Pedagogical models for enhancing the cross-cultural online public health learning environment

Introduction

Due to technological advancement in the past 10 years, there has been a growth of interest in online public health education. E-learning may be defined as the ‘learning facilitated and supported through the use of information and communications technology’ (JISC, 2007). This rapid growth and increased globalisation has led to groups of students and faculty from diverse cultural backgrounds interacting to attain a specific knowledge and skill set. At a local level, individuals from different careers and backgrounds are coming together to understand public health thus creating a need for higher levels of cultural diversity, sensitivity and understanding.

Education in and of itself is intimately linked to the transmission of culture. Even though there are many components of education like collaboration, interaction and curriculum, no discussion of online education is complete without examining its cross-cultural implications (Jung and Gunawardena, 2014). There presently exists a dearth in research pertaining to culture in online education (Goodfellow, 2008; Jung and Gunawardena, 2014). This is unfortunate given that education entails the intentional and unintentional transmission of behaviour and thinking, making cultural sensitivity much more critical. Culture cannot be perceived as an independent concept from education, but instead should be viewed as interconnected.

Literature search

We conducted a systematic review of the literature to describe the historical development and foundational models for a novel theoretical framework of multicultural education. Inclusion criteria were as follows: publication date before 31 July 2016, written in the English language and a focus on multicultural education. In order to identify eligible articles, we first searched the following databases – Education Resources Information Center (ERIC), MEDLINE, PsycINFO and Cumulative Index of Nursing and Allied Health Literature (CINAHL) using a search strategy unique to each database. We used keywords such as ‘e-learning’, ‘multicultural online education’, ‘cultural sensitivity’, ‘transcultural’, ‘cultural diversity’, ‘multicultural education theory’, ‘distance learning’, ‘public health’ and ‘cultural competence’. Additionally, we identified priority journals that provided the most citations and then scanned their tables of contents. Finally, we scanned the reference lists of key review articles that were identified in the electronic search and of all eligible articles. The search yielded 187 results. After those articles not related to education or culture were removed, along with duplicates, the abstracts were reviewed. Forty-three potentially relevant results remained, of which 12 were excluded. After applying the inclusion and exclusion criteria of dissertations, grey literature or insufficient detail provided in the paper, 31 papers remained.

Historical development of a multicultural theoretical framework

The dynamic characteristics of culture can be better understood from a historical perspective. Any discussion concerning multiculturalism and diversity cannot be complete without discussing the opposition between the ‘self’ and ‘others’ (Schwartz, 1990, 1992). From a sociological perspective, in-groups are formed by individuals who consider themselves more psychologically similar to the ‘self’ while out-groups can be defined as ‘others’. Emile Durkheim (1933 [1887]) defined mechanical solidarity as the bonds created between similar others and organic solidarity between dissimilar others. From this opposition follows the binary opposition between individualism versus collectivism. Individualism purports that individuals value independence from one another and self-fulfilment as the foundation of identity (Schwartz, 1990, 1992). In contrast, collectivism argues for the importance of honouring mutual expectations and obligations as part of a larger community (Cialdini et al., 1999), with the needs of the individual being secondary to those of the group. While the assumption is often made that Western societies are individualistic and African and Asian societies are more collectivistic, it is more appropriate to view these as two competing worldviews in which learners and instructors are situated (Oyo and Kalema, 2014). Nonetheless, understanding what is the predominant worldview within a particular context can help us design and teach concepts in a multicultural way. Diversity can thus be defined as the ability to transcend the simplistic dichotomy of collectivistic versus the individualistic perspectives. Only when learners and instructors embrace ‘dissimilar others’ can they correct specific misconceptions and move beyond stereotypes.

Diversity and cultural competence are concepts that are often used in conjunction with notions of social justice. As can be seen in Table 1, since the US Supreme Court’s decision of Regents of University of California v Bakke (1978), ¹ connotations of the term ‘diversity’ have become more varied. Diversity has transitioned from an emphasis on racial integration to a term that embraces a plethora of concerns, including gender, sexuality, ethnicity and so on (Delton, 2007; Gose, 2007). Even though, the Bakke case revolved around the entry of a white male to a medical school and age discrimination, the end result was the acceptance of affirmative action across a range of settings, which allows for the educational and economic improvement of a large number of disadvantaged groups. As a result, there has been a growing trend in many educational institutions towards greater diversity.

