To a certain extent, stress serves as a beneficial stimulus for human growth and development (1, 2). However, ongoing high levels of stress may lead to negative outcomes, such as psychological distress, anxiety, depression, physical illness, substance abuse, and impaired academic or work performance (3–7).

Among university students stress is a major issue as they cope with numerous stressors and transitional events in academic, social, and personal domains (8, 9). This unique combination of personal change and situational challenges creates an environment that can elevate stress levels to a problematic state, often marked by persistent feelings of worry, hopelessness, or exhaustion. Globally, studies indicate an increasing number of university students experiencing stress (5, 10, 11). Although prevalence rates vary across countries, approximately 50% of the student population experiences significant levels of stress (3, 12, 13).

In Low-and middle-income-countries (LMICs), university students often face additional stressors such as being sole providers for the family, insecurity, living in a war zone or isolated area, inadequate resources, lack of water, and poor study conditions (14). These unique challenges can exacerbate stress levels and affect the overall well-being of the university students. The inability to cope with stress has been shown to negatively impact their health behaviors manifesting as e.g., alcohol abuse, smoking, and eating disorders (15–17). Furthermore, studies have also shown that stressed university students show a decrease in their mental health status, contributing to depression (18, 19) and lower self-esteem (20). These conditions, in turn, can impair students' academic performance and social functioning, leading to significant burden at university, such as academic probation and delayed graduation, which may potentially affect their future career opportunities (7, 21, 22).

A variety of interventions developed to reduce stress level in university students utilize numerous strategies and techniques such as psychoeducation, relaxation training, cognitive behavioral therapy (CBT), social support, coping skills training, and mindfulness training (23). Stress management interventions (SMIs) have been shown to effectively reduce stress among student populations (12, 23, 24) and improve their quality of life (3). Previous meta-analyses have reported effect sizes ranging from 0.30 to 0.61 for SMIs in reducing stress levels among university students (12, 24–26).

However, most of the studies have been conducted in high income countries (HICs), and the potential benefit of SMIs for reducing stress levels are less well-established in LMICs. It is important to recognize that findings from HICs may not be generalizable to university students in LMICs due to the distinct stressors they face. Therefore, it is important to examine whether SMIs are as effective in LMICs to fill the knowledge gap. This present study is a systematic review and meta-analysis of such interventions with the aim of providing an evidence-based approach for effectiveness of SMIs in decreasing the stress levels among university students in LMICs.

The study protocol was registered in The Open Science Framework which can be retrieved via https://doi.org/10.17605/OSF.IO/GHSEB. The PRISMA 2020 guidelines for reporting the systematic review and meta-analysis were followed (27). The completed PRISMA checklist is provided in the Supplementary Material S1.

We conducted a meta-analysis on the effectiveness of SMIs in reducing stress among university students in LMICs. A total of 28 studies with 31 comparisons were included in the meta-analysis. We found a significant high effect size with high heterogeneity across all included studies. After conducting a sensitivity analysis by removing outliers, we discovered a moderate and significant effect size of SMIs compared to the control condition with moderate heterogeneity across studies.

Our findings align with previous meta-analyses that have demonstrated the effectiveness of stress management interventions (SMIs) in reducing stress among college students (23, 26). Yusufov et al. (23) reported a moderate effect size [d = 0.44, 95% CI (0.24, 0.64), p < .01] among undergraduate and graduate students, while Amanvermez et al. (23) found a moderate pooled effect size [g = 0.56, 95% CI (0.44, 0.68), p < .001] in studies involving unselected college students. However, the majority of studies included in these meta-analyses were conducted in HICs, and no separate analysis was performed for HICs and LMICs, limiting the generalizability of their findings to students in LMICs.

Therapeutical orientation used among SMIs in LMICs varied, with mindfulness-based interventions being the most commonly used (n = 14). This aligns with global trends, as mindfulness-based interventions have been increasingly adopted in both HICs and LMICs due to their effectiveness in reducing stress, anxiety, and depression (81). Mindfulness-based SMIs' effectiveness has also been demonstrated specifically among university students (82–84). The preference for mindfulness-based SMIs in LMICs may be attributed to their cultural relevance and alignment with regional values, beliefs, and practices. Many LMICs have long-standing contemplative traditions rooted in Buddhist, Hindu, and Islamic philosophies, which emphasize self-awareness, acceptance, and emotional regulation—all core principles of modern mindfulness interventions (85). Additionally, mindfulness-based SMIs are often embedded within preventive mental health approaches, which are generally perceived as less stigmatizing than treatment-focus intervention in LMICs, where mental health stigma remains a significant barrier to care (86).

