As far as its management is concerned, a meta-analysis by Huntley et al. (2019) found that cognitive-behavioral therapy (CBT), study skills training, and combined psychological & study skills interventions alleviated test anxiety [ 12 ]. In another systematic review and metanalysis, relaxation and mindfulness strategies also reduced test anxiety or stress among health professional students [ 3 ]. However, limited availability of mental health care counsellors on college campuses has become a critical barrier in addressing the growing demand for mental health support among students [ 13 , 14 ]. Indeed, the need for innovative local solutions to mitigate the critical shortfall of mental health professionals is imperatively felt [ 15 ]. This has prompted many colleges to implement peer-based counseling and/or support systems which are more student friendly in terms of accessibility, feasibility and relatability [ 15 ]. The peer-based support programs in colleges can be either one-on-one or in groups [ 16 ]. A Canadian university’s pilot testing during COVID-19 showed such programs are feasible and well-received, particularly for students with mild to moderate anxiety and depression [ 16 ]. These models incorporate workshops, regular check-ins, and feedback mechanisms to foster a supportive learning environment, thereby reducing stress and improving academic performance [ 14 ]. However, there is dearth of studies investigating the effectiveness of peer-led mentoring interventions on test anxiety and examination performance among medical students [ 6 , 17 ]. Therefore, the present study, was aimed to develop a validated mental health module for medical students and prospectively evaluate the effectiveness of a peer mentoring program in reducing test anxiety among undergraduate MBBS students in India. The primary outcome was test-anxiety scores measured using the validated Westside Test Anxiety (WTA) Scale. Secondary outcomes included academic performance and qualitative assessments of acceptability and feasibility through focus group discussions. Materials and Methods Study design : A prospective cohort study with pre- and post-intervention assessments were carried out at two time points: at baseline prior to midterm examinations (block/unit tests) and at follow up before send-up examinations (Mock Boards). As such, these are not formative assessments aimed at enhancing learning but are high-stakes assessments, with the potential to result in student detention if performance thresholds are not met. Setting The study was conducted at a newly established (in year 2021) public medical college in Punjab, India. Study period The study was conducted from April 2024 to December 2024. Participants Participants were undergraduate medical students from 2022 MBBS batch. Inclusion criteria for the study were undergraduate MBBS students from 2022 batch who provided written informed consent and were willing to complete standardized assessments related to test anxiety both pre- and post-intervention assessments. Exclusion criteria were students with severe psychiatric disorders or other mental health conditions that required specialized clinical intervention, who were unable or unwilling to commit to the entire duration of the study or were already receiving external counselling or coaching specifically targeted at test anxiety. Sample size To detect a 20% reduction in the proportion of students experiencing test anxiety (from 40–20%) after a peer-led mentoring intervention, with a 90% power and 5% significance level, a sample size at least 91 medical students was required which was increased to 100 to account for potential dropouts in the study. Development of the module for Intervention The peer-led mentoring module for addressing test anxiety among MBBS students was developed through a structured, evidence-based approach following the ADDIE model. (Analysis, Design, Development, Implementation and Evaluation) [ 18 ]. To begin with, a landscape analysis was done and informal feedback was taken from the students regarding their needs with respect to test anxiety. The module was structured around core psychological and academic coping strategies, including: i) Overview of Test Anxiety ii) Study skills training and time management iii) Test taking skills iv) Cognitive restructuring techniques (CBT-based) v) Relaxation exercises and mindfulness practices vi) Positive Psychology and Lifestyle intervention. The draft version of the module was peer-reviewed by senior faculty, mental health professionals, and medical educationists. Experts in psychiatry, medical education, and psychology reviewed the module to ensure accuracy, relevance, and appropriateness. The content of the module was validated by 9 experts using a 13-item questionnaire wherein the item wise content validity index (CVI) was found to be more than 0.78 for each item. This threshold is based on Lynn’s criteria (1986), which suggest that for an instrument evaluated by six or more experts, a CVI of 0.78 or above indicates adequate content validity [ 19 ]. Then, pilot testing was conducted with a small cohort of students, and feedback was gathered to refine content and get structured feedback on its clarity, applicability, and effectiveness. Based on feedback, the module underwent modifications to ensure it met students' needs. Peer mentors were selected based on academic performance, interpersonal skills, and leadership experience from senior MBBS batches who were part of Rotaract Club Chandigarh, a youth-led service club affiliated with Rotary International, designed for young adults for leadership development, community service, professional networking, and personal growth. Training for Peer Mentors Next step was to train the peer leaders in implementation of the module. Peer mentors received training on principles of positive psychology, psychoeducational strategies, cognitive-behavioral techniques, and disclosure-focused interventions. Training included strategies for recognizing triggers of test anxiety and effective management techniques. A total of 6 sessions were taken for training of the peer leaders by the core team. Following this, the peer leaders implemented the intervention for 2022 MBBS students. Outcome assessment Anxiety testing was carried out half an hour prior to examinations at baseline and follow up. A validated 10-item Westside Test Anxiety (WTA) Scale was utilized to measure the levels of test anxiety among students. Self-reported Westside Test Anxiety (WTA) Scale scores were collected before and after the intervention to assess its effectiveness. Baseline data, including gender and NEET (National Entrance Eligibility Test for medical entrance) scores, were obtained from the student cell to provide additional context. Two focus group discussions (FGDs) were conducted to gather qualitative data on students' experiences with peer-led mentoring intervention. These discussions explored the acceptability, feasibility, and sustainability of the intervention, providing insights into participant experiences and potential areas for improvement. Sessions were conducted with 10–12 participants per group, lasting 60–90 minutes, and included both student participants and peer mentors. Participants for the FGDs were purposefully selected to ensure diverse representation across gender, varying levels of academic performance, and a range of anxiety scores. The discussions were digitally recorded using dual devices for backup, with concurrent field notes documenting non-verbal cues and group dynamics. The sessions followed a standardized discussion guide, progressing from general academic experiences to specific feedback about the intervention's impact. Dual recording methods, software transcription, and independent quality checks further ensured the reliability and objectivity of the qualitative data. Data analysis: Descriptive statistics included summarized quantitative (mean, median, IQR) and categorical (frequencies, proportions) variables. Non-parametric tests (Wilcoxon signed-rank, Kruskal-Wallis, McNemar’s) compared pre- and post-intervention outcomes (p < 0.05). Odds ratios with their 95% CIs were also computed. All statistical tests for 2-tailed and level of significance was kept at 0.05 or 5%. Qualitative data analysis included thematic analysis as well as sentiment analysis of feedback given by students during FGDs. Results A total of 100 second-year MBBS students (Batch 2022) were enrolled in the study, with 44% boys and 56% girls. At baseline, the median (IQR) Westside Test Anxiety (WTA) score was 2.7 (IQR: 2.25–3.25), with scores ranging from 1.3 (minimum) to 4.8 (maximum). About 40% (n = 40) of students had test anxiety (WTA score ≥ 3), of whom 32% (n = 32) had mild to moderate anxiety (WTA score 3 to < 4) and 8% (n = 8) had severe anxiety (WTA score ≥ 4). Prevalence of test anxiety was higher among girls (42.9%, n = 24/56) compared to boys (36.4%, n = 16/44) (OR: 1.31; 95% CI: 0.58–2.95), but this difference failed to reach statistically significance (P value 0.51). Median WTA scores among girls (2.7, IQR: 2.25–3.35) and boys (2.7, IQR: 2.25–3.20) were similar. During the study period, at least 3 group mentoring sessions were taken for each group of mentees. In addition to group sessions, individual peer mentoring support was provided to students with severe levels of test anxiety. While most students with severe anxiety required 3 to 4 individual sessions, a few needed more intensive support, with one participant receiving up to 10 individual sessions. In addition, all students identified with severe anxiety received one-on-one counselling from a trained mental health specialist as well. Some students with moderate anxiety also benefited from additional individual peer-led sessions, typically ranging from 4 to 5. In certain cases, virtual or online support was provided when in-person follow-up was not possible. This flexible and responsive approach ensured that the intensity and mode of support were tailored to the severity of anxiety, thus strengthening the overall impact of the intervention. Post-intervention, median baseline WTA scores decreased from 2.7 (IQR: 2.25–3.25) to 2.35 (IQR: 2.0–2.9), with a median difference of -0.35 (95% CI: -0.5 to -0.2), which was statistically significant on the Wilcoxon signed-rank test (P < 0.001) (Fig. 1 ). This suggests that the peer-led intervention was effective in reducing test anxiety among medical students. Post intervention, odds of anxiety decreased by 17% among girls as compared to boys (OR 0.83; 95% CI: 0.32 to 2.18), but again this effect size was statistically not significant (P-value 0.70). Table 1 shows the percentage change in WTA scores computed among students stratified into 3 anxiety groups based on WTA score cut off (Normal, Moderate-High Anxiety & Severe Anxiety). The median (IQR) percentage change in WTA scores (follow up vs baseline) was zero (IQR: -18.44–10.53%) among students who were normal at baseline. On the other hand, WTA scores showed a median percentage decrease of approx. 