Introduction

Culture is an attractive but complex concept. Among the numerous factors that can play a vital role in multicultural environments in terms of understanding and toleration of other cultures, cultural intelligence is one of the most important ones (1). Individuals must be aware of cultural diversity and be able to communicate with other people in order to reduce the uncertainty arisen from cultural differences. In other words, the individuals who adapt themselves to better conditions accept the differences more easily (2). This kind of intelligence can serve as an indicator of the ability to be adapted to the new cultural structure (3). Cultural intelligence, as a new domain of intelligence, is closely related to the living environments, especially academic diversity, and allows people to recognize how others think and respond to behavioral patterns (4). Therefore, it can be argued that cultural intelligence is the inner and apparent perception of the people in terms of intellectual and practical aspects. In addition, cultural intelligence provides individuals with a kind of framework and language by which they can understand the differences and invest in them rather than tolerate, or ignore them. As a result, the communication barriers between cultural differences will be reduced, and individuals will be able to acquire management skills and cultural diversity (5). If individuals enjoy a high degree of cultural intelligence, they will be able to successfully learn in a new cultural environment and will enjoy new cultures; otherwise, they will have serious problems in interactive behaviors, learning, and psychological state (6). The Cultural Intelligence Center is a four-dimensional model for the measurement of cultural intelligence, which includes: cognitive cultural intelligence, motivation cultural intelligence, meta-motivation cultural intelligence, and behavioral cultural intelligence. Cognitive cultural intelligence represents one's understanding of cultural similarities and differences. Motivation cultural intelligence reflects the attentional ability and the ability to spend direct energy to learn and work in different cultural settings. Meta-motivation cultural intelligence is placed at a higher level of cognitive processes and promotes active thinking about different individuals and cultural situations. Finally, behavioral cultural intelligence reflects the individual's ability to provide verbal and non-verbal behaviors in interaction with people from different cultures (7). In their study, Deng & Gibson (8) state that university students will show some emotional reactions due to a lack of adaptability to the university environment, the campus and dormitory environment, and their inclusion in the new network of relations. If they do not enjoy mental health and suffer from mental and emotional disorders such as depression due to the aforementioned problems, not only will they themselves undergo some problems but the community will also be harmed ultimately. In this regard, researchers have referred to beliefs, values, norms, and cultural experiences as guides to the way people interact with each other (9-11). The results of the studies recently carried out on the culture and human adaptation to different cultural foundations show that some people take advantage of some capabilities that help them adapt themselves to their own culture and other cultures more effectively and also accept cultural diversities and benefit from a restrained psyche in this respect compared to others (12, 13). The following include the most important factors that may affect students' mental health: personal factors, factors pertaining to the university, and social factors (14). The unfamiliarity of many students with the environment and the people who come into contact with them at the beginning, a distance from the family, the lack of interest in the field of study, etc. can exacerbate these disorders (15). These disorders are of greater importance in medical science students (16) because the students will be present in hospitals and health centers in the form of internships and will also be in interaction with patients during the years of study. Therefore, the students' inability to be in cultural interaction with other students and patients with different cultures and beliefs can cause permanent anxiety and distrust, and may lead to the loss of their confidence in the fulfillment of the entrusted tasks. In addition, they may also undergo prolonged psychiatric disorders, such as depression, which, in turn, affect the vicious cycle of occupational stress and efficiency (17). The continuation of this cycle may gradually lead to the erosion of mental and physical abilities and may eventually lead to permanent neuropsychiatric disorders (18). In fact, these two factors of cultural adaptation, i.e. cultural intelligence and mental health, are multidimensional and complex concepts, and entail both objective and subjective factors in students, especially students of health systems. Therefore, it is of high importance for the health team to realize how cultural intelligence influences the behavioral state and, consequently, mental health. Through the achievement of comprehensive information on the quality of these two important and effective factors in clinical services, the authorities can provide the grounds for accurate planning to increase the level of cultural interactions and mental health to accelerate the adaptation process and to reduce the complications in each of these important factors. In this regard, the concepts of cultural intelligence and mental health and their related factors have been assessed among Iranian medical students to a lesser extent and, consequently, these students have been less studied through psychological interventions by researchers. Accordingly, the present study has examined the relationship between the cultural intelligence and mental health among these students so that the results of this study can lead to interventional initiatives in this regard while supporting the university students.

