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Intercultural qualitative research andPh.D. studentsMary Ditton aa University of New England , AustraliaPublished online: 02 Mar 2007.

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Intercultural Education,Vol. 18, No. 1, March 2007, pp. 41–52

ISSN 1467-5986 (print)/ISSN 1469-8439 (online)/07/010041–12© 2007 Taylor & Francis DOI: 10.1080/14675980601143660

RESEARCH NOTE

Intercultural qualitative research and Ph.D. students

Mary Ditton*University of New England, AustraliaTaylor and Francis LtdCEJI_A_214297.sgm10.1080/14675980601143660Intercultural Education1467-5986 (print)/1469-8439 (online)Research Note2007Taylor & Francis181000000March 2007MaryDittonmary.ditton@une.edu.au

The educational environment for postgraduate health professionals from developing countries incontemporary western universities is an intermediate zone between home and host culture. In thiszone, knowledge is shaped through the development of concepts within the limitations of (often)pre-fluent language capacity. It is characterized by the mutual exchange of knowledge betweenwestern teachers and their developing-country students, who will return home to leadership rolesworking with marginalized individuals, communities and populations. This qualitative researchaims to improve health education for global health professionals from developing countries, and inso doing it illustrates many of the difficulties and benefits involved in intercultural qualitativeresearch for Ph.D. students.

Thai

*School of Health, University of New England, Armidale, New South Wales 2351, AustraliaEmail: mary.ditton@une.edu.au

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Arabic

Introduction

Qualitative research with student informants who are in ‘the intermediate zone’—between home and host culture—is challenging. The increasingly interculturalnature of academic work is characteristic of the changing world of higher education,where educational markets are expanding into global commerce. Until recently, theAnglo–American–Australian educational approach has been essentially monocul-tural, predominantly to serve the interests of the host country. Ninnes (1999)pointed out that the process of acculturalization of international students inAustralian universities maintains hegemonic knowledge relations, ignores otherepistemologies, and generally serves international business and capitalism ratherthan students’ needs.

However, there is a growing interest in cultural bridges, including links with inter-national students’ home countries. These bridges are now occurring in multiculturalAustralia, where non-white migrants have been welcomed for only one generation(Lotherington, 2003). This educational environment is an intermediate zone wherecultural differences between the teacher and the student lie in contrast with eachother (Knapp and Knapp-Potthoff, 1987) and multiliteracies that exist in thissocially contested terrain operate as a considerable challenge for teacher and studentalike—the socialization of the students as scholars and the teachers as practitioners.

Background

Graduate health professionals from developing countries (e.g. Indonesia andThailand) come to Australian universities for doctoral degrees. As a result, westernacademics are faced with the problem of teaching about health and health interven-tions that are sensitive in context and culture, with literature and technologyappropriate to western countries. Even though students’ research topics frequentlydeal with health problems in their home country (e.g. HIV/AIDS, malaria or perina-tal maternal health), the health issues—by their nature, scope or resources availableto manage them—differ significantly from those encountered in western countries.When graduates return home with their new degrees, they face the task of transpos-ing the knowledge they have gained to suit a totally different set of conditions.

The explicit responsibility of the host university is to supervise the research processand assist the student to complete a Ph.D. or professional doctorate. However, thereis another, implicit, responsibility—to equip the student with leadership qualities

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Intercultural qualitative research and Ph.D. students 43

essential to tackle health, literacy and socio-economic issues in better and innovativeways, and to devise strategies to reduce health inequalities between developing andwestern countries. To fulfil this responsibility, host universities must add to theirunderstanding of, and adapt to, the cultures of the developing countries they aretrying to assist. In turn, this will lead to improved collaboration with, and teaching of,students in ‘the intermediate zone’.

The research presented here brings together educational practice informed bytheory, and conducted in participation with those who are immediately affected bythe quality of their educational experience and who will have a major impact in thefuture on the health inequalities of their home countries. The research seeks practi-cal solutions to issues of pressing concern to these post graduate students and theireducators. The quality of education of postgraduate health professionals is a primeconcern to host institutions and sponsoring organizations.

