The Adaptation Paradox Beyond NEET-UG Scores: A Cross-sectional Study of Post-admission Adaptation and Academic Performance among Medical Undergraduates in North India

1. Associate Professor, Department of Community Medicine, Naraina Medical College and Research Centre, Kanpur, Uttar Pradesh, India. 2. Assistant Professor, Department of Community Medicine, Jaipur National University Institute of Medical Sciences and Research Centre, Jaipur, Rajasthan, India. 3. Associate Professor, Department of Microbiology, KD Medical College, Mathura, Uttar Pradesh, India. 4. Professor, Department of Community Medicine, Jaipur National University Institute of Medical Sciences and Research Centre, Jaipur, Rajasthan, India. 5. Professor, Department of Community Medicine, Jaipur National University Institute of Medical Sciences and Research Centre, Jaipur, Rajasthan, India.

Abstract

Introduction: National Eligibility-cum-Entrance Test for Undergraduates (NEET-UG) score provides an entry-level marker of academic preparedness for Bachelor of Medicine and Bachelor of Surgery (MBBS) students, but academic performance after admission may also depend on study behaviour, peer context and self-regulation within the medical-college environment.

Aim: To assess factors associated with satisfactory academic performance among MBBS students, with particular focus on NEET-UG category, study pattern, academic peer orientation and peer-related academic resilience.

Materials and Methods: This cross-sectional study was conducted among 358 MBBS students from second year onward at the Department of Community Medicine, Jaipur National University Institute of Medical Sciences and Research Centre, Jaipur, Rajasthan, India between January 2025 and March 2025. Data were collected using an anonymous, structured, self-administered online questionnaire assessing NEET-UG category, most recent university examination performance, study pattern, residence, alcohol/smoking status, psychological distress indicators, academic peer orientation and peer-related academic resilience. Satisfactory academic performance was defined as a self-reported score of ≥60% in the most recent university examination. Associations were assessed using a Chi-square test and multivariable logistic regression. Adjusted Odds Ratios (aOR) with 95% Confidence Intervals (CI) were reported.

Results: Overall, 243 students (67.9%) reported satisfactory academic performance. On adjusted analysis, NEET-UG category, gender, study pattern and peer-related academic resilience remained independently associated with satisfactory performance. Compared with the <250/not disclosed NEET-UG category, higher odds were observed among students scoring 250-349 (aOR=2.14; 95% CI: 1.21–3.78; p=0.009) and ≥350 (aOR=2.22; 95% CI: 1.19-4.16; p=0.012). Female students had higher odds of satisfactory performance than male students (aOR=2.05; 95% CI: 1.26–3.33; p=0.004). Students reporting ≥3 hours/day or a need-based variable study pattern had higher odds than those reporting <3 hours/day (aOR=1.71; 95% CI: 1.04-2.80; p=0.033). Peer-related academic resilience was independently associated with satisfactory performance (aOR=1.83; 95% CI: 1.13-2.97; p=0.015), while academic peer orientation alone was not.

Conclusion: Academic performance among MBBS students was associated with both entry-level academic profile and post-admission adaptation factors. Study pattern and peer-related academic resilience appear important beyond NEET-UG category alone.

Educational measurement, Medical, National eligibility-cum-entrance test for undergraduates Peer group, Psychological, Self-directed learning, Students

Undergraduate medical education in India is a competitive and academically demanding pathway. Admission to the Bachelor of Medicine and Bachelor of Surgery programme is through the NEET-UG, which functions as a common entrance examination for admission to undergraduate medical education across medical institutions in India (1). NEET-UG score therefore provides an entry-level marker of academic preparedness. However, its relevance after admission is not deterministic, because students subsequently enter a different academic environment that requires sustained adaptation, self-directed learning and increasing personal responsibility (2),(3).

Admission to medical college is followed by a major academic and developmental transition. Students move from school- or coaching-centred preparation into a professional course where academic outcomes may be influenced by study behaviour, self-regulation, peer context, residential environment and access to support (4),(5),(6). This transition occurs during late adolescence or early adulthood, when autonomy, identity and social relationships are still evolving (7). Under the competency-based undergraduate curriculum, students are also expected to progressively develop independent learning, professionalism and responsiveness within a demanding academic environment (8).