22% (IQR: -34.21% to -11.96%) among students with moderate-high test anxiety and a median decrease of approx. 30% (IQR: -45.55% to -18.51%) among students with severe anxiety at baseline (Table 1 ). Table 1 Percentage Change in Westside Test Anxiety (WTA) scores from baseline to post-intervention period when stratified by baseline WTA groups Anxiety Group N Mean % Change (95% CI) Median % Change (95% CI) Normal (WTA score < 3) 60 -1.00(-6.27 to 4.22) 0(-9.09 to 6.73) Moderate to High (WTA score 4) 8 -31.4(-43.60 to -19.16) -30.2(-46.48 to -16.55) WTA-Westside Test Anxiety The proportion of students with normal or high normal anxiety (WTA < 3), moderate to high anxiety (WTA 4) were 60%, 32% and 8% respectively at baseline. However, after intervention, students with normal or high normal anxiety were 79% while remaining 21% had moderate to high anxiety (Fig. 2 ). None of the students had very severe test anxiety after the intervention. This difference was statistically significant (P-value 0.002). Academic performance of students Our study also compared the academic performance (total marks obtained in %) of study participants at mid-term (block/unit exams) and send ups (Mock Boards) examinations after stratifying the study cohort into normal, moderate-high and severe anxiety based on recommended WTA score cut offs (< 3- normal, 3 to < 4-moderate-high and ≥ 4 -very severe anxiety) (Table 2 ). Table 2 Mid-term & Send-Up Examination total marks percentage and % change in marks stratified by baseline anxiety groups based on West test Anxiety (WTA) scale cut offs Anxiety Group N Midterm Mean % Marks Send-Up Mean % Marks Mean Percentage Improvement (%) \(\:\frac{\varvec{S}\varvec{e}\varvec{n}\varvec{d}\varvec{u}\varvec{p}-\varvec{B}\varvec{a}\varvec{s}\varvec{e}\varvec{l}\varvec{i}\varvec{n}\varvec{e}}{\varvec{B}\varvec{a}\varvec{s}\varvec{e}\varvec{l}\varvec{i}\varvec{n}\varvec{e}}\times\:100\) 95% CI Normal (WTA score < 3) 60 55.43 60.16 9.16 6.98 to 11.35 Moderate to High (WTA score 3 to 4) 8 56.74 60.65 7.42 1.83 to 13.0 Baseline mid-term % marks did not significantly differ among various anxiety groups (normal, moderate-high and very severe anxiety) (P-value 0.92). Also, post-intervention comparison of total percentage marks in Send-Up (Mock Boards) examination among various categories of anxiety were also not statistically significantly different (P-value 0.91). In addition, we also statistically compared the percentage change in total marks from mid-term to send up among all groups (normal, moderate-high and severe anxiety) using non-parametric Kruskal Wallace test. Again, there was no statistically significant difference among the anxiety groups (P-value 0.64). The study also investigated whether scores on the National Eligibility cum Entrance Test (NEET), an all-India medical entrance examination for admission to undergraduate and postgraduate medical programs, had any impact on the prevalence of baseline test anxiety scores. The mean (SD) NEET (National Eligibility Entrance test) marks of the total batch were 546(88) with minimum of 147 and maximum of 665. The median WTA scores were 2.3 (IQR: 2.1–2.7) and 2.8 (IQR: 2.3–3.5) between students with NEET scores in 4th quartile (high achievers) versus NEET scores in 1st to 3rd quartiles (low to moderate achievers). This difference in WTA scores was statistically significant (P-value 0.02). In addition, the odds of having test anxiety at baseline were significantly decreased by 76% among students who had scored in highest quartile in NEET as compared to remaining students (OR 0.24;95% CI: 0.075 to 0.77) (P-value 0.02). Satisfaction and Perceived Effectiveness The effectiveness of the peer-led intervention was assessed through satisfaction ratings from both undergraduate students who participated and peer mentors who facilitated the sessions. Undergraduate students generally reported a positive experience with the intervention. The median satisfaction score was 7 (IQR: 6–9), with individual ratings ranging from 4 to 10. The open communication and shared experiences helped normalize test anxiety and foster a sense of emotional support. However, some students expressed discomfort in discussing personal issues with assigned mentors, preferring to choose their own. The peer mentors also provided feedback on their experience in facilitating the intervention. Peer mentors found the experience meaningful and empowering, as it allowed them to share coping strategies and bridge the gap between juniors and seniors, though concerns about trust, privacy, and initial student hesitancy were noted. Their reported satisfaction scores ranged between 3 and 4 on a Likert scale of 1 to 5, indicating moderate to high satisfaction with their role. Additionally, when asked whether they felt adequately trained for the intervention, there was a unanimous consensus, with all mentors rating their training as 5 out of 5. This suggests that the training process was effective in preparing mentors to lead the sessions confidently. The feasibility of the intervention was affected by logistical challenges such as scheduling conflicts, particularly for day scholars (15% of participants) who had limited availability after college hours. In contrast, hostel residents engaged more frequently through informal interactions. Privacy concerns and inconsistent participation also impacted overall engagement. Students and mentors expressed willingness to continue, with suggestions such as allowing mentees to choose their mentors, flexible timing, and informal engagement opportunities. Qualitative feedback highlighted emotional benefits of intervention, with students feeling ‘heard’ and ‘understood,’ enhancing well-being. Peer mentors reported a sense of purpose and fulfilment, but also faced moments of frustration and self-doubt when mentees hesitated to engage. Despite these challenges, the overall sentiment was hopeful, with both students and mentors recognizing the intervention’s potential to create a lasting culture of peer support in medical education. The intervention helped normalize discussions on mental health within the institution. Students noted that conversations about anxiety and well-being became more common, indicating a cultural shift toward greater openness and support. Overall, the intervention was well-received, demonstrating high feasibility and acceptability among participants. Participants strongly advocated for ongoing, structured peer mentoring programs rather than short-term interventions. Strengthening mentor training and expanding accessibility were identified as crucial for long-term success. Discussion The prevalence of test anxiety in our study cohort was 40%, with 32% experiencing moderate to high anxiety and 8% reporting severe anxiety. These findings are consistent with existing literature. A meta-analysis by Quek TT et al. estimated a global prevalence of anxiety among medical students at 33.8%, while test-specific anxiety has been reported in nearly 50% of medical students [ 7 , 20 ]. An Indian study reported a higher mean WTA score (3.15 ± 1) with 60.2% of students experiencing moderate or higher levels of anxiety, likely due to their evaluation just before high-stakes final examination [ 10 ]. Surprisingly, the present study found no significant gender differences in test anxiety, in contrast to earlier research that reported significantly higher anxiety levels among female students [ 1 , 21 , 22 ]. Overall, there was significant reduction in anxiety post-intervention, with median WTA scores reduced from 2.7 (IQR: 2.25–3.25) to 2.35 (IQR: 2–2.90). The prevalence of anxiety decreased from 40–21%, with no cases of severe anxiety post-intervention. Westside Test Anxiety Scale had previously been already validated for measuring test anxiety [ 23 ]. Our results mirror the findings by a study in large German medical school where a peer-to-peer mentoring program for freshmen was reported very helpful by students [ 24 ]. Though mental health service utilization has shown upward trends among college students nationally and internationally, yet peer-led interventions had been underexplored in test anxiety management [ 25 , 26 ]. Importantly, peer support is a mutual system of emotional, informational, and appraisal support, grounded in shared understanding, equality and lived experience, while bypassing the hierarchical dominance inherent in traditional doctor–patient relationships [ 27 ]. A previous RCT on an online peer-led mental health program found increased engagement but no significant difference in anxiety scores, contrasting with our in-person peer intervention which showed statistically significant improvement [ 28 ]. A study on a student-led peer support service at a Canadian university found that 89% of participants reported improved well-being, 92% felt that the peer support provider understood their experiences, and 71% received useful information, including referrals to other resources [ 16 ]. Indeed, novel peer mentorship programs such as near-peer coaching as well as step-siblings intervention had demonstrated effectiveness in reducing test anxiety among prospective medical students during their Medical College Admission test (MCAT) [ 29 ] and USMLE Step 1 Preparation [ 30 ]. A recent review further supports the peer mentoring as a valuable approach, reinforcing the success of our intervention, in which experienced peers provided guidance to junior students [ 14 ]. Additionally, the emergence of peer-led mentoring has been recognized as a feasible and cost-effective strategy to alleviate the growing burden on mental health professionals [ 31 – 33 ]. Though the peer-led intervention led to marked reduction in test anxiety scores and severity, it did not show significant corresponding improvement in academic performance. This aligns with recent findings that show no clear association between test anxiety and performance in high-stakes examinations [ 34 ]. Notably, a recent review also highlighted that various self-care and wellness interventions aimed at reducing test anxiety among medical students have shown limited impact on academic outcomes [ 6 ]. Moreover, peer mentors in our study were trained only to support well being and mental health of their peer mentees and were clearly instructed to avoid giving any unsolicited study advice. The peer-led mentoring intervention was moderately to highly acceptable, with many students reporting feeling more relaxed, confident, and connected after engaging with their peers. The opportunity for open communication and shared experiences played a crucial role in normalizing test anxiety, fostering a supportive environment that helped students manage stress more effectively. This study has several limitations that warrant consideration. First, the single-batch, single-institute design limits generalizability, though the diverse