Methods

The participatory, qualitative research, approved by the Human Research EthicsCommittee at the University of New England, Armidale, Australia, was conductedin 2005. In attempting to improve the educational process of doctoral students fromthe Asia–Pacific rim, this research advances Australia’s understanding of countriesin our region and is therefore consistent with the Description of Designated NationalResearch Priorities and Associated Priority Goals: safeguarding Australia and the needsof sponsoring agencies (Australian Research Council, 2003).

Participatory research has been defined by Green et al. (1995) as: ‘systematicenquiry, with the collaboration of those affected by the issue being studied, for thepurposes of education and taking action or effecting social change’.

Participatory research is well suited to philosophies and theories underpinningresearch in health (George et al., 1998–99). According to George et al., the purposeof participatory research should be reflected not only in the research question, butalso in the involvement of the participants, who should have the opportunity toaddress their issues of interest and benefit from the outcomes of the research.

The primary research question was ‘How can we improve the education of healthprofessionals who work with marginalized individuals, communities and populations?

Data were collected during six focus groups held weekly with postgraduate healthprofessionals undertaking Australian doctorates. The discussions were within theframework of health issues that the students were likely to face in their homecultures, and the suitability of their current training in equipping them to tacklethose issues. The discussions focused on material from the health literature.Content, context and cultural aspects of the literature were examined for relevanceto the students’ theses, and to their future work dealing with contemporary transi-tional health issues. With critical awareness of the cultural divides, the researcherwas present as a teacher in these groups (Kemmis & Grundy, 1997; Mills, 2003).

Thirteen informants offered their insights. They represented countries as diverseas Mainland China, Nepal, Hong Kong, Thailand, Saudi Arabia and Taiwan. The

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discussions were taped and transcribed. Analysis of the texts was in the sociologicaltradition, in order to understand the experience of the students in this complexintercultural context. Cortazzi’s (1999) concept of intertextual analysis providedunderstanding of the students’ shared meanings, as concepts were refined withsuccessive students offering their contributions in the discussions. Informants in thisthesis are referred to by pseudonyms, and the focus group (FG) from which thequote comes is referred to by number (e.g. FG1).

Results

Challenges and opportunities of learning in the intermediate zone

Literacy is a multidimensional phenomenon. Students generally find Australianspeech difficult to understand, and therefore they find academic reading and writingdifficult. In social conversations, the foreign students are confused by the speed andaccent of Australians and understand very little:

Because my room mate is Australian, every day he told me something about his life; Ithink ‘Oh, what are you talking about?’ He talk, talk, talk. ‘Oh, what are you talkingabout?’ Talk, talk, talk. If he said ten sentences I only understood about three of them.(Ricki: FG1)

Understandably, they prefer to speak their mother language socially:

With each other we always speak in Thai. We never speak in English because I think wefeel that if we speak in English it would be like speaking to a stranger. (Pilut: FG1)

Reading English alone is easier than understanding conversational English. In class,students would like the teachers to be more interactive with them to ensure that theydo understand concepts. Swani (FG1) said that being quiet and respectful in class is:

really part of the traditional Chinese culture, even the same in Chinese society.Especially when there is a hierarchy concerned, like students talking to teachers.Normally students just try to be quiet from respect. So from the point of view [of teach-ing], this means the lecturers should show more cultural sensitivity and understand thatit is the students’ background that they keep quiet. It doesn’t mean that they under-stand. The teachers can be more pro-active and talk to us, ‘Are you sure you reallyunderstand?’ I mean, if you keep on asking questions like that, the student may developbetter ideas in their minds.

Ballard and Clanchy (1991) have indicated that students from overseas arrive inAustralia with an expectation of ‘explicit direction and regular guidance’. However,in the previous passage from Swani, she is talking about the need for teachers to havebetter skills in effective knowledge communication, rather than any preference fordidactic as opposed to self-directed learning.