Peer-related influences are particularly relevant because peer networks are central to student life in medical college. Peers may shape learning through discussion, shared resources and motivation, but they may also influence comparison, distraction, social participation, lifestyle behaviours and emotional support. While peer-assisted learning has shown beneficial effects on academic outcomes in medical education (9), naturally occurring peer influence may operate through broader and less structured pathways (10). These interactions are also part of students’ broader developmental journey, shaping autonomy, coping behaviour, identity, social responsibility and professional socialisation during medical training (11).

In such multidimensional peer environments, academic performance may depend not only on whether students have academically oriented peers, but also on whether they can maintain academic autonomy and self-regulation despite competing peer-social demands. This peer-related academic resilience may help explain why some students perform well despite exposure to non-academic or distracting peer environments, while others may underperform even when peer networks appear academically supportive. This framing is consistent with self-regulated learning literature, which views learning as an interaction between the learner, context and learning strategies (12),(13).

Medical students also experience substantial psychological distress, anxiety and stress, which may interact with academic engagement, peer context and support-seeking behaviour (14),(15),(16). Available Indian studies have examined academic performance and related factors among medical students (4),(5), and recent literature has also explored study habits, peer influence and self-regulated learning in medical education (6),(10),(12),(13),(17),(18),(19),(20),(21),(22). However, evidence simultaneously examining entry-level academic profile, study pattern, academic peer orientation and peer-related academic resilience in relation to undergraduate medical performance remains limited. The present study was therefore conducted to assess factors associated with satisfactory academic performance among MBBS students, with particular focus on NEET-UG category, study pattern, academic peer orientation and peer-related academic resilience.

Material and Methods

This cross-sectional study was conducted among undergraduate medical students enrolled in the MBBS programme at the Department of Community Medicine, Jaipur National University Institute of Medical Sciences and Research Centre, Jaipur, Rajasthan, India between January and March 2025. The study was reported in accordance with the STROBE recommendations for observational studies (23). The study was approved by the Institutional Ethics Committee (Approval No.: JNUIMSRC/IEC/2024/140; dated 19 December 2024). Written informed consent was obtained from all participants before data collection. Participation was voluntary, and students were informed that non participation would not affect their academic standing. No identifying information was collected, and data were analysed in aggregate form to maintain confidentiality.

Inclusion criteria: Consenting MBBS students from second year onward who were present during data collection were eligible.

Exclusion criteria: First-year students were excluded because they had limited exposure to sustained medical-college peer networks and had not uniformly completed university examinations at the time of data collection. Pilot participants and non consenting students were excluded.

Sample size: The eligible source population was approximately 750 students from second year onward. For this population, a conservative prevalence estimate of 50%, 95% confidence level and 5% absolute precision gave an initial sample size of 384. After finite population correction, the required sample size was 254; with 20% allowance for non response/non availability, the target sample size was 318 (24). The final analysed sample included 358 students.

Study Procedure

Data were collected during routine academic sessions. The date of data collection was not announced in advance. Sessions were selected when at least half of the eligible class was present, and all eligible students present were invited to participate. More than 90% of students present completed the questionnaire. Participation was voluntary and anonymous. No personal identifiers such as name, roll number, email address or mobile number were collected.

Data were collected using an anonymous, structured, self-administered online questionnaire developed by the investigators. The questionnaire assessed academic profile, study practices, peer influence, lifestyle behaviours, psychological distress indicators and support-system access. It included both core analytical and broader 16
context-setting questions. Several sensitive lifestyle and relationship items had substantial “prefer not to say” responses, and further subgrouping produced cell sizes too small for meaningful inferential analysis. The present analysis was therefore restricted to variables relevant to academic performance. The draft tool was reviewed by departmental faculty for content coverage and pre-tested among 30 interns for clarity, feasibility and face validity. Pilot responses were excluded from the final analysis. The primary outcome was satisfactory academic performance, defined as a self-reported score of ≥60% in the most recent university examination. Entry-level academic profile was assessed using self-reported NEET-UG score. NEET-UG is scored out of a maximum of 720 marks. For analysis, scores were grouped as <250/not disclosed, 250-349 and ≥350.

The academic section included both core analytical and context-setting items; the present analysis used recent university examination performance as the outcome and usual study duration/pattern as the principal study-behaviour variable. Study pattern outside scheduled academic activities was categorised as <3 hours/day or ≥3 hours/day/need-based variable study pattern.

