Towards Inclusive Medical Education in Egypt: A Cross-Sectional Study of Socio-Cultural Adaptation Among International Students

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Elkhouly, Sarah M. Yunis, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6719590/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 Nov, 2025 Read the published version in BMC Medical Education → Version 1 posted 13 You are reading this latest preprint version Abstract Background International medical students face unique challenges in adjusting to new sociocultural environments, particularly in resource-limited settings. In Egypt, despite calls for increasing cultural diversity in medical education, limited research has explored how international students adapt and what factors influence their experience. This study aimed to assess the sociocultural adaptation of international medical students at Mansoura University to inform targeted strategies enhancing their inclusion and wellbeing. Methods A cross-sectional study was conducted between September and November 2024 among international medical students at Mansoura University. Utilizing a combination of convenience and snowball sampling, along with a non-probability proportionate quota technique based on academic year, data were collected using an online survey that included sociodemographic questions and the Sociocultural Adaptation Scale–Revised (SCAS-R). Results A total of 395 international students participated, with a mean SCAS-R adaptation score of 3.37 (SD = 0.69). Adaptation peaked in 1st-year students (3.52), dropped in 2nd year (3.21), and gradually increased in later years (3rd: 3.39; 4th: 3.31; 5th: 3.48). Males reported higher scores in personal interest/community involvement (3.09 vs. 2.86, p = 0.011) and language proficiency (4.25 vs. 4.00, p = 0.036). Arab students had significantly higher overall adaptation than non-Arabs (3.40 vs. 3.21, p = 0.046), primarily due to stronger language proficiency (4.42 vs. 2.76, p < 0.001). Students with sufficient income showed better adaptation in communication (3.41 vs. 3.15, p = 0.021), ecological adjustment (3.32 vs. 2.99, p = 0.008), and language (4.18 vs. 3.83, p = 0.039). Conclusion The findings of this study emphasize the need for medical institutions to implement inclusive support strategies, including bilingual language training, targeted financial assistance, and sustained integration efforts beyond the first academic year. Trial Registration Not applicable Sociocultural adaptation International medical students Medical education Egypt SCAS-R Cultural diversity Introduction Medical education worldwide is notorious for the various academic demands and the psychological stressors it places on those who choose to pursue it [1] . These stressors can have a significant negative impact on students’ academic and mental well-being, especially in the case of international medical students, who lack adequate support systems and face the additional challenge of needing to adapt and integrate into their new cultures [2, 3] . According to Berry et al, sociocultural adaptation is the dynamic process of how people manage and adjust to their lives in new cultural settings [4] . It includes the capability to cope and utilize a range of multicultural knowledge, skills, and attributes during intercultural communication in order to facilitate integration into the host culture [5] . In this regard, international medical students not only face the challenges of adapting to language barriers, cultural differences, and financial difficulties, but these challenges are also exacerbated by the stressors of the medical field [6] . As a result, international medical students face notable difficulty in adapting, which can have a significant impact on their academic and mental wellbeing [7, 8] . For instance, lower levels of host-country language competence are associated with higher acculturative stress [9, 10] . Language and cultural differences impede international students from grasping the unique communication style of their host country, which impacts their academic performance in group assignments [11] . Furthermore, given the essential role of language for expanding social networks, international students' psychological and physical well-being may be at risk when their level of language proficiency impedes their help-seeking methods [12] . Collectively, these factors often lead international students to isolate themselves and experience significant homesickness, which in turn negatively affects their quality of life [13] . Recognizing the significant difficulties international medical students face during their education, medical educators have repeatedly called for proper inclusivity and cultural diversity in medical education. After all, cultural diversity is a cornerstone aspect of graduating culturally competent healthcare providers [14] . It brings valuable cultural assets such as varied life experiences and perspectives that enhance students’ ability to deliver culturally sensitive care and contribute to reducing health disparities [15] . Moreover, exposure to diverse peers fosters the development of unconscious cultural competence through interaction and dialogue, enriching students’ understanding of different cultural backgrounds [16] . However, despite these benefits, international medical students often report experiences of exclusion and stereotyping due to their cultural differences [17] . These findings underscore the urgent need for medical institutions to foster inclusive, supportive, and culturally responsive environments that affirm and empower the diverse student populations they serve. The need for inclusive educational environments is particularly true for countries such as Egypt, which has become an appealing destination for students from both neighboring and foreign reaching a total of 51649 inbound international students in 2024 [18] . This is partly due to the relatively low cost of living and education, the presence of internationally accredited medical schools, and its shared cultural and religious background [2] . Egypt also hosts students from non-Arab countries, who come with an additional set of challenges, including language and cultural barriers [2] . Unfortunately, despite international calls for inclusivity and cultural diversity in medical education, and the increasing numbers of international medical students in Egyptian Universities, the structural support systems that help them in sociocultural adaptation often remain lacking to meet students' needs. While some initiatives exist such as Mansoura University’s orientation days for new incoming international medical students, these are typically limited to initial welcome activities without sustained follow-up or long-term integration support. Studies at other Egyptian institutions, like Tanta University, reveal that many international students face significant difficulties in sociocultural adaptation, particularly in terms of cultural isolation, language barriers, and lack of ongoing mentorship [19] . Similarly, another research on acculturative stress in an Egyptian medical school highlights persistent cultural challenges, including perceived discrimination and academic pressures, particularly among non-Arab and female students [20] . Collectively, these findings suggest a need for more comprehensive and continuous support systems to foster inclusive academic and social environments for international students. Therefore, this study aims to assess Mansoura University’s international medical students’ socio-cultural adaptation and how it relates to their socio-demographic backgrounds. The goal is to generate data that can inform the development of targeted strategies to enhance integration, inclusivity, and well-being success among this student population. Methods Study design and study period A descriptive cross-sectional study with an analytical component was conducted among international medical students. The study was conducted in the Faculty of Medicine, Mansoura University, Egypt, between September and November 2024. This study followed the STROBE guidelines for reporting observational studies [21] . Study population The study population included international medical students enrolled at the Faculty of Medicine, Mansoura University, during the 2024–2025 academic year. This encompassed students from both the Traditional program and the Mansoura Manchester Program for Medical Education, across first to fifth academic years. According to official records from the Students’ Affairs Department, approximately 3572 international students were enrolled during this period. A non-probability quota sampling technique was employed to ensure proportional representation across academic years. Quotas were established based on the actual distribution of international students in each year. Pilot study and sample size A pilot study involving 30 international students was conducted to assess clarity and determine the standard deviation of sociocultural adaptation scores to calculate the sample size. Based on the pilot study’s participants' feedback, a few words in the English version of the Revised Sociocultural Adaptation Scale (SCAS-R) [22] , were reported to be difficult, and their Arabic translation was included between parentheses in the final version of the survey. Since the survey was changed based on the feedback of the pilot study, these responses were not included in the final analysis. The sample size was calculated using MedCalc 23.2.1 software [23] , considering the mean score on the SCAS-R scale as the primary outcome of interest. Our pilot study reported a mean sociocultural adaptation score of 3.29 with a standard deviation of 0.819. With a margin of error of 5% and a study power of 80%, the calculated required sample was 208. To account for convenience sampling, we used a design effect of 1.5, yielding a total sample size of 312. In total, 408 responses were collected. Thirteen responses were excluded; ten participants did not consent to share their data, and three entries were incomplete, leaving a total of 395 responses. Sampling and data collection approach After determining the required sample size, the study used a combination of convenience and snowball sampling, along with a non-probability proportionate quota technique based on academic year. Data was collected using a self-administered questionnaire using Google Forms. The survey was shared with all international students through official groups via the Telegram app and other social media platforms. A team of collaborators was assembled and trained by the authors to assist in data collection. Participation was anonymous, voluntary, and completed at the participants’ convenience without compensation. Study tools A structured self-reported online questionnaire was distributed to the faculty’s international students, which consisted of two sections. The first included the SCAS-R [22] , with the minor aforementioned adaptations based on the pilot study, which was used to assess the level of adaptability of international medical students to their current environment. The tool comprises 21 questions and was set to measure interpersonal communication, academic performance, personal interests & community involvement, ecological adaptation, and language proficiency. These items were scored on a five-point Likert scale ranging from 1 (not at all competent) to 5 (extremely competent). A total score was calculated by summing the responses across all items (possible range: 21 to 105), then dividing by the number of items to yield a final score ranging from 1 to 5. Higher scores reflect greater levels of sociocultural adaptation. The SCAS-R is a valid tool for measuring sociocultural adaptation and has a good test-retest reliability (r = 0.92) [22] . Additionally, the pilot study resulted in a Cronbach’s α of 0.93, indicating high internal consistency of the scale in line with that of the original scale (α = 0.92) [22, 24] . The second section of the questionnaire collected non-identifying sociodemographic characteristics, which included: age, sex, academic year, nationality, and income sufficiency. Statistical analysis Statistical analysis was conducted using Jamovi 2.3.28 software [25] . Sociodemographic data were summarized using descriptive statistics. Categorical variables were reported as frequencies and percentages, while continuous variables were reported as mean and standard deviation (SD). Normality was assessed using a Quantile-Quantile (Q-Q) plot. An Independent Samples T-test and One-Way Analysis of Variance (ANOVA) were employed to compare the means of independent groups and determine whether significant differences existed among them. For variables found to be significant in the ANOVA, post hoc analysis was conducted using the Games-Howell test. The relationship between sociocultural adaptation scores and participants’ sociodemographic characteristics was examined using Pearson’s correlation. Additionally, factors associated with sociocultural adaptation scores were identified through linear regression analysis. A p-value of less than 0.05 was considered statistically significant. Results Sociodemographic Characteristics of the Study participants A total of 395 international students participated in