In contrast to the image that Australians like to have of themselves—as friendlyand outgoing—some students found Australians less than helpful. Joan (FG3)thought that students had ‘quite negative things’ to say ‘about finding Australiansnot very friendly’ and that ‘sometimes Australians seem a little bit forward orpushy—aggressive almost—to some of the students from Asia’.

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Intercultural qualitative research and Ph.D. students 45

There are many assumptions about national stereotypes and citizenry in the class-rooms of multicultural Australia. The following dialogue from FG1 points out thatnegotiating identity in multicultural Australia is difficult for newcomers. They maywish to assume identity and/or they may have identity imposed on them.

Joan: This is the way you do think and I don’t know if that’s typical ofChinese people but you have a very positive way of looking at things.

Lau: Yes. Severe, determined, they try their best. That’s the Chinese way.Teacher: Well thanks for that. I’m the only one here to represent the

Australians. But Sze, you are Australian aren’t you?Sze: Yes. (Sze is a naturalised Australian of Chinese origin.)Teacher (to Joan): And you’re not, are you?Joan: Yes, I’m an Australian citizen and a British citizen.Swani: I’m a Chinese Australian.Teacher: You’re Australian?Swani: Australian and Chinese, but still Chinese.

Two of the postgraduate students in the groups talked about their supervision. Theirsupervisors visited the students’ home countries ‘and saw how things were there’(Sari: FG6). This hands-on knowledge helped the supervisor ‘understand the data’in their sociocultural context, and helped put the student on track in their thesis writ-ing. However, the student was empowered by the process to decide when to reject thesupervisor’s point of view. Relating to her home visit with her supervisor, Sari (FG6)said ‘I am the expert at this. You people are not.’ Being with the student in his/herhome country is challenging for the teacher, because he/she sees how his/herknowledge works in practice, and sometimes there are limitations to that knowledge.

Pilut (FG6) was accompanied by his two supervisors to his home country in thecourse of a collaborative project. He said that, ‘It is good if you get good advice andthey [the supervisors] know the context well’, because it was hard to imagine ‘howthings work there’ without having experience of the country.

Health inequalities and contrasting health services

Members of the discussion group were preoccupied by ‘the great inequality of health’(Sari: FG6) that exists within countries (between the rich and the poor) and betweendeveloping and developed countries. In fact, Awat (FG4) said that the difference inhealth status between advantaged and disadvantaged groups within his country wasas big as ‘the gap between the top and the bottom of Mt Everest in the Himalayas’.

Students provided informed observations on comparative health systems inThailand, Hong Kong, China, Saudi Arabia and the other countries. Ree (FG2)compared access to health care for the poor in the US, South America and Sweden,with the US and its market-based health services not faring well: ‘In the States if youcan’t afford private health insurance because you’re poor then bad luck’, comparedwith Sweden where:

they valued the health of their people and just the whole ideology was completely differ-ent to what we know and overall the health of that society was ten-fold better than here.

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I know Sweden has a similar thing; they pay higher taxes and things like that but theaccess to health care was better.

Although several countries tried to offer health services to all, the students wereaware that many developed countries fell short of their objectives, and health-services reform was a constant issue.

Contrasting health services was sometimes a source of amusement in the groups.Sari was taken to see a modern labour room in a metropolitan hospital. Shedescribed the situation with some flourish in FG6:

Health system is different here. I went to a hospital, I went to X, then my friend, she’s anurse, you know, and she took me to a hospital and she showed me a labour room andas soon as I saw labour room it came so spontaneous: ‘Is this a labour room, is this whatit looks like?’ And she was so surprised, ‘What’s wrong with this? It is really good withtelevision and everything’, and I said, ‘Our labour room is not like this—it’s crowded,wet, blood and two or three women they are delivering and so much of noise and peopleare moving from here to there. That’s what delivery room look like. What’s this?’ Andshe said, ‘OK. Eight days ago we had a delivery.’ And I said that we have 20 deliveriesper day.

In spite of high maternal mortality rates in her home country, Sari knew thatbiotechnology alone would not solve the problem, because of the lack of facilitiesand supporting personnel. She said: ‘I learn how things work here. I didn’t take it[back to my country] because I don’t want to copy it because it’s not going to workin my country—it’s different’ (Sari: FG6).