backgrounds of both peer mentors and mentees—selected from various country quotas—may enhance broader applicability. Second, confounding variables such as differences in academic workload, external support systems, or family interventions were not fully controlled, potentially impacting both anxiety levels and academic performance. Third, underlying psychopathologies were not evaluated, which could have influenced outcomes. Regarding the intervention approach, while peer interventions may not match the effectiveness of professional counselling, research demonstrates that many college students prefer informal peer support as a first step, as it helps overcome common barriers including perceived stigma by offering a less formal and more approachable option [ 35 – 37 ]. The involvement of mental health professionals for managing severe anxiety cases in our study might have enhanced the peer-led intervention's impact; however, a meta-analysis of 23 studies by Bryan & Arkowitz showed that adding health professionals to peer-administered interventions did not enhance outcomes and was actually associated with reduced effectiveness of peer intervention in alleviating depression symptoms [ 38 ]. Conclusions This study highlighted the effectiveness of structured peer-led mentoring program in reducing test anxiety among medical students before high-stakes assessment. The intervention resulted in a statistically significant reduction in median Westside Test Anxiety Scale scores from 2.7 to 2.35 (P < 0.001), with the proportion of students experiencing normal or high-normal anxiety levels (WTA score 3) from 40% to 21%. Notably, no students exhibited severe anxiety following the intervention, indicating the program's particular effectiveness for those with the highest baseline anxiety levels. While the study did not demonstrate significant improvements in academic performance, this finding aligns with existing literature and does not diminish the value of anxiety reduction for overall student well-being and quality of life. The high satisfaction scores from both students and mentors, coupled with positive qualitative feedback, indicate strong acceptability and feasibility of such programs. The normalization of mental health discussions and the creation of supportive peer networks may have lasting benefits beyond anxiety reduction, potentially contributing to a more resilient and emotionally intelligent healthcare workforce. As medical education continues to evolve, peer-based interventions should be recognized as valuable components of comprehensive student support strategies. Future Directions Evaluating Transformative Potential through Rigorous Trials: Transformative potential of peer led intervention in mitigating test anxiety can be robustly evaluated in a randomized controlled trial setting, providing high quality evidence on their effectiveness. Optimizing Mental Health Support through Structured Training: Structured training programs can be undertaken strengthening mentor–mentee relationships and overall program impact. Advancing Implementation Research for Student Support: Implementation research is further warranted for developing student support initiatives especially in resource-constrained or high-stakes assessment environments. Abbreviations CBT Cognitive-Behavioral Therapy WTA Westside Test Anxiety ADDIE Analysis, Design, Development, Implementation and Evaluation FDG Focus Group Discussion Declarations Clinical trial number : not applicable Ethics approval & Consent to participate: The Institute Ethics Committee (Human Research) DR. B. R. AMBEDKAR STATE INSTITUTE OF MEDICAL SCIENCES SAS NAGAR, MOHALI (PUNJAB) INDIA- 160055 provided ethical clearance (No.AIMS/IEC-HR/2024/13) dated on 8 th May 2024. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Written informed consent was obtained from all participants prior to their inclusion in the study. Consent for publication Written informed consent for participation and publication of anonymized data was obtained from all participants prior to inclusion in the study. The consent process was approved by the Institutional Ethics Committee. No identifying details of individual participants are included in this manuscript. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to confidentiality and sensitivity of participant information but are available from the corresponding author on reasonable request. Competing Interests: Authors declare no competing interests. During the preparation of this manuscript, the authors used ChatGPT 4.0 to improve English grammar. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication. Funding: No funding was received for this project. Authors' contributions Bhavneet Bharti conceptualized and planned the study, led the implementation of the intervention, and oversaw data analysis. Nidhi Malhotra & Prahbhjot Malhi played key role in the development of the mental health intervention module, its validation and the training of peer mentors. Amrit Virk contributed to the study design, methodology, intervention implementation & data analysis, Vaneet Kaur helped in data collection, implementation of peer led intervention and manuscript writing and Poonam Loomba provided critical inputs in refining the study design and methodology, and significantly contributed to manuscript revisions. Acknowledgements We acknowledge the students, faculty, and peer mentors of AIMS Mohali for their participation. References Jirjees F, Odeh M, Al-Haddad A, Ass'ad R, Hassanin Y, Al-Obaidi H, Kharaba Z, Alfoteih Y, Alzoubi KH. Test anxiety and coping strategies among university students an exploratory study in the UAE. Sci Rep. 2024 Oct 28;14(1):25835. doi: 10.1038/s41598-024-59739-4. Mirza AA, Baig M, Beyari GM, Halawani MA, Mirza AA. Depression and Anxiety Among Medical Students: A Brief Overview. Adv Med Educ Pract. 2021 Apr 21;12:393-398. doi: 10.2147/AMEP.S302897 Lo K, Waterland J, Todd P, Gupta T, Bearman M, Hassed C, Keating JL. Group interventions to promote mental health in health professional education: a systematic review and meta-analysis of randomised controlled trials. Adv Health Sci Educ Theory Pract. 2018 May;23(2):413-447. doi: 10.1007/s10459-017-9770-5. Almutairi AG, Baabbad NM, Alhumaidan AA, Alshahrani AM, Alabdulkarim AI, Alsughier N . Prevalence and factors causing test anxiety among medical students. Middle East Curr Psychiatry 31 , 48 (2024). https://doi.org/10.1186/s43045-024-00437-2 Kroshus E, Hawrilenko M, Browning A. Stress, self-compassion, and well-being during the transition to college. Soc Sci Med. 2021 Jan;269:113514. doi: 10.1016/j.socscimed.2020.113514. Williamson C, Wright ST, Beck Dallaghan GL. Test Anxiety Among US Medical Students: A Review of the Current Literature. Med Sci Educ. 2024 Feb 14;34(2):491-499. doi: 10.1007/s40670-024-01999-w. Quek TT, Tam WW, Tran BX, Zhang M, Zhang Z, Ho CS, Ho RC. The Global Prevalence of Anxiety Among Medical Students: A Meta-Analysis. Int J Environ Res Public Health. 2019 Jul 31;16(15):2735. doi: 10.3390/ijerph16152735. Bughi SA, Sumcad J, Bughi S. Effect of Brief Behavioral Intervention Program in Managing Stress in Medical Students from Two Southern California Universities. Med Educ Online. 2006 Dec;11(1):4593. doi: 10.3402/meo.v11i.4593. Andrews B, Wilding JM. The relation of depression and anxiety to life-stress and achievement in students. Br J Psychol. 2004 Nov;95(Pt 4):509-21. doi: 10.1348/0007126042369802. Patel R, Varma J, Phatak A, Nimbalkar SM. Study of test anxiety amongst undergraduate medical students from the state of Gujarat. J Educ Health Promot. 2023 Sep 29;12:325. doi: 10.4103/jehp.jehp_1680_22. Balaji NK, Murthy PS, Kumar DN, Chaudhury S. Perceived stress, anxiety, and coping states in medical and engineering students during examinations. Ind Psychiatry J. 2019 Jan-Jun;28(1):86-97. doi: 10.4103/ipj.ipj_70_18. Huntley CD, Young B, Temple J, Longworth M, Smith CT, Jha V, Fisher PL. The efficacy of interventions for test-anxious university students: A meta-analysis of randomized controlled trials. J Anxiety Disord. 2019 Apr; 63:36-50. doi: 10.1016/j.janxdis.2019.01.007. Harra RC, Vargas I. A peer-based mentoring program for reducing anxiety and depression symptoms among college students: A preliminary study. J Am Coll Health. 2024 Dec;72(9):3491-3498. doi: 10.1080/07448481.2023.2172580. Pointon-Haas J, Waqar L, Upsher R, Foster J, Byrom N, Oates J. A systematic review of peer support interventions for student mental health and well-being in higher education. BJPsych Open. 2023 Dec 15;10(1): e12. doi: 10.1192/bjo.2023.603. Kitzrow MA. The mental health needs of today’s college students: challenges and recommendations. NASPA Journal 2003;41(1):167– 181. doi: 10.2202/1949-6605.1310) Suresh R, Karkossa Z, Richard J, Karia M. Program evaluation of a student-led peer support service at a Canadian university. Int J Ment Health Syst 2021;15(1):1–11. doi: 10.1186/S13033-021-00479-7 Iqbal S, Gupta S, Venkatarao E. Stress, anxiety and depression among medical undergraduate students and their socio-demographic correlates. Indian J Med Res. 2015 Mar;141(3):354-7. doi: 10.4103/0971-5916.156571. Peterson, C. (2003). Bringing ADDIE to Life: Instructional Design at Its Best. Journal of Educational Multimedia and Hypermedia , 12 (3), 227-241. Norfolk, VA: Association for the Advancement of Computing in Education (AACE). Retrieved July 20, 2025 from https://www.learntechlib.org/primary/p/2074/. Lynn MR. Determination and quantification of content validity. Nurs Res. 1986;35(6):382–385. doi: 10.1097/00006199-198611000-00017 Bacon A, Taylor T. Tackling exam-induced anxiety at medical school. Med Teach. 2018 Feb;40(2):212. doi: 10.1080/0142159X.2017.1386294. Tsegay L, Shumet S, Damene W, Gebreegziabhier G, Ayano G. Prevalence and determinants of test anxiety among medical students in Addis Ababa Ethiopia. BMC Med Educ. 2019 Nov 14;19(1):423. doi: 10.1186/s12909-019-1859-5. Memon I, Omair A, Barradah OM, Almegren NM, Almuqbil MM, Batarfi OH, Masuadi E, Feroz Z. Measurement of Exam Anxiety Levels Among Medical Students and Their Association with the Influencing Factors. Cureus. 2023 Jul 5;15(7):e41417. doi: 10.7759/cureus.41417. Driscoll R. Westside Test Anxiety Scale validation and use. ERIC Document Reproduction Service No. ED495968. 