Understanding Medical Students’ Perceptions of Evolutionary Medicine and Evolution: A Cross-Sectional Analysis of Acceptance, Knowledge, and Barriers in Egypt

Abstract

Evolutionary medicine (EM) applies evolutionary principles to explain disease mechanisms and improve clinical practice, yet it remains underrepresented in medical education, particularly in non-Western settings. This study investigated Egyptian medical students’ perceptions of EM by assessing their acceptance of evolutionary theory, knowledge of natural selection, and perceived barriers to EM education. A cross-sectional, multicentre online survey was conducted among 589 undergraduate medical students from seven Egyptian medical schools. Acceptance of evolution was measured using the Measure of Acceptance of the Theory of Evolution (MATE 2.0), and knowledge was assessed using the Conceptual Inventory of Natural Selection (CINS). Students demonstrated limited knowledge and relatively low acceptance of evolutionary theory, while a substantial proportion had no previous awareness of EM. Nevertheless, many students supported integrating EM into medical curricula and recognized its potential contribution to research and clinical practice. Curriculum overload and religious concerns were among the most frequently perceived barriers to EM integration. These findings identify important gaps in students’ exposure to and understanding of evolutionary concepts and support the integration of clinically relevant, culturally responsive evolutionary education into undergraduate medical curricula to strengthen evolutionary literacy and facilitate meaningful engagement with EM.

1. Introduction

Evolutionary medicine (EM), also known as Darwinian medicine, is an interdisciplinary field that applies principles of evolutionary biology to explain the origins of health, disease, and human vulnerability to illness providing a broader understanding of why diseases occur and persist [1]. EM is gaining increased importance as an emerging interdisciplinary field in medical education that complements conventional approaches by providing ultimate explanations—those that explore why certain vulnerabilities to disease exist—alongside the more established physiological, genetic, or molecular mechanisms [2,3,4]. In response to this growing recognition, several medical education programs, particularly in Western countries, have introduced EM into their curricula by integrating concepts into existing courses, using case-based clinical examples and active learning strategies such as discussion and problem-based learning [5,6,7]. However, the inclusion of EM in medical curricula varies globally, and only little is known about how EM is perceived, understood, or accepted by medical students in non-Western regions—particularly where sociocultural and religious factors may shape attitudes toward evolutionary concepts [8,9,10].

In Western contexts, particularly in North America, evolutionary thinking has been identified as a core competency for undergraduate medical education: The Association of American Medical Colleges (AAMC) recognized its value as early as 2009, leading to its inclusion in multiple undergraduate curricula [7,11,12,13]. Similarly, medical schools in countries such as Switzerland and Australia have successfully introduced EM modules, frequently reporting high levels of student interest and engagement [14,15]. The integration of EM into undergraduate medical curricula has been advocated because it complements traditional biomedical teaching by providing an evolutionary framework for understanding disease susceptibility, host–pathogen interactions, antimicrobial resistance, and evolutionary mismatches underlying many chronic diseases [16]. Rather than introducing entirely new concepts, EM strengthens links between basic science and clinical practice, supporting clinical reasoning and a deeper understanding of disease mechanisms [1].

Teaching strategies include embedding evolutionary concepts in existing basic science courses, such as anatomy, physiology, and pathology [5]; demonstrating their relevance to diagnosis and treatment using clinical and case-based examples [12]; encouraging interdisciplinary, problem-based learning [17]; and promoting active student engagement through discussions and inquiry-based activities [18]. Recommendations for curriculum design emphasize making evolutionary content clinically relevant and incorporating locally relevant, culturally aligned clinical examples that resonate with students’ culture and worldviews.

Research from non-Western countries, such as Pakistan, has revealed that medical students have low levels of acceptance and understanding of evolutionary concepts [19]. These discrepancies are commonly attributed to a combination of curricular limitations, lack of faculty expertise, religious concerns, and cultural resistance [20,21,22]. Similarly, teaching evolutionary concepts is particularly challenging in the Middle East and North Africa (MENA) region. In many countries, it is a sensitive subject shaped not only by educational access, but also by deeply embedded religious and cultural values. A cross-national sociological study found that over 84% of respondents in countries such as Egypt, Indonesia, Pakistan and Malaysia expressed skepticism towards Darwin’s theory of evolution, with rates as high as 92% in Egypt alone [23]. In these contexts, evolution, particularly human evolution, is often seen as incompatible with traditional worldviews [24]. Despite these challenges, integrating evolutionary principles into medical education remains important, particularly in settings where students have limited exposure to evolutionary concepts.