this survey. Participants were nearly equally distributed across gender and academic years, with 2nd year students representing the highest proportion of the participants (24.8%) and 3rd year the lowest (15.4%). Most of the study participants were from Arabic countries (n = 327, 82.8%), mostly from Syria (23.8%), Sudan (17.7%), and Palestine (11.1%), while 17.2% of the participants were non-Arabs mostly from Malaysia (n = 59, 14.9%). Most (86.6%) of the students reported sufficient income (Table 1 ). Table 1 Participants’ sociodemographic characteristics (N = 395) Characteristics n (%) Overall 395 (100) Age 21 or less 250 (63.3) Older than 21 145 (36.7) Sex Male 213 (53.9) Female 182 (46.1) Academic year 1st year 64 (16.2) 2nd year 98 (24.8) 3rd year 61 (15.4) 4th year 89 (22.5) 5th year 83 (21.0) Nationality Arab country Syria 94 (23.8) Sudan 70 (17.7) Palestine 44 (11.1) Bahrain 37 (9.4) Jordan 28 (7.1) Saudi Arabia 19 (4.8) Yemen 15 (3.8) Algeria 7 (1.8) Others* 13 (3.3) Total Arabs 327 (82.8) Non-Arab country Malaysia 59 (14.9) Somalia 3 (0.8) Nigeria 3 (0.8) Philippines 1 (0.3) Indonesia 1 (0.3) Canada 1 (0.3) Total Non-Arabs 68 (17.2) Income sufficiency Sufficient 342 (86.6) Less than Sufficient 53 (13.4) *Others: Iraq, Kuwait, Lebanon, Libya, South Sudan, and the United Arab Emirates (each had a frequency of 3 or less) Association Between Sociodemographic Characteristics and SCAS-R Scores The overall mean SCAS-R score was 3.37 (SD = 0.69) (Table 2 ). Males displayed significantly higher adaptation scores particularly in personal interest & community involvement (3.09 vs 2.86, p = 0.011) and language proficiency (4.25 vs 4.00, p = 0.036) than females. Moreover, 1st-year students had the highest overall mean SCAS-R scores (3.52, SD = 0.72), which dropped significantly in the 2nd-year (3.21, SD = 0.62), and increased relatively steadily among 3rd (3.39, SD = 0.50), 4th (3.31, SD = 0.81) and 5th-year students (3.48, SD = 0.71). Table 2 Comparison of SCAS-R Scores Across Sociodemographic Characteristics Among International Medical Students at Mansoura University (N = 395) Characteristics Overall sociocultural adaptation 1 Interpersonal Communication 1 Academic/Work Performance 1 Personal Interests & Community Involvement 1 Ecological Adaptation 1 Language Proficiency 1 Overall 3.37 (0.69) 3.38 (0.77) 3.44 (0.86) 2.98 (0.88) 3.28 (0.86) 4.13 (1.15) Age ≤ 21 3.36 (0.65) 3.37 (0.73) 3.43 (0.83) 3.00 (0.85) 3.27 (0.84) 4.13 (1.14) > 21 3.37 (0.76) 3.40 (0.84) 3.44 (0.91) 2.95 (0.92) 3.29 (0.89) 4.14 (1.17) p-value 0.931 0.706 0.934 0.584 0.851 0.925 Sex Male 3.42 (0.72) 3.40 (0.80) 3.49 (0.84) 3.09 (0.90) 3.30 (0.89) 4.25 (1.10) Female 3.31 (0.66) 3.35 (0.74) 3.37 (0.87) 2.86 (0.84) 3.25 (0.83) 4.00 (1.19) p-value 0.111 0.599 0.159 0.011 0.602 0.036 Academic year 1st year 3.52 (0.72) 3.51 (0.78) 3.61 (0.77) 3.39 (0.92) 3.50 (0.86) 3.70 (1.21) 2nd year 3.21 (0.62) (a) 3.19 (0.72) (b) 3.32 (0.91) 2.81 (0.74) (a) 3.10 (0.75) (a) 4.11 (1.15) 3rd year 3.39 (0.50) 3.35 (0.64) 3.45 (0.67) 2.90 (0.69) (a) 3.39 (0.69) 4.34 (0.97) (c) 4th year 3.31 (0.81) 3.37 (0.85) 3.35 (0.93) 2.96 (0.96) (a) 3.14 (1.01) 4.07 (1.22) 5th year 3.48 (0.71) 3.52 (0.78) 3.54 (0.88) 2.96 (0.96) 3.38 (0.89) 4.42 (1.06) (c) p-value 0.026 0.029 0.166 0.002 0.009 0.003 Nationality Arab country 3.40 (0.72) 3.40 (0.81) 3.45 (0.91) 2.97 (0.91) 3.26 (0.89) 4.42 (0.97) Non-Arab country 3.21 (0.49) 3.29 (0.57) 3.38 (0.56) 3.03 (0.72) 3.34 (0.70) 2.76 (0.97) p-value 0.046 0.284 0.515 0.664 0.497 < 0.001 Income sufficiency Less than Sufficient 3.40 (0.68) 3.15 (0.82) 3.28 (0.95) 2.80 (0.87) 2.99 (0.90) 3.83 (1.24) Sufficient 3.14 (0.73) 3.41 (0.76) 3.46 (0.84) 3.01 (0.88) 3.32 (0.85) 4.18 (1.13) p-value 0.011 0.021 0.161 0.097 0.008 0.039 1 Mean (SD), (a) significantly less than 1st years, p-value < 0.05, (b) significantly less than 5th years, p-value < 0.05, (c) significantly higher than 1st years, p-value < 0.05. Arab students had significantly higher mean SCAS-R scores than non-Arab students (3.40 vs 3.21, p-value = 0.046), with this difference being largely attributed to differences in language proficiency (4.42 vs 2.76, p < 0.001). In addition, students with sufficient income showed less difficulty in sociocultural adaptation in terms of interpersonal communication (3.41 vs 3.15, p = 0.021), ecological adaptation (3.32 vs 2.99, p = 0.008), and language proficiency (4.18 vs 3.83, p = 0.039) than students with insufficient income (Table 2 ). Correlation Between Sociodemographic Variables and Total SCAS-R Scores As shown in Table 3 , a significant positive correlation was observed between language proficiency and being from an Arab country (r = 0.543, p < 0.001). Additionally, income sufficiency was positively correlated with better overall sociocultural adaptation (r = 0.127, p = 0.011), as well as with interpersonal communication (r = 0.115, p = 0.021), ecological adaptation (r = 0.132, p = 0.008), and language proficiency (r = 0.104, p = 0.039). Table 3 Pearson Correlation Coefficients Between Sociodemographic Variables and SCAS-R Scores Among International Medical Students at Mansoura University Variable Overall sociocultural adaptation Interpersonal Communication Academic/Work Performance Personal Interests & Community Involvement Ecological Adaptation Language Proficiency Age (continuous) 0.054 0.078 0.053 0.003 0.019 0.046 Sex -0.079 -0.025 -0.069 -0.127* -0.024 -0.104* Academic year 0.022 0.057 -0.001 -0.086 -0.01 0.156** Nationality 0.099* 0.053 0.032 -0.022 -0.035 0.543*** Income sufficiency 0.127* 0.115* 0.07 0.084 0.132** 0.104* Categorical variables were included in the model as dummy variables: Nationality (0 = Non-Arab, 1 = Arab), Sex (0 = Male, 1 = Female), Academic year (1–5), and Income sufficiency (0 = Less than sufficient, 1 = Sufficient). * p-value < 0.05, **p-value < 0.01, ***p-value < 0.001. Multivariate Associations Between Sociodemographic Characteristics and SCAS-R Scores In the multivariate linear regression analysis (Table 4 ), income sufficiency was the only significant predictor of overall sociocultural adaptation (β = 0.14, p < 0.01). Nationality showed the strongest association with language proficiency, with Arab students reporting significantly higher proficiency (β = 0.55, p < 0.001). Academic year was positively associated with language proficiency (β = 0.13, p < 0.05) but negatively associated with personal interests and community involvement (β = −0.14, p < 0.05). Female gender was also negatively associated with personal interests and community involvement (β = −0.14, p < 0.01). Table 4 Multivariate Linear Regression of Factors Associated with SCAS-R Scores Among International Medical Students at Mansoura University Variable Overall sociocultural adaptation 1 Interpersonal Communication 1 Academic/Work Performance 1 Personal Interests & Community Involvement 1 Ecological Adaptation 1 Language Proficiency 1 Age (continuous) 0.07 (-0.06, 0.19) 0.07 (-0.06, 0.20) 0.09 (-0.04, 0.21) 0.09 (-0.03, 0.22) 0.04 (-0.08, 0.17) -0.08 (-0.18, 0.02) Sex -0.07 (-0.17, 0.04) -0.02 (-0.13, 0.08) -0.07 (-0.17, 0.03) -0.14 (-0.25, -0.04)** -0.04 (-0.15, 0.06) 0.03 (-0.06, 0.11) Academic year -0.04 (-0.17, 0.09) -0.00 (-0.13, 0.12) -0.06 (-0.19, 0.06) -0.14 (-0.27, -0.02)* -0.05 (-0.17, 0.08) 0.13 (0.03, 0.24)* Nationality 0.09 (-0.01, 0.20) 0.05 (-0.05, 0.16) 0.02 (-0.08, 0.12) -0.04 (-0.15, 0.06) -0.03 (-0.14, 0.07) 0.55 (0.47, 0.64)*** Income sufficiency 0.14 (0.04, 0.24)** 0.12 (0.02, 0.22)* 0.08 (-0.02, 0.18) 0.10 (0.00, 0.20)* 0.14 (0.04, 0.24)** 0.14 (0.06, 0.22)** Categorical variables were included in the model as dummy variables: Nationality (0 = Non-Arab, 1 = Arab), Sex (0 = Male, 1 = Female), Academic year (1–5), and Income sufficiency (0 = Less than sufficient, 1 = Sufficient). 1 β (95% CI), * p-value < 0.05, **p-value < 0.01, ***p-value < 0.001. CI: Confidence Intervals. Discussion Adjusting to life in a new cultural setting comes with a substantial set of challenges, which are further exacerbated by the demanding nature of medical education [6] . Evaluating international medical students’ adaptation to new settings and understanding the factors that shape it is key in supporting their academic and personal success [26] . It is also imperative to ensure an inclusive learning environment that caters to the culturally diverse student population in Egypt [27] [17] . Hence, this study aimed to assess Mansoura University’s international medical students’ socio-cultural adaptation and how it relates to their socio-demographic backgrounds, providing recommendations for a more welcoming academic setting. Using the SCAS-R, the mean total sociocultural adaptation score of our study’s participants was 3.37. This was slightly less than the scores reported among international students in Hong Kong (3.53) [28] , Turkey (3.57) [29] and at a metropolitan university in the USA (3.50) [30] . The comparatively lower adaptation observed in our sample may be due to differences in sample characteristics, as the aforementioned studies assessed international students in general rather than medical students specifically. This is further supported by the findings of Shehata et al. [19] , who reported a mean sociocultural adaptation score of 3.3 among Malaysian medical students in Tanta University in Egypt. The lower socio-cultural adaptation scores among medical students may be attributed to the intense academic demands of medical education, which significantly hinder students’ engagement with their communities, thereby affecting their adaptation to new cultures [26, 31] . This is further evidenced by the personal interests & community involvement scores among our study’s participants, which were the lowest across the SCAS-R subscales. This finding is of serious consequence, given that community involvement and interpersonal communication both play a critical role in helping students adapt to cultures [32] . For instance, engaging in the community through participation in extracurricular activities and volunteering has shown to foster a strong sense of belonging among medical students and to enhance soft skills such as teamwork and communication [33] . Consequently, this involvement promotes the formation of meaningful interpersonal relationships with students of the host culture, providing international students with much-needed social support systems in the absence of their families and social networks [32] . These relationships in turn become crucial for navigating cultural transitions, and ultimately facilitating successful sociocultural adaptation [34] . Notably, the significantly higher sociocultural adaptation scores among male students were largely a reflection of higher personal interests & community involvement scores compared to females. This is also consistent with similar studies conducted in Egypt which highlight lower sociocultural adaptation [19] , higher acculturative stress [20] and increased social media [35] use among female students compared to their male counterparts. This may be due to males having more opportunities to engage in Egyptian culture as compared to females who may face more constraints in doing so. Collectively, these findings underpin the importance of encouraging early community engagement as a key strategy to support international students’ adaptation and integration into the host culture. Surprisingly, in our study, personal interests & community involvement scores peaked in first year students, declined significantly in second year and then gradually rebounded to by the fifth year- a trend also observed in terms of interpersonal relationships and overall socio-cultural adaptation scores. The pattern found in our study closely mirrors the classic U-curve model of cross-cultural adjustment as described by Lysgaard et al [36] . The elevated first-year scores likely reflect the “honeymoon phase”; the initial stage of arriving to a new cultural environment. During this phase, sojourners are captivated by the host culture, open to new experiences and have great motivation to integrate into the host culture [37] . In second year, students appear to enter the “shock phase,” as the novelty fades and academic pressures and social fatigue set in; thereafter, a “recovery phase” sees adaptation scores rise again [20, 38] . However, Chien et al. contends that the U-curve oversimplifies the acculturation process, which is influenced by a complex interplay of individual, cultural, and contextual factors [39] . Another interpretation for the higher adaptation scores among first years is that universities often focus integration efforts -such as mentoring schemes and structured social events- primarily on first-year students [40, 41] . While such programs prove to be effective for first year students’ adjustment, sustained engagement is recommended in further years to maintain the adaptation gains [42] . Accordingly, targeted support and campus services should be extended into the intermediate academic years to prevent the marked decline in sociocultural adaptation that can undermine both student well-being and academic performance. The overall sociocultural adaptation score was also significantly influenced by nationality, with non-Arab students reporting lower adaptation levels compared to their Arab counterparts. This difference may