2007. Dederichs M, Weber J, Muth T, Angerer P, Loerbroks A. Students' perspectives on interventions to reduce stress in medical school: A qualitative study. PLoS One. 2020 Oct 15;15(10):e0240587. Jaisoorya T S, Joseph S, Kalarani K S, Menon M, Smita G S, Shini V S, Jose SE, Mahesh M M, Shibu K, Sujisha T G, Jayaprakashan K P, Kiran P S, Anil Kumar T V, Vigneshwari V, Titus U. Framework and Overview of a State-Wide College Mental Health Program in Kerala, India. Indian J Psychol Med. 2023 Sep;45(5):526-532. doi: 10.1177/02537176221122407 Lipson, S. K., Kern, A., Eisenberg, D., & Breland-Noble, A. M. (2018). Mental Health Disparities Among College Students of Color. Journal of Adolescent Health, 63(3), 348– 356. https://doi.org/10.1016/j.jadohealth.2018.04.014 Mead, S., Hilton, D., & Curtis, L. (2001). Peer support: A theoretical perspective. Psychiatric Rehabilitation Journal, 25(2), 134–141. https://doi.org/10.1037/h0095032 Ugarte DA, Cumberland WG, Singh P, Saadat S, Garett R, Young SD. A HOPE Online Community Peer Support Intervention for Help Seeking: A Randomized Controlled Trial. Psychiatr Serv. 2023 Jun 1;74(6):648-651. doi: 10.1176/appi.ps.202000817. Liu, B., Hodge, A., Jushka, C., & Hueston, W. J. (2022). A Pilot Study of Reducing Test Anxiety in a Cohort of Underrepresented in Medicine MCAT Students Using Near-Peer Coaching. International Journal of Medical Students , 10 (2), 139–147. https://doi.org/10.5195/ijms.2022.1185 Lynch TV, Beach IR, Kajtezovic S, Larkin OG, Rosen L. Step Siblings: a Novel Peer-Mentorship Program for Medical Student Wellness During USMLE Step 1 Preparation. Med Sci Educ. 2022 Jun 13;32(4):803-810. doi: 10.1007/s40670-022-01571-4. Singh S, Singh N, Dhaliwal U. Near-peer mentoring to complement faculty mentoring of first-year medical students in India. J Educ Eval Health Prof. 2014 Jun 30;11:12. doi: 10.3352/jeehp.2014.11.12. Day V, McGrath PJ, Wojtowicz M. Internet-based guided self-help for university students with anxiety, depression and stress: a randomized controlled clinical trial. Behav Res Ther. 2013 Jul;51(7):344-51. doi: 10.1016/j.brat.2013.03.003. Harrer M, Adam SH, Fleischmann RJ, Baumeister H, Auerbach R, Bruffaerts R, Cuijpers P, Kessler RC, Berking M, Lehr D, Ebert DD. Effectiveness of an Internet- and App-Based Intervention for College Students With Elevated Stress: Randomized Controlled Trial. J Med Internet Res. 2018 Apr 23;20(4):e136. doi: 10.2196/jmir.9293. Jerrim, J. (2022). Test anxiety: Is it associated with performance in high-stakes examinations? Oxford Review of Education , 49 (3), 321–341. https://doi.org/10.1080/03054985.2022.2079616. Eisenberg D, Hunt J, Speer N, Zivin K. Mental health service utilization among college students in the United States. J Nerv Ment Dis. 2011 May;199(5):301-8. doi: 10.1097/NMD.0b013e3182175123. Lipson SK, Lattie EG, Eisenberg D. Increased Rates of Mental Health Service Utilization by U.S. College Students: 10-Year Population-Level Trends (2007-2017). Psychiatr Serv. 2019 Jan 1;70(1):60-63. doi: 10.1176/appi.ps.201800332. Reavley NJ, McCann TV, Jorm AF. Mental health literacy in higher education students. Early Interv Psychiatry. 2012 Feb;6(1):45-52. doi: 10.1111/j.1751-7893.2011.00314.x. Bryan AE, Arkowitz H. Meta-analysis of the effects of peer-administered psychosocial interventions on symptoms of depression. Am J Community Psychol. 2015 Jun;55(3-4):455-71. doi: 10.1007/s10464-015-9718-y. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 02 Feb, 2026 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 03 Nov, 2025 Reviews received at journal 03 Nov, 2025 Reviewers agreed at journal 27 Oct, 2025 Reviews received at journal 08 Oct, 2025 Reviewers agreed at journal 03 Oct, 2025 Reviews received at journal 25 Sep, 2025 Reviewers agreed at journal 25 Sep, 2025 Reviewers invited by journal 25 Sep, 2025 Editor assigned by journal 23 Sep, 2025 Editor invited by journal 02 Sep, 2025 Submission checks completed at journal 01 Sep, 2025 First submitted to journal 01 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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07:19:25","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":106722,"visible":true,"origin":"","legend":"","description":"","filename":"0101531424684094a743c4e1eeb884491structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7353237/v1/160e04ac6fee9bcab73328bd.xml"},{"id":93010068,"identity":"479f1bb9-4ce1-4976-8730-fc0d86feacbe","added_by":"auto","created_at":"2025-10-08 07:11:25","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":121697,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7353237/v1/3d262cee000d0a8ce8ba4bb7.html"},{"id":93010058,"identity":"7263af9b-a306-4787-a429-c1417fc3b47b","added_by":"auto","created_at":"2025-10-08 07:11:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":69924,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of Westside Test Anxiety (WTA) scores at baseline and after intervention. \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/em\u003e\u003cem\u003eInterquartile Range\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7353237/v1/5d62846db6224731977f5bfc.png"},{"id":93010059,"identity":"41b2d1e8-77c6-48b5-b1cb-3d42f491eccc","added_by":"auto","created_at":"2025-10-08 07:11:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":67770,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of Test Anxiety Severity (%) at baseline and post-intervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the students had very severe test anxiety after the intervention. This difference was statistically significant (P-value 0.002).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7353237/v1/500f35fca2dd7a3b7357a068.png"},{"id":102235146,"identity":"1b0e16fe-6614-444d-9638-4980d4153bc4","added_by":"auto","created_at":"2026-02-09 16:15:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":966553,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7353237/v1/3cf468dd-569a-4f01-a8ff-c9f7aa0d639e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Peer-Led Mentoring Intervention for Test Anxiety Reduction among Medical Students: Development, Implementation, and Prospective Evaluation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTest anxiety is a common experience among students related to examinations in higher education [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, medical students experience higher levels of test anxiety compared to their age-matched peers in other disciplines [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This heightened anxiety stems from the unique challenges they face, including daunting academic landscape, rigorous professional examinations and demanding cognitive workloads inherent to medical education [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Test or exam anxiety affects between 27\u0026ndash;65% of medical students and is characterized by negative behavioral, physiological, or emotional responses that may hinder both learning and academic performance [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In India, studies also report high test anxiety prevalence among MBBS students [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Unfortunately, this phenomenon is often normalized and overlooked by teachers, parents, and students, leading to a lack of support [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAs far as its management is concerned, a meta-analysis by Huntley et al. (2019) found that cognitive-behavioral therapy (CBT), study skills training, and combined psychological \u0026amp; study skills interventions alleviated test anxiety [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In another systematic review and metanalysis, relaxation and mindfulness strategies also reduced test anxiety or stress among health professional students [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, limited availability of mental health care counsellors on college campuses has become a critical barrier in addressing the growing demand for mental health support among students [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Indeed, the need for innovative local solutions to mitigate the critical shortfall of mental health professionals is imperatively felt [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This has prompted many colleges to implement peer-based counseling and/or support systems which are more student friendly in terms of accessibility, feasibility and relatability [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The peer-based support programs in colleges can be either one-on-one or in groups [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. A Canadian university\u0026rsquo;s pilot testing during COVID-19 showed such programs are feasible and well-received, particularly for students with mild to moderate anxiety and depression [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These models incorporate workshops, regular check-ins, and feedback mechanisms to foster a supportive learning environment, thereby reducing stress and improving academic performance [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, there is dearth of studies investigating the effectiveness of peer-led mentoring interventions on test anxiety and examination performance among medical students [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Therefore, the present study, was aimed to develop a validated mental health module for medical students and prospectively evaluate the effectiveness of a peer mentoring program in reducing test anxiety among undergraduate MBBS students in India. The primary outcome was test-anxiety scores measured using the validated Westside Test Anxiety (WTA) Scale. Secondary outcomes included academic performance and qualitative assessments of acceptability and feasibility through focus group discussions.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e\u003cb\u003eStudy design\u003c/b\u003e:\u003c/h2\u003e\u003cp\u003eA prospective cohort study with pre- and post-intervention assessments were carried out at two time points: at baseline prior to midterm examinations (block/unit tests) and at follow up before send-up examinations (Mock Boards). As such, these are not formative assessments aimed at enhancing learning but are high-stakes assessments, with the potential to result in student detention if performance thresholds are not met.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSetting\u003c/strong\u003e\u003cp\u003eThe study was conducted at a newly established (in year 2021) public medical college in Punjab, India.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eStudy period\u003c/strong\u003e\u003cp\u003eThe study was conducted from April 2024 to December 2024.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003cp\u003eParticipants were undergraduate medical students from 2022 MBBS batch. Inclusion criteria for the study were undergraduate MBBS students from 2022 batch who provided written informed consent and were willing to complete standardized assessments related to test anxiety both pre- and post-intervention assessments. Exclusion criteria were students with severe psychiatric disorders or other mental health conditions that required specialized clinical intervention, who were unable or unwilling to commit to the entire duration of the study or were already receiving external counselling or coaching specifically targeted at test anxiety.