Although the challenges of teaching EM in culturally conservative societies have previously been documented, there is still a lack of comparative analysis across countries in a similar situation. In some contexts, evolution has been more systematically integrated into science education, despite prevailing cultural sensitivities [25]. This suggests important variations in how students are exposed to, and engage with, evolutionary concepts. These differences emphasize the importance of examining how cultural context, educational exposure, and individual background influence students’ acceptance of and understanding of EM.

Understanding students’ responses to evolutionary medicine requires consideration of more than factual knowledge alone. Contemporary educational research suggests that acceptance of evolution is shaped by interactions between conceptual understanding, educational experiences, personal beliefs, and sociocultural influences. The Conceptual Ecology of Evolutionary Science Understanding (CEESU) framework provides a useful lens for examining these interacting factors and for understanding why students with similar levels of knowledge may differ in their acceptance of evolutionary concepts.

This study aims to assess the level of knowledge and acceptance of EM among Egyptian undergraduate medical students, identify perceived barriers to integrating evolutionary principles into medical curricula and explore the relationship between students’ socio-demographic characteristics and their understanding and acceptance of evolutionary theory. By addressing a critical gap in the literature, this research—designed and conducted by a team of undergraduate medical students acting as change agents within their own educational context—provides empirical evidence to inform curriculum developers, educators, and policymakers seeking to advance culturally responsive strategies for integrating EM into undergraduate medical education curricula in non-Western settings.

2. Materials and Methods

2.1. Study Design and Theoretical Framework

This quantitative cross-sectional nationwide study is underpinned by the Conceptual Ecology of Evolutionary Science Understanding (CEESU) framework, which conceptualizes learners’ responses to evolution as the result of complex interactions among cognitive factors (e.g., prior knowledge), affective dispositions (e.g., interest or discomfort), epistemological beliefs (e.g., about the nature of science), and broader cultural or religious worldviews [26]. To evaluate cognitive understanding, we used the Conceptual Inventory of Natural Selection (CINS), which assesses knowledge of fundamental evolutionary concepts. To evaluate affective and epistemological acceptance, we used the validated tool, Measure of Acceptance of the Theory of Evolution (MATE 2.0), which is aligned with CEESU’s affective domain. Grounding our study in this framework allowed us to design a multidimensional investigation into how Egyptian undergraduate medical students engage with EM, both as scientific content and as a culturally and personally meaningful topic. The study was conceptualised, and the data was collected and analysed by undergraduate medical students (MIM, NA, OE and YE) as part of a supervised research initiative at the Faculty of Medicine, Alexandria University. MS, assistant professor in medical education, and AB, a senior professor of pharmacology, provided supervision, methodological support, and guidance throughout the research process.

2.2. Setting and Participants

As of 2023, Egypt has 28 accredited public and private medical schools that enroll an estimated 80,000 to 100,000 undergraduate medical students nationwide [27,28]. Undergraduate medical education in Egypt has recently undergone reform and now follows a competency-based curriculum aligned with the National Academic Reference Standards (NARS), the national competency framework which was introduced nationwide in 2017 [27]. The reformed program consists of five academic years, followed by a two-year clinical internship. The curriculum is modular and integrated, offering early clinical exposure, self-directed learning, and research training. Although the NARS 2017 does not explicitly mention EM, it includes implicit evolutionary elements, such as an understanding of disease pathogenesis, human development and aging, and the biological basis of health and behaviour [29]. Inclusion criteria were undergraduate medical students aged 17–26 of both sexes and enrolled in any year of study (including house officers) at a range of public and private Egyptian medical schools. The exclusion criteria included students who were not currently enrolled in the undergraduate medical program in Egypt, as well as postgraduate students.

2.3. Sampling and Recruitment

To ensure representation from different medical schools in Egypt and from various years of the undergraduate medical curriculum, maximum variation sampling was employed. To maintain methodological rigour, the study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist [30]. To reduce selection bias, recruitment was conducted across multiple Egyptian medical schools and targeted undergraduate medical students from different academic years using a range of university-affiliated social media platforms and student communication channels, including WhatsApp groups. The survey was accessible to all eligible students during the predefined data collection period, participation was voluntary and anonymous, and no incentives were offered. Although these measures were intended to maximize the diversity of the sample, the possibility of selection bias inherent to voluntary online surveys cannot be completely excluded. A total of 589 eligible participants completed the questionnaire and constituted the final analyzed sample. Only fully completed questionnaires that met the predefined inclusion criteria were included in the analysis; therefore, no participants were excluded after recruitment.

