1 Introduction

The development of globalization strongly demands intercultural communicative competence between people for all of us to survive and prosper in the modern world. It is widely accepted that intercultural communicative competence is composed of abilities in three aspects of cognition, affect/attitudes, and behavior, and intercultural sensitivity is the affective aspect of intercultural communicative competence.

Bronfenbrener, Harding, & Gallwey's study (1958) proposed that sensitivity to the generalized other and sensitivity to individual differences are the two major types of ability in social perception. Hart and Burks (1972) and Hart, Carlson, and Eadie (1980) treated sensitivity as a mind-set in everyday life, and sensitive persons are supposed to accept personal complexity, avoid communication inflexibility, be conscious in interaction, appreciate the ideas exchanged, and tolerate intentional searching. Bennett (1984) considered intercultural sensitivity as a developmental process in which affective, cognitive, and behavioral transformation occurs from ethnocentric stages to ethnorelative stages, and six phases of denial, defense, minimization, acceptance, adaptation, and integration are identified.  According to Bhawuk, D. P. S., &Brislin (1992), intercultural sensitivity has been frequently defined as a sensitivity to the importance of cultural differences and to the perceptions of people in other cultures. Chen & Starosta (1997) view intercultural sensitivity as a dynamic concept and generated a working definition: "an individual's ability to develop a positive emotion towards understanding and appreciating cultural differences that promotes an appropriate and effective behavior in intercultural communication." He also examined six components of intercultural sensitivity: self-esteem, self-monitoring, open-mindedness, empathy, interaction involvement, and non-judgment. Chen & Starosta (1997) reveal that interculturally sensitive persons must have a desire to motivate themselves to understand, appreciate, and accept differences among cultures, and to produce a positive outcome from intercultural interactions.

Outline of the National Medium- and Long-Term Education Reform and Development (2010-2020 years), issued by the Ministry of Education, the People’s Republic of China, pointed out colleges and universities should cultivate a large number of international talents with international perspectives, knowledge of international rules, and the ability to participate in international affairs and competition. International medical talents need a global perspective as well as solid medical basic knowledge and skills in order to integrate into the mainstream medical education, medical services, and clinical research on a global scale. Medical colleges and universities shoulder the responsibility of cultivating professionals in health care, and there is obvious urgency to cultivate high-quality medical professionals as the COVID-19 epidemic in past years has demonstrated.  Zhang (2012) defined intercultural education in foreign language teaching as an educational activity about personal worldviews, values, identity, intercultural awareness, and intercultural competence, and she set six goals for intercultural education, of which the first goal is to enhance students' intercultural awareness and sensitivity, and help them view, analyze, and solve problems from an intercultural perspective.

It is therefore necessary to investigate the language learners to examine their intercultural sensitivity in order to design targeted language teaching activities for college students, so that they can raise their intercultural awareness and sensitivity and develop intercultural communicative competence after they take the course of College English. The research on intercultural sensitivity started relatively late—in the early 21^st century—in China and a few empirical studies deal with the status quo of intercultural sensitivity in certain populations, including English majors, non-English majors, students of ethnic minorities, international students, and practitioners in foreign trade, etc. However, there is little research on the intercultural sensitivity in medical undergraduates. Most studies available adopt the Intercultural Sensitivity Scale (ISS) developed by Chen & Starosta (2000) for its strong reliability and appropriate validity. The 24 items in ISS are about five dimensions of interaction engagement, respect for cultural differences, interaction confidence, interaction enjoyment, and interaction attentiveness.

This research aims to answer the following four questions:

1. What is the overall level of intercultural sensitivity in medical undergraduates?

2. What is the correlation between intercultural sensitivity level of medical undergraduates and the five factors involved?

3. Is there a correlation between intercultural sensitivity level of medical undergraduates and their gender?

4. Is there a correlation between intercultural sensitivity level of medical undergraduates and their ethnicity?

2 Methodology

An online questionnaire survey was conducted, and a combination of quantitative and qualitative research was adopted for data analysis. The Software SPSS 25 was used to perform descriptive and inferential statistical analysis, and the replies to the written interview questions were analyzed to investigate the status quo of intercultural communication in medical undergraduates and identify major problems.