Mind-body-based SMIs such as physical exercise and yoga were the second most utilized approach (n = 8). These interventions may provide a non-stigmatizing and widely accepted means of reducing stress particularly in low resources setting. Effectiveness of mind-body based SMIs in reducing stress, anxiety, and depression among adult and college students is supported by previous RCTs (87, 88). Furthermore, a cross-sectional study among university students in LMICs found that physical activity was associated with improved stress regulation and well-being (89). Similarly, systematic reviews have reported that mind-body based intervention, including yoga and structured movement therapies, contribute to stress reduction (90, 91). Mind-body SMIs may be preferred in LMICs due to their social acceptability, and ease of implementation as physical exercise and yoga can be integrated seamlessly into daily life. Beside stand-alone intervention, mind-body interventions may serve as a complementary component within more intensive SMIs programs, enhancing overall effectiveness by addressing physical well-being alongside other psychological strategies (91).

Internet-based interventions have expanded in LMICs, particularly during and after the COVID-19 pandemic. Our findings indicate that both face-to-face and online formats are effective in delivering SMIs to university students. However, previous meta-analyses suggest that internet-based interventions, particularly those delivered without support, tend to yield smaller effects in reducing stress compared to face-to-face interventions (92–94). This may be attributed to lower engagement and higher dropout rates in unguided internet-based interventions. The guided format that incorporates professional or facilitator support has demonstrated better adherence and stronger outcomes (95, 96). Despite this, digital interventions remain a viable alternative for early intervention, particularly in low-resource settings, where access to traditional mental health services is often limited.

The predominance of face-to-face SMIs in the present study suggests that in-person formats remain highly valued in LMICs, while digital interventions are emerging but remain underrepresented in RCTs. However, with increasing technological accessibility, the growth of digital mental health fields, and the “digital native” characteristics of university students, online SMIs have significant potential for expansion. Studies show that university students perceive internet-based interventions positively and report significant benefits (97, 98). These interventions also offer scalability and accessibility, enabling them to reach a diverse student population in LMICs. Compared to face-to-face interventions, digital programs eliminate geographical barriers, allow users to engage at their convenience, and can be disseminated to large populations without a proportional increase in resources, making them a potentially cost-effective solution for student mental health in LMICs (99, 100). Recent advances in artificial intelligence (AI) also present promising future directions, particularly through virtual therapists and chatbots that may offer more conversational and human-like interactions, further enhancing the relatability and accessibility of digital interventions in these settings (101).

Despite the growing interest in digital interventions, existing digital programs in LMICs primarily focus on clinical conditions such as depression, anxiety, post-traumatic stress disorder, and substance misuse (102), with limited emphasis on subclinical and preventive applications. Concurrently, a wide range of digital tools such as apps and wearable-supported platforms that promote exercise, yoga, and mindfulness are now available to support self-care and general well-being. These tools represent important developments in the broader digital mental health landscape. However, their usage and effectiveness among university students in LMICs remain underexamined. Expanding culturally adapted, low-intensity interventions particularly unguided and group-based formats could help bridge existing gaps in student mental health care. Given the barriers to access individualized psychological support in LMICs, integrating low-intensity, scalable interventions within university settings may improve accessibility to mental health services.

Among the included studies, most SMIs (n = 25) were delivered by trained professionals, with no studies utilizing lay providers. In LMICs, lay personnel have been increasingly recognized as a viable resource for expanding mental health services, particularly in settings with limited access to professional mental health care (103). Given the importance of peer influence during university years, integrating peer counselors into structured, low-intensity interventions may be promising in university settings. While concerns have been raised about the quality and consistency of care delivered by non-professionals, evidence suggests that, when supported by proper training, supervision, and clear intervention guidelines, lay providers can deliver mental health intervention effectively and safely (104). Incorporating trained peer counselors into university-based programs may thus enhance feasibility, accessibility, and engagement in university-based mental health programs without compromising intervention quality (105).