2.4. Sample Size Calculation

Sample size calculation was done using Sample Size Calculator website (Sample Size Calculator, n.d.) [27], using the specific formula for finite population: nʹ = n/1+ ((z² × $\widehat{\mathbf{p}}$ (1 − $\widehat{\mathbf{p}}$))/Ɛ²N) where z is the z-score which is 1.96 for the significance level of 5%, $\widehat{\mathbf{p}}$ is the population proportion (50%), ε is the margin of error (5%), and N is the population size. Therefore, our predetermined sample size was 384 [28]. The calculated sample size represented the minimum number of participants required to achieve adequate statistical power. No over-recruitment or oversampling strategy was planned or implemented. Recruitment remained open during the predefined data collection period, and all eligible responses received within this period were included in the analysis. This recruitment approach was consistent with the approved study protocol and ethical approval, and no protocol deviations occurred.

2.5. Data Collection

Data were collected online during the 2024/25 academic year using a structured Google Forms questionnaire which comprised two previously validated instruments (MATE 2.0 and CINS) together with study-specific items assessing awareness of evolutionary medicine, attitudes toward its integration into medical education, and perceived barriers. The study-specific questions were adapted from a previously published survey of Pakistani medical students [19]. Prior to data collection, the questionnaire was piloted among 30 undergraduate medical students to evaluate the clarity, comprehensibility, and flow of the questions. Minor wording modifications were made based on participant feedback to improve clarity and contextual appropriateness. The responses collected during this phase were not included in the final analysis. The questionnaire included the following 4 sections (Supplementary File):

• Socio-demographics—including age, gender, nationality, academic year, university, GPA, residential background, religion, religiosity score (1 to 5), parental education (maternal and paternal), self-reported social class, type of secondary education, and English reading proficiency (self-rated on a 10-point scale).
• Attitudes toward Evolutionary Medicine—assessed through custom-designed questions based on a neutral, accessible definition of EM adapted from the Oxford Handbook of Evolutionary Medicine [31]. Questions were adapted from a 2011 cross-sectional study from Pakistan [19], and aimed to understand whether students were exposed to the word “evolutionary medicine”, whether they would advocate for EM integration into medical curricula, and whether EM may help improve clinical or research practices. This section also includes a multiple-choice question to identify barriers to including EM in Egyptian medical curricula.
• Acceptance of Evolution—measured using the Measure of Acceptance of the Theory of Evolution 2.0 (MATE 2.0) [32]. This is a 9-item instrument with a Likert scale of (1) strongly disagree, (2) somewhat disagree, (3) neutral, (4) somewhat agree, and (5) strongly agree, collected the students’ opinions, with reverse-coding on questions 3 and 5, as endorsed by the developers of MATE 2.0.
• Knowledge of Evolution—assessed through the Conceptual Inventory of Natural Selection (CINS) [33]. The CINS questionnaire comprises 20 questions, with each question carrying a point.

2.6. Statistical Analysis

Descriptive and inferential statistical analyses were performed on the study data using IBM SPSS Statistics version 26.0. Categorical variables were summarized as frequencies and percentages, and continuous variables were reported as means and standard deviations. One-way analysis of variance (ANOVA) was used to examine group differences in scores on the Measure of Acceptance of the Theory of Evolution (MATE 2.0) and the Conceptual Inventory of Natural Selection (CINS). Statistical significance was determined at a threshold of p < 0.05. For comparisons involving dichotomous variables, independent-samples t-tests were performed. Pearson’s correlation coefficient was used to assess the association between MATE 2.0 and CINS scores. A more stringent significance level of p < 0.01 was adopted for correlational analyses to account for multiple testing. Furthermore, linear regression analyses were conducted to identify significant predictors of evolutionary understanding and acceptance. Predictor variables were considered statistically significant at p < 0.05 and standardized beta coefficients (β) were reported to compare the relative influence of each predictor.

2.7. Ethical Considerations

This study was conducted in accordance with the ethical standards outlined in the Declaration of Helsinki and reviewed and approved by the Ethics Committee of Alexandria University (IRB number: 00012098; Serial number: 0307371). Participation in the study was entirely voluntary and anonymous. Informed consent was obtained electronically prior to data collection, and to ensure privacy and confidentiality, no personally identifiable information (e.g., names, dates of birth, student IDs) was collected. Participants were informed that they could withdraw from the study at any time without consequence. No coercion or undue influence was used, and no financial or academic incentives were provided for participation.

3. Results

3.1. Participants

A total of 589 undergraduate medical students across 7 different medical schools in Egypt enrolled at Alexandria University (337/589, 57.2%), Cairo University (5.9%), Mansoura University (5.1%), Tanta University (4.4%), Ain Shams University (4.1%), Kafr El-Sheikh University (1.7%), and Al-Azhar University (1.7%). The detailed distribution of participants by institution is presented in Supplementary Table S1. The majority of participants were Egyptian (75.2%), female (53.3%), from an urban area (83.5%), and Muslim (92.4%) with a mean age of 21 ± 2 years (Figure 1, Supplementary Table S1).