2.1 Participants

The participants are undergraduates of clinical medicine in a medical university in northern China, and convenient sampling was used and the online questionnaire was distributed to the undergraduates by English teachers in online teaching platform.

2.2 Research Instruments

The instruments include a general information questionnaire and the Intercultural Sensitivity Scale ((ISS). Both are written in Chinese language for the convenience and clarity for the respondents.

1) General information questionnaire

The general information questionnaire was designed by the researcher herself and it includes questions on personal information of the respondents (gender, age, and ethnicity) and three semi-structured interview questions. The three questions are: a) Do you have any intercultural communicative experience? If yes, describe your behavior and feelings, please. b) Do you think language proficiency will influence intercultural communicative competence? And why? c) What do you expect to take away from the course of College English, as far as intercultural communicative competence is concerned?  These three interview questions are designed to provide data to complement the quantitative research, so that the behavior and viewpoints of individual participants can be better understood, providing reference for future teaching of College English.

2)  Intercultural Sensitivity Scale

This research adopted the Intercultural Sensitivity Scale (thereinafter referred to as ISS for short) developed by Chen & Starosta (2000), which was translated into Chinese language before distribution for the convenience of the respondents. ISS includes 24 items for the measurement of five dimensions, or five factors: interaction engagement (items of 1, 11, 13, 21, 22, 23, 24) is about the people’s feeling of participation in intercultural communication; respect for cultural differences (items of 2, 7, 8, 16, 18, 20) is about how people are tolerant of their counterparts’ culture and opinion; interaction confidence (items of 3, 4, 5, 6, 10) is about how confident participants are in the intercultural communication; interaction enjoyment (items of 9, 12, 15) is about the positive or negative reaction the participants have in communication towards people from different cultures; and interaction attentiveness (items of 14, 17, 19) is about participants’ effort to understand what is going on in intercultural communication.

A five-point Likert scale was used in ISS for the participants to respond to each item: 5 = strongly agree, 4 = agree, 3 = uncertain, 2 = disagree, and 1 = strongly disagree. The higher the participants’ score, the higher their level of intercultural sensitivity is. The reliability of ISS was measured again in this research and the value of Cronbach's α is 0.876, demonstrating high internal consistency among the 24 items.

3)  Statistical methods

The data from online questionnaires were collected and entered in Microsoft Excel, and the statistical software of SPSS 25 was used for data analysis. At first, perform reverse coding on 9 reverse items (2, 4, 7, 9, 12, 15, 18, 20, 22) and assign new values. Descriptive statistical analysis was performed for general information data, and t-tests and nonparametric tests were used to compare intercultural sensitivity between different genders and ethnic groups. Differences with P<0.05 were considered as statistically significant. Pearson correlation was computed to analyze the correlation between intercultural sensitivity score and each factor, and a difference of P<0.01 was considered as statistically significant.

3 Results and Discussion

A total of 373 valid questionnaires were collected. Each item scores 5 points and the total score is 120 points. The higher the score, the higher the level of intercultural sensitivity is. The statistical results show that the age of these medical undergraduate ranges from 18 to 24. Among them, male students account for 38.07% and female students 61.93%. There are a total of 327 Han students, accounting for 87.67%, and students from 7 ethnic minorities account for 12.33%. Among the students from 7 ethnic minorities, Uyghur students are of the highest proportion, accounting for 8.85%.  Each of the four research questions mentioned earlier will be explored and the implication for college English teaching will also be discussed.

3.1 Analysis of the Overall Level of Intercultural Sensitivity in Medical Undergraduates

The statistical results show that the intercultural sensitivity score of 373 participants ranges from 120 to 61 points, and the average score is 87.21 points, with a standard deviation of 11.82. According to common evaluation standard, a score of 100-120 is considered excellent, a score of 80-99 is considered moderate, and a score below 79 is considered low. The results indicate that the intercultural sensitivity level of medical undergraduate students is at a moderate level, with significant differences among the participants.

table 1  descriptive statistics of five factors of iss

The maximum values of all five factors are 5 points, while the minimum values of two factors of “interaction confidence” and “interaction enjoyment” are only 1 point, indicating significant differences among the participants. The original data are subjected to dimensionless processing for comparison due to the fact that the number of items used to measure these five factors ranges from 3 to 7, making these factors incomparable.