Alcohol and smoking/vaping responses were retained as a combined adjustment variable because these could be grouped into analytically interpretable categories. Alcohol/smoking status was grouped as no reported use versus reported use/non disclosure; no reported use required “never” responses for both alcohol and smoking/vaping.

Recent emotional symptoms were assessed using two items on feeling nervous, anxious or on edge and having little interest or pleasure in doing things during the preceding two weeks. Each item was scored from 0 to 3, yielding a total score of 0-6. Scores were grouped as <3 and ≥3 for exploratory analysis.

The 12 peer-related Likert statements represented multiple dimensions of peer influence. Conceptually related items were grouped to assess peer orientation and peer-related academic resilience rather than being treated as a single scale.

Academic peer orientation was derived from items assessing whether friends improved understanding, encouraged good study habits and motivated better performance. Peer-related academic resilience was derived from items assessing the ability to say “no” when study was required, adherence to one’s own study plan regardless of peers and independence of academic decisions from friends’ opinions. Responses were recorded on a five-point Likert scale. Participants responding “agree” or “strongly agree” to at least two of the three constituent items were classified as academically oriented or peer-resilient, respectively.

Academic peer orientation and peer-related academic resilience were first analysed as two separate binary constructs. These binary classifications are presented separately in the descriptive results. Subsequently, the two constructs were cross-classified to generate four mutually exclusive peer adaptation groups: academic-resilient, academic-compromised, non academic-resilient and non academic-compromised.

Batch-wise analysis was not undertaken because batches represented different admission cohorts and participation varied across batches. Age group was retained as a maturity-related adjustment variable.

STATISTICAL ANALYSIS

Data were analysed using Statistical Package for Social Sciences (SPSS) statistical software. Categorical variables were summarised as frequencies and percentages. Associations with satisfactory academic performance were assessed using Pearson’s Chi-square test or Fisher’s-exact test, as appropriate. Internal consistency of peer-item clusters was assessed using Cronbach’s alpha. Multivariable logistic regression was performed to identify factors independently associated with satisfactory academic performance.

The model included age group, NEET-UG category, gender, residence, study pattern, alcohol/smoking status, two-item emotional symptom score, academic peer orientation and peer-related academic resilience. aOR with 95% CIs was reported. A p-value<0.05 was considered statistically significant.

Results

A total of 358 MBBS students were included in the analysis. Most participants were aged 20-21 years 198 (55.3%), and females constituted 220 (61.5%) of the study population. Regarding entry-level academic profile, 136 (38.0%) were in the NEET-UG <250/not disclosed category, 123 (34.4%) in the 250-349 category and 99 (27.7%) in the ≥350 category. Most students resided either in Institutional hostel accommodation or with family, 328 (91.6%) (Table/Fig 1).

Academic, Distress and Peer Profile
Overall, 243 students (67.9%) reported satisfactory academic performance. A study pattern of ≥3 hours/day or need-based variable study pattern was reported by 152 students (42.5%), while 206 students (57.5%) reported studying <3 hours/day. A higher two-item emotional symptom score (≥3) was present in 112 students (31.3%).

An academically oriented peer environment was reported by 222 students (62.0%), while 193 students (53.9%) were classified as peer-resilient. Internal consistency was good for academic peer orientation items (Cronbach’s alpha=0.81) and acceptable for peer-related academic resilience items (Cronbach’s alpha=0.72) (Table/Fig 2).

Univariate Analysis of Factors Associated with Satisfactory Academic Performance
On univariate analysis, satisfactory academic performance was significantly associated with gender, NEET-UG category, residence, study pattern and peer-related academic resilience (Table/Fig 3).

Female students had higher satisfactory performance than male students (75.0% vs 56.5%, p<0.001). Satisfactory performance was higher in the 250-349 and ≥350 NEET-UG categories than in the <250/not disclosed category (p=0.004).

Students reporting ≥3 hours/day or a need-based variable study pattern had higher satisfactory performance than those reporting <3 hours/day (73.7% vs 63.6%, p=0.043). Peer-related academic resilience was significantly associated with satisfactory performance (75.1% vs 59.4%, p=0.001). Academic peer orientation showed a favourable but non significant association (p=0.088). The two-item emotional symptom score was not associated with satisfactory academic performance (p=0.996).