In terms of their academic characteristics, most participants had completed the Egyptian secondary school curriculum (43.3%), had achieved excellent grades in the previous academic year (41.8%), and had self-reported an English proficiency level of above seven on a ten-point scale (Figure 2).

Regarding the socioeconomic characteristics, most participants came from middle-to-upper social class families (47.7%), with parents predominantly holding bachelor’s degrees (47.4% of fathers and 56.4% of mothers) (Figure 3).

3.2. Awareness, Interest, and Perceptions Regarding Evolutionary Medicine

Participants demonstrated a limited understanding of evolutionary concepts, as indicated by their Conceptual Inventory of Natural Selection (CINS) average score of 7.5 (SD = 4.0), suggesting a relatively low level of knowledge about fundamental evolutionary mechanisms. Almost half of the students (43.3%) reported having no prior knowledge of EM. Of those who had encountered EM before, online resources were the most common initial source (18.5%), followed by school education (18.0%) and university curricula (12.1%). Fewer students became aware of EM through reading books independently (5.1%) or via discussions with family or friends (3.1%) (Figure 4A).

The mean acceptance score on the Measure of Acceptance of the Theory of Evolution (MATE 2.0) was 2.8 (SD = 0.9), indicating a neutral stance towards evolutionary theory and suggesting a cautious approach rather than strong support or rejection. Around 36.8% of participants expressed a strong interest in learning more about EM. Conversely, around a quarter of students (24.8%) reported relatively low interest, indicating varied levels of enthusiasm and openness towards further EM education within this group (Figure 4B).

Participants reported several barriers to the integration of EM into the medical curriculum. The most frequently cited obstacle was curriculum overload (23%), followed by religious issues (21%). Other notable barriers included a lack of student interest (19%), insufficient teaching resources (18%), and doubts about the scientific or clinical value of EM (11%). Additionally, 10% of participants cited moral concerns as a hindrance (Figure 5).

3.3. Comparison of MATE 2.0 and CINS Scores Across Participant Characteristics

Analysis of variance (ANOVA) revealed statistically significant differences in MATE 2.0 scores (acceptance of evolution) according to study year (p = 0.035), university (p = 0.010), religious affiliation (p = 0.005) and degree of religiosity (p < 0.001). However, academic performance (grade achieved in the previous academic year) had no significant influence on MATE 2.0 scores (p = 0.682) (

Table 1. Analysis of Variance (ANOVA) Comparing Mean Differences in MATE and CINS Scales across Groups.

Variable	MATE 2.0 Scale						CINS Scale
	Sum of Squares	Degrees of Freedom	Mean Square	F-Value	p-Value	Partial Eta Squared (ηp2)	Sum of Squares	Degrees of Freedom	Mean Square	F-Value	p-Value	Partial Eta Squared
Study year	10.244	5	2.049	2.422	0.035	0.010	201.462	5	40.292	2.545	0.027	0.020
University	15.727	7	2.247	2.677	0.010	0.028	96.856	7	13.837	0.861	0.537	0.013
The grade of the last year	1.970	4	0.493	0.574	0.682	0.004	41.985	4	10.496	0.653	0.625	0.002
Religion	12.674	4	3.169	3.77	0.005	0.006	79.441	4	19.860	1.24	0.293	0.009
Religiosity (1–5)	26.304	4	6.576	8.050	0.000	0.055	127.945	4	31.986	2.007	0.092	0.009
Secondary education (high school) curriculum	9.004	6	1.501	1.766	0.104	0.011	578.895	6	96.483	6.342	0.000	0.021
English proficiency (1–10)	11.452	9	1.272	1.498	0.145	0.022	561.672	9	62.408	4.073	0.000	0.016
Father’s education	7.942	8	0.993	1.162	0.320	0.017	433.773	8	54.222	3.495	0.001	0.010
Mother’s education	10.266	8	1.283	1.509	0.151	0.020	465.661	8	58.208	1.509	0.000	0.017
Social class	2.515	4	0.629	0.733	0.570	0.010	292.570	4	73.143	4.673	0.001	0.008
Partial eta squared (ηp2) effect size interpretation: 0.01 = small, 0.06 = medium, 0.14 = large.

Table 1 shows ANOVA results testing demographic influences on MATE 2.0 and CINS scale scores. Significant p-values (<0.05, bolded) indicate meaningful group differences, including study year, religion, religiosity, university (MATE 2.0), and English proficiency, father’s education, mother’s education, social class, and secondary education curriculum (CINS).