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Table 1.

Philosophical underpinnings of the multicultural theoretical framework.

Year	Philosophical starting point	Online public health cross-cultural implications
Durkheim (1933 [1887])	Emile Durkheim’s work provides the basis for distinguishing between and collectivism.	This theory serves as a gradual historical development in the concept of widening cross-cultural teaching by transcending simplistic binary oppositions.
Archer (1995)	Margaret Archer’s realist social theory argues that change agents are connected and must make changes by taking socio-cultural and historical context into consideration.	In the context of the online learning environment, developing change agents requires us to educate students about the importance of understanding each individual’s cultural context.
Cole and Wertsch (1996)	Jean Piaget and Lev Vygotsky’s constructivism purports that learning is best achieved through collaboration and is affected by prejudice and experience.	The concept of cognitive dissonance can serve to help break down cultural prejudices and lead to the incorporation of new ideas in the online public health learning environment.
Ceci (2006)	Uri Bronfenbrenner’s social ecological model was inspired by interactions between organisms and their natural ecosystems.	The foundational tenets are used to form the basis of the novel theoretical framework to explain cross-cultural peer-peer and peer-instructor interactions.
Delton (2007)	Social justice achieved through the supreme court decision on Regents of University of California v Bakke (1978)	Social justice serves as the guiding principle for attaining optimal level cross-cultural interaction in a diverse public health learning environment.
Guay et al. (2013)	Edward Deci and Richard Ryan’s self-determination theory is a motivational theory which purports that enhancing competence, relatedness and autonomy can foster the highest level of achievement.	Stemming from the need for relatedness, self-determination theory can be used to explain how peer interactions can create diverse notions about different cultural groups in the online environment.
Kashima (2015)	Dynamic concept of ‘culture’ is advanced over a more static concept in order to understand how groups communicate	A dynamic definition of how culture allows for the creation of a more fluid model of cross-cultural communication. This in turn lays the foundations for a pastiche of different ideologies.

In principle, diversity can lead to a more fulfilling student experience and a more complete perspective on the environment of which individuals are a part. Once the learner takes part in an educational experience involving people who are even slightly different, they attain more educational value from their experience than individuals who remain in an environment that is customarily familiar (Gose, 2007). Working through prejudices, positive and negative stereotyping can lead to an eventual broadening of perspectives and embracing of multiculturalism (Blinkhorn and Gittani, 2009; Stratton et al., 2006). Preconceived ideas, whether positive or negative, about an out-group can be a hindrance to education; however, when these ideas are critically examined, there exists the potential for a more fulfilling experience for the instructor and learner, as reflected in multicultural community health education (Wagemakers et al., 2015).

Social ecological framework

A novel theoretical framework may be valuable in understanding the changes afoot in public health education, especially its online variants. The social ecological model can provide the basis for understanding cultural diversity in online public health settings. Bronfenbrenner’s social ecological model suggests that the nature of the community in addition to individual demographic indicators such as race, gender and socioeconomic status makes a difference to student receptivity to learning (Ceci, 2006; Nuss et al., 2012). Student receptivity may differ according to the sociodemographic group, according to place of residence and with the familiarity of an online interface. Additionally, there may be complex social determinants such as community, interpersonal, societal and personal interactions which impact student’s understanding in different environments (Chatterji et al., 2012; Fleming and George, 2008).

Extrapolating from this theory, understanding the social nature of a community is the first step to understanding its social-ecological resilience or its ability to withstand external shocks to its infrastructure. Enhanced awareness of the social infrastructure not only provides the basis for public health education, but also the foundation for greater understanding of how the public health trainees can become an effective change agent within their community (Koh and Jacobson, 2009; Welker et al., 2014). Cultural competence is essential to bringing about behaviour change through public health. According to Archer (1995), change agents can act to bring about positive results, but are limited by emergent cultural properties and social and ecological properties. For Archer (1995: 148), these limitations may be extreme. To bring about social change, it needs to be recognised that

… these [structures] are the effects of past actions, often by long dead people, which survive them (and this temporal escape is precisely what makes them sui generis). Thus they [are the] autonomous possessors of causal powers.

