Emotional Intelligence and Academic Performance Among Egyptian and Saudi Arabian Undergraduate Medical Students: A Cross Sectional Study

The purpose of this study was to explore the domains of emotional intelligence among medical students and ascertain its relationship to academic achievement. Method: A cross-sectional study was conducted on 2340 undergraduate medical students from different Egyptian and Saudi Arabian universities using a semi-structured online abstract including two parts: Socio-demographic data and emotional intelligence questionnaire. The study was conducted on 2340 medical students aged (21.5 ± 1.9, range = 17–24 years) from two countries, Saudi Arabia (28.8%) and Egypt (71.2%). Females represented 68.4%. Academic achievement was distributed as excellent 54.1%, very good (28%), good (14.5%) and accepted (3.4%). The total EI score reported that 63.9% of the students had strength while 35.9% needed attention. Managing emotion, motivating oneself and total EI score were signicantly higher among Egyptian students in comparison to Saudi Arabia students (P < 0.001). Females showed signicantly higher EI scores than males. Egyptian males showed signicantly higher EI scores than Saudi Arabian males (P < 0.001). Self-awareness was signicantly high in Saudi Arabian females while managing emotions was signicantly high among Egyptian females (P < 0.01). Academic achievement showed that EI scores were signicantly higher among very good and excellent achievement in comparison to good or accepted achievement except self-awareness which showed that those with accepted achievement had higher self-awareness than those with high achievement. Signicant positive correlation was found between EI scores and academic achievement (P < 0.001) and analyzed PC using the Statistical Package for Social Sciences software (SPSS version 20). Data were expressed as number, percent, mean, SD and range. Tests of normality were applied. Unpaired t test and one-way ANOVA were used for normally distributed quantitative variables. Spearman correlation was used to detect association between ordinal and quantitative variables. A p < 0.05 was set to be the level of signicance.


Conclusion
Emotional intelligence domains relate signi cantly to academic achievements in medical students. Therefore, this study recommended the necessity of improving the students 'emotional intelligence in the scienti c and community environment with proper interventions strategies through developing program that enhances their academic achievement to play a pivotal role when transforming into business world and recently in academic study.

Background:
Emotional intelligence (EI) is de ned as the ability to monitor one's own and other people's emotions, to discriminate between different emotions and label them appropriately, and to use emotional information to guide thinking and behavior and to manage and/or adjust emotions to adapt to environments or achieve one's goals [1]. This de nition encompasses two subtypes of personal intelligence: intrapersonal and interpersonal intelligence. Intrapersonal intelligence, inner intelligence, is the ability to access one's own feeling life. This is important for self-awareness, selfregulation, and self-motivation. Interpersonal intelligence, outer intelligence, is the ability to read the moods, intentions, and desires of others. This is important for developing qualities like empathy and building up effective relationships [2,3].
The concept of EI was rst described by Salovey and Mayer more than two decades ago. It is a relatively new construct compared with intelligence or personality, with the rst academic article appearing in 1990 [4]. The concept was relatively unknown until it was popularized by science journalist Daniel Goleman in his 1995 book Emotional Intelligence: Why It Can Matter More Than IQ. This book aroused great interest from researchers and the general public in the late 1990s [4]. According to them, emotional intelligence can be categorized into ve domains: self-awareness, emotional management, self-motivation, empathy, and interpersonal skills [4].
Academic achievement or performance is the extent to which a student, teacher, or institution achieves its short or long-term educational goals. Completion of educational standards such as completion of the school year examination represents an academic achievement.
These different dimensions of EI are likely to in uence the academic and professional success particularly in the eld of medicine. The medical students learn and doctors work in a high-stress environment created by multiple factors which include demanding workloads, long hours of work, and having to interact with different personnel ranging from patients to healthcare teams. High level of stress and psychological distress among medical students and doctors are well documented [6,8].
There are number of studies from different populations showing that EI is related to academic and professional success in many elds including medicine [2,5,[9][10][11][12]. Their ndings highlight that EI plays a critical role in making a balanced doctor who is competent in practicing both the art and the science of medicine. Moreover, the doctors and medical students with higher EI are likely to be more competent regarding selfcare, which prevents them from becoming victims of the inevitable stress associated with the medical profession [2].
In the Middle East and African region, to the best of our knowledge, data regarding the effect of EI on the academic performance of medical undergraduates is limited. Therefore, this study was conducted to explore the association between EI and academic performance among medical students and demonstrate the elements that interfere with medical students' emotional intelligence in different areas of the Middle East and Africa region.
Salovey and Mayer introduced the concept of EI more than two decades ago. In comparison to IQ or personality, it is a relatively new construct, with the rst academic article published in 1990 [4]. Until science journalist Daniel Goleman popularized the concept in his 1995 book Emotional Intelligence: Why It Can Matter More Than IQ, the topic was virtually unknown. [5] The concept of EI refers to "the ability to accurately perceive, evaluate, and express emotions; the ability to access and/or generate feelings when facilitating thought 1; the ability to comprehend feelings and emotional knowledge; and the ability to regulate emotions to promote emotional and intellectual growth." EI is categorized into ve domains: self-awareness, emotional management, self-motivation, empathy, and interpersonal skills [4].
These difference of EI dimension are likely to have an impact on academic and professional achievement, especially in the medical eld. The medical students learn and doctors work in a high-stress environment created by multiple factors which include demanding workloads, long hours of work, and having to interact with different personnel ranging from patients to healthcare teams. Therefore, the medical students and professionals are known to experience high levels of stress and psychological anguish.
Emotional intelligence (EI) is a key determinant in academic success, and it encompasses vital components of interpersonal and intrapersonal relationships, exibility, moods, and stress management skills, all of which have a signi cant impact on students' academic performance. People and college students with higher emotional intelligence perform better in interpersonal relationships and are seen as more pro-social, less aggressive, and con icted by their peers.
EI, in a more direct approach, aids in the prioritization of thoughts, as well as the right regulation of behavior and lifestyle choices that improve academic achievement. In medical education, emotional intelligence, one of the psycho-emotional domains, has also been linked to better clinical outcomes and academic progress. This relationship has also been linked to enhanced empathy in medical advice, physician-patient interactions, clinical performance, and patient satisfaction in clinical practice. EI is important in developing a well-balanced practitioner who can practice both the art and science of medicine. Furthermore, doctors and medical students with greater EI are more likely to be pro cient in selfcare, preventing them from becoming victims to the inevitable stress of the medical profession [2]. So, many medical schools programmed emphasize, preserve, and develop these character attributes as part of their admissions process, and medical education in medical schools is focused on ensuring that these qualities and talents are respected, kept, and cultivated.