). Significant variation in CINS scores (evolutionary knowledge) was found according to study year (p = 0.027), secondary education curriculum (p < 0.001), English reading proficiency (p < 0.001), father’s education (p = 0.001), mother’s education (p < 0.001) and social class (p = 0.001). No statistically significant differences in CINS scores were observed according to university attended (p = 0.537), religious affiliation (p = 0.293), or degree of religiosity (p = 0.092) (Table 1, Figure 6). As illustrated in Figure 6, significant associations with MATE 2.0 scores were primarily observed for religiosity, whereas significant associations with CINS scores were more evident for English proficiency, secondary education, parental education, and social class. These findings show that students’ acceptance and understanding of evolutionary theory are influenced by both structural academic factors and individual sociocultural background factors. Overall, the ANOVA analyses yielded small effect sizes (partial η² = 0.008–0.055), indicating that although several demographic variables were significantly associated with MATE 2.0 and CINS scores, the proportion of variance explained by these factors was modest (Table 1). Likewise, the independent-samples t-tests demonstrated negligible to small effect sizes (Cohen’s d = −0.35 to 0.11), suggesting that the observed group differences were generally of limited practical magnitude, despite the statistically significant difference in CINS scores according to residency (

Table 2. Independent Sample T-test Comparing MATE and CINS Scores across variable Groups.

Variable		MATE Composite Score			CINS Score
		Mean ± SD	p-Value	Cohen’s-d	Mean ± SD	p-Value	Cohen’s-d
Gender	Male	2.7 ± 0.9	0.068	−0.15	7.4 ± 4.0	0.773	−0.02
	Female	2.9 ± 0.9			7.5 ± 4.0
Nationality	Egyptian	2.8 ± 0.9	0.229	0.11	7.6 ± 4.1	0.473	0.07
	Non-Egyptian	2.7 ± 0.9			7.3 ± 3.8
Residency	Rural	2.8 ± 0.9	0.689	−0.04	6.3 ± 3.4	0.002	−0.35
	Urban	2.8 ± 0.93			7.7 ± 4.1
Cohen’s d effect size interpretation: 0.20 = small, 0.50 = medium, 0.80 = large. The sign indicates the direction of the group difference.

Table 2 summarizes independent sample t-test results comparing MATE 2.0 composite and CINS scores across gender, nationality, and residency. Significant p-values (<0.05, bolded) indicate differences between groups, found only in residency (rural vs. urban) for the CINS scale.

).

Independent sample t-tests revealed no statistically significant differences in MATE 2.0 or CINS scores based on gender or nationality (all p > 0.05). However, a significant difference in CINS scores was observed according to residency status: students living in urban areas demonstrated significantly greater evolutionary knowledge (mean = 7.7, SD = 4.1) than those living in rural areas (mean = 6.3, SD = 3.4; p = 0.002) (Table 2). No corresponding difference in MATE 2.0 scores was found between urban and rural participants (p = 0.689). This suggests that, while geographic background may influence conceptual understanding, it does not necessarily impact acceptance of evolutionary theory.

3.4. Predictors of Evolution Knowledge (CINS) and Acceptance (MATE 2.0)

Multiple linear regression analyses were conducted to identify the predictors of students’ acceptance of evolutionary theory, as measured by the MATE 2.0 score. English reading proficiency was a significant positive predictor of MATE 2.0 scores (β = 0.116, p = 0.009), indicating that higher English proficiency was associated with greater acceptance of evolution. Additional significant predictors included gender (β = 0.082, p = 0.045) and university (β = 0.121, p = 0.004), while religiosity emerged as a significant negative predictor (β = −0.181, p < 0.001), indicating that higher levels of religiosity were associated with lower acceptance of evolution. None of the remaining demographic, educational, or socioeconomic variables were significant predictors of MATE 2.0 scores (

Table 3. Multiple Linear Regression Analysis Predicting MATE 2.0 Scale Scores.