While this definition shows the influence of the social-ecological infrastructure, a more complete understanding of change must also provide adequate room for supervenience – a sociological concept which demonstrates how lower level properties impact higher level properties. Fischer (2013) offers a more dynamic understanding of cultural processes as influenced by present considerations, rather than being embedded in traditions exclusively left behind by individuals in the past. By understanding the generativity and dynamic force of cultural processes through such a lens, the educator can provide a more complete experience to the student (Hajjar, 2014). The level to which experiences and actions play a role in cognition and learning depends on the specific cultural context as well.

Constructivism and self-determination theory

Cultural diversity adds an important component to the building blocks of constructivism. Intrinsic motivation is integral to successful performance and learner centeredness. Hagger and Chatzisarantis (2015) and Ryan and Deci (2000) among others suggest that each learner must discover and transform for themselves complex information if they are to make it their own. Other researchers have drawn on the work of Jean Piaget and Lev Vygotsky to suggest that previous perspectives go through a process of disequilibration in light of new information (Cole and Wertsch, 1996). This process of disequilibration allows the learner to acquire information from other students and compare this with personal experience. For example, the ‘self’ may go through a process of disequilibration and be broadened when the learner reads that another student, ‘other’, has experience of the same problems of diarrhoeal disease and high rates of maternal mortality that she or he is used to (Kaplan and Assor, 2012).

Researchers have also used self-determination theory to explore student motivation (Guay et al., 2013). Combining this theory with constructivist accounts in the context of online public health learning has the potential to yield dynamic results. For instance, in order to increase involvement among students and create higher levels of motivation, satisfying intrinsic psychological needs such as autonomy, competence and relatedness is essential (Hagger and Chatzisarantis, 2015). When an educator creates an environment that generates discussion or fosters choice, this gives credence to the student’s perspective and may help identify when choice is not possible. Often, there are times when an ideal or correct answer is the only option and in such instances it is the teacher’s role to gently ‘coax’ the learner to think along these lines. However, in other situations, the teacher’s role is to create an environment that allows for any number of responses – as there may be no one ‘right’ or ‘wrong’ response, and all that is required is that the learner takes a stance and defends their position. To help master challenges, teachers should seek to build upon competence, whatever the source of this may be. If a learner already possesses knowledge by way of a nursing background, for example, the teacher may engage the student by encouraging the integration of this experience into new learning in the field of public health.

Even though an appreciation of cultural difference is critical to being a successful online public health educator, encouraging relatedness through group discussion is just as important. Relatedness is central to developing a sense of self-determination and is promoted when students feel they are in an environment where they feel ‘connected’ (Niemiec and Ryan, 2009). This is especially critical in an online teaching setting where at first glance fostering relationships may seem more challenging due to feelings of isolation. Relatedness can also help to integrate diverse cultural viewpoints.

A multicultural theoretical framework for the development of public health online education

Bringing together the aforementioned theories can provide a more comprehensive understanding of how cultural considerations affect both the instructor and the learner when it comes to online learning (Figure 1).

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Figure 1.

A comprehensive framework combining the social-ecological model, self-determination theory and relationships motivation theory to integrate intercultural communication in online public health learning.

The starting point lies in understanding whether the teacher or learner comes from a collectivistic society or an individualistic culture. While this binary classification is simplistic, it provides the opportunity for the individual to understand the point along the social-ecological spectrum at which they start. The model allows for movement in both directions depending on specific interests and needs. Those who come from a collectivistic society are more likely to be guided by community values, while those from a more individualistic may start off with autonomous values, move through community and onward to societal interaction. Motivation for learning and developing competence is the driving force across the continuum.

At some point, internal conflict arises as new ideas begin to form. During this point of disequilibrium in the learning process, the learner must maintain a degree of social-ecological resilience in order to engage with and incorporate new information. Contending with this new information can be challenging to the notion of self and in-groups. The conflict that can arise in an online discussion between the teacher and learner or between different learners may attempt to integrate the shock arising from the disequilibrium. Depending on whether she or he has had an individualistic or collectivistic cultural upbringing, the individual will handle the conflict in a different way (Oyserman et al., 2002). The challenge for the instructor lies in transcending personal stereotypes and promoting social-ecological resilience within the teaching environment. McCalman (2014) highlights that an instructor needs to be strongly aware of their own cultural attributes. Crucially, cultural awareness is not only about understanding the ‘other’ and going beyond stereotypes, but also about self-reflection. McCalman (2014) suggests that training in English as a Second Language may offers a starting point for the development of this kind of cultural awareness. For learners, only when psychological needs for competence, relatedness and autonomy are met by the instructor, will the teaching environment be a constructive one. These same intrinsic psychological needs need to be satisfied by the teacher working with a multicultural student population in an online environment. If effective, the learning process continues for both the instructor and the student well beyond the end of the online class. This learning process continues as an iterative process for both the learner and the teacher.