Research methodology

The present study was a cross-sectional one conducted at the Medical University of Mazandaran in 2017. The required sample size has been estimated 385 subjects with [, = 3.84; P=0.88; d²=0.001] and similar research results for comparing Cultural Intelligence (6, 18). The research population included all students in the Medical University of Mazandaran, who had the criteria for inclusion in the study, such as no use of anti-anxiety and anti-depressant drugs, as well as complete satisfaction to participate in the study. The sampling method used here is a random method with proportional allocation. To this end, each educational department was first considered as a stratum and, then, a sample was randomly selected from each of them. In order to fit the size of the selected samples from each of the strata (disciplines) with the number of the students in that discipline, the total sample size was divided among the disciplines. The data collection tool was a questionnaire containing three sections: demographic characteristics, cultural intelligence, and mental health. The demographic profile questionnaire contained questions about age, gender, marital status, educational level, native/non-native status, place of residence, religion, etc. The Cultural Intelligence Questionnaire, developed by Ang et al. (19) in 2004, encompasses four subscales, i.e. meta-motivation cultural intelligence (4 questions), cognitive cultural intelligence (6 questions), motivation cultural intelligence (5 questions), and behavioral cultural intelligence (5 questions). The questionnaire items were answered through a 7-point Likert scale (6, 20, 21) from strongly agree (score 7) to strongly disagree (score 1). The validity and reliability of this questionnaire have already been studied and approved in various studies (22). Similarly, the study approved the mentioned questionnaire with the Cronbach's alpha coefficient of 0.85 (23). The Mental Health Questionnaire also consists of 28 questions in four domains of physical symptoms, anxiety, social dysfunction, and depression. Each of the domains has 7 questions. The questions numbered 1 to 7 are related to physical symptoms, the questions numbered 8 to 14 ask about anxiety, the questions numbered 15 to 21 are   on social dysfunction, and the questions numbered 22 to 28 measure depression. The items are scored based on a 4-point Likert scale from 0 to 3 and the score range of each domain varies from 0 to 21 and the total score is between 0 and 84. In fact, as the score increases, the quality of mental health decreases. This is a standardized questionnaire whose validity and reliability in its Persian version have been confirmed in various studies (24, 25). Molavi et al. confirmed the validity of this questionnaire (r = 0.91) and reported its reliability as 0.9 by using Cronbach's alpha (26). The questionnaires were collected, then were coded and analyzed by the Pearson correlation coefficient, independent t-test, and chi-square test using SPSS version 18 at the significance level of 0.05.

Results

The results of this study showed that 183 (47.5%) students were male and 202 (52.5%) students were female. The mean age of the students participating in the study was 23.7 ± 2.9 years old. The frequency distribution of the demographic characteristics of the sample units has been shown in Table 1.

The cultural intelligence was 95.2 ± 12.8. The lowest score (18.55 ± 2.9) and the highest score (29 ± 3.46) in the students' cultural intelligence were related to the meta-motivation and cognitive subscales, respectively (Table 2). Studying the relationship between cultural intelligence and demographic characteristics of the students, the independent t-test showed that the meta-motivation subscale had a significant correlation with the male gender (P = 0.003). According to this test, there was a significant correlation between the total score of cultural intelligence and non-native status (P = 0.001). Moreover, the Pearson correlation test showed that there was a significant relationship between educational level (r = +0.4, P = 0.01) and total cultural intelligence score. Regarding the mental health status of the students, the mean± SD of total mental health in the four subscales equaled 23.37 ± 7.43, where the social dysfunction subscale with the mean± SD of 6.86 ± 3.5 took up higher values in this regard than the other domains (Table 2).

Similarly, there was a significant positive correlation between the total score of cultural intelligence and mental health (r = +0.6, P = 0.001). In addition, the results of the Chi - square test indicated that all the subscales of mental health except the subscale of physical symptoms had a statistically significant correlation with the total score of cultural intelligence (Table 3).

In terms of the relationship between mental health and demographic characteristics, there was a significant correlation between the total mental health score and native/non-native status (P = 0.03) and the educational level (r = +0.4, P = 0.015). There was a significant correlation between the students' scores on the depression subscale and gender, based on the independent t-test results (P = 0.003), in such a way that the prevalence of these disorders in girls (45.4%) was higher than that in boys (29.9%).