Variables	Unstandardized Coefficients (B)	Std. Error	Standardized Coefficients (Beta)	t-Statistics	95% Confidence Interval for B	p-Value
Age	0.017	0.035	0.037	0.498	[−0.051, 0.086]	0.618
Gender	0.152	0.076	0.082	2.011	[0.004, 0.300]	0.045
Nationality	−0.122	0.095	−0.057	−1.288	[−0.309, 0.064]	0.198
Study year	−0.052	0.044	−0.087	−1.170	[−0.139, 0.035]	0.242
University	0.040	0.014	0.121	2.867	[0.013, 0.067]	0.004
The grade of the last year	0.071	0.041	0.073	1.717	[−0.010, 0.151]	0.087
Residency	0.012	0.106	0.005	0.109	[−0.196, 0.219]	0.913
Religion	0.164	0.086	0.079	1.919	[−0.004, 0.333]	0.055
Religiosity (1–5)	−0.187	0.044	−0.181	−4.286	[−0.273, −0.101]	0.000
Secondary education (high school) curriculum	0.009	0.024	0.015	0.367	[−0.038, 0.055]	0.714
English proficiency (1–10)	0.058	0.022	0.116	2.604	[0.014, 0.102]	0.009
Father’s education	0.006	0.030	0.010	0.211	[−0.052, 0.064]	0.833
Mother’s education	0.025	0.030	0.041	0.849	[−0.033, 0.084]	0.396
Social class	0.068	0.055	0.055	1.246	[−0.039, 0.176]	0.213
Dependent Variable: Score of MATE 2.0

Table 3 summarizes predictors of MATE 2.0 scores from multiple linear regression. Significant p-values (<0.05, bolded) indicate independent predictors, while standardized β coefficients show the direction and relative strength of associations.

).

Multiple linear regression analyses were also conducted to identify predictors of students’ knowledge of evolutionary theory, as measured by the CINS score. English reading proficiency was a significant positive predictor of CINS scores (β = 0.203, p < 0.001), while father’s education was also positively associated with higher CINS scores (β = 0.098, p = 0.043). None of the remaining variables were significant predictors of CINS scores (

Table 4. Multiple Linear Regression Analysis Predicting CINS Scale Scores.

Variables	Unstandardized Coefficients (B)	Std. Error	Standardized Coefficients (Beta)	t-Statistics	95% Confidence Interval for B	p-Value
Age	0.000	0.152	0.000	−0.003	[−0.299, 0.298]	0.998
Gender	0.037	0.327	0.005	0.114	[−0.606, 0.680]	0.909
Nationality	−0.172	0.412	−0.019	−0.418	[−0.981, 0.637]	0.676
Study year	−0.167	0.191	−0.065	−0.873	[−0.543, 0.209]	0.383
University	−0.109	0.060	−0.077	−1.817	[−0.228, 0.009]	0.070
The grade of the last year	0.084	0.178	0.020	0.471	[−0.266, 0.434]	0.638
Residency	0.686	0.458	0.064	1.496	[−0.215, 1.588]	0.135
Religion	0.477	0.371	0.053	1.285	[−0.252, 1.205]	0.199
Religiosity (1–5)	−0.145	0.189	−0.032	−0.767	[−0.517, 0.226]	0.443
Secondary education (high school) curriculum	0.030	0.102	0.012	0.298	[−0.170, 0.230]	0.766
English proficiency (1–10)	0.441	0.097	0.203	4.544	[0.250, 0.632]	0.000
Father’s education	0.260	0.128	0.098	2.032	[0.009, 0.511]	0.043
Mother’s education	0.006	0.129	0.002	0.044	[−0.248, 0.259]	0.965
Social class	0.130	0.238	0.024	0.548	[−0.337, 0.598]	0.584
Dependent Variable: Score of CINS

Table 4 summarizes the results of the multiple linear regression analysis predicting CINS scores. Significant p-values (<0.05, bolded) indicate independent predictors of evolutionary knowledge, while standardized beta coefficients (β) reflect the direction and relative strength of each association.

).

As illustrated in Figure 7, English proficiency emerged as the strongest positive predictor of both evolutionary knowledge and acceptance, whereas higher religiosity was associated with lower acceptance of evolution. Other demographic variables showed comparatively smaller effects on the two outcomes.

3.5. Post Hoc Analyses

The results of the multiple post hoc analyses of the CINS and MATE 2.0 scores, based on study year (Table S2), university (Table S3), religion (Table S4), religiosity level (Table S5), secondary education (Table S6), English proficiency level (Table S7), father’s education (Table S8), mother’s education (Table S9) and socioeconomic status (Table S10), are displayed in the Supplementary File.

4. Discussion

The integration of EM into undergraduate medical curricula requires more than curriculum reform; it demands an understanding of how students perceive, accept, and engage with the topic, particularly in culturally sensitive contexts. The current study contributes to this understanding by examining Egyptian undergraduate medical students’ knowledge and acceptance of EM, using the Conceptual Ecology of Evolutionary Science Understanding (CEESU) framework to explore the intersections of educational background, English proficiency, religiosity, and social context. These findings are interpreted through the CEESU framework to inform curriculum design and the integration of EM into undergraduate medical education through practical strategies for medical educators and curriculum designers to foster a more receptive and inclusive environment for teaching EM in non-Western settings.