be attributed to the language and cultural barriers faced by non-Arab students in a predominantly Arab environment like Egypt, which may hinder their participation in social interactions and integration within the local community. This interpretation is further supported by subscale findings, as non-Arab students scored significantly lower in both language proficiency and interpersonal communication compared to non-Arab students. Previous studies among international medical students in Egypt further support this notion. In a study by Shehata et al. in Tanta university [19] , Malaysian students proficient in Arabic reported significantly higher adaptation scores. Meanwhile, Ali et al. in Ain Shams University identified language deficiencies and nationality as key sources of acculturative stress [20] , highlighting the central role of language in the adaptation process. Language difficulties are well documented as a significant barrier to sociocultural adaptation in various international contexts, including Australia [31] , Hungary [34] , USA [30] , Malaysia [43] and Saudi Arabia [44] . Such challenges are particularly concerning in medical education, where language proficiency is critical for both academic success and clinical communication [45] , [46] , [6] , [26] . Non-Arab medical students, in particular, have repeatedly reported language barriers as a major challenge, especially in clinical settings where communication with Arabic-speaking patients is essential [2, 46] . In fact, the significantly higher adaptation scores among participants with sufficient income may have been largely due to their ability to afford language courses, which corresponded with notably higher language proficiency scores. Given the critical role of language in not only the sociocultural adaptation of international medical students but also their overall academic and clinical success, medical institutions should prioritize native language training as a core component of their integration efforts [47] . One effective approach is the adoption of bilingual language programs. In Egypt, medical education is primarily delivered in English - the global language of medicine - while clinical interactions typically occur in Arabic. Non-Arab students may therefore benefit from a bilingual curriculum that maintains English as the medium of instruction while incorporating targeted Arabic training to ease the transition into clinical environments [45] . In addition to bilingual strategies, foreign language support programs have shown promising results in other health education contexts. For instance, Seibold et al. reported significant improvements in clinical communication skills among nurses whose first language was not English after they received tailored English language instruction [48] . While several similar programs have demonstrated positive outcomes, the development of context-specific, needs-based language interventions remains essential [49] . Another proposed program directed at medical students is the English for Medical Purposes (EMP) program for international medical graduates in Canada, which aims to enhance communication skills in medical contexts [50] .While such initiatives may face logistical and financial constraints, they have been shown to strengthen international students’ academic confidence and facilitate relationship-building with host-country peers and patients which is an essential factor linked to greater self-reported satisfaction, enhanced social connectedness, and ultimately, improved sociocultural adaptation [51] . Income sufficiency also emerged as a significant predictor of overall sociocultural adaptation, aligning with existing literature that links financial stress to reduced well-being among international students [52] and as a key contributor to acculturative stress [10, 20] . In our study, students reporting a less than sufficient income also scored lower on the ecological adaptation subscale, suggesting that students with adequate financial resources are better able to navigate the day-to-day practical demands of life in Egypt. This may reflect their greater ability to secure comfortable housing, access local services, and engage with the host environment without the added burden of financial stress all of which are central to ecological adjustment. In recent years, Egypt has experienced significant inflation, with rates reaching 28.3% in 2024, contributing to rising rent, tuition fees, and daily living costs for both local and international students [53] . These economic pressures may disproportionately impact international students, many of whom rely on private rentals for accommodation [20] . Accordingly, medical schools and higher education institutions should prioritize the expansion of financial support mechanisms. These may include increasing scholarship opportunities for international students, implementing flexible tuition payment plans, and providing part-time work opportunities on campus. Such interventions can alleviate financial stress, promote student well-being, and support greater socio-cultural engagement. Strengths and limitations Our study, conducted in a resource-constrained setting amid rising inflation and economic instability, provides practical relevance and applicable findings, particularly for similarly affected regions. However, this study is not without limitations. Conducting the study in a single faculty limits the generalizability of the findings to the broader population of international medical students in Egypt. Future research should include multiple institutions and non-medical students across the country to better capture nationwide trends. Moreover, its cross-sectional design limits the ability to infer causality; therefore, longitudinal research is recommended to better understand changes in adaptation over time. Additionally, the use of convenience and snowball sampling may have introduced selection bias and limits the generalizability of the findings; future studies should consider employing randomized sampling strategies. The reliance on self-reported data also poses a risk of recall or social desirability bias, which may have influenced how participants rated their adaptation experiences. Conclusions The present study provides important insights into the sociocultural adaptation of international medical students in a single Egyptian faculty. Key sociodemographic factors - including gender, nationality, income sufficiency, and academic year - were found to significantly influence adaptation levels. These findings highlight the need for targeted institutional support, particularly in the areas of language training, community engagement, and financial assistance, to foster inclusive and culturally responsive learning environments that promote student well-being and success. Abbreviations ANOVA Analysis of Variance CI Confidence Interval EMP English for Medical Purposes Q Q-Quantile-Quantile SCAS R-Sociocultural Adaptation Scale-Revised SD Standard Deviation STROBE Strengthening the Reporting of Observational studies in Epidemiology Declarations Acknowledgments The authors would like to express their sincere appreciation to the Mansoura Students’ Scientific Association (MSSA-Mansoura) for their contribution to this study. This research was conducted as part of the 2023/2024 Research Club under the Research Support Division of MSSA-Mansoura. Special thanks are extended to Yusof M. Omar and Basma Kamel for their unwavering support, dedication, and continuous feedback. Their guidance and mentorship were instrumental in the initiation and successful completion of this research. The authors would also like to acknowledge Mostafa Ismael, Alya Bahari, Abdullah Mosaad, Mohammad Diaa and Noor Salman for their help in disseminating the questionnaire. Author contributions The conception and design of the study were done by TD, MY, RE, SA, EH, MA, NR, MA. Acquisition of data was done by TD, MY, RS, SY, SA, EH, MA, EN, NR, TI, MA. Analysis and interpretation of data were done by TD. Drafting the manuscript was done by TD, MY, RE, SY, SA, EH, MA, EN, NR, TI, MA. Revising the manuscript critically for important intellectual content was done by TD, AE, HS. All authors read and approved the final manuscript. Funding No funding or sponsorship was received from any companies, groups, individuals, organizations, or any other entities. Data Availability The data of this study is available from the corresponding author upon reasonable request. Conflict of interests The authors declare that they have no conflict of interest. Ethical approval Ethical permission to conduct this study was obtained from the Institutional Research Board of Mansoura University's Faculty of Medicine under the approval number R.24.08.2757. This study was completed in compliance with the Helsinki Declaration for medical research involving human participants. Participants were asked to willingly and anonymously complete our online survey, providing electronic informed consent and having the flexibility to finish the survey at their convenience. Consent for publication Not applicable. Clinical trial number Not applicable. * SCA team of collaborators Abdulrahman Jamal, Nehal Ezzat, Shahd Ismail, Abdelaziz Mohamed, AhmedEltayeb Emad, Mohamed G. Elsayed, Moath Alhaj Ali, Khaled Abuzeid, Tengu Nurul Farihah Binti Tengku Nasrudin. References Ragab EA, Dafallah MA, Salih MH, et al. 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Socio-Cultural Adaptation of Malaysian Medical Students in Tanta University, Egypt. The Egyptian Family Medicine Journal . 2020;4(2):96-111. doi:10.21608/efmj.2020.21786.1007 Ali YA, Hussein RS, Mostafa NS, Manzour AF. Factors associated with acculturative stress among international medical students in an Egyptian university. BMC Med Educ . 2024;24(1):1009. doi:10.1186/s12909-024-05947-5 Ghaferi AA, Schwartz TA, Pawlik TM. STROBE reporting guidelines for observational studies. JAMA Surg . 2021;156(6):577-578. doi:10.1001/jamasurg.2021.0528 Wilson J. Exploring the Past, Present, and Future of Cultural Competency Research: The Revision and Expansion of the Sociocultural Adaptation Construct . 2013. MedCalc Software Ltd. MedCalc’s Sample size for Single mean (Version 23.2.1). 2025. Accessed May 19, 2025. https://www.medcalc.org/calc/sample-size-single-mean.php Taber KS. The use of cronbach’s alpha when developing and reporting research instruments in science education. 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Sustainability . 2020;12(6):2317. doi:10.3390/su12062317 Mahmood H, Galloway Burke M. Analysis of Acculturative Stress and Sociocultural Adaptation Among International Students at a Non-Metropolitan University. JIS . 2018;8(1). doi:10.32674/jis.v8i1.166 Malau-Aduli BS. Exploring the experiences and coping strategies of international medical students. BMC Med Educ . 2011;11:40. doi:10.1186/1472-6920-11-40 Sheng L, Dai J, Lei J. The impacts of academic adaptation on psychological and sociocultural adaptation among international students in China: The moderating role of friendship. International Journal of Intercultural Relations . 2022;89:79-89. doi:10.1016/j.ijintrel.2022.06.001 Kim S, Jeong H, Cho H, Yu J. Extracurricular activities in medical education: an integrative literature review. BMC Med Educ . 2023;23(1):278. doi:10.1186/s12909-023-04245-w Gebregergis WT, Csukonyi C. Unveiling psychological and sociocultural adaptation patterns of international students in Hungary. JIS . 2025;15(4):97-118. doi:10.32674/21yqse06 Saied S, Elsabagh H, El-Afandy A. Internet and facebook addiction among Egyptian and Malaysian medical students: a comparative study, Tanta University, Egypt. Int J Community Med Public Health . 2016:1288-1297. doi:10.18203/2394-6040.ijcmph20161400 Lysgaard S. Adjustment in a foreign society: Norwegian Fulbright grantees visiting the United States. International Social Science Bulletin . Published online 1955. Accessed May 10, 2025. https://unesdoc.unesco.org/ark:/48223/pf0000033837 Schartner A. Culture Shock or Love at First Sight? Exploring the ‘Honeymoon’ Stage of the International Student Sojourn. In: Transcultural Interaction and Linguistic Diversity in Higher Education . ; 2015. Demes KA, Geeraert N. The highs and lows of a cultural transition: a longitudinal analysis of sojourner stress and adaptation across 50 countries. J Pers Soc Psychol . 2015;109(2):316-337. doi:10.1037/pspp0000046 Chien Y-YG. After six decades: Applying the U-curve hypothesis to the adjustment of international postgraduate students. Journal of Research in International Education . 2016;15(1):32-51. doi:10.1177/1475240916639398 Betweli OK. Assisting the First-Year International Students’ Socio-cultural Adjustment, Through a Peer Mentoring Program, at One University in China . Journal of Education and Practice . February 29, 2020. Luo J. Examining the Educational Benefits of Interacting with International Students. Journal of International Students . 2013. Gentling K. First-Year Experience: International Students . 2016. GulRaihan Mst, S. C. S. Sociocultural adaptation challenges of international students at a higher learning institution in malaysia. LSPI . 2018;4(2). doi:10.11113/lspi.v4n2.58 Alasmari AA. Challenges and social adaptation of international students in Saudi Arabia. Heliyon . 