Peer Adaptation Matrix and Satisfactory Academic Performance
Academic peer orientation and peer-related academic resilience were initially presented as separate binary constructs in (Table/Fig 2). For further interpretation, these two constructs were cross-classified into four peer adaptation groups, as shown in (Table/Fig 4). Satisfactory academic performance varied significantly across the four peer adaptation groups (overall p=0.010). Using the non academic–compromised group as reference, crude odds of satisfactory academic performance were higher among non academic–resilient students and academic–resilient students. The academic–compromised group showed only a modest increase (Table/Fig 4).

Multivariable Analysis of Factors Associated with Satisfactory Academic Performance
In multivariable logistic regression, NEET-UG category, gender, study pattern and peer-related academic resilience remained independently associated with satisfactory academic performance (Table/Fig 5). Compared with the <250/not disclosed NEET-UG category, students in the 250-349 category had higher odds of satisfactory academic performance (aOR=2.14; 95% CI: 1.21–3.78; p=0.009), as did students in the ≥350 category (aOR=2.22; 95% CI: 1.19-4.16; p=0.012). Female students had higher odds of satisfactory academic performance than male students (aOR=2.05; 95% CI: 1.26-3.33; p=0.004).

Students reporting ≥3 hours/day or a need-based variable study pattern had higher odds of satisfactory academic performance than those reporting <3 hours/day (aOR=1.71; 95% CI: 1.04-2.80; p=0.033). Peer-related academic resilience was also independently associated with satisfactory performance (aOR=1.83; 95% CI: 1.13-2.97; p=0.015). Academic peer orientation was not independently associated after adjustment (aOR=1.18; 95% CI: 0.72-1.94; p=0.514). Age group, residence, alcohol/smoking status and two-item emotional symptom score were not independently associated with satisfactory academic performance.

Discussion

Academic performance after entry into medical college reflects the combined effect of baseline academic preparedness and post-admission adaptation. In the present study, NEET-UG category remained associated with satisfactory academic performance, indicating that entry-level academic profile continued to matter. However, study pattern and peer-related academic resilience were also independently associated with performance, suggesting that adaptation within the medical-college environment is an important post-admission determinant of academic outcomes.

The key peer-related finding was that academic peer orientation alone was not independently associated with satisfactory performance after adjustment, whereas peer-related academic resilience was. This distinction is important because peer influence in medical college is not a single positive or negative exposure. Students navigate multidimensional peer environments involving academic support, comparison, social participation, distraction and emotional support. The ability to maintain academic autonomy within this environment may therefore be more important than simply having academically oriented peers.

The NEET-UG category remained independently associated with satisfactory academic performance, supporting its role as a marker of entry-level academic preparedness. Previous literature has shown that prior academic achievement and admission-related indicators are associated with subsequent medical-school outcomes (2),(3). However, this association should not be interpreted as deterministic. In the present study, students in the 250-349 and ≥350 NEET-UG categories had broadly similar proportions of satisfactory performance, suggesting that after admission, higher entry scores alone may not fully determine academic outcomes. This is consistent with studies showing that medical student performance is influenced by multiple academic and non-academic factors, including study behaviour, residence, psychological factors and institutional context (3),(4),(5).

Study pattern was independently associated with satisfactory performance. Students reporting ≥3 hours/day or a need-based variable study pattern had higher odds of satisfactory performance than those reporting <3 hours/day. This finding should not be interpreted as a simple linear relationship between longer study hours and higher marks. Rather, it may reflect sustained academic engagement, flexible planning and self-regulated learning according to academic need. Recent literature on medical students’ study habits similarly emphasises time management, reduction of distractions, sociocultural context, learning skills and adaptive study strategies rather than study duration alone (6),(17),(18),(19),(20),(21),(22). Self-regulated learning frameworks emphasise that effective learning depends on the interaction between the learner, context and learning strategies, rather than on ability alone (12),(13). In a medical-college environment, the ability to organise study time despite academic workload and peer-social demands may therefore be an important adaptation skill.