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSample size\u003c/strong\u003e\u003cp\u003eTo detect a 20% reduction in the proportion of students experiencing test anxiety (from 40\u0026ndash;20%) after a peer-led mentoring intervention, with a 90% power and 5% significance level, a sample size at least 91 medical students was required which was increased to 100 to account for potential dropouts in the study.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eDevelopment of the module for Intervention\u003c/h3\u003e\n\u003cp\u003eThe peer-led mentoring module for addressing test anxiety among MBBS students was developed through a structured, evidence-based approach following the ADDIE model. (Analysis, Design, Development, Implementation and Evaluation) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. To begin with, a landscape analysis was done and informal feedback was taken from the students regarding their needs with respect to test anxiety. The module was structured around core psychological and academic coping strategies, including: i) Overview of Test Anxiety ii) Study skills training and time management iii) Test taking skills iv) Cognitive restructuring techniques (CBT-based) v) Relaxation exercises and mindfulness practices vi) Positive Psychology and Lifestyle intervention.\u003c/p\u003e\u003cp\u003eThe draft version of the module was peer-reviewed by senior faculty, mental health professionals, and medical educationists. Experts in psychiatry, medical education, and psychology reviewed the module to ensure accuracy, relevance, and appropriateness. The content of the module was validated by 9 experts using a 13-item questionnaire wherein the item wise content validity index (CVI) was found to be more than 0.78 for each item. This threshold is based on Lynn\u0026rsquo;s criteria (1986), which suggest that for an instrument evaluated by six or more experts, a CVI of 0.78 or above indicates adequate content validity [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Then, pilot testing was conducted with a small cohort of students, and feedback was gathered to refine content and get structured feedback on its clarity, applicability, and effectiveness. Based on feedback, the module underwent modifications to ensure it met students' needs.\u003c/p\u003e\u003cp\u003ePeer mentors were selected based on academic performance, interpersonal skills, and leadership experience from senior MBBS batches who were part of Rotaract Club Chandigarh, a youth-led service club affiliated with Rotary International, designed for young adults for leadership development, community service, professional networking, and personal growth.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTraining for Peer Mentors\u003c/strong\u003e\u003cp\u003eNext step was to train the peer leaders in implementation of the module. Peer mentors received training on principles of positive psychology, psychoeducational strategies, cognitive-behavioral techniques, and disclosure-focused interventions. Training included strategies for recognizing triggers of test anxiety and effective management techniques. A total of 6 sessions were taken for training of the peer leaders by the core team. Following this, the peer leaders implemented the intervention for 2022 MBBS students.\u003c/p\u003e\u003c/p\u003e\n\u003ch3\u003eOutcome assessment\u003c/h3\u003e\n\u003cp\u003eAnxiety testing was carried out half an hour prior to examinations at baseline and follow up. A validated 10-item Westside Test Anxiety (WTA) Scale was utilized to measure the levels of test anxiety among students. Self-reported Westside Test Anxiety (WTA) Scale scores were collected before and after the intervention to assess its effectiveness. Baseline data, including gender and NEET (National Entrance Eligibility Test for medical entrance) scores, were obtained from the student cell to provide additional context.\u003c/p\u003e\u003cp\u003eTwo focus group discussions (FGDs) were conducted to gather qualitative data on students' experiences with peer-led mentoring intervention. These discussions explored the acceptability, feasibility, and sustainability of the intervention, providing insights into participant experiences and potential areas for improvement. Sessions were conducted with 10\u0026ndash;12 participants per group, lasting 60\u0026ndash;90 minutes, and included both student participants and peer mentors. Participants for the FGDs were purposefully selected to ensure diverse representation across gender, varying levels of academic performance, and a range of anxiety scores. The discussions were digitally recorded using dual devices for backup, with concurrent field notes documenting non-verbal cues and group dynamics. The sessions followed a standardized discussion guide, progressing from general academic experiences to specific feedback about the intervention's impact. Dual recording methods, software transcription, and independent quality checks further ensured the reliability and objectivity of the qualitative data.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eData analysis:\u003c/h2\u003e\u003cp\u003eDescriptive statistics included summarized quantitative (mean, median, IQR) and categorical (frequencies, proportions) variables. Non-parametric tests (Wilcoxon signed-rank, Kruskal-Wallis, McNemar\u0026rsquo;s) compared pre- and post-intervention outcomes (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Odds ratios with their 95% CIs were also computed. All statistical tests for 2-tailed and level of significance was kept at 0.05 or 5%.\u003c/p\u003e\u003cp\u003eQualitative data analysis included thematic analysis as well as sentiment analysis of feedback given by students during FGDs.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 100 second-year MBBS students (Batch 2022) were enrolled in the study, with 44% boys and 56% girls. At baseline, the median (IQR) Westside Test Anxiety (WTA) score was 2.7 (IQR: 2.25\u0026ndash;3.25), with scores ranging from 1.3 (minimum) to 4.8 (maximum). About 40% (n\u0026thinsp;=\u0026thinsp;40) of students had test anxiety (WTA score\u0026thinsp;\u0026ge;\u0026thinsp;3), of whom 32% (n\u0026thinsp;=\u0026thinsp;32) had mild to moderate anxiety (WTA score 3 to \u0026lt;\u0026thinsp;4) and 8% (n\u0026thinsp;=\u0026thinsp;8) had severe anxiety (WTA score\u0026thinsp;\u0026ge;\u0026thinsp;4).\u003c/p\u003e\u003cp\u003ePrevalence of test anxiety was higher among girls (42.9%, n\u0026thinsp;=\u0026thinsp;24/56) compared to boys (36.4%, n\u0026thinsp;=\u0026thinsp;16/44) (OR: 1.31; 95% CI: 0.58\u0026ndash;2.95), but this difference failed to reach statistically significance (P value 0.51). Median WTA scores among girls (2.7, IQR: 2.25\u0026ndash;3.35) and boys (2.7, IQR: 2.25\u0026ndash;3.20) were similar.\u003c/p\u003e\u003cp\u003eDuring the study period, at least 3 group mentoring sessions were taken for each group of mentees. In addition to group sessions, individual peer mentoring support was provided to students with severe levels of test anxiety. While most students with severe anxiety required 3 to 4 individual sessions, a few needed more intensive support, with one participant receiving up to 10 individual sessions. In addition, all students identified with severe anxiety received one-on-one counselling from a trained mental health specialist as well. Some students with moderate anxiety also benefited from additional individual peer-led sessions, typically ranging from 4 to 5. In certain cases, virtual or online support was provided when in-person follow-up was not possible. This flexible and responsive approach ensured that the intensity and mode of support were tailored to the severity of anxiety, thus strengthening the overall impact of the intervention.\u003c/p\u003e\u003cp\u003ePost-intervention, median baseline WTA scores decreased from 2.7 (IQR: 2.25\u0026ndash;3.25) to 2.35 (IQR: 2.0\u0026ndash;2.9), with a median difference of -0.35 (95% CI: -0.5 to -0.2), which was statistically significant on the Wilcoxon signed-rank test (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This suggests that the peer-led intervention was effective in reducing test anxiety among medical students.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003ePost intervention, odds of anxiety decreased by 17% among girls as compared to boys (OR 0.83; 95% CI: 0.32 to 2.18), but again this effect size was statistically not significant (P-value 0.70). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the percentage change in WTA scores computed among students stratified into 3 anxiety groups based on WTA score cut off (Normal, Moderate-High Anxiety \u0026amp; Severe Anxiety).\u003c/p\u003e\u003cp\u003eThe median (IQR) percentage change in WTA scores (follow up vs baseline) was zero (IQR: -18.44\u0026ndash;10.53%) among students who were normal at baseline. On the other hand, WTA scores showed a median percentage decrease of approx. 22% (IQR: -34.21% to -11.96%) among students with moderate-high test anxiety and a median decrease of approx. 30% (IQR: -45.55% to -18.51%) among students with severe anxiety at baseline (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePercentage Change in Westside Test Anxiety (WTA) scores from baseline to post-intervention period when stratified by baseline WTA groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean % Change\u003c/p\u003e\u003cp\u003e(95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMedian % Change\u003c/p\u003e\u003cp\u003e(95% CI)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003cp\u003e(WTA score\u0026thinsp;\u0026lt;\u0026thinsp;3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-1.00(-6.27 to 4.22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0(-9.09 to 6.73)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate to High (WTA score\u0026thinsp;\u0026lt;\u0026thinsp;4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-20.9(-27.58 to -14.22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-21.9(-29.03 to -14.28)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere\u003c/p\u003e\u003cp\u003e(WTA score\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-31.4(-43.60 to -19.16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-30.2(-46.48 to -16.55)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eWTA-Westside Test Anxiety\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe proportion of students with normal or high normal anxiety (WTA\u0026thinsp;\u0026lt;\u0026thinsp;3), moderate to high anxiety (WTA\u0026thinsp;\u0026lt;\u0026thinsp;4) and very severe test anxiety (WTA\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;4) were 60%, 32% and 8% respectively at baseline. However, after intervention, students with normal or high normal anxiety were 79% while remaining 21% had moderate to high anxiety (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eNone of the students had very severe test anxiety after the intervention. This difference was statistically significant (P-value 0.002).