Based on the mean values, the five factors are ranked from high scores to low scores as follows: respect for cultural differences 3.93 > interaction engagement 3.75 > interaction attentiveness 3.61 > interaction enjoyment 3.51 > interaction confidence. All the mean values of first four factors are higher than 3.5, but the mean value of interaction confidence is much lower, with a value of 3.18, which is consistent with previous studies (Zhou 2007, Li 2015, Yao 2022). The first three factors with highest mean values (respect for cultural differences, interaction engagement, and interaction attentiveness) are concerned about the cognitive and behavioral aspects of intercultural communication, while the last two factors (interaction enjoyment and interaction confidence) are more concerned about the affective aspect of intercultural communication. The study shows that the participants are much tolerant of the viewpoints from other cultures, have a positive attitude, and make efforts to understand the other in intercultural communication. However, the participants lack confidence in the intercultural communication and find it not easy to enjoy the interactive process.  

Textual analysis on the interview questions shows that lack of confidence in intercultural communication may result from the following reasons. First, medical undergraduates have few opportunities to experience authentic intercultural communication, thus having little chance to practice and improve their intercultural communicative competence. When they do have a chance occasionally, they may find it difficult to communicate with people from other cultures due to insufficient language proficiency. Secondly, the traditional teaching method still prevail, although the cultivation of intercultural communicative competence has long been listed as one of the main objectives of college English teaching. Therefore, teachers tend to focus on specific language skills such as vocabulary and grammar, instead of intercultural contents and critical thinking ability. Intercultural communication courses are not available for medical undergraduates, either. Thirdly, the passages in their textbooks are mainly about western cultures and values, especially American values, and they have been much more exposed to foreign cultures from various channels than any previous generation, which can also account for why the undergraduates lack confidence but have a high level of “respect for cultural differences”. It is suggested that college English teachers need to add teaching contents of Chinese culture and compare the corresponding parts in different cultures, so that the students can have a deeper understanding of cultural diversity, build their cultural confidence, and increase their intercultural sensitivity.

3.2 Correlation between Intercultural Sensitivity Level and Each of the Five Factors

After the overall level of intercultural sensitivity in medical undergraduates was measured, Pearson correlations were computed and it was found that significant correlation exists between ISS and all the five factors at the p< .01 level.

table 2  correlation between iss level and five factors

** Significant correlation at the p< .01 level (bilateral)

The data analysis shows that correlation (r=.875) between intercultural sensitivity level and the factor of interaction engagement is the strongest, the correlation (r=.758) between intercultural sensitivity level and the factor of interaction enjoyment is less strong, and the correlation (r=.534) between intercultural sensitivity level and the factor of interaction attentiveness is the weakest. To be specific, the correlation significance levels between ISS value and five factors are ranked from strong to weak as follows: interaction engagement > interaction enjoyment > respect for cultural differences > interaction confidence > interaction attentiveness. Of the five factors, interaction engagement and interaction enjoyment have the biggest influence on intercultural sensitivity level, indicating that those with a stronger feeling of engagement have a higher level of intercultural sensitivity, and those people who generate more positive reactions in intercultural communication also have a higher level of intercultural sensitivity. The participants can increase their intercultural sensitivity level if they can be more tolerant of viewpoints of the people from other cultures, become more confident, and make more efforts to understand what is going on in intercultural communication.

Chen & Starosta (2000) pointed out that “successful intercultural communication demands interactants’ ability of intercultural awareness by learning cultural similarities and differences, while the process of achieving awareness of cultural similarities and differences is enhanced and buffered by the ability of intercultural sensitivity”. Since the level of intercultural sensitivity can be increased through learning and accumulating experience, teachers are encouraged to create favorable environments for students to learn more about cultural similarities and differences, raise their awareness, build confidence, and eventually improve their intercultural communicative competence.