While non-group formats dominated in the included studies, some interventions adopted group-based approaches, which may provide a cost-effective alternative for delivering SMIs in low-resources university settings. Although evidence specifically among university students in LMICs remains limited, studies from other youth population suggest promising outcomes. RCTs in Kenya and China have demonstrated the effectiveness and cost-effectiveness of group-and school-based interventions for adolescents' anxiety, depression, and post-traumatic stress symptoms, delivered by trained lay providers (106, 107). However, in-person group-based interventions may be less accessible in remote areas due to travel-related barriers. In such context, online formats offer a promising alternative. Group-based therapy delivered via video teleconference has been shown to yield outcomes comparable to in-person sessions, with high level of participant satisfaction (108). Moreover, online peer groups that facilitate the sharing of activities or lived experiences may further enhance engagement and expand the reach of mental health support in university populations.

The subgroup analysis did not reveal statistically significant differences across factors such as country region, theoretical orientation, delivery format, control condition, and risk of bias, suggesting that these variables alone do not fully explain the variability in effect sizes. One possible explanation for the lack of significant findings is the presence of extreme outliers, which may have disproportionately influenced the pooled results, obscuring meaningful patterns in the data. However, notably smaller effect sizes were observed in studies with higher methodological quality and in those employing control conditions other than no treatment or waitlist. Although these differences did not reach statistical significance, the consistent direction and magnitude of the effect reduction may carry clinical relevance. This pattern suggests that methodological rigor and choice of comparator condition can meaningfully influence outcome estimates. In particular, studies using active or evidence-based comparators may yield smaller between-group effects, which reflect the strength of the control rather than reduced efficacy of the intervention. Taken together, these findings highlight the importance of cautious interpretation of pooled effects, especially those derived from lower-quality studies or studies with passive control conditions. Furthermore, a sensitivity analysis was conducted by performing the subgroup analysis after excluding outliers. This analysis yielded statistically significant differences in country region, theoretical orientation, control condition, and risk of bias, indicating that outliers may have masked the effects in the original analysis (see Supplementary Material S3). The sensitivity analysis revealed that interventions conducted in the Middle East, those grounded in cognitive-behavioral theoretical orientations, studies employing waitlist control conditions, and those with a high risk of bias were associated with larger effect sizes.

Our study contributes to the growing evidence on the effectiveness of SMIs for university students in LMICs, highlighting their preventive potential in resource-limited settings. However, several limitations should be noted. First, the high risk of bias in many included studies may affect the credibility of the findings. Second, the small sample size in most studies, along with the higher proportions on first- and second-year students may limit generalizability. Third, follow-up assessments were typically short and varied considerably across studies, limiting the ability to assess long-term effects and precluding a pooled analysis of follow-up outcomes. Fourth, the presence of extreme outliers increased variability in the data, making it more difficult to detect meaningful differences in subgroup analysis and potentially obscuring sources of heterogeneity. Fifth, this review focused exclusively on studies conducted in LMICs to address a critical gap in the literature and provide context-specific evidence. While this focus adds value, it also precluded direct comparisons with studies from HICs and limited the ability to examine income level as a potential moderator. Sixth, most studies provided limited or no information on cultural adaptation, which limited our ability to examine its potential role as a moderator of intervention effectiveness. Seventh, the review included only peer reviewed studies published in English, which may have excluded relevant research published in other languages thereby limiting the comprehensiveness of the evidence base. Finally, only ten of the included RCTs were preregistered, with four providing an accessible link, which limits transparency and warrants cautious interpretation of the findings.

Transparency in this field could be strengthened if researchers in LMICs more consistently adopted preregistration of trial protocols. In the absence of preregistration, it is difficult to rule out selective reporting or post hoc analytic flexibility, both of which compromise the reliability of findings. Registering protocols on established public registries such as ClinicalTrials.gov, the International Standard Randomised Controlled Trial Number (ISRCTN) registry, or the Open Science Framework (OSF) represents a feasible minimum standard that can meaningfully enhance research credibility. In recent years, the Registered Reports (RRs) format has been increasingly recognized as a more rigorous publishing model, whereby study protocols are peer reviewed prior to data collection and granted in-principle acceptance independent of study outcomes. Evidence from recent literature indicates that the Registered Reports (RRs) format can strengthen methodological rigor by reducing publication bias, increasing the proportion of published null findings, and improving overall reporting quality (109–112). Nonetheless, the feasibility of implementing RRs in LMICs may be constrained by short funding cycles, limited infrastructure, and uneven access to journals offering this format. A pragmatic way forward may therefore be to normalize preregistration as a field-wide expectation, while fostering an environment that enables the gradual uptake of the RR model through context-appropriate adaptations aligned with local research conditions.