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eAcademic performance of students\u003c/h2\u003e\u003cp\u003eOur study also compared the academic performance (total marks obtained in %) of study participants at mid-term (block/unit exams) and send ups (Mock Boards) examinations after stratifying the study cohort into normal, moderate-high and severe anxiety based on recommended WTA score cut offs (\u0026lt;\u0026thinsp;3- normal, 3 to \u0026lt;\u0026thinsp;4-moderate-high and \u0026ge;\u0026thinsp;4 -very severe anxiety) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMid-term \u0026amp; Send-Up Examination total marks percentage and % change in marks stratified by baseline anxiety groups based on West test Anxiety (WTA) scale cut offs\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMidterm Mean % Marks\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSend-Up Mean % Marks\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMean Percentage Improvement (%)\u003c/p\u003e\u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\frac{\\varvec{S}\\varvec{e}\\varvec{n}\\varvec{d}\\varvec{u}\\varvec{p}-\\varvec{B}\\varvec{a}\\varvec{s}\\varvec{e}\\varvec{l}\\varvec{i}\\varvec{n}\\varvec{e}}{\\varvec{B}\\varvec{a}\\varvec{s}\\varvec{e}\\varvec{l}\\varvec{i}\\varvec{n}\\varvec{e}}\\times\\:100\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal (WTA score\u0026thinsp;\u0026lt;\u0026thinsp;3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e55.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e60.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6.98 to 11.35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate to High (WTA score 3 to \u0026lt;\u0026thinsp;4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e55.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e59.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5.30 to 9.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere (WTA score\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e56.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e60.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.83 to 13.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eBaseline mid-term % marks did not significantly differ among various anxiety groups (normal, moderate-high and very severe anxiety) (P-value 0.92). Also, post-intervention comparison of total percentage marks in Send-Up (Mock Boards) examination among various categories of anxiety were also not statistically significantly different (P-value 0.91).\u003c/p\u003e\u003cp\u003eIn addition, we also statistically compared the percentage change in total marks from mid-term to send up among all groups (normal, moderate-high and severe anxiety) using non-parametric Kruskal Wallace test. Again, there was no statistically significant difference among the anxiety groups (P-value 0.64).\u003c/p\u003e\u003cp\u003eThe study also investigated whether scores on the National Eligibility cum Entrance Test (NEET), an all-India medical entrance examination for admission to undergraduate and postgraduate medical programs, had any impact on the prevalence of baseline test anxiety scores. The mean (SD) NEET (National Eligibility Entrance test) marks of the total batch were 546(88) with minimum of 147 and maximum of 665. The median WTA scores were 2.3 (IQR: 2.1\u0026ndash;2.7) and 2.8 (IQR: 2.3\u0026ndash;3.5) between students with NEET scores in 4th quartile (high achievers) versus NEET scores in 1st to 3rd quartiles (low to moderate achievers). This difference in WTA scores was statistically significant (P-value 0.02). In addition, the odds of having test anxiety at baseline were significantly decreased by 76% among students who had scored in highest quartile in NEET as compared to remaining students (OR 0.24;95% CI: 0.075 to 0.77) (P-value 0.02).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSatisfaction and Perceived Effectiveness\u003c/h3\u003e\n\u003cp\u003e The effectiveness of the peer-led intervention was assessed through satisfaction ratings from both undergraduate students who participated and peer mentors who facilitated the sessions. Undergraduate students generally reported a positive experience with the intervention. The median satisfaction score was 7 (IQR: 6\u0026ndash;9), with individual ratings ranging from 4 to 10. The open communication and shared experiences helped normalize test anxiety and foster a sense of emotional support. However, some students expressed discomfort in discussing personal issues with assigned mentors, preferring to choose their own.\u003c/p\u003e\u003cp\u003e The peer mentors also provided feedback on their experience in facilitating the intervention. Peer mentors found the experience meaningful and empowering, as it allowed them to share coping strategies and bridge the gap between juniors and seniors, though concerns about trust, privacy, and initial student hesitancy were noted. Their reported satisfaction scores ranged between 3 and 4 on a Likert scale of 1 to 5, indicating moderate to high satisfaction with their role. Additionally, when asked whether they felt adequately trained for the intervention, there was a unanimous consensus, with all mentors rating their training as 5 out of 5. This suggests that the training process was effective in preparing mentors to lead the sessions confidently.\u003c/p\u003e\u003cp\u003eThe feasibility of the intervention was affected by logistical challenges such as scheduling conflicts, particularly for day scholars (15% of participants) who had limited availability after college hours. In contrast, hostel residents engaged more frequently through informal interactions. Privacy concerns and inconsistent participation also impacted overall engagement. Students and mentors expressed willingness to continue, with suggestions such as allowing mentees to choose their mentors, flexible timing, and informal engagement opportunities.\u003c/p\u003e\u003cp\u003eQualitative feedback highlighted emotional benefits of intervention, with students feeling \u0026lsquo;heard\u0026rsquo; and \u0026lsquo;understood,\u0026rsquo; enhancing well-being. Peer mentors reported a sense of purpose and fulfilment, but also faced moments of frustration and self-doubt when mentees hesitated to engage. Despite these challenges, the overall sentiment was hopeful, with both students and mentors recognizing the intervention\u0026rsquo;s potential to create a lasting culture of peer support in medical education. The intervention helped normalize discussions on mental health within the institution. Students noted that conversations about anxiety and well-being became more common, indicating a cultural shift toward greater openness and support.\u003c/p\u003e\u003cp\u003eOverall, the intervention was well-received, demonstrating high feasibility and acceptability among participants. Participants strongly advocated for ongoing, structured peer mentoring programs rather than short-term interventions. Strengthening mentor training and expanding accessibility were identified as crucial for long-term success.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe prevalence of test anxiety in our study cohort was 40%, with 32% experiencing moderate to high anxiety and 8% reporting severe anxiety. These findings are consistent with existing literature. A meta-analysis by Quek TT et al. estimated a global prevalence of anxiety among medical students at 33.8%, while test-specific anxiety has been reported in nearly 50% of medical students [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. An Indian study reported a higher mean WTA score (3.15\u0026thinsp;\u0026plusmn;\u0026thinsp;1) with 60.2% of students experiencing moderate or higher levels of anxiety, likely due to their evaluation just before high-stakes final examination [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Surprisingly, the present study found no significant gender differences in test anxiety, in contrast to earlier research that reported significantly higher anxiety levels among female students [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOverall, there was significant reduction in anxiety post-intervention, with median WTA scores reduced from 2.7 (IQR: 2.25\u0026ndash;3.25) to 2.35 (IQR: 2\u0026ndash;2.90). The prevalence of anxiety decreased from 40\u0026ndash;21%, with no cases of severe anxiety post-intervention. Westside Test Anxiety Scale had previously been already validated for measuring test anxiety [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Our results mirror the findings by a study in large German medical school where a peer-to-peer mentoring program for freshmen was reported very helpful by students [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThough mental health service utilization has shown upward trends among college students nationally and internationally, yet peer-led interventions had been underexplored in test anxiety management [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Importantly, peer support is a mutual system of emotional, informational, and appraisal support, grounded in shared understanding, equality and lived experience, while bypassing the hierarchical dominance inherent in traditional doctor\u0026ndash;patient relationships [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. A previous RCT on an online peer-led mental health program found increased engagement but no significant difference in anxiety scores, contrasting with our in-person peer intervention which showed statistically significant improvement [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. A study on a student-led peer support service at a Canadian university found that 89% of participants reported improved well-being, 92% felt that the peer support provider understood their experiences, and 71% received useful information, including referrals to other resources [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Indeed, novel peer mentorship programs such as near-peer coaching as well as step-siblings intervention had demonstrated effectiveness in reducing test anxiety among prospective medical students during their Medical College Admission test (MCAT) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and USMLE Step 1 Preparation [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. A recent review further supports the peer mentoring as a valuable approach, reinforcing the success of our intervention, in which experienced peers provided guidance to junior students [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Additionally, the emergence of peer-led mentoring has been recognized as a feasible and cost-effective strategy to alleviate the growing burden on mental health professionals [\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThough the peer-led intervention led to marked reduction in test anxiety scores and severity, it did not show significant corresponding improvement in academic performance. This aligns with recent findings that show no clear association between test anxiety and performance in high-stakes examinations [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Notably, a recent review also highlighted that various self-care and wellness interventions aimed at reducing test anxiety among medical students have shown limited impact on academic outcomes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Moreover, peer mentors in our study were trained only to support well being and mental health of their peer mentees and were clearly instructed to avoid giving any unsolicited study advice.