2023;9(5):e16283. doi:10.1016/j.heliyon.2023.e16283 Hamad AA, Mustaffa DB, Alnajjar AZ, et al. Decolonizing medical education: a systematic review of educational language barriers in countries using foreign languages for instruction. BMC Med Educ . 2025;25(1):701. doi:10.1186/s12909-025-07251-2 Mostafa NS. Challenges and expectations of first year international medical students in egypt. Educational Research and Innovation Journal . 2024;4(12):1-12. doi:10.21608/erji.2024.323645 Chan SMH, Mamat NH, Nadarajah VD. Mind your language: the importance of english language skills in an International Medical Programme (IMP). BMC Med Educ . 2022;22(1):405. doi:10.1186/s12909-022-03481-w Seibold C, Rolls C, Campbell M. Nurses on the move: evaluation of a program to assist international students undertaking an accelerated Bachelor of Nursing program. Contemp Nurse . 2007;25(1-2):63-71. doi:10.5555/conu.2007.25.1-2.63 Crawford T, Candlin S. A literature review of the language needs of nursing students who have English as a second/other language and the effectiveness of English language support programmes. Nurse Educ Pract . 2013;13(3):181-185. doi:10.1016/j.nepr.2012.09.008 Meehan SC. English for Medical Purposes: A Program to Ensure the Success of Our International Medical Graduates . Applied Language Associates; 2004. Hendrickson B, Rosen D, Aune RK. An analysis of friendship networks, social connectedness, homesickness, and satisfaction levels of international students. International Journal of Intercultural Relations . 2011;35(3):281-295. doi:10.1016/j.ijintrel.2010.08.001 Wilson S, Hastings C, Morris A, Ramia G, Mitchell E. International students on the edge: The precarious impacts of financial stress. SAGE Publications . 2022. doi:10.1177/14407833221084756 Central Agency for Public Mobilization and Statistics (CAPMAS) - Annual inflation rate for urban areas of the Republic. Accessed May 19, 2025. https://www.capmas.gov.eg/Pages/IndicatorsPage.aspx?page_id=6130&ind_id=2542 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6719590","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":469468826,"identity":"d8b888e3-c137-4bcd-9922-553ee634668b","order_by":0,"name":"Tasneem Deibes","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABNElEQVRIiWNgGAWjYBADxgZmHiBVAcQHYGIHsCvlQdVyhkGCBC0gJmMbEVrs2Y8/e/ChYptsfzvvwYc/59XV8R3gTvxc8IdBju9GAuPDL1hs4ckxN5xx5rbxjMN8yca82w5LSB7g3Sw9s43BWPJGArOxDDaH5bBJ87bdTmw4zGMmzbjtgITBAd4N0rwNDIkbbiSwSUtg0cL//Jn033+3E+cf5jH/+XNOHUjL5t88fxjqgVrYf2PTIpEANLzhduIGoC0MvA3MIC3bpHnYGBIMgLYwfsCi5cYbM8meY7eNNwL9Is1z7LDkzMO826x52yQMZ5552CyNJcTY+9OfSfyouS077/zZgx9/1NTx8x3v3Xyb54+NPN/xZKAI9oBGA8xgEuQJaPySBhiJs2UUjIJRMAqGNwAAMWxsxQhXyjYAAAAASUVORK5CYII=","orcid":"","institution":"Integrated Program, Faculty of Medicine, Mansoura University, Mansoura","correspondingAuthor":true,"prefix":"","firstName":"Tasneem","middleName":"","lastName":"Deibes","suffix":""},{"id":469468827,"identity":"13a3fea4-c509-491c-9839-5e5fed903751","order_by":1,"name":"Mohammad Yaseen","email":"","orcid":"","institution":"Integrated Program, Faculty of Medicine, Mansoura University, Mansoura","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"","lastName":"Yaseen","suffix":""},{"id":469468828,"identity":"9c83203e-6be7-4752-b50c-4f462e7f7878","order_by":2,"name":"Rodina S. 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Awadh","email":"","orcid":"","institution":"Medical Program, Mansoura University Hospitals, Mansoura","correspondingAuthor":false,"prefix":"","firstName":"Mariam","middleName":"M.","lastName":"Awadh","suffix":""},{"id":469468841,"identity":"b41a3ec8-7cde-46bc-8255-0726d6080fc5","order_by":11,"name":"Abdel-Hady El-Gilany","email":"","orcid":"","institution":"Public Health and Community Department, Faculty of Medicine, Mansoura University, Mansoura","correspondingAuthor":false,"prefix":"","firstName":"Abdel-Hady","middleName":"","lastName":"El-Gilany","suffix":""},{"id":469468842,"identity":"274a46ed-86b2-4cb4-afa2-65db2b9584f8","order_by":12,"name":"Heba Sheta","email":"","orcid":"","institution":"Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura","correspondingAuthor":false,"prefix":"","firstName":"Heba","middleName":"","lastName":"Sheta","suffix":""}],"badges":[],"createdAt":"2025-05-21 21:53:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6719590/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6719590/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-025-08232-1","type":"published","date":"2025-11-29T15:57:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":97179368,"identity":"d7f492d7-d77c-4498-bf3b-ea1f2801f482","added_by":"auto","created_at":"2025-12-01 16:15:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1471187,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6719590/v1/448cd52e-7892-4145-baeb-09ef3a51c8ba.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Towards Inclusive Medical Education in Egypt: A Cross-Sectional Study of Socio-Cultural Adaptation Among International Students","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMedical education worldwide is notorious for the various academic demands and the psychological stressors it places on those who choose to pursue it \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[1]\u003c/span\u003e. These stressors can have a significant negative impact on students\u0026rsquo; academic and mental well-being, especially in the case of international medical students, who lack adequate support systems and face the additional challenge of needing to adapt and integrate into their new cultures \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[2, 3]\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eAccording to Berry et al, sociocultural adaptation is the dynamic process of how people manage and adjust to their lives in new cultural settings \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[4]\u003c/span\u003e. It includes the capability to cope and utilize a range of multicultural knowledge, skills, and attributes during intercultural communication in order to facilitate integration into the host culture \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[5]\u003c/span\u003e. In this regard, international medical students not only face the challenges of adapting to language barriers, cultural differences, and financial difficulties, but these challenges are also exacerbated by the stressors of the medical field \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[6]\u003c/span\u003e. As a result, international medical students face notable difficulty in adapting, which can have a significant impact on their academic and mental wellbeing \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[7, 8]\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eFor instance, lower levels of host-country language competence are associated with higher acculturative stress \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[9, 10]\u003c/span\u003e. Language and cultural differences impede international students from grasping the unique communication style of their host country, which impacts their academic performance in group assignments \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[11]\u003c/span\u003e. Furthermore, given the essential role of language for expanding social networks, international students' psychological and physical well-being may be at risk when their level of language proficiency impedes their help-seeking methods \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[12]\u003c/span\u003e. Collectively, these factors often lead international students to isolate themselves and experience significant homesickness, which in turn negatively affects their quality of life \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[13]\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eRecognizing the significant difficulties international medical students face during their education, medical educators have repeatedly called for proper inclusivity and cultural diversity in medical education. After all, cultural diversity is a cornerstone aspect of graduating culturally competent healthcare providers \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[14]\u003c/span\u003e. It brings valuable cultural assets such as varied life experiences and perspectives that enhance students\u0026rsquo; ability to deliver culturally sensitive care and contribute to reducing health disparities \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[15]\u003c/span\u003e. Moreover, exposure to diverse peers fosters the development of unconscious cultural competence through interaction and dialogue, enriching students\u0026rsquo; understanding of different cultural backgrounds \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[16]\u003c/span\u003e. However, despite these benefits, international medical students often report experiences of exclusion and stereotyping due to their cultural differences \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[17]\u003c/span\u003e. These findings underscore the urgent need for medical institutions to foster inclusive, supportive, and culturally responsive environments that affirm and empower the diverse student populations they serve.\u003c/p\u003e \u003cp\u003eThe need for inclusive educational environments is particularly true for countries such as Egypt, which has become an appealing destination for students from both neighboring and foreign reaching a total of 51649 inbound international students in 2024 \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[18]\u003c/span\u003e. This is partly due to the relatively low cost of living and education, the presence of internationally accredited medical schools, and its shared cultural and religious background \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[2]\u003c/span\u003e. Egypt also hosts students from non-Arab countries, who come with an additional set of challenges, including language and cultural barriers \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[2]\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eUnfortunately, despite international calls for inclusivity and cultural diversity in medical education, and the increasing numbers of international medical students in Egyptian Universities, the structural support systems that help them in sociocultural adaptation often remain lacking to meet students' needs. While some initiatives exist such as Mansoura University\u0026rsquo;s orientation days for new incoming international medical students, these are typically limited to initial welcome activities without sustained follow-up or long-term integration support. Studies at other Egyptian institutions, like Tanta University, reveal that many international students face significant difficulties in sociocultural adaptation, particularly in terms of cultural isolation, language barriers, and lack of ongoing mentorship \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[19]\u003c/span\u003e. Similarly, another research on acculturative stress in an Egyptian medical school highlights persistent cultural challenges, including perceived discrimination and academic pressures, particularly among non-Arab and female students \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[20]\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eCollectively, these findings suggest a need for more comprehensive and continuous support systems to foster inclusive academic and social environments for international students. Therefore, this study aims to assess Mansoura University\u0026rsquo;s international medical students\u0026rsquo; socio-cultural adaptation and how it relates to their socio-demographic backgrounds. The goal is to generate data that can inform the development of targeted strategies to enhance integration, inclusivity, and well-being success among this student population.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and study period\u003c/h2\u003e \u003cp\u003eA descriptive cross-sectional study with an analytical component was conducted among international medical students. The study was conducted in the Faculty of Medicine, Mansoura University, Egypt, between September and November 2024. This study followed the STROBE guidelines for reporting observational studies \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[21]\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eThe study population included international medical students enrolled at the Faculty of Medicine, Mansoura University, during the 2024\u0026ndash;2025 academic year. This encompassed students from both the Traditional program and the Mansoura Manchester Program for Medical Education, across first to fifth academic years. According to official records from the Students\u0026rsquo; Affairs Department, approximately 3572 international students were enrolled during this period.\u003c/p\u003e \u003cp\u003eA non-probability quota sampling technique was employed to ensure proportional representation across academic years. Quotas were established based on the actual distribution of international students in each year.