The peer adaptation matrix further supported the central interpretation.Satisfactory performance was highest among academic-resilient students and lowest among non-academic-compromised students. Notably, students in the non-academic-resilient group had higher crude odds of satisfactory performance than the reference group, whereas the academic-compromised group showed only a modest increase. This suggests that academic autonomy or resilience may partly offset a less academically oriented peer environment, whereas academically oriented peers may not be sufficient when the student’s own self-regulation is compromised. Structured peer-assisted learning has demonstrated beneficial effects on academic outcomes in medical education (9), but naturally occurring peer influence in student life is broader than formal peer learning and may operate through both academic and social pathways (10).

These findings have practical implications for medical education. Interventions should not only promote peer learning, but also strengthen students’ ability to maintain study plans, set academic boundaries and navigate peer-social pressures. Peer interaction is a normal and important part of student development, social integration and professional identity formation. The relevant institutional goal is therefore not to discourage peer socialisation, but to help students balance social engagement with academic self-regulation. Peer interaction may also contribute to broader developmental outcomes, including social responsibility and professional formation (11). Peer-based and mentoring interventions may support student well-being, although evidence from higher education remains heterogeneous (25).

A higher two-item emotional symptom score was present in nearly one-third of students but was not associated with satisfactory academic performance. This finding should not reduce the importance of emotional symptoms as a student well-being Global evidence shows that depression, depressive symptoms and anxiety are common among medical students (14),(15), and Indian evidence also highlights depression, anxiety and stress as important concerns in this population (16). The lack of association with academic performance may indicate that academic achievement and emotional distress follow partly different pathways. Some students may maintain academic performance despite distress, while others may experience distress in domains not captured by examination scores. Academic performance alone is therefore unlikely to be sufficient for identifying students who require psychosocial support.

Female gender remained independently associated with satisfactory academic performance. Gender-related differences in academic performance have been variably reported in medical education literature and are likely to be context-specific (2),(3),(19). In the present study, this association may reflect differences in study behaviour, academic engagement, peer networks or other unmeasured contextual factors. It should not be interpreted as a fixed biological gender effect. Further longitudinal or mixed-method studies may help clarify the mechanisms underlying gender differences in academic outcomes.

The present study has several strengths. It included a relatively large sample from the eligible undergraduate population, used anonymous data collection for sensitive domains and examined both entry-level and post-admission factors. The peer framework avoided treating peer influence as a single positive or negative construct and instead distinguished academic peer orientation from peer-related academic resilience. The use of both univariate and multivariable analysis helped identify factors independently associated with satisfactory academic performance.

Limitation(s)

The study also has limitations. It was conducted in a single Institution, which limits generalisability. Its cross-sectional design precludes causal inference. Academic performance, NEET-UG category and sensitive behaviours were self-reported. Because the questionnaire was anonymous, individual-level comparison of respondents and non respondents was not possible. Batch-wise comparisons were not undertaken because batches represented different admission cohorts and participation varied across batches; therefore, findings should be interpreted as overall undergraduate patterns rather than batch-specific estimates. The questionnaire was investigator-developed and pre-tested, but it was not an externally validated psychometric instrument. Although academic peer orientation and peer-related academic resilience showed acceptable internal consistency, some peer-social item clusters showed lower reliability and were therefore interpreted descriptively.

Overall, the findings support a post-admission adaptation framework in which entry profile, study pattern and peer-related academic resilience jointly shape academic performance among MBBS students.

Conclusion

Academic performance among undergraduate medical students was associated with both entry-level academic profile and post-admission adaptation factors. NEET-UG category remained associated with satisfactory performance, but study pattern and peer-related academic resilience were also independently associated. Academic peer orientation alone was not independently associated after adjustment, suggesting that academically oriented peers may be insufficient unless students maintain academic autonomy and self-regulation within peer networks. Medical colleges should therefore complement academic teaching with mentoring, study-skills support and counselling visibility to help students balance peer-social engagement with academic self-regulation. Supporting students’ ability to navigate peer environments without compromising study behaviour may be an important strategy for improving academic adaptation and performance.

Authors’ contribution: NR: Conceptualisation, Study design, Data analysis Manuscript drafting; MS: Study design, Data collection; SS: Data collection; VB: Data analysis; MG: Manuscript drafting.

DOI and Others

DOI: 10.7860/JCDR/2026/90938.24366

Date of Submission: Jun 02, 2026
Date of Peer Review: Jun 30, 2026
Date of Acceptance: Aug 03, 2026
Date of Publishing: Sep 01, 2026

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

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