\u003c/p\u003e\u003cp\u003eThe peer-led mentoring intervention was moderately to highly acceptable, with many students reporting feeling more relaxed, confident, and connected after engaging with their peers. The opportunity for open communication and shared experiences played a crucial role in normalizing test anxiety, fostering a supportive environment that helped students manage stress more effectively.\u003c/p\u003e\u003cp\u003eThis study has several limitations that warrant consideration. First, the single-batch, single-institute design limits generalizability, though the diverse backgrounds of both peer mentors and mentees\u0026mdash;selected from various country quotas\u0026mdash;may enhance broader applicability. Second, confounding variables such as differences in academic workload, external support systems, or family interventions were not fully controlled, potentially impacting both anxiety levels and academic performance. Third, underlying psychopathologies were not evaluated, which could have influenced outcomes. Regarding the intervention approach, while peer interventions may not match the effectiveness of professional counselling, research demonstrates that many college students prefer informal peer support as a first step, as it helps overcome common barriers including perceived stigma by offering a less formal and more approachable option [\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The involvement of mental health professionals for managing severe anxiety cases in our study might have enhanced the peer-led intervention's impact; however, a meta-analysis of 23 studies by Bryan \u0026amp; Arkowitz showed that adding health professionals to peer-administered interventions did not enhance outcomes and was actually associated with reduced effectiveness of peer intervention in alleviating depression symptoms [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study highlighted the effectiveness of structured peer-led mentoring program in reducing test anxiety among medical students before high-stakes assessment. The intervention resulted in a statistically significant reduction in median Westside Test Anxiety Scale scores from 2.7 to 2.35 (P \u0026lt; 0.001), with the proportion of students experiencing normal or high-normal anxiety levels (WTA score \u0026lt;3) increasing from 60% to 79%. Overall, there was significant reduction in test anxiety prevalence (WTA score \u0026gt;3) from 40% to 21%. Notably, no students exhibited severe anxiety following the intervention, indicating the program's particular effectiveness for those with the highest baseline anxiety levels. While the study did not demonstrate significant improvements in academic performance, this finding aligns with existing literature and does not diminish the value of anxiety reduction for overall student well-being and quality of life. The high satisfaction scores from both students and mentors, coupled with positive qualitative feedback, indicate strong acceptability and feasibility of such programs. The normalization of mental health discussions and the creation of supportive peer networks may have lasting benefits beyond anxiety reduction, potentially contributing to a more resilient and emotionally intelligent healthcare workforce. As medical education continues to evolve, peer-based interventions should be recognized as valuable components of comprehensive student support strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFuture Directions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvaluating Transformative Potential through Rigorous Trials:\u0026nbsp;\u003c/strong\u003eTransformative potential of peer led intervention in mitigating test anxiety can be robustly evaluated in a randomized controlled trial setting, providing high quality evidence on their effectiveness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOptimizing Mental Health Support through Structured Training:\u003c/strong\u003e Structured training programs can be undertaken strengthening mentor–mentee relationships and overall program impact. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdvancing Implementation Research for Student Support:\u003c/strong\u003e Implementation research is further warranted for developing student support initiatives especially in resource-constrained or high-stakes assessment environments.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCBT \u0026nbsp; \u0026nbsp; \u0026nbsp; Cognitive-Behavioral Therapy\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWTA \u0026nbsp; \u0026nbsp; \u0026nbsp;Westside Test Anxiety\u003c/p\u003e\n\u003cp\u003eADDIE \u0026nbsp;\u0026nbsp;Analysis, Design, Development, Implementation and Evaluation\u003c/p\u003e\n\u003cp\u003eFDG \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Focus Group Discussion\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval \u0026amp; Consent to participate:\u003c/strong\u003e The Institute Ethics Committee (Human Research) DR. B. R. AMBEDKAR STATE INSTITUTE OF MEDICAL SCIENCES SAS NAGAR, MOHALI (PUNJAB) INDIA- 160055 provided ethical clearance (No.AIMS/IEC-HR/2024/13) dated on 8\u003csup\u003eth\u003c/sup\u003e May 2024. \u0026nbsp;The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Written informed consent was obtained from all participants prior to their inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for participation and publication of anonymized data was obtained from all participants prior to inclusion in the study. The consent process was approved by the Institutional Ethics Committee. No identifying details of individual participants are included in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to confidentiality and sensitivity of participant information but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e Authors declare no competing interests. During the preparation of this manuscript, the authors used ChatGPT 4.0 to improve English grammar. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e No funding was received for this project.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cbr\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBhavneet Bharti\u003c/strong\u003e conceptualized and planned the study, led the implementation of the intervention, and oversaw data analysis. \u003cstrong\u003eNidhi Malhotra\u003c/strong\u003e \u0026amp; \u003cstrong\u003ePrahbhjot Malhi\u003c/strong\u003e played key role in the development of the mental health intervention module, its validation and the training of peer mentors. \u003cstrong\u003eAmrit Virk\u003c/strong\u003e contributed to the study design, methodology, intervention implementation \u0026amp; data analysis, \u003cstrong\u003eVaneet Kaur\u0026nbsp;\u003c/strong\u003ehelped in data collection, implementation of peer led intervention and manuscript writing and \u003cstrong\u003ePoonam Loomba\u003c/strong\u003e provided critical inputs in refining the study design and methodology, and significantly contributed to manuscript revisions.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003cbr\u003e We acknowledge the students, faculty, and peer mentors of AIMS Mohali for their participation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eJirjees F, Odeh M, Al-Haddad A, Ass\u0026apos;ad R, Hassanin Y, Al-Obaidi H, Kharaba Z, Alfoteih Y, Alzoubi KH. Test anxiety and coping strategies among university students an exploratory study in the UAE. Sci Rep. 2024 Oct 28;14(1):25835. doi: 10.1038/s41598-024-59739-4. \u003c/li\u003e\n\u003cli\u003eMirza AA, Baig M, Beyari GM, Halawani MA, Mirza AA. Depression and Anxiety Among Medical Students: A Brief Overview. Adv Med Educ Pract. 2021 Apr 21;12:393-398. doi: 10.2147/AMEP.S302897\u003c/li\u003e\n\u003cli\u003eLo K, Waterland J, Todd P, Gupta T, Bearman M, Hassed C, Keating JL. Group interventions to promote mental health in health professional education: a systematic review and meta-analysis of randomised controlled trials. Adv Health Sci Educ Theory Pract. 2018 May;23(2):413-447. doi: 10.1007/s10459-017-9770-5.\u003c/li\u003e\n\u003cli\u003eAlmutairi AG, Baabbad NM, Alhumaidan AA, Alshahrani AM, Alabdulkarim AI, Alsughier N\u003cem\u003e.\u003c/em\u003e Prevalence and factors causing test anxiety among medical students. \u003cem\u003eMiddle East Curr Psychiatry\u003c/em\u003e\u003cstrong\u003e31\u003c/strong\u003e, 48 (2024). https://doi.org/10.1186/s43045-024-00437-2\u003c/li\u003e\n\u003cli\u003eKroshus E, Hawrilenko M, Browning A. Stress, self-compassion, and well-being during the transition to college. Soc Sci Med. 2021 Jan;269:113514. doi: 10.1016/j.socscimed.2020.113514.\u003c/li\u003e\n\u003cli\u003eWilliamson C, Wright ST, Beck Dallaghan GL. Test Anxiety Among US Medical Students: A Review of the Current Literature. Med Sci Educ. 2024 Feb 14;34(2):491-499. doi: 10.1007/s40670-024-01999-w. \u003c/li\u003e\n\u003cli\u003eQuek TT, Tam WW, Tran BX, Zhang M, Zhang Z, Ho CS, Ho RC. The Global Prevalence of Anxiety Among Medical Students: A Meta-Analysis. Int J Environ Res Public Health. 2019 Jul 31;16(15):2735. doi: 10.3390/ijerph16152735. \u003c/li\u003e\n\u003cli\u003eBughi SA, Sumcad J, Bughi S. Effect of Brief Behavioral Intervention Program in Managing Stress in Medical Students from Two Southern California Universities. Med Educ Online. 2006 Dec;11(1):4593. doi: 10.3402/meo.v11i.4593.\u003c/li\u003e\n\u003cli\u003eAndrews B, Wilding JM. The relation of depression and anxiety to life-stress and achievement in students. Br J Psychol. 2004 Nov;95(Pt 4):509-21. doi: 10.1348/0007126042369802. \u003c/li\u003e\n\u003cli\u003ePatel R, Varma J, Phatak A, Nimbalkar SM. Study of test anxiety amongst undergraduate medical students from the state of Gujarat. J Educ Health Promot. 2023 Sep 29;12:325. doi: 10.4103/jehp.jehp_1680_22.\u003c/li\u003e\n\u003cli\u003eBalaji NK, Murthy PS, Kumar DN, Chaudhury S. Perceived stress, anxiety, and coping states in medical and engineering students during examinations. Ind Psychiatry J. 2019 Jan-Jun;28(1):86-97. doi: 10.4103/ipj.ipj_70_18.\u003c/li\u003e\n\u003cli\u003eHuntley CD, Young B, Temple J, Longworth M, Smith CT, Jha V, Fisher PL. The efficacy of interventions for test-anxious university students: A meta-analysis of randomized controlled trials. J Anxiety Disord. 2019 Apr; 63:36-50. doi: 10.1016/j.janxdis.2019.01.007.\u003c/li\u003e\n\u003cli\u003eHarra RC, Vargas I. A peer-based mentoring program for reducing anxiety and depression symptoms among college students: A preliminary study. J Am Coll Health. 