Despite some limitations, our findings suggest that SMIs are effective in improving stress among university students in low resources settings. This has significant implications for student mental health promotion and early prevention, as chronic stress is a known risk factor for anxiety, depression, and other mental health problems. In practice, universities could begin embedding SMIs into the academic curriculum and student support services, ensuring that mental health care is both accessible and normalized within the university environment. This may involve integrating mental health screening, structured feedback, and appropriate referrals for further support.

To maximize accessibility and minimize resource constraints, internet-based interventions present a promising alternative, offering scalable, flexible, and potentially cost-effective solutions for stress management interventions. However, digital formats- particularly those with limited or no guidance- often face challenges in sustaining user engagement. While effect size may be modest, these interventions remain valuable for non-clinical populations, especially in LMICs, where the ability to reach large groups with low intensity support can translate into meaningful public health gains.

The implementation of digital interventions, whether guided or unguided, should be grounded in ethical principles to ensure responsible use. This is especially critical in settings where users may have limited access to alternative forms of support. Ethical implementation entails ensuring informed consent, providing clear usage boundaries, offering access to referral resources, and maintaining user safety throughout the intervention process.

To address engagement challenges in digital SMIs, future implementation efforts may benefit from prioritizing minimally guided approaches that integrate human or interactive support mechanisms. Such approaches are particularly relevant in LMICs, where mental health service gaps remain substantial. Involving trained lay or peer counsellors, for example, can enhance relevance and engagement through peer-led psychoeducation, counselling, and support (113). Group-based delivery formats offer an additional layer of social interaction and cost-efficiency and can be implemented online to reach underserved student populations. These socially embedded approaches may not only increase participation but also strengthen social connectedness and resilience within university communities. The rapid development of AI technologies further expands the possibilities for enhancing digital interventions. Features such as real-time feedback, personalization, and conversational interfaces can improve user experience and adherence (101). Moreover, AI-powered tools may also support the scalability of peer- and group-based interventions by facilitating adaptive content delivery and tailored interaction at scale (101).

In addition to improving engagement, the effectiveness of SMIs may also depend on how well their content and design align with users' individual needs and contextual realities. Engagement and effectiveness are often interrelated; when interventions are perceived as relevant, acceptable, and responsive to the user's lived experience, they are more likely to produce sustained outcomes. Tailored content, culturally relevant materials, and evidence-based strategies can enhance both acceptability and therapeutic impact (114–116). In digital formats, strategies such as gamification (117), interactive features (118), and brief guidance provided by trained lay personnel (119) have been shown to support personalization and increase user engagement. In face-to-face settings, effectiveness may be promoted through interactive group discussions, peer-led sessions, and experiential learning activities that foster emotional connection and practical skill development (113, 120). A structured process of cultural adaptation, including co-design with students or localization of intervention content, may further improve contextual fit and foster meaningful engagement and outcomes (121). Finally, aligning SMIs with broader institutional mental health systems may help sustain impact by ensuring continuity of care and embedding interventions within students' academic and psychosocial environments (122, 123).

Future research directions include the following suggestions: despite the barriers LMICs face in conducting an RCT, higher quality trials are needed to provide sound evidence in this area. This may be achieved by building local researcher capacity on RCT methodologies through partnerships with established institutions for mentorship, fostering collaboration between local researchers and international experts, and increasing access to funding opportunities specifically designated for RCTs in these regions. Strengthening methodological rigor will also require greater attention to practices that enhance transparency, such as preregistration of trial protocols. Moreover, future research should examine the long-term effects of SMIs in reducing stress among university students. In addition, future meta-analyses would benefit from including studies from both LMICs and HICs, allowing for direct comparisons across economic contexts and enabling the examination of country income classification as a potential moderator. Finally, given the limited reporting in the current evidence base, more consistent documentation and integration of cultural adaptation processes is needed to better understand their contribution to intervention relevance and effectiveness.

SMIs are effective in reducing stress among university students in LMICs. Implementing SMIs in university setting would be a valuable step to enhance university students' well-being. To achieve this, we recommend universities in LMICs to gradually incorporating SMIs into their academic curriculum to ensure accessibility and sustainability and embedding SMIs withing student support programs. Additionally, leveraging existing resources, such as peer support networks and digital platforms, may provide scalable and cost-effective ways to expand mental health support for students in resource-limited settings. To support our conclusion, more randomized controlled trials are needed across the diverse LMIC regions represented in this meta-analysis, and future studies are expected to meet higher standards of methodological rigor to ensure more reliable and generalizable evidence.