Methods:
A cross-sectional study was conducted on a convenience sample of 2340 undergraduate medical students, from different universities of Egypt and Saudi Arabia, during the academic year 2020-2021. Students in the college come from various backgrounds, rural, urban, and even from different socio-economic backgrounds.
The students who were at the rst academic year, refused to participate, and ever diagnosed to have psychiatric disorders, were excluded from the study.
Data were collected from February to April 2021, using an online quantitative survey. The survey was prepared on Google form (https://forms.gle/GWi1Q2Eko6HnARU49) and sent to the students via institutional emails, university-a liated websites, and various social media platforms, whether o cial or non-o cial groups. Students who agreed to participate in the study, after the explanation of objectives, procedures, voluntary nature of participation and declarations of con dentiality, were asked to complete the online questionnaire.
There was a plan number to reach a sample size of 377 participants as there is no previous study in the Arabic region studying the topic the relation between EI and academic achievement among medical students so the probability to occur equals probability of not to occur (p = q = 50%). The number of persons who answered the questionnaire was 2340. The time required to complete the questionnaire was about nine minutes.
The questionnaire is composed of two parts: part (I) Socio-demographic characteristic and part (II) Emotional intelligence questionnaire [13]. Socio-demographic characteristics included questions about age, sex, country and academic achievement. Academic achievement of each student had been obtained from the examination department after proper written permission from the controller of examinations with maintenance of full con dentiality. Students with cumulative percentage of marks in all professional examination in the rst attempt of 85 or above were classed as excellent achievers, less than 85-75% were classi ed as very good, less than 75-65% were classi ed as good achievers, less than 65-60% were classi ed as accepted and below 60% was set as a level of failure.
Emotional intelligence questionnaire is self-assessment tool designed to enable students thinking about the various competences of emotional intelligence as they apply to them. The questionnaire focused on exploring ve competencies involving: i. Self-awareness is the self-observation and identi cation of a feeling when it appears.
ii. Emotional management is the feeling that it is su cient to handle the behavior, recognizing the feelings behind.
iii. Self-motivation is a move to the goal of positive emotions, better self-control and to delay grati cation and impulse weakens.
iv. Empathy is sensitive to the feelings of others, caring and accepting their perspective and appreciate the differences that exist in the feelings of others.
v. Interpersonal skills to control the emotions of other people, have social competence and social skills Each of the ve competencies was asked about using ten questions. Emotional intelligence questions used a 5-point Likert scale (as the chosen number means how strongly the statement applies to the student) based on the following guide: one for 'Does not apply', three for 'Applies half the time'; and ve for 'Always applies'. The total score of each emotional competency was calculated. For each competency the score was interpreted as: score of 35-50 indicates it is area of strength for the student, 18-34 means that giving attention to where the student feel weakest will pay dividends, 10-17 indicates there is a need to make this area a development priority.
A pilot study on twenty participants (about 6%) was applied to validate the translated questionnaire. Experts in public health and family medicine specialties measured the questionnaire relevancy and ability to correctly perform the self-assessment of various competences of emotional intelligence and relates it to the academic achievement of the students. The questionnaire has a good reliability as Cronbach's alpha was calculated, and it was 0.83.