2024 Dec;72(9):3491-3498. doi: 10.1080/07448481.2023.2172580.\u003c/li\u003e\n\u003cli\u003ePointon-Haas J, Waqar L, Upsher R, Foster J, Byrom N, Oates J. A systematic review of peer support interventions for student mental health and well-being in higher education. BJPsych Open. 2023 Dec 15;10(1): e12. doi: 10.1192/bjo.2023.603.\u003c/li\u003e\n\u003cli\u003eKitzrow MA. The mental health needs of today\u0026rsquo;s college students: challenges and recommendations. NASPA Journal 2003;41(1):167\u0026ndash; 181. doi: 10.2202/1949-6605.1310)\u003c/li\u003e\n\u003cli\u003eSuresh R, Karkossa Z, Richard J, Karia M. Program evaluation of a student-led peer support service at a Canadian university. Int J Ment Health Syst 2021;15(1):1\u0026ndash;11. doi: 10.1186/S13033-021-00479-7\u003c/li\u003e\n\u003cli\u003eIqbal S, Gupta S, Venkatarao E. Stress, anxiety and depression among medical undergraduate students and their socio-demographic correlates. Indian J Med Res. 2015 Mar;141(3):354-7. doi: 10.4103/0971-5916.156571. \u003c/li\u003e\n\u003cli\u003ePeterson, C. (2003). Bringing ADDIE to Life: Instructional Design at Its Best. Journal of Educational Multimedia and Hypermedia\u003cem\u003e, 12\u003c/em\u003e(3), 227-241. Norfolk, VA: Association for the Advancement of Computing in Education (AACE). Retrieved July 20, 2025 from https://www.learntechlib.org/primary/p/2074/.\u003c/li\u003e\n\u003cli\u003eLynn MR. Determination and quantification of content validity. Nurs Res. 1986;35(6):382\u0026ndash;385. doi: 10.1097/00006199-198611000-00017\u003c/li\u003e\n\u003cli\u003eBacon A, Taylor T. Tackling exam-induced anxiety at medical school. Med Teach. 2018 Feb;40(2):212. doi: 10.1080/0142159X.2017.1386294. \u003c/li\u003e\n\u003cli\u003eTsegay L, Shumet S, Damene W, Gebreegziabhier G, Ayano G. Prevalence and determinants of test anxiety among medical students in Addis Ababa Ethiopia. BMC Med Educ. 2019 Nov 14;19(1):423. doi: 10.1186/s12909-019-1859-5. \u003c/li\u003e\n\u003cli\u003eMemon I, Omair A, Barradah OM, Almegren NM, Almuqbil MM, Batarfi OH, Masuadi E, Feroz Z. Measurement of Exam Anxiety Levels Among Medical Students and Their Association with the Influencing Factors. Cureus. 2023 Jul 5;15(7):e41417. doi: 10.7759/cureus.41417.\u003c/li\u003e\n\u003cli\u003eDriscoll R. Westside Test Anxiety Scale validation and use. ERIC Document Reproduction Service No. ED495968. 2007.\u003c/li\u003e\n\u003cli\u003eDederichs M, Weber J, Muth T, Angerer P, Loerbroks A. Students\u0026apos; perspectives on interventions to reduce stress in medical school: A qualitative study. PLoS One. 2020 Oct 15;15(10):e0240587. \u003c/li\u003e\n\u003cli\u003eJaisoorya T S, Joseph S, Kalarani K S, Menon M, Smita G S, Shini V S, Jose SE, Mahesh M M, Shibu K, Sujisha T G, Jayaprakashan K P, Kiran P S, Anil Kumar T V, Vigneshwari V, Titus U. Framework and Overview of a State-Wide College Mental Health Program in Kerala, India. Indian J Psychol Med. 2023 Sep;45(5):526-532. doi: 10.1177/02537176221122407\u003c/li\u003e\n\u003cli\u003eLipson, S. K., Kern, A., Eisenberg, D., \u0026amp; Breland-Noble, A. M. (2018). Mental Health Disparities Among College Students of Color. Journal of Adolescent Health, 63(3), 348\u0026ndash; 356. https://doi.org/10.1016/j.jadohealth.2018.04.014 \u003c/li\u003e\n\u003cli\u003eMead, S., Hilton, D., \u0026amp; Curtis, L. (2001). Peer support: A theoretical perspective. Psychiatric Rehabilitation Journal, 25(2), 134\u0026ndash;141. https://doi.org/10.1037/h0095032\u003c/li\u003e\n\u003cli\u003eUgarte DA, Cumberland WG, Singh P, Saadat S, Garett R, Young SD. A HOPE Online Community Peer Support Intervention for Help Seeking: A Randomized Controlled Trial. Psychiatr Serv. 2023 Jun 1;74(6):648-651. doi: 10.1176/appi.ps.202000817.\u003c/li\u003e\n\u003cli\u003eLiu, B., Hodge, A., Jushka, C., \u0026amp; Hueston, W. J. (2022). A Pilot Study of Reducing Test Anxiety in a Cohort of Underrepresented in Medicine MCAT Students Using Near-Peer Coaching. \u003cem\u003eInternational Journal of Medical Students\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e(2), 139\u0026ndash;147. https://doi.org/10.5195/ijms.2022.1185 \u003c/li\u003e\n\u003cli\u003eLynch TV, Beach IR, Kajtezovic S, Larkin OG, Rosen L. Step Siblings: a Novel Peer-Mentorship Program for Medical Student Wellness During USMLE Step 1 Preparation. Med Sci Educ. 2022 Jun 13;32(4):803-810. doi: 10.1007/s40670-022-01571-4.\u003c/li\u003e\n\u003cli\u003eSingh S, Singh N, Dhaliwal U. Near-peer mentoring to complement faculty mentoring of first-year medical students in India. J Educ Eval Health Prof. 2014 Jun 30;11:12. doi: 10.3352/jeehp.2014.11.12. \u003c/li\u003e\n\u003cli\u003eDay V, McGrath PJ, Wojtowicz M. Internet-based guided self-help for university students with anxiety, depression and stress: a randomized controlled clinical trial. Behav Res Ther. 2013 Jul;51(7):344-51. doi: 10.1016/j.brat.2013.03.003.\u003c/li\u003e\n\u003cli\u003eHarrer M, Adam SH, Fleischmann RJ, Baumeister H, Auerbach R, Bruffaerts R, Cuijpers P, Kessler RC, Berking M, Lehr D, Ebert DD. Effectiveness of an Internet- and App-Based Intervention for College Students With Elevated Stress: Randomized Controlled Trial. J Med Internet Res. 2018 Apr 23;20(4):e136. doi: 10.2196/jmir.9293.\u003c/li\u003e\n\u003cli\u003eJerrim, J. (2022). Test anxiety: Is it associated with performance in high-stakes examinations? \u003cem\u003eOxford Review of Education\u003c/em\u003e, \u003cem\u003e49\u003c/em\u003e(3), 321\u0026ndash;341. https://doi.org/10.1080/03054985.2022.2079616.\u003c/li\u003e\n\u003cli\u003eEisenberg D, Hunt J, Speer N, Zivin K. Mental health service utilization among college students in the United States. J Nerv Ment Dis. 2011 May;199(5):301-8. doi: 10.1097/NMD.0b013e3182175123.\u003c/li\u003e\n\u003cli\u003eLipson SK, Lattie EG, Eisenberg D. Increased Rates of Mental Health Service Utilization by U.S. College Students: 10-Year Population-Level Trends (2007-2017). Psychiatr Serv. 2019 Jan 1;70(1):60-63. doi: 10.1176/appi.ps.201800332. \u003c/li\u003e\n\u003cli\u003eReavley NJ, McCann TV, Jorm AF. Mental health literacy in higher education students. Early Interv Psychiatry. 2012 Feb;6(1):45-52. doi: 10.1111/j.1751-7893.2011.00314.x. \u003c/li\u003e\n\u003cli\u003eBryan AE, Arkowitz H. Meta-analysis of the effects of peer-administered psychosocial interventions on symptoms of depression. Am J Community Psychol. 2015 Jun;55(3-4):455-71. doi: 10.1007/s10464-015-9718-y.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7353237/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7353237/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground and objectives:\u003c/strong\u003e \u0026nbsp;Medical students face significant test anxiety due to academic pressure and limited mental health support. Peer led interventions offer a promising alternative, but evidence in medical education is limited. This study was aimed to develop a validated mental health intervention module and evaluate the impact of peer-led mentoring program on test anxiety among undergraduate MBBS students in India.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A structured, evidence-based peer-led mentoring module was developed using ADDIE model and validated by experts (Content Validity Index \u0026gt; 0.78). A prospective pre-and post-intervention cohort study involved 100 second-year MBBS students of a public medical college. Peer mentors, trained using a validated module, provided group and individual mentoring before high-stakes examinations (Mock Boards). The primary outcome was test anxiety scores measured using Westside Test Anxiety (WTA) Scale. Secondary outcomes included academic performance and qualitative assessments of acceptability and feasibility through focus group discussions.\u003cbr\u003e\n\u003cstrong\u003eResults: \u003c/strong\u003eAt baseline, 40% of students had test anxiety (WTA ≥ 3) (32% moderate-high, 8% severe), with a median WTA score of 2.7 (IQR: 2.25-3.25). Post-intervention, median WTA scores significantly decreased to 2.35 (difference: -0.35; 95% CI: -0.5 to -0.2; P \u0026lt; 0.001). The proportion of students with normal/high-normal anxiety (WTA score \u0026lt;3) increased from 60% to 79%, and no students had severe anxiety post-intervention (P = 0.002). Students with moderate-high anxiety showed ~22% reduction, while those with severe anxiety showed ~30% reduction in median WTA scores. Academic performance showed no significant differences among anxiety groups. Students reported high satisfaction (median score: 7/10), and the intervention was deemed highly acceptable and feasible.\u003cbr\u003e\n\u003cstrong\u003eConclusions:\u003c/strong\u003e The peer-led mentoring program effectively reduced test anxiety among medical students during high stakes examination. While academic performance did not significantly improve, integration of such programs into formal support systems could enhance sustainability and impact in medical education settings.\u003c/p\u003e","manuscriptTitle":"Peer-Led Mentoring Intervention for Test Anxiety Reduction among Medical Students: Development, Implementation, and Prospective Evaluation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-08 07:11:20","doi":"10.21203/rs.3.rs-7353237/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-03T17:53:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-03T06:14:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"26992647436179245235585718292092136935","date":"2025-10-27T06:00:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-08T12:36:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"228765456401157577748335154359042819761","date":"2025-10-03T12:48:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-26T00:55:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"328983190888287392696447501361083189897","date":"2025-09-26T00:49:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-25T13:38:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-23T11:37:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-02T11:43:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-02T03:41:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-09-02T03:38:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8473cab3-f3e6-43d0-9644-a0b6b968cfe5","owner":[],"postedDate":"October 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T16:11:26+00:00","versionOfRecord":{"articleIdentity":"rs-7353237","link":"https://doi.org/10.1186/s12909-026-08697-8","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2026-02-02 15:58:45","publishedOnDateReadable":"February 2nd, 2026"},"versionCreatedAt":"2025-10-08 07:11:20","video":"","vorDoi":"10.1186/s12909-026-08697-8","vorDoiUrl":"https://doi.org/10.1186/s12909-026-08697-8","workflowStages":[]},"version":"v1","identity":"rs-7353237","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7353237","identity":"rs-7353237","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}