Nevertheless she did develop a community mobilization strategy utilizing the ‘onepositive thing in developing countries [which is that] usually they have joint familyand strong family backing’. She developed a three-pronged culturally appropriateapproach that involved: allowing mothers-in-law into labour rooms to assist withthe process, and bond more closely with the woman in labour and the child for theimmediate and later benefit of all; playing classical music to reduce anxiety for thedelivering women; and interviewing women in depth to find out what is important tothem, rather than using the stereotyped medical interview that categorizes patients.She felt that she had changed as a health professional during the process of herdoctoral studies. Interestingly, rather than adopting biotechnology, she adopted amore patient-centred orientation to clinician interviewing:

I’m much more sympathetic towards [patients], towards their feelings; I learn how torespect their feelings; before I was treating them not exactly like objects, but now moreso as my partner [in the joint task of delivering healthy babies to healthy mothers]. (Sari:FG6)

Chai (FG4) was also concerned about the rationale for use of biotechnical medicinein an extremely poor country with high maternal and infant mortality:

In Nepal for the first time they introduced IVF. There were about 50 patients. Then 30of them were successful, and they were able to conceive and some of them actually gavebirth. But this technology is only for the richer people.

Far from being passive and naive, these students examined their home countries’health problems and saw them as multileveled and complex. As Sari (FG6) said,

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policy decisions are made by ‘high class people’ and there are ‘no people represent-ing the lower class, to voice their needs, to raise their voice about their immediateconcerns’. The dominance of medical practitioners who push biotechnology to‘support their specialist careers’ (Pikul: FG4) ensure that their preferences andprejudices affect local policies, and ‘they don’t care how much people benefit fromthem’. In addition, biotechnical and pharmaceutical companies ‘want to sell becausethey make a profit’ (Pikul: FG4).

Awat (FG4) was concerned that policy-makers ‘don’t make evaluations of whatthey need before they do it’. And many decisions are for personal glory so that apolitician can say: ‘I built X number of hospitals’.

Incompetence in medical administration combines with political abuse of powerto perpetuate problems in developing countries that ‘copy and paste’ (Joan: FG5)western health models, rather than strategically innovate for themselves appropriatehealth services. As Awat (FG4) said:

Some ministers of health in my country, as the last one, are physicians and spend theirwhole life in a hospital, in an operation room or practising medicine, and when theybecome bureaucrats or politicians there are a lot of administrative issues they can’t dealwith; or they have little experience and sometimes they give this issue to other person tomanage. I mean, like, decentralisation or something. If they give it to the wrong personthe result also will be bad; and if he’s very centralised person also there is other prob-lem, because he doesn’t have any experience to deal with administrative and financialevaluations.

The problems of health services in developing countries are not just ‘human’ or‘cultural’—they are also systemic. Most postgraduate doctoral students, like Sari(FG6), want to go back home for personal and professional reasons. Simply put, shesays: ‘I don’t want to leave my country, I want to go home.’ However, postgraduatestudents are enticed to stay in the host country by offers of permanent residency,and Sari (FG6) says frankly that ‘many people when they undertake higher qualifica-tions abroad, like America and UK, they like to stay there; they don’t want to goback home’. Some postgraduates on scholarships from their home country ‘justdisappear’ (Sari: FG6), because of the western way of life with its freedom and highsalaries. There is little incentive to return, and neither are there the regulatorymechanisms to force return.

The fate of these professionals who disappear is complex. Often, they want to gohome at some stage because of different social and cultural needs as life progresses,but usually their children are ensconced in the adopted culture, as illustrated by thefollowing exchange in FG6:

Teacher: They want to come back?Pikul: They want to come back to retire in Thailand because they said they lost

some part of their life. But sometimes, they couldn’t go because they just hadyoung kids and they don’t want to go.

Sari: After study it becomes difficult you know and you have kids and they studyand they start adapting to that life, their education and everything and theparents just get stuck. They don’t know if come back what will happen to

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these kids. If they do not return eventually they say exactly, ‘We have lostsome part of our life’.