In line with global trends, our data show that a significant proportion of Egyptian students (43.3%) were unfamiliar with the term ‘evolutionary medicine’, suggesting a gap in the curriculum rather than an inherent resistance to EM. Encouragingly, many students recognised its relevance to research (57.9%) and clinical reasoning (44.1%), suggesting latent receptivity when appropriate exposure is provided. These findings are consistent with international patterns, as evidenced by surveys of U.S. dietetics students and medical school deans, which report similarly limited EM exposure despite growing institutional interest [16,34]. Similarly, a study of Pakistani medical students revealed that 61% had never come across EM, highlighting the widespread lack of exposure to it in non-Western contexts [19]. The comparatively lower figure in our sample may reflect the increasing availability of online content about evolution. In both settings, EM was perceived as being more applicable to research than to clinical practice, indicating a tendency among students to overlook its clinical relevance.

Our analyses demonstrated that greater religiosity was associated with lower acceptance of evolution, while students with lower levels of religiosity also exhibited higher evolutionary knowledge scores. This finding is consistent with the multiple regression analysis, in which religiosity emerged as a significant negative predictor of MATE 2.0 scores. Previous studies have shown that religious belief is a key factor associated with lower acceptance of evolution among Black and Hispanic biology students in the United States [35], and among Christian and Muslim biology and medical students in Scotland [36]. However, this relationship is not universally negative. Some studies suggest that religiosity does not necessarily hinder the learning of evolutionary concepts [37]. Similarly, students of applied health sciences showed strong interest in integrating evolution into training programs, despite their religious beliefs [34,38]. Taken together, these findings highlight that, while religiosity may influence how students engage with the concept of evolution, it does not necessarily hinder learning. Our study contributes to this broader discourse by suggesting that even when explicit rejection is absent, religious identity may still influence students’ engagement with evolutionary content. From the perspective of CEESU, these findings suggest that religiosity operates primarily as part of students’ conceptual ecology rather than as an isolated determinant of learning [39]. Religious worldview may shape students’ willingness to accept evolutionary explanations without necessarily preventing them from acquiring scientific knowledge when educational opportunities are available.

Notably, our study is one of the first in the MENA region to establish a clear correlation between English proficiency and acceptance of, and understanding of, evolution. This may reflect the dominance of the English-language scientific literature on EM, coupled with the scarcity of accessible Arabic-language resources. Additionally, higher paternal education was associated with greater knowledge of evolutionary principles, potentially due to increased intellectual stimulation at home and greater exposure to international education systems. These findings demonstrate how educational privilege, mediated through family background, language proficiency and access to educational pathways, can influence students’ engagement with EM. Within the CEESU framework, these findings suggest that English proficiency functions as a cognitive and educational resource facilitating access to scientific information, while family educational background reflects broader educational opportunities [39]. Together, the regression analyses support the multidimensional assumptions of the CEESU framework by demonstrating that educational, linguistic, and sociocultural variables contribute differently to students’ evolutionary knowledge and acceptance.

Our findings also provide a unique lens on the broader context of evolutionary theory acceptance among Egyptian medical students. The average MATE 2.0 score of 2.8 reflects a position between disagreement and neutrality, noticeably lower than the 3.99 average reported in a diverse U.S. student sample across multiple disciplines [32]. This aligns with earlier research in Egypt, for example, a survey that found that only 8% of participants expressed a probable or strong belief in Darwin’s theory of evolution [23]. A persistent barrier to acceptance appears to stem from conceptual misunderstandings, with BouJaoude et al. noting that Egyptian and Lebanese secondary students frequently misinterpret the term ‘theory’ as implying unproven speculation rather than a well-supported scientific explanation [40]. Addressing this misconception may be crucial in improving students’ openness to evolutionary biology, particularly by explicitly teaching the scientific definition of theories as frameworks underpinned by robust empirical evidence.

Second-year students in our sample demonstrated greater knowledge and acceptance than those in higher years, which contrasts with the findings of Rissler et al., who observed an increase in evolutionary literacy with academic seniority among nearly 3000 U.S. students across different subjects [41]. This suggests that, in Egypt, pre-university education has a more lasting impact on evolutionary understanding than progressing through the current medical curriculum. Our study also confirmed a positive correlation between evolutionary knowledge and acceptance—a relationship that is also evident in the work of Rissler et al., who found that higher performance on the Knowledge of Evolution Exam (KEE) was associated with higher MATE scores. Together, these findings highlight the importance of addressing misconceptions at an early stage and meaningfully integrating evolution throughout medical training in order to foster conceptual clarity and attitudinal openness. These findings reinforce the CEESU proposition that educational experiences shape both conceptual understanding and attitudes toward evolution, supporting the longitudinal integration of clinically relevant evolutionary concepts throughout undergraduate medical training.