Discussion

Social and psychological behaviors determine that culture often influences the organizational processes and outcomes and can direct them. Differences in cultural values and beliefs have been shown to affect work perceptions and can also be effective in the increase or reduction of productivity (9). The results of this study showed that there was a significant positive correlation between the total score of cultural intelligence and mental health. This finding was consistent with the results of the studies carried out by Heidari et al. (20), and Van Dyne et al. (27). In order to explain this finding, cultural intelligence can be expressed as a set of social behaviors, which interacts with other individuals and is very effective in the acceptance of conditions, attitudes, and behaviors of others, as well as the individual's stability in different situations (8). This type of intelligence is very important for medical students who attend university with the priority of healthcare education and are directly involved with the clinical situation and patients. Here, the relationship and interaction with patients is one of the most important factors of success and progress for students (22). On the other hand, mental health that was also shown in a positive correlation with cultural intelligence in this study is an important criterion in the student's achievements. Therefore, adaptation in the field of cultural intelligence can be considered to be in direct interaction with the individual's mental state. In this case, the two variables, i.e. cultural intelligence and mental health, can affect each other in such a way that the inability in the acceptance and cultural adaptation to different individuals in such environments such as university and clinical settings can lead to a decline in one's mental state and brings about isolation and other consequences, such as anxiety, depression, and other mental disorders (28). As it was shown in the results, cultural intelligence has a significant relationship with the mental health subscales, including social interactions, depression, and anxiety, which is consistent with the above finding. The results of studying the relationship between cultural intelligence and demographic characteristics showed that there was a significant relationship between the meta-motivation subscale of cultural intelligence and male gender. This finding was consistent with the results of the studies conducted by Hasani et al. (2) and Ghaffari et al. (29). The meta-motivation subscale of emotional intelligence reflects the individual's perception of cultural similarities and differences and shows the individual's general knowledge and cognitive maps of the other cultures. Upon arrival to a foreign culture, one needs to gain the necessary information about the ways of penetrating into the inner layers of that culture (30), particularly because the most important point in communication is to find the available commonalities with the other party and to emphasize on them. Hence, meta-motivation cultural intelligence allows the individual to understand cultural relationships and take advantage of them in making communications with other cultures. This case is generally greater and is executed more easily in males because of higher self-esteem and higher curiosity (31). On the other hand, it generally takes females a longer time to be integrated with this matter and, thereby, they communicate harder due to their resistance in trusting others and the establishment of deep relations, which is considered natural (32). The results also showed that there was a significant correlation between the total score of cultural intelligence and the students' non-native status. This finding was consistent with the results of the studies by Heidari et al. (20) and Furnhum et al. (31). Therefore, this finding can be interpreted by the argument that non-native students become familiar with different cultures due to their distance from family and residence in dormitory settings, and this leads to their adaptation to different cultures, and increases their cultural intelligence. The results also showed that there was a statistically significant relationship between cultural intelligence and education level in such a way that the level of cultural intelligence increased as the level of education increased from bachelor or general PhD programs to masters and technical PhD programs. This finding was consistent with the results of the study done by Ahanchian et al. (22). This finding can be attributed to the presence of students at different educational programs and encounter with different cultures and, consequently, different cultural environments that make them more adapted to the conditions. Ramis (33) believes that the students who attend only one program at the university and study over the years at the same university may still have lower emotional intelligence and interactive and adaptive power than those who have attended different universities at higher programs and even in different cities. This can be attributed to the sense of maturity, the management ability, and the sense of impact on the environment in students at higher academic programs. Although students in one academic program may be involved with different cultures and may gain a high degree of adaptation, the sense of advancement that is followed by the change of the educational situation can stabilize the status and make a great contribution to the cultural and the mutual productivity of the individual. Regarding the mental health status of the students, the results showed that they were generally at the optimal level, which was consistent with the results of the studies carried out by Slavin et al (14) and Hosseini et al. (18). In terms of the relationship between mental health and demographic characteristics, the results indicated that mental health had a significant relationship with native/non-native status and educational program in such a way that this situation was more favorable in native students and students at higher programs. This factor, as expressed for cultural intelligence, is greater in the higher programs due to the better adaptability of the individual with different cultures and easier acceptance, and the closer and faster communication with people in the initial days of the school year. Therefore, they are more relaxed and enjoy their relaxed feelings. On the other hand, non-native students may have more problems due to the distance from family. Stress and anxiety in cultural and educational settings, especially in the first years of the study can exacerbate the situation. In the present study, there was a significant difference between male and female students in terms of the depression subscale of mental health in such a way that girls suffered a higher level of depression than boys. This finding was consistent with the results of the study done by Hosseini et al. (18). Therefore, this finding reveals that boys can communicate easily and quickly with others in the community and the university; it also indicates their high cultural intelligence (as the results of this study also showed) as well as the ability to cope with problems and difficulties, and the ability to earn money. In contrast, females have an overly emotional attachment to the family and the lack of social security in society.

Finally, it can be concluded that cultural intelligence and mental health in the sample students were in a positive and significant correlation with each other. Therefore, the provision of specific educational program for the promotion of the both variables can be effective in the increase of vitality and social interactions on the one hand, and can lead to an increase in clinical productivity and to the improvement of the status of health care services in the students who will be involved in the clinical cycle in a short time and communicate directly with patients, on the other hand. This requires the understanding and recognition of the diversity of different cultural levels of the students as well as their mental health status, and the assignment of attention to the improvement of their quality of life through more serious and extensive educational programs at dormitories and educational settings. In this regard, it is suggested that the professors of various educational departments as well as the cultural authorities of universities pay attention to the training of other dimensions of communication and health (even if this attention is short-term) in addition to the therapeutic and physiological aspects so that they can provide better and more effective mental health support in the mental and the subsistence adjustment of students via the provision of appropriate training. Among the limitations of this study, one can refer to the constraint in the selection of the students from different educational departments, and the random sampling with a limited sample size, which may influence on the generalizability of the findings. Therefore, it is suggested that the cultural sections of universities conduct a similar study in a broader scope among all students.

Acknowledgement

The researchers hereby express their thankful regards to the authorities of Mazandaran University of Medical Sciences and the respected students who sincerely collaborated on this research.