3.3 Comparison of Intercultural Sensitivity Levels between Male Students and Female Students

Of 373 medical undergraduates in this study, male students account for 38.07% and female students account for 61.93%. Male students and female students are variables for research; their levels of intercultural sensitivity are measured respectively, and the mean values and standard deviation of five factors are measured as well.

table 3  descriptive statistics of iss level and five factors of male and female participants

* Significant difference compared with female students

The researcher compares the intercultural sensitivity levels and mean values of 5 factors between male and female students, and the results show no significant difference in the level of intercultural sensitivity, although the mean level of female students (87.4) is slightly higher than that of male students (86.9). Of the five factors, there is significant difference in two factors of “respect for cultural differences” and “interaction confidence”. In the dimension of “respect for cultural differences”, the mean value of female students (24.4) is significantly higher than that of male students (22.5); while in the dimension of “interaction confidence”, the mean value of male students (16.8) is significantly higher than that of female students (15.4). The results show that female students are more tolerant of viewpoints from different cultures, while male students are more confident in intercultural settings, which may be influenced by traditional Chinese culture. As to the standard deviation of intercultural sensitivity level and all five factors, all SD values of male students are higher than that of female students, indicating a greater difference among male students.

3.4 Comparison of Intercultural Sensitivity Levels between Han Students and Students from Ethnic Minorities

Of all 373 participants in this study, 327 are Han nationality students, accounting for 87.67%, and the remaining are ethnic minority students, accounting for 12.33%. The minority ethnic groups are ranked according to the number of students from high to low, and the Uyghur students are of the highest proportion, accounting for 8.85%, followed by students of Kazak, Hui, Manchu, Tujia, Mongols, and Daur. As the respective numbers of participants from these 7 ethnic minorities are small, less than 10, it does not make much sense to make comparisons using each ethnic minority as a single variable. Therefore, all 7 ethnic minorities in total are considered as a single variable and then compared with Han nationality, and the mean values and standard deviation of intercultural sensitivity and five factors from different nationalities are computed.

table 4  descriptive statistics of iss level and five factors of different nationalities

* Significant difference compared with students from ethnic minorities

The statistics show that ethnic minority students have an ISS mean value of 90.7 points, nearly 4 points higher than that of Han nationality students (86.7 points), but the difference is not statistically significant (p＞0.05). As to the five dimensions of intercultural sensitivity, the mean values of ethnic minority students are significantly higher than Han nationality students in three dimensions of “respect for cultural differences”, “interaction confidence”, and “interaction enjoyment”, which is consistent with previous studies in China, see detailed information in Table 4. Zhao (2015) investigated the Uyghur and Han Students at a university in Xinjiang Uygur Autonomous Region and found that the Uyghur freshmen students have a significantly higher mean value of intercultural affective ability than that of Han freshmen students, and Uyghur students have a significantly higher mean value of Interaction confidence than that of Han students.

For most college students of ethnic minorities, Chinese language is their second language, and English is their third language, which makes it a great challenge for them to take the course of College English, a public compulsory course at universities. The university where this research was conducted offers remedial English courses for the students of ethnic minorities and it also adjusts the assessment standards in final examinations to ensure that they keep up with other Han students in their academic performance. All these positive experience and friendly treatment in a mainland university helps to account for a higher mean value of ethnic minority students in the dimension of Respect for cultural differences than that of Han Students. The fact that the ethnic minority students attend a mainland university and adapt to a different culture itself is a living proof of successful intercultural communication in a broad sense, therefore they exhibit a significantly higher level than Han Students in the two dimensions of Interaction confidence and Interaction enjoyment.