Connection between foundational models and novel framework

Foundations of constructivism, self-determination theory and social-ecological theory are closely intertwined with the novel framework. Constructivism highlights the learner’s need to understand ideas, compare them to personal beliefs and then integrate or discard the new ideas (Hagger and Chatzisarantis, 2015). Applying this foundational principle to the novel framework, a learner whose belief system is more individualistic may need to go through a phase of disequilibrium before deciding whether to integrate or discard new ideas (Oyserman et al., 2002). Self-determination theory can help explain how a moment of crisis and disequilibrium will influence the propensity to move along the continuum between one binary opposition to the other. Finally, the social-ecological model serves as the foundation for the continuum between individualism or autonomy to collectivism or society (Ceci, 2006). It is the bringing together of these foundational models that provides the backdrop for the novel framework.

Implications for public health education

In a pedagogical context, engaging with cultural sensitivities is critical to creating a more effective learning experience. While a difference in cultural background between teacher and student (or between different students) can create a barrier and result in lack of student receptivity in an online learning environment, encountering these same differences can be a profound learning experience. Another source of difference that may potentially impact the learning experience is place of residence. A person who has lived in an inner city environment may have a different set of social norms and cultural attitudes than those living in the suburbs. Applying Fischer’s (2008) theories, by understanding how cultural processes shape each person’s perspective, there is all these situations powerful potential for dialogue. Socioeconomic disparities can be an unexpected source of bridging the chasm between instructor and student through disequilibrium (Figure 1) and the resolution of cognitive dissonance. By resolving the disequilibrium, the teacher can learn from the student and in some ways take on a ‘student’ role, blurring the distinction between instructor and student. When the cognitive dissonance is being resolved, there is a momentary deconstruction of roles with both teacher and student emerging on the other side with greater level of respect and appreciation of diversity.

Broadening an appreciation of diversity is a critical component of training world-class public health leaders. Integrating this diversity into online education ensures that learners can transition from passive learning to higher-order cognitive work, in which critical analysis is emphasised (Galway et al., 2015). The range of viewpoints generated by a diverse student body can create a high-quality education system in the online learning style.

This dynamic, iterative framework will allow students to continually evolve as the parameters of educational practice change in different disciplines. Crucially, parameters defining diversity are constantly evolving as educators increasingly rely on online educational systems and technologies to appeal to different student populations. Communication is opening newer frontiers and creating connections between citizens of countries that did not previously have any interaction. A renewed sense of nationalism among learners makes the need to acknowledge identities through novel frameworks all the more important (Bannier, 2016). As political developments such as the growth of nationalism come to play a more dominant role, this novel framework allows the learner and educational institutions to adapt to the changing environment.

Along with allowing for adaptability in both teachers and learners, this novel theory allows students from all backgrounds to develop their understanding of the social determinants of health. Even though some authors (Wei and Hindman, 2011) suggest that online education may serve to reinforce existing social disparities by empowering only individuals of higher socioeconomic status, by widening opportunities for education in low- and middle-income countries online education may create opportunities for those in the lower echelons of society (Atkins et al., 2016; Jaggars and Xu, 2016). More specifically, embracing diversity and multiculturalism in the online environment has the potential to allow learners to transcend ‘in-groups’ and embrace a larger reality in which learners fulfil their roles as a change agent.

Model implementation

To date, there remains a significant gap between the diversity and cultural sensitivity training that exists and the strategies needed to deliver good-quality multicultural education (Jernigan et al., 2016). To bridge this gap, an understanding of the dynamic character of culture is needed by all participants in a learning experience. To prepare for the future, cultural competence needs to go beyond mere mutual respect at the