Statistical analysis:
The collected data has revised, coded, tabulated, and analyzed PC using the Statistical Package for Social Sciences software (SPSS version 20). Data were expressed as number, percent, mean, SD and range. Tests of normality were applied. Unpaired t test and one-way ANOVA were used for normally distributed quantitative variables. Spearman correlation was used to detect association between ordinal and quantitative variables. A p < 0.05 was set to be the level of signi cance.

Ethical Considerations:
Ethical approval for the study was obtained from the relevant IRB with an informed consent applied for the questionnaire and was obtained electronically from those who voluntarily accepted to take part in answering the anonymous dissemination of information in the questionnaire. The students were noti ed of the study purpose and its signi cance to the medical education eld. Only those who agreed to take part in the research were included. Any data included in the survey by the students was addressed merely anonymously.

Results:
The study was conducted on 2340 medical students aged (21.5 ± 1.9, range = 17-24 years) from two countries, Saudi Arabia (28.8%) and Egypt (71.2%). Females represented 68.4%, almost 2/3 the sample. Academic achievement was distributed as excellent 54.1%, very good (28%), good (14.5% and accepted (3.4%) ( Table 1)  Managing emotion, motivating oneself and total EI score were signi cantly higher among Egyptian students in comparison to Saudi Arabia students (P < 0.001). Females showed signi cantly higher EI scores than males. Egyptian males showed signi cantly higher EI scores than Saudi Arabian males (P < 0.001). Self-awareness was signi cantly high in Saudi Arabian females while managing emotions was signi cantly high among Egyptian females (P < 0.01). Academic achievement showed that EI scores were signi cantly higher among very good and excellent achievement in comparison to good or accepted achievement except self-awareness which showed that those with accepted achievement had higher self-awareness than those with high achievement. Signi cant positive correlation was found between EI scores and academic achievement (P < 0.001) ( Table 3) Table 3 Relationship between Emotional intelligence (EI) domains and country, sex and academic achievement among studied participants (n = 2340): Discussion: Higher EI is associated with better academic achievement among the studied medical students in Egypt and KSA universities. Similar results have been observed in other smaller studies conducted elsewhere, not only among medical students, but also among nursing students in different countries [2,[14][15][16][17]. There could be explained by that higher EI scorers could get adjusted to the emotionally demanding medical curriculum more easily and thus perform better.
The mean total EI score of our study sample was 36.5 out of 50; the maximum possible score. Different domains of EI reported that the highest scores were for social skills and the lowest scores were for self-motivation skills. This agrees with Wijekoon et.al. [2] The current results indicated that female medical students have higher EI than their male counterparts. In agreement, studies from the United Kingdom [19], Malaysia [20]. and India [21] have shown that female physicians as well as medical and dental students have higher EI than males. Other studies report few or no differences in EI among males and females [16,18,22,23]. Females tend to be more skillful at understanding and dealing with their emotions, whereas males demonstrate better regulation of emotions [19,24,25]. Evidence also suggests that women tend to have lower self-perceptions of EI than their male counterparts [26,27].
There were signi cant differences between overall EI scores among Egyptian and Saudi-Arabian medical students with the higher scores among the Egyptians participants. Although, outsiders usually view the Arab world as a homogenous entity, closer examination reveals important cultural, political and economic differences. For example, the GLOBE cross cultural leadership study showed that Arabic countries scored differently on a number of cultural dimensions [28]. Such differences may have a signi cant impact on EI.
To our knowledge, this is the rst study to assess the relationship between EI and academic performance in a large cohort of medical students from different years of the undergraduate Arab medical curriculum medical students. However, there is a similar study on non-medical professionals among four Arab countries Egypt, Kuwait, the UAE, and Saudi Arabia using an Arabic language emotional intelligence scale [29], which found that there are no signi cant differences between overall EI scores among the four Arab countries. However, using post hoc analysis, the authors could discern that Egypt has the lowest score on two factors; emotion regulation and utilization. They explained the differences in these two sub-dimensions between Egypt on one hand and Kuwait, the UAE, and Saudi Arabia on the other may be attributed to the national emotional climate in these countries.
Male Egyptian medical students have higher EI than their Saudi-Arabian counterparts. However, there is no signi cant difference in total EI between Egyptian and Saudi-Arabian female medical students. Although Egyptian female participants show signi cantly higher scores in selfmotivation and managing emotions, their Saudi-Arabian counterparts show signi cantly higher scores in self-awareness with no signi cant difference in other EI domains.

Conclusion:
This study gures out the relationship between emotional intelligence and academic achievement among medical students in Arab region.
These nding illustrate the importance of involving certain emotional competencies in medical education to graduate physicians who can deal with the problem they may face through their career and their life. Therefore, this study recommended that medical students should understand the concept of emotional intelligence by integrating related topics in mentoring programs and intervention strategies to help them develop their emotional intelligence skills through in-depth training leading to improvement in their personal character, Interpersonal relationships and communication and hence rising their academic achievement. Also, for academic view Curriculum developers should also consider incorporating emotional intelligence skills to the curriculum.