\u003c/p\u003e\n\u003ch3\u003ePilot study and sample size\u003c/h3\u003e\n\u003cp\u003eA pilot study involving 30 international students was conducted to assess clarity and determine the standard deviation of sociocultural adaptation scores to calculate the sample size. Based on the pilot study\u0026rsquo;s participants' feedback, a few words in the English version of the Revised Sociocultural Adaptation Scale (SCAS-R) \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[22]\u003c/span\u003e, were reported to be difficult, and their Arabic translation was included between parentheses in the final version of the survey. Since the survey was changed based on the feedback of the pilot study, these responses were not included in the final analysis.\u003c/p\u003e \u003cp\u003eThe sample size was calculated using MedCalc 23.2.1 software \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[23]\u003c/span\u003e, considering the mean score on the SCAS-R scale as the primary outcome of interest. Our pilot study reported a mean sociocultural adaptation score of 3.29 with a standard deviation of 0.819. With a margin of error of 5% and a study power of 80%, the calculated required sample was 208. To account for convenience sampling, we used a design effect of 1.5, yielding a total sample size of 312. In total, 408 responses were collected. Thirteen responses were excluded; ten participants did not consent to share their data, and three entries were incomplete, leaving a total of 395 responses.\u003c/p\u003e\n\u003ch3\u003eSampling and data collection approach\u003c/h3\u003e\n\u003cp\u003eAfter determining the required sample size, the study used a combination of convenience and snowball sampling, along with a non-probability proportionate quota technique based on academic year. Data was collected using a self-administered questionnaire using Google Forms. The survey was shared with all international students through official groups via the Telegram app and other social media platforms. A team of collaborators was assembled and trained by the authors to assist in data collection. Participation was anonymous, voluntary, and completed at the participants\u0026rsquo; convenience without compensation.\u003c/p\u003e\n\u003ch3\u003eStudy tools\u003c/h3\u003e\n\u003cp\u003eA structured self-reported online questionnaire was distributed to the faculty\u0026rsquo;s international students, which consisted of two sections.\u003c/p\u003e \u003cp\u003eThe first included the SCAS-R \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[22]\u003c/span\u003e, with the minor aforementioned adaptations based on the pilot study, which was used to assess the level of adaptability of international medical students to their current environment. The tool comprises 21 questions and was set to measure interpersonal communication, academic performance, personal interests \u0026amp; community involvement, ecological adaptation, and language proficiency. These items were scored on a five-point Likert scale ranging from 1 (not at all competent) to 5 (extremely competent). A total score was calculated by summing the responses across all items (possible range: 21 to 105), then dividing by the number of items to yield a final score ranging from 1 to 5. Higher scores reflect greater levels of sociocultural adaptation. The SCAS-R is a valid tool for measuring sociocultural adaptation and has a good test-retest reliability (r\u0026thinsp;=\u0026thinsp;0.92) \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[22]\u003c/span\u003e. Additionally, the pilot study resulted in a Cronbach\u0026rsquo;s α of 0.93, indicating high internal consistency of the scale in line with that of the original scale (α\u0026thinsp;=\u0026thinsp;0.92) \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[22, 24]\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe second section of the questionnaire collected non-identifying sociodemographic characteristics, which included: age, sex, academic year, nationality, and income sufficiency.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was conducted using Jamovi 2.3.28 software \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[25]\u003c/span\u003e. Sociodemographic data were summarized using descriptive statistics. Categorical variables were reported as frequencies and percentages, while continuous variables were reported as mean and standard deviation (SD). Normality was assessed using a Quantile-Quantile (Q-Q) plot. An Independent Samples T-test and One-Way Analysis of Variance (ANOVA) were employed to compare the means of independent groups and determine whether significant differences existed among them. For variables found to be significant in the ANOVA, post hoc analysis was conducted using the Games-Howell test. The relationship between sociocultural adaptation scores and participants\u0026rsquo; sociodemographic characteristics was examined using Pearson\u0026rsquo;s correlation. Additionally, factors associated with sociocultural adaptation scores were identified through linear regression analysis. A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic Characteristics of the Study participants\u003c/h2\u003e \u003cp\u003eA total of 395 international students participated in this survey. Participants were nearly equally distributed across gender and academic years, with 2nd year students representing the highest proportion of the participants (24.8%) and 3rd year the lowest (15.4%). Most of the study participants were from Arabic countries (n\u0026thinsp;=\u0026thinsp;327, 82.8%), mostly from Syria (23.8%), Sudan (17.7%), and Palestine (11.1%), while 17.2% of the participants were non-Arabs mostly from Malaysia (n\u0026thinsp;=\u0026thinsp;59, 14.9%). Most (86.6%) of the students reported sufficient income (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\u003eParticipants\u0026rsquo; sociodemographic characteristics (N\u0026thinsp;=\u0026thinsp;395)\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=\"left\" 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\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverall\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e395 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e21 or less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e250 (63.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eOlder than 21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e145 (36.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e213 (53.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e182 (46.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eAcademic year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1st year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64 (16.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e2nd year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e98 (24.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e3rd year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61 (15.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e4th year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e89 (22.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e5th year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83 (21.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"16\" rowspan=\"17\"\u003e \u003cp\u003e\u003cb\u003eNationality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"9\" rowspan=\"10\"\u003e \u003cp\u003eArab country\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSyria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94 (23.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSudan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70 (17.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePalestine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44 (11.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBahrain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (9.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eJordan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (7.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSaudi Arabia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (4.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYemen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAlgeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOthers*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (3.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal Arabs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e327 (82.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eNon-Arab country\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMalaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59 (14.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSomalia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (0.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (0.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhilippines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndonesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal Non-Arabs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68 (17.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eIncome sufficiency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e342 (86.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eLess than Sufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53 (13.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e*Others: Iraq, Kuwait, Lebanon, Libya, South Sudan, and the United Arab Emirates (each had a frequency of 3 or less)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAssociation Between Sociodemographic Characteristics and SCAS-R Scores\u003c/h2\u003e \u003cp\u003eThe overall mean SCAS-R score was 3.37 (SD\u0026thinsp;=\u0026thinsp;0.69) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Males displayed significantly higher adaptation scores particularly in personal interest \u0026amp; community involvement (3.09 vs 2.86, p\u0026thinsp;=\u0026thinsp;0.011) and language proficiency (4.25 vs 4.00, p\u0026thinsp;=\u0026thinsp;0.036) than females. Moreover, 1st-year students had the highest overall mean SCAS-R scores (3.52, SD\u0026thinsp;=\u0026thinsp;0.72), which dropped significantly in the 2nd-year (3.21, SD\u0026thinsp;=\u0026thinsp;0.62), and increased relatively steadily among 3rd (3.39, SD\u0026thinsp;=\u0026thinsp;0.50), 4th (3.31, SD\u0026thinsp;=\u0026thinsp;0.81) and 5th-year students (3.48, SD\u0026thinsp;=\u0026thinsp;0.71).\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\u003eComparison of SCAS-R Scores Across Sociodemographic Characteristics Among International Medical Students at Mansoura University (N\u0026thinsp;=\u0026thinsp;395)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\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=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOverall sociocultural adaptation\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInterpersonal Communication\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAcademic/Work Performance\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePersonal Interests \u0026amp; Community Involvement\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEcological Adaptation\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLanguage Proficiency\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverall\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.37 (0.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.38 (0.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.44 (0.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.98 (0.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.28 (0.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.13 (1.15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.36 (0.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.37 (0.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.43 (0.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.00 (0.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.27 (0.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.13 (1.14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.37 (0.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.40 (0.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.44 (0.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.95 (0.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.29 (0.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.14 (1.17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.931\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.706\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.934\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.584\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.851\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.925\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.42 (0.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.40 (0.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.49 (0.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.09 (0.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.30 (0.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.25 (1.10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.31 (0.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.35 (0.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.37 (0.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.86 (0.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.25 (0.