Joan: But meanwhile the country has lost the use of the usable years.

Knowledge transfer between countries

The application of western knowledge to the health inequalities of developingcountries has proved problematic. The wholesale adoption of the western model ofhealth care has occurred in Thailand (Pikul: FG4) and other countries. However,because of lack of planning for infrastructure and personnel development, this verti-cal imposition of policy, procedures and technology does not work. As Awat (FG4)has pointed out:

I think also they adopt some high technology that is expensive and just put it in thehospital or other area and there’s also no person who know how to deal with this hightech or a few people just know; maybe one person in this hospital and when he has avacation or go anywhere or is sick or something nobody can operate this machine or thistechnology. And value of money in this case, I think, I feel we lose a lot of moneybecause this is cost, for example, 100 million and maybe we don’t use it more than 10times in a year. So maybe after 3 years, 2 or 3 years, new technology come after that, anewer product, so on.

Lack of integration of this knowledge transfer into existing social and culturalstructures means that the ‘hoped for’ health improvements are not sustainable.

Globalization and the disadvantaged poor

According to Joan (FG2), globalization is ‘two-headed’, because:

the benefits that come from being able to see what other countries are doing and toimport programmes, especially in mental health. You can import a good idea fromanother country. Like Australia is trialling safe injection places for heroin users inSydney. It’s very hard to set up a trial like that, but of course the information from thatwill benefit lots of other countries you know, if you decide that it’s a good or worthwhilething. But on the other side of it I see globalisation as homogenising everything, makingeverything the same; making us all have to fit into a certain pattern. So that’s the sort ofdown side of it, I think, which is why I brought up the DSM (IV) before. It has becomevery dominant as the only way to look at mental health [in the Western world], which Ithink is not a good thing.

Transborder illnesses such as SARS, HIV/AIDS and avian influenza are importantto the students, as some of them have been involved in containing outbreaks,developing prevention strategies, and formulating disaster control plans:

Well the same thing [outbreaks of pandemics] could happen with Thailand; just thedistance these days of traveling and what-not—it’s not like you have to sit on a ship forso many hundreds of hours to get anywhere these days, so the transmission is just veryfast. I suppose it comes back to [institutions such as] the World Health Organization.How quickly can policies be set up in order to prevent further spread once the SARShas started? We’re working almost at a computer level these days; now everything is sofast, everything is quite intense just because of expectations I guess. (Ree: FG2)

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Intercultural qualitative research and Ph.D. students 49

The students spoke of the vulnerability of individuals and societies in spite of amass of information available. Assessing the information was the problem. But theessential question facing health professionals in the midst of this information is, interms of globalization: ‘What is the best model for the world to take care of thepeople who are poor, and don’t have money? What is the most efficient model?’(Pikul: FG2). Joan, Pikul and Awat—students from three different continents—observed sociodemographic changes characterized by the drift of the populationfrom rural areas to the urban environment, and the accompanying loss to commu-nities: ‘Right now in rural area the young people do not stay there, they go to thebig city for work and earn money and send it back to their hometown’(Pikul:FG3).

The disadvantaged in developing countries live in poor housing conditions: ‘theylive for example in one room, 10 persons or 15 persons or more’ (Awat: FG3). Joan(FG3) reminds the group of marginalization in Australia:

Well, it’s more than embarrassing; it’s immoral that an aboriginal person will live 20years less than a white person in Australia. I mean, it’s shocking and we need to changethat situation because we have groups living in the equivalent of a developing country inthat level of poverty within our own country.

Discussion

When cultures are bought into juxtaposition, the contrasts that are highlighted accen-tuate the differences in ways of thinking, acting and speaking, whether or not there isfluency in the majority language. These differences contribute to opportunities andchallenges to learning in the intermediate zone.