From an educational perspective, these findings have important implications for curriculum design and implementation. The observed differences according to study year, educational background, English proficiency, and sociocultural factors suggest that successful integration of evolutionary medicine requires more than simply introducing new content. Rather, evolutionary concepts should be embedded longitudinally within existing basic science and clinical courses, reinforced throughout medical training, and presented using clinically relevant, case-based examples [42,43]. Educational resources should also accommodate varying levels of English proficiency and reflect students’ cultural and educational backgrounds. These recommendations are consistent with the recent medical education literature, which emphasizes that, despite growing recognition of its educational value, evolutionary medicine remains underrepresented worldwide and is most effectively integrated through longitudinal, clinically relevant teaching embedded within existing curricula. Such approaches have been shown to improve curricular feasibility while maintaining relevance to future clinical practice [44,45].

Importantly, the effective integration of EM in culturally diverse contexts requires viewing students as active partners in educational design rather than passive recipients of knowledge. This study, designed and conducted by a team of undergraduate medical students under academic supervision, demonstrates the valuable role students can play in identifying curricular gaps and shaping reform. Engaging learners as co-designers enhances the relevance and responsiveness of curriculum development, and fosters shared ownership, particularly when addressing sensitive or underrepresented scientific content.

Overall, our findings support the usefulness of the CEESU framework for understanding how cognitive, educational, and sociocultural factors interact to shape students’ engagement with evolutionary medicine. Applying this framework may help educators design context-sensitive strategies for integrating evolutionary medicine into undergraduate medical curricula.

Limitations: This study provides valuable insights into the engagement of Egyptian medical students with EM; however, it is important to acknowledge some limitations. Although our sampling method was nationwide, it was based on voluntary online participation and non-probability sampling, which may limit the generalisability of our findings. Participants with stronger English proficiency or a greater interest in evolution-related topics may have been more likely to participate, which could have introduced selection bias. The fact that some answers are socially acceptable and others are not—for example, those relating to parents’ highest level of education—could lead to social desirability bias in the responses. The MATE scale appears to have some limitations; for example, it does not distinguish between macro and microevolution, which provides a narrower horizon on students’ differential perspectives on both concepts [32]. Although validated instruments (MATE 2.0 and CINS) were used to assess acceptance of evolution and knowledge of natural selection, the study-specific questions regarding awareness of evolutionary medicine, attitudes, and perceived barriers were adapted from the previously published literature and were not formally psychometrically validated in the Egyptian context. This should be considered when interpreting these findings.

Future studies should explore the long-term effects of integrating EM into the undergraduate medical curricula in culturally diverse, non-Western countries. Pilot interventions that embed EM concepts within existing subjects—rather than as standalone modules—may offer a practical and context-sensitive approach. Integrating EM content into clinical reasoning and problem-based scenarios, supported by clinically relevant case studies, can enhance student engagement, demonstrate diagnostic and therapeutic applications, and bridge the gap between basic science and clinical practice [46]. Mixed-methods evaluations are recommended to assess both learning outcomes and student receptivity. To align with national priorities, consensus-building approaches involving faculty and key stakeholders, such as the Delphi method and Nominal Group Technique, can guide the adaptation of EM content to local competency frameworks and health needs [11]. In parallel, qualitative studies involving faculty, religious scholars, and curriculum developers may help identify institutional and cultural barriers to implementation. Integration efforts should remain attuned to students’ religious and cultural worldviews, framing EM as a complementary scientific perspective that supports, rather than challenges, existing clinical reasoning paradigms. Although multiple linear regression was appropriate for identifying independent predictors of evolutionary knowledge and acceptance, future studies could employ hierarchical regression models informed by the CEESU framework. Entering demographic, educational, and sociocultural variables in theoretically meaningful blocks would enable evaluation of the incremental contribution of each domain and provide a more comprehensive assessment of the framework’s explanatory value.

5. Conclusions

By equipping future physicians with evolutionary literacy, medical education can better prepare graduates to understand, and ultimately anticipate, the complex and dynamic challenges of 21st-century health and disease. If introduced thoughtfully and contextually, EM offers not just scientific insights, but also a transformative, integrative lens through which future physicians can approach health and disease. Ensuring that students are engaged as active partners in this process will be essential for creating responsive, inclusive, and sustainable curricular integration of EM. In culturally diverse settings, curriculum development should adopt context-sensitive approaches that emphasize the clinical relevance of EM while acknowledging the educational and sociocultural factors that may influence student engagement. Such an approach may facilitate the sustainable integration of EM into medical education and better prepare future physicians to apply evolutionary principles in clinical practice.