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.00 (1.19)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.599\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.602\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.036\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003eAcademic year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1st year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.52 (0.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.51 (0.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.61 (0.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.39 (0.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.50 (0.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.70 (1.21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2nd year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.21 (0.62)\u003csup\u003e\u003cb\u003e(a)\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.19 (0.72)\u003csup\u003e\u003cb\u003e(b)\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.32 (0.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.81 (0.74)\u003csup\u003e\u003cb\u003e(a)\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.10 (0.75)\u003csup\u003e\u003cb\u003e(a)\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.11 (1.15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3rd year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.39 (0.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.35 (0.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.45 (0.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.90 (0.69)\u003csup\u003e\u003cb\u003e(a)\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.39 (0.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.34 (0.97)\u003csup\u003e\u003cb\u003e(c)\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4th year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.31 (0.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.37 (0.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.35 (0.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.96 (0.96)\u003csup\u003e\u003cb\u003e(a)\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.14 (1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.07 (1.22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5th year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.48 (0.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.52 (0.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.54 (0.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.96 (0.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.38 (0.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.42 (1.06)\u003csup\u003e\u003cb\u003e(c)\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.026\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eNationality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eArab country\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.40 (0.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.40 (0.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.45 (0.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.97 (0.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.26 (0.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.42 (0.97)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-Arab country\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.21 (0.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.29 (0.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.38 (0.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.03 (0.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.34 (0.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.76 (0.97)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.046\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.515\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.664\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.497\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eIncome sufficiency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLess than Sufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.40 (0.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.15 (0.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.28 (0.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.80 (0.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.99 (0.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.83 (1.24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.14 (0.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.41 (0.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.46 (0.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.01 (0.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.32 (0.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.18 (1.13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.021\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.097\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.039\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003eMean (SD),\u003csup\u003e\u003cb\u003e(a)\u003c/b\u003e\u003c/sup\u003e significantly less than 1st years, p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u003csup\u003e\u003cb\u003e(b)\u003c/b\u003e\u003c/sup\u003e significantly less than 5th years, p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u003csup\u003e\u003cb\u003e(c)\u003c/b\u003e\u003c/sup\u003e significantly higher than 1st years, p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\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\u003eArab students had significantly higher mean SCAS-R scores than non-Arab students (3.40 vs 3.21, p-value\u0026thinsp;=\u0026thinsp;0.046), with this difference being largely attributed to differences in language proficiency (4.42 vs 2.76, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In addition, students with sufficient income showed less difficulty in sociocultural adaptation in terms of interpersonal communication (3.41 vs 3.15, p\u0026thinsp;=\u0026thinsp;0.021), ecological adaptation (3.32 vs 2.99, p\u0026thinsp;=\u0026thinsp;0.008), and language proficiency (4.18 vs 3.83, p\u0026thinsp;=\u0026thinsp;0.039) than students with insufficient income (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCorrelation Between Sociodemographic Variables and Total SCAS-R Scores\u003c/h2\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, a significant positive correlation was observed between language proficiency and being from an Arab country (r\u0026thinsp;=\u0026thinsp;0.543, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additionally, income sufficiency was positively correlated with better overall sociocultural adaptation (r\u0026thinsp;=\u0026thinsp;0.127, p\u0026thinsp;=\u0026thinsp;0.011), as well as with interpersonal communication (r\u0026thinsp;=\u0026thinsp;0.115, p\u0026thinsp;=\u0026thinsp;0.021), ecological adaptation (r\u0026thinsp;=\u0026thinsp;0.132, p\u0026thinsp;=\u0026thinsp;0.008), and language proficiency (r\u0026thinsp;=\u0026thinsp;0.104, p\u0026thinsp;=\u0026thinsp;0.039).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePearson Correlation Coefficients Between Sociodemographic Variables and SCAS-R Scores Among International Medical Students at Mansoura University\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\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=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall sociocultural adaptation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInterpersonal Communication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAcademic/Work Performance\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePersonal Interests \u0026amp; Community Involvement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEcological Adaptation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLanguage Proficiency\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (continuous)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.078\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.053\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.079\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.069\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e-0.127*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e-0.104*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcademic year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.086\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.156**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNationality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.099*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.053\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.543***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIncome sufficiency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.127*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.115*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.084\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.132**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.104*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eCategorical variables were included in the model as dummy variables: Nationality (0\u0026thinsp;=\u0026thinsp;Non-Arab, 1\u0026thinsp;=\u0026thinsp;Arab), Sex (0\u0026thinsp;=\u0026thinsp;Male, 1\u0026thinsp;=\u0026thinsp;Female), Academic year (1\u0026ndash;5), and Income sufficiency (0\u0026thinsp;=\u0026thinsp;Less than sufficient, 1\u0026thinsp;=\u0026thinsp;Sufficient). * p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.01, ***p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMultivariate Associations Between Sociodemographic Characteristics and SCAS-R Scores\u003c/h2\u003e \u003cp\u003eIn the multivariate linear regression analysis (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), income sufficiency was the only significant predictor of overall sociocultural adaptation (β\u0026thinsp;=\u0026thinsp;0.14, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Nationality showed the strongest association with language proficiency, with Arab students reporting significantly higher proficiency (β\u0026thinsp;=\u0026thinsp;0.55, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Academic year was positively associated with language proficiency (β\u0026thinsp;=\u0026thinsp;0.13, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) but negatively associated with personal interests and community involvement (β = \u0026minus;0.14, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Female gender was also negatively associated with personal interests and community involvement (β = \u0026minus;0.14, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate Linear Regression of Factors Associated with SCAS-R Scores Among International Medical Students at Mansoura University\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\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=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall sociocultural adaptation\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInterpersonal Communication\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAcademic/Work Performance\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePersonal Interests \u0026amp; Community Involvement\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEcological Adaptation\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLanguage Proficiency\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (continuous)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.07 (-0.06, 0.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.07 (-0.06, 0.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.09 (-0.04, 0.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.09 (-0.03, 0.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.04 (-0.08, 0.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.08 (-0.18, 0.02)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.07 (-0.17, 0.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.02 (-0.13, 0.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.07 (-0.17, 0.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e-0.14 (-0.25, -0.04)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.04 (-0.15, 0.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.03 (-0.06, 0.11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcademic year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.04 (-0.17, 0.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.00 (-0.13, 0.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.06 (-0.19, 0.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e-0.14 (-0.27, -0.02)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.05 (-0.17, 0.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.13 (0.03, 0.24)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNationality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.09 (-0.01, 0.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.05 (-0.05, 0.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.02 (-0.08, 0.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.04 (-0.15, 0.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.03 (-0.14, 0.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.55 (0.47, 0.64)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIncome sufficiency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.14 (0.04, 0.24)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.12 (0.02, 0.22)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.08 (-0.02, 0.