Within this learning environment there were several sub-cultures of differentethnicities; for example, Thai, Saudi and Chinese. The linguistic diversity in thegroup was an opportunity to interconnect in a translingual environment, rather thanassume English as the lingua franca and therefore the political and ideological highground. In the group process, the students break down the dyadic stance of teacherto students by negotiating reality between themselves. Consequently, the teacherdoes not take the position of gatekeeper of knowledge in relation to students andavoids imposing western ideologies.

The structure of the group experience provides a better learning environment thandidactic teaching. Comparative observations and subsequent network learning arekey features of the intermediate zone of multiliteracies and multilingualism. Theintercultural communication is marked by mutuality of learning, where the focus ison seeing the problem from the point of view of the student, no matter whether thatproblem deals with assimilation, learning problems or the health issues of their homecountry. The differences in ways of thinking, acting and speaking by the studentsand teacher were converted by the group process into mutual learning.

Learning from one another in this reflective process requires a critical perspective.Some of the processes in Guilherme’s (2002) critical pedagogy, such as reflection,dissent, difference, dialogue and action, are evident in this study.

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The viewpoints of the students accessed in this project demonstrate the extent oftheir knowledge of health inequalities and health services and the limitations ofwholesale knowledge and social engineering transfers between countries. They arenot ignorant of the political landscapes of home and host countries. As aconsequence, they are not passive, or ‘cultural dopes’, as Giddens (1979) warns,with no idea of social and cultural relationships. Rather, they are active players in theexchange. In fact, they are experienced in the failures of western ideologies appliedto foreign contexts.

The reflective nature of this participatory research (Kemmis & Grundy, 1997)provided a learning situation in which the tension between the system of educationand the reality of ‘lifeworlds’ (Habermas, 1984) of both the teacher and the studentsas health professionals could be explored. A key feature of such participatoryresearch is that of a ‘spiral of self-reflective cycles’ (Kemmis & McTaggart, 2000), inwhich reflection on processes and consequences motivates the professional toimprove.

Postgraduate health professionals are faced with many choices. They may joinfellow health professionals from developing countries, and migrate to developedcountries, attracted by jobs with more money that offer the potential for develop-ment in their professional career (Davies, 2006). If, however, they return to thecomplex problems of their financially constrained home countries, choices must bemade in relation to interventions and strategies.

Outside agencies find vertically imposed programmes most appealing, especiallywhen local health infrastructures are not well developed. These are discrete, quan-titatively measured, supported by dedicated funding, and administered throughhierarchical management structures. However, horizontal programmes that arelocally based and directed are most likely to achieve major gains in health (Powles& Comim, 2003). Policy communities of global, regional and local actors, bothpublic and private, are now wanting sustained health improvements throughhorizontal participation rather than vertical representation (Walt, 2005). The lead-ership of the health professional is grounded in his/her ability to determine the bestbalance of vertical and horizontal programmes for sustained health improvementsfor the population. The path forward from the reality of health inequalities tobetter health for those in developing countries is trod by those health professionalswho immerse themselves with critical awareness in contrasting cultures and learnfrom each other.

Conclusion

The changing world of higher education for health academics presents newchallenges, and the research presented here contributes to knowledge about sucheducation across cultures. The critical perspective of the health academic and thereflective process of the multicultural group interaction facilitated mutual learning.Teachers must develop intercultural competence in the teacher–learner process toguide students in acquiring the skills of debate, conflict, reflection and difference

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Intercultural qualitative research and Ph.D. students 51

that are inherent in this critical perspective, and so important in solving problemsacross cultures.

Globalization expands the concept of educators’ responsibilities in cross-culturallearning. Further, responsibilities towards marginalized populations at home andabroad must be added to the prime task of achieving successful results for postgrad-uate students doing doctoral studies. These students will acquire and then applyhealth knowledge, and develop broad-based horizontal programmes that offer thegreatest hope of overcoming the gaps in health status within developing countriesand between developing and developed countries.

Notes on contributor

Dr Mary Ditton entered academic life after a career in Medicine practising as apsychiatrist. She is currently researching quality in primary health care in ruralThailand. Her interconnected research interests include: doctoral education inmulticultural Australia; work and health; and primary health care for disadvan-taged people.

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