3.5 Status Quo of Intercultural Communication in Chinese Medical Undergraduates

Because all 24 items in ISS are close-ended questions, three open-ended interview questions are added to provide qualitative research data for a more comprehensive investigation, see Table 5 for part of the results of textual analysis.

table 5  intercultural communicative behavior of medical undergraduates and influence factors

Textual analysis of interview questions showed that 93.57% of the students don’t have any experience of intercultural communication, and only 4 students out of all 373 participants have communicative experience with foreigners, among which two students had conversations with the international students from India, another student had been to Australia and attended the class there for different teaching style, and the last student had been to Luxemburg and ordered food in a fast-food chain. Except for above-mentioned experiences, all the remaining intercultural communicative behavior occurs between the participants and the ethnic minority students in the same university, and some Han nationality students are vaguely aware that the ethnic minority students from Xinjiang Uyghur Autonomous Region have different cultural background, because they don’t speak Chinese as their first language and they have different lifestyles and religious background, etc.

As to the role that language proficiency plays in intercultural communication, most students (86.86%) think language proficiency does have an impact on intercultural communicative competence. Five participants are quite sure of this point and explained they believe so because they encountered various difficulties in intercultural communication due to inadequate English language proficiency: “Several other classmates and I taught the international students to play cards at the university playground, and I found it extremely difficult to express myself”, “I have some difficulty in conversation”, “I am afraid of communication”, “The communication is not smooth”, “I used a lot of gestures and guessing”, “I speak broken English and fail to communicate with others effectively”, etc. All the honest feedback verifies the results of quantitative research based on ISS, and most students hold the opinion that language proficiency, especially English language proficiency, does have influence on the intercultural communicative competence. This also accounts for the fact that nearly half of the participants hope to improve their listening and speaking proficiency of English language, and it is necessary to add teaching contents about intercultural communication to the course of College English. They hope to learn more about other cultures and have opportunities to perform authentic communication with people from other cultures. However, as many as 13% participants hold a negative attitude towards the role of English language proficiency, because they feel the translation software will do if they do not speak that target language well, or they simply believe “Money talks”, and language proficiency is not that important as claimed.

College English is a public compulsory course for all the medical undergraduates, and it is offered in the first four semesters with 48 teaching hours for each semester. The results show that nearly half of the students (46.9%) expect more opportunities to practice and improve their speaking and listening ability and experience intercultural communication, and only a much smaller percentage of students (7.5%) hope to learn more about different cultures. It reveals that college students have a low demand for the knowledge-based instruction of different cultures, possibly because such information is easily accessible thanks to modern Internet technology. College students have a much stronger demand for a better language proficiency, especially speaking and listening abilities, and authentic intercultural communication, laying a solid foundation for prospective studying and working overseas in the near future. The strong and urgent needs of the college students revealed by the analysis put forward higher requirements on the teaching of College English, because traditional teaching model of intensive reading still prevail in current teaching and assessment, in which listening comprehension accounts for 10% only, and teaching of speaking ability is not required at all. The big gap between the real demands of students and the current status quo of College English teaching poses great challenges for teachers, and more importance should be attached to the teaching of speaking, listening, and intercultural communicative competence in future teaching reforms.

4 Conclusions

Since this study investigated the medical undergraduates in a single university only, the sampling is not big enough to reveal the whole situation of intercultural sensitivity in Chinese medical undergraduates. Another limitation is planned in-depth oral interview with individual participants is not conducted because all questionnaires are collected anonymously so that the participants can provide feedback in an honest way without worrying about the possible negative consequences.

Education of intercultural communication is the trend of educational development in the new era and foreign language teaching is bound to become the important platform of intercultural education, for it combines the language, culture, and communication effectively. Foreign language teaching has the dual goals of language teaching and social humanities; the former views foreign languages as a tool, while the latter deal with the cultivation of abilities in learners for the abilities of effective communication, cooperation, and harmonious coexistence with people from different cultures. The cognitive and affective development in learners is also included, therefore it is necessary to explore the intercultural sensitivity in the students to design classroom teaching accordingly.