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.10 (0.00, 0.20)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.14 (0.04, 0.24)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.14 (0.06, 0.22)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eCategorical variables were included in the model as dummy variables: Nationality (0\u0026thinsp;=\u0026thinsp;Non-Arab, 1\u0026thinsp;=\u0026thinsp;Arab), Sex (0\u0026thinsp;=\u0026thinsp;Male, 1\u0026thinsp;=\u0026thinsp;Female), Academic year (1\u0026ndash;5), and Income sufficiency (0\u0026thinsp;=\u0026thinsp;Less than sufficient, 1\u0026thinsp;=\u0026thinsp;Sufficient). \u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e β (95% CI), * p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.01, ***p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001. CI: Confidence Intervals.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAdjusting to life in a new cultural setting comes with a substantial set of challenges, which are further exacerbated by the demanding nature of medical education \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[6]\u003c/span\u003e. Evaluating international medical students\u0026rsquo; adaptation to new settings and understanding the factors that shape it is key in supporting their academic and personal success \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[26]\u003c/span\u003e. It is also imperative to ensure an inclusive learning environment that caters to the culturally diverse student population in Egypt \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[27] [17]\u003c/span\u003e. Hence, this study aimed to assess Mansoura University\u0026rsquo;s international medical students\u0026rsquo; socio-cultural adaptation and how it relates to their socio-demographic backgrounds, providing recommendations for a more welcoming academic setting.\u003c/p\u003e \u003cp\u003eUsing the SCAS-R, the mean total sociocultural adaptation score of our study\u0026rsquo;s participants was 3.37. This was slightly less than the scores reported among international students in Hong Kong (3.53) \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[28]\u003c/span\u003e, Turkey (3.57) \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[29]\u003c/span\u003e and at a metropolitan university in the USA (3.50) \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[30]\u003c/span\u003e. The comparatively lower adaptation observed in our sample may be due to differences in sample characteristics, as the aforementioned studies assessed international students in general rather than medical students specifically. This is further supported by the findings of Shehata et al.\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[19]\u003c/span\u003e, who reported a mean sociocultural adaptation score of 3.3 among Malaysian medical students in Tanta University in Egypt.\u003c/p\u003e \u003cp\u003eThe lower socio-cultural adaptation scores among medical students may be attributed to the intense academic demands of medical education, which significantly hinder students\u0026rsquo; engagement with their communities, thereby affecting their adaptation to new cultures \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[26, 31]\u003c/span\u003e. This is further evidenced by the personal interests \u0026amp; community involvement scores among our study\u0026rsquo;s participants, which were the lowest across the SCAS-R subscales. This finding is of serious consequence, given that community involvement and interpersonal communication both play a critical role in helping students adapt to cultures \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[32]\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eFor instance, engaging in the community through participation in extracurricular activities and volunteering has shown to foster a strong sense of belonging among medical students and to enhance soft skills such as teamwork and communication \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[33]\u003c/span\u003e. Consequently, this involvement promotes the formation of meaningful interpersonal relationships with students of the host culture, providing international students with much-needed social support systems in the absence of their families and social networks \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[32]\u003c/span\u003e. These relationships in turn become crucial for navigating cultural transitions, and ultimately facilitating successful sociocultural adaptation \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[34]\u003c/span\u003e. Notably, the significantly higher sociocultural adaptation scores among male students were largely a reflection of higher personal interests \u0026amp; community involvement scores compared to females. This is also consistent with similar studies conducted in Egypt which highlight lower sociocultural adaptation \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[19]\u003c/span\u003e, higher acculturative stress \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[20]\u003c/span\u003e and increased social media \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[35]\u003c/span\u003e use among female students compared to their male counterparts. This may be due to males having more opportunities to engage in Egyptian culture as compared to females who may face more constraints in doing so. Collectively, these findings underpin the importance of encouraging early community engagement as a key strategy to support international students\u0026rsquo; adaptation and integration into the host culture.\u003c/p\u003e \u003cp\u003eSurprisingly, in our study, personal interests \u0026amp; community involvement scores peaked in first year students, declined significantly in second year and then gradually rebounded to by the fifth year- a trend also observed in terms of interpersonal relationships and overall socio-cultural adaptation scores. The pattern found in our study closely mirrors the classic U-curve model of cross-cultural adjustment as described by Lysgaard et al \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[36]\u003c/span\u003e. The elevated first-year scores likely reflect the \u0026ldquo;honeymoon phase\u0026rdquo;; the initial stage of arriving to a new cultural environment. During this phase, sojourners are captivated by the host culture, open to new experiences and have great motivation to integrate into the host culture \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[37]\u003c/span\u003e. In second year, students appear to enter the \u0026ldquo;shock phase,\u0026rdquo; as the novelty fades and academic pressures and social fatigue set in; thereafter, a \u0026ldquo;recovery phase\u0026rdquo; sees adaptation scores rise again \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[20, 38]\u003c/span\u003e. However, Chien et al. contends that the U-curve oversimplifies the acculturation process, which is influenced by a complex interplay of individual, cultural, and contextual factors \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[39]\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eAnother interpretation for the higher adaptation scores among first years is that universities often focus integration efforts -such as mentoring schemes and structured social events- primarily on first-year students \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[40, 41]\u003c/span\u003e. While such programs prove to be effective for first year students\u0026rsquo; adjustment, sustained engagement is recommended in further years to maintain the adaptation gains \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[42]\u003c/span\u003e. Accordingly, targeted support and campus services should be extended into the intermediate academic years to prevent the marked decline in sociocultural adaptation that can undermine both student well-being and academic performance.\u003c/p\u003e \u003cp\u003eThe overall sociocultural adaptation score was also significantly influenced by nationality, with non-Arab students reporting lower adaptation levels compared to their Arab counterparts. This difference may be attributed to the language and cultural barriers faced by non-Arab students in a predominantly Arab environment like Egypt, which may hinder their participation in social interactions and integration within the local community. This interpretation is further supported by subscale findings, as non-Arab students scored significantly lower in both language proficiency and interpersonal communication compared to non-Arab students. Previous studies among international medical students in Egypt further support this notion. In a study by Shehata et al. in Tanta university \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[19]\u003c/span\u003e, Malaysian students proficient in Arabic reported significantly higher adaptation scores. Meanwhile, Ali et al. in Ain Shams University identified language deficiencies and nationality as key sources of acculturative stress \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[20]\u003c/span\u003e, highlighting the central role of language in the adaptation process.\u003c/p\u003e \u003cp\u003eLanguage difficulties are well documented as a significant barrier to sociocultural adaptation in various international contexts, including Australia \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[31]\u003c/span\u003e, Hungary \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[34]\u003c/span\u003e, USA \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[30]\u003c/span\u003e, Malaysia \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[43]\u003c/span\u003e and Saudi Arabia \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[44]\u003c/span\u003e. Such challenges are particularly concerning in medical education, where language proficiency is critical for both academic success and clinical communication \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[45]\u003c/span\u003e, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[46]\u003c/span\u003e, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[6]\u003c/span\u003e, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[26]\u003c/span\u003e. Non-Arab medical students, in particular, have repeatedly reported language barriers as a major challenge, especially in clinical settings where communication with Arabic-speaking patients is essential \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[2, 46]\u003c/span\u003e. In fact, the significantly higher adaptation scores among participants with sufficient income may have been largely due to their ability to afford language courses, which corresponded with notably higher language proficiency scores.\u003c/p\u003e \u003cp\u003eGiven the critical role of language in not only the sociocultural adaptation of international medical students but also their overall academic and clinical success, medical institutions should prioritize native language training as a core component of their integration efforts \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[47]\u003c/span\u003e. One effective approach is the adoption of bilingual language programs. In Egypt, medical education is primarily delivered in English - the global language of medicine - while clinical interactions typically occur in Arabic. Non-Arab students may therefore benefit from a bilingual curriculum that maintains English as the medium of instruction while incorporating targeted Arabic training to ease the transition into clinical environments \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[45]\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eIn addition to bilingual strategies, foreign language support programs have shown promising results in other health education contexts. For instance, Seibold et al. reported significant improvements in clinical communication skills among nurses whose first language was not English after they received tailored English language instruction \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[48]\u003c/span\u003e. While several similar programs have demonstrated positive outcomes, the development of context-specific, needs-based language interventions remains essential \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[49]\u003c/span\u003e. Another proposed program directed at medical students is the English for Medical Purposes (EMP) program for international medical graduates in Canada, which aims to enhance communication skills in medical contexts \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[50]\u003c/span\u003e.While such initiatives may face logistical and financial constraints, they have been shown to strengthen international students\u0026rsquo; academic confidence and facilitate relationship-building with host-country peers and patients which is an essential factor linked to greater self-reported satisfaction, enhanced social connectedness, and ultimately, improved sociocultural adaptation \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[51]\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eIncome sufficiency also emerged as a significant predictor of overall sociocultural adaptation, aligning with existing literature that links financial stress to reduced well-being among international students \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[52]\u003c/span\u003e and as a key contributor to acculturative stress \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[10, 20]\u003c/span\u003e. In our study, students reporting a less than sufficient income also scored lower on the ecological adaptation subscale, suggesting that students with adequate financial resources are better able to navigate the day-to-day practical demands of life in Egypt. This may reflect their greater ability to secure comfortable housing, access local services, and engage with the host environment without the added burden of financial stress all of which are central to ecological adjustment.\u003c/p\u003e \u003cp\u003eIn recent years, Egypt has experienced significant inflation, with rates reaching 28.3% in 2024, contributing to rising rent, tuition fees, and daily living costs for both local and international students \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[53]\u003c/span\u003e. These economic pressures may disproportionately impact international students, many of whom rely on private rentals for accommodation \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[20]\u003c/span\u003e. Accordingly, medical schools and higher education institutions should prioritize the expansion of financial support mechanisms. These may include increasing scholarship opportunities for international students, implementing flexible tuition payment plans, and providing part-time work opportunities on campus. Such interventions can alleviate financial stress, promote student well-being, and support greater socio-cultural engagement.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003e Our study, conducted in a resource-constrained setting amid rising inflation and economic instability, provides practical relevance and applicable findings, particularly for similarly affected regions.\u003c/p\u003e \u003cp\u003eHowever, this study is not without limitations. Conducting the study in a single faculty limits the generalizability of the findings to the broader population of international medical students in Egypt. Future research should include multiple institutions and non-medical students across the country to better capture nationwide trends. Moreover, its cross-sectional design limits the ability to infer causality; therefore, longitudinal research is recommended to better understand changes in adaptation over time. Additionally, the use of convenience and snowball sampling may have introduced selection bias and limits the generalizability of the findings; future studies should consider employing randomized sampling strategies. The reliance on self-reported data also poses a risk of recall or social desirability bias, which may have influenced how participants rated their adaptation experiences.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe present study provides important insights into the sociocultural adaptation of international medical students in a single Egyptian faculty. Key sociodemographic factors - including gender, nationality, income sufficiency, and academic year - were found to significantly influence adaptation levels. These findings highlight the need for targeted institutional support, particularly in the areas of language training, community engagement, and financial assistance, to foster inclusive and culturally responsive learning environments that promote student well-being and success.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eANOVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAnalysis of Variance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence Interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEMP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEnglish for Medical Purposes\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eQ-Quantile-Quantile\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSCAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eR-Sociocultural Adaptation Scale-Revised\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTROBE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStrengthening the Reporting of Observational studies in Epidemiology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAcknowledgments\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express their sincere appreciation to the Mansoura Students\u0026rsquo; Scientific Association (MSSA-Mansoura) for their contribution to this study. This research was conducted as part of the 2023/2024 Research Club under the Research Support Division of MSSA-Mansoura. Special thanks are extended to Yusof M. Omar and Basma Kamel for their unwavering support, dedication, and continuous feedback. Their guidance and mentorship were instrumental in the initiation and successful completion of this research. The authors would also like to acknowledge Mostafa Ismael, Alya Bahari, Abdullah Mosaad, Mohammad Diaa and Noor Salman for their help in disseminating the questionnaire.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAuthor contributions\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe conception and design of the study were done by TD, MY, RE, SA, EH, MA, NR, MA. Acquisition of data was done by TD, MY, RS, SY, SA, EH, MA, EN, NR, TI, MA. Analysis and interpretation of data were done by TD. Drafting the manuscript was done by TD, MY, RE, SY, SA, EH, MA, EN, NR, TI, MA. Revising the manuscript critically for important intellectual content was done by TD, AE, HS. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding or sponsorship was received from any companies, groups, individuals, organizations, or any other entities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eData Availability\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data of this study is available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical permission to conduct this study was obtained from the Institutional Research Board of Mansoura University\u0026apos;s Faculty of Medicine under the approval number R.24.08.2757.\u0026nbsp;This study was completed in compliance with the Helsinki Declaration for medical research involving human participants. Participants were asked to willingly and anonymously complete our online survey, providing electronic informed consent and having the flexibility to finish the survey at their convenience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e*\u003cstrong\u003eSCA team of collaborators\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAbdulrahman Jamal, Nehal Ezzat, Shahd Ismail, Abdelaziz Mohamed, AhmedEltayeb Emad, Mohamed G. Elsayed, Moath Alhaj Ali, Khaled Abuzeid, Tengu Nurul Farihah Binti Tengku Nasrudin.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRagab EA, Dafallah MA, Salih MH, et al. 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Nurses on the move: evaluation of a program to assist international students undertaking an accelerated Bachelor of Nursing program. \u003cem\u003eContemp Nurse\u003c/em\u003e. 2007;25(1-2):63-71. doi:10.5555/conu.2007.25.1-2.63\u003c/li\u003e\n\u003cli\u003eCrawford T, Candlin S. A literature review of the language needs of nursing students who have English as a second/other language and the effectiveness of English language support programmes. \u003cem\u003eNurse Educ Pract\u003c/em\u003e. 2013;13(3):181-185. doi:10.1016/j.nepr.2012.09.008\u003c/li\u003e\n\u003cli\u003eMeehan SC. \u003cem\u003eEnglish for Medical Purposes: A Program to Ensure the Success of Our International Medical Graduates \u003c/em\u003e. Applied Language Associates; 2004.\u003c/li\u003e\n\u003cli\u003eHendrickson B, Rosen D, Aune RK. An analysis of friendship networks, social connectedness, homesickness, and satisfaction levels of international students. \u003cem\u003eInternational Journal of Intercultural Relations\u003c/em\u003e. 2011;35(3):281-295. doi:10.1016/j.ijintrel.2010.08.001\u003c/li\u003e\n\u003cli\u003eWilson S, Hastings C, Morris A, Ramia G, Mitchell E. International students on the edge: The precarious impacts of financial stress. \u003cem\u003eSAGE Publications\u003c/em\u003e. 2022. doi:10.1177/14407833221084756\u003c/li\u003e\n\u003cli\u003eCentral Agency for Public Mobilization and Statistics (CAPMAS) - Annual inflation rate for urban areas of the Republic. Accessed May 19, 2025. https://www.capmas.gov.eg/Pages/IndicatorsPage.aspx?page_id=6130\u0026amp;ind_id=2542\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":"Sociocultural adaptation, International medical students, Medical education, Egypt, SCAS-R, Cultural diversity","lastPublishedDoi":"10.21203/rs.3.rs-6719590/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6719590/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eInternational medical students face unique challenges in adjusting to new sociocultural environments, particularly in resource-limited settings. In Egypt, despite calls for increasing cultural diversity in medical education, limited research has explored how international students adapt and what factors influence their experience. This study aimed to assess the sociocultural adaptation of international medical students at Mansoura University to inform targeted strategies enhancing their inclusion and wellbeing.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted between September and November 2024 among international medical students at Mansoura University. Utilizing a combination of convenience and snowball sampling, along with a non-probability proportionate quota technique based on academic year, data were collected using an online survey that included sociodemographic questions and the Sociocultural Adaptation Scale\u0026ndash;Revised (SCAS-R).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e A total of 395 international students participated, with a mean SCAS-R adaptation score of 3.37 (SD\u0026thinsp;=\u0026thinsp;0.69). Adaptation peaked in 1st-year students (3.52), dropped in 2nd year (3.21), and gradually increased in later years (3rd: 3.39; 4th: 3.31; 5th: 3.48). Males reported higher scores in personal interest/community involvement (3.09 vs. 2.86, p\u0026thinsp;=\u0026thinsp;0.011) and language proficiency (4.25 vs. 4.00, p\u0026thinsp;=\u0026thinsp;0.036). Arab students had significantly higher overall adaptation than non-Arabs (3.40 vs. 3.21, p\u0026thinsp;=\u0026thinsp;0.046), primarily due to stronger language proficiency (4.42 vs. 2.76, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Students with sufficient income showed better adaptation in communication (3.41 vs. 3.15, p\u0026thinsp;=\u0026thinsp;0.021), ecological adjustment (3.32 vs. 2.99, p\u0026thinsp;=\u0026thinsp;0.008), and language (4.18 vs. 3.83, p\u0026thinsp;=\u0026thinsp;0.039).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe findings of this study emphasize the need for medical institutions to implement inclusive support strategies, including bilingual language training, targeted financial assistance, and sustained integration efforts beyond the first academic year.\u003c/p\u003e\u003ch2\u003eTrial Registration\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e","manuscriptTitle":"Towards Inclusive Medical Education in Egypt: A Cross-Sectional Study of Socio-Cultural Adaptation Among International Students","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-12 11:19:35","doi":"10.21203/rs.3.rs-6719590/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-13T10:14:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-30T08:52:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-23T22:03:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"259912499485755887059426283172130758864","date":"2025-07-23T15:25:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-21T11:54:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"188636472133179297332474925077464937321","date":"2025-07-18T01:09:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"289708741782998037375584642991225540195","date":"2025-07-16T05:44:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"115241576693284062028968797125806904075","date":"2025-07-15T23:17:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"223596151694891945002802500665446902361","date":"2025-06-10T14:04:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-10T13:58:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-05T12:42:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-04T12:25:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-06-04T12:16:21+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":"a77be7ff-fc9f-41d7-beaf-51dd0fe08dbe","owner":[],"postedDate":"June 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:09:25+00:00","versionOfRecord":{"articleIdentity":"rs-6719590","link":"https://doi.org/10.1186/s12909-025-08232-1","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2025-11-29 15:57:05","publishedOnDateReadable":"November 29th, 2025"},"versionCreatedAt":"2025-06-12 11:19:35","video":"","vorDoi":"10.1186/s12909-025-08232-1","vorDoiUrl":"https://doi.org/10.1186/s12909-025-08232-1","workflowStages":[]},"version":"v1","identity":"rs-6719590","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6719590","identity":"rs-6719590","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}