Culture is the coherent, learned, shared view of a group of people about life’s concerns that ranks what is important, furnishes attitudes about what things are appropriate, and dictates behavior. People in a culture share symbols of that culture. The most obvious set of symbols is language (Iris Varner & Linda Beamer: 2006). In this study, unlike Han nationality students, the ethnic minority students don’t speak Chinese as their first language, and they also have different lifestyles and religions etc., so it is reasonable to assume that the ethnic minority students have different cultural backgrounds from the Han students, although they belong to the same country. Therefore, it makes sense that the contact and exchanges between ethnic groups should be encouraged to increase the intercultural sensitivity level in undergraduates. Wang (2012) also indicated that proper contact between ethnic groups can improve intercultural communicative competence, benefiting both ethnic minority students and Han students equally.

The course of College English is the single major source for college students to be exposed to different cultures and improve their intercultural communicative competence, because ordinary students have few opportunities to get to know foreigners and have effective intercultural communication, and no special courses are offered at the university to cultivate the intercultural communicative competence to prepare them for the prospective studying and working overseas.

Teachers of College English need to lead the students to learn more about cultural differences, build their confidence, and increase their intercultural sensitivity level in the end. Intercultural communicative competence is the results of much practice and experience, instead of a simple combination of language proficiency and cultural awareness, and cultural experience is an indispensable link in the process of knowledge internalization. Outside the classroom of College English, teachers should encourage students to communicate with international students and students of different ethnic groups, since it has proved a feasible way to improve intercultural communicative competence and intercultural sensitivity level, and the affective and behavioral abilities, such as interaction enjoyment, interaction confidence, and interaction attentiveness, can be improved only through much authentic communication and practice.

Acknowledgment

This study is supported by Shanxi Medical University Science and Technology Innovation Fund Project “Research on the Intercultural Communication Ability in Medical Undergraduate Students” (No: 2014-29)

References

[1] Bronfenbrener, U., Harding, J, & Gallwey, M. (1958). The measurement of skill in social perception. In McClelland, D.C. (Ed.).Talent and society. NY: Van Nostrand.

[2] Hart, R. P., & Burks, D. M. (1972). Rhetorical sensitivity and social interaction. Speech Monographs, 39, 75 - 91.

[3] Hart, R. P., Carlson, R. E., & Eadie, W. F. (1980). Attitudes toward communication and the assessment of rhetorical sensitivity.

Communication Monographs, 47, 1-22.

[4] Bennett, M. J. (1984). Towards ethnorelativism: A developmental model of intercultural sensitivity. Paper presented at the Annual

Conference of the Council on International Exchange, Minneapolis, Minnesota.

[5] Bhawuk,D. P. S.,& Brislin,R.The measurement of international sensitivity using the concepts of individualism and collectivism[J]. International Journal of Intercultural Relations, 1992,16:413-436.

[6] Chen, G. M., & Starosta, W. J. (1997). A review of the concept of intercultural sensitivity. Human Communication, 1, 1-16.

[7] 国家中长期教育改革和发展规划纲要（2010-2020年） - 中华人民共和国教育部政府门户网站 (moe.gov.cn)

[8] 张红玲.以跨文化教育为导向的外语教学:历史、现状与未来[J].外语界,2012,No.149(02):2-7.

[9] Chen, G. M.& Starosta, W. J. The development and validation of the Intercultural sensitivity scale[J]. Human Communication, 2000(3):1-15.

[10] 周杏英.大学生跨文化敏感水平测评[J].山东外语教学,2007,No.120(05)

[11] 李燕.北京市大学生跨文化敏感度调查研究——以N大学为例[J].教育理论与实践,2015,35(18)

[12] 姚蓓,李玉荣.基于ISS量表的医学院校大学生跨文化敏感度调查[J].池州学院学报,2022,36(01)

[13] 赵智云.新疆高校维吾尔族、汉族大学生跨文化情感与行为能力调查与比较研究——以塔里木大学为例[J].塔里木大学学报,2015,27(01).

[14] Varner, I. &Beamer,L.全球化工作环境中的跨文化沟通[M].上海:上海外语教育出版社, 2006.

[15] 王晓玲.论群际接触对跨文化敏感的影响——一项基于民族院校和非民族院校学生的实证研究[J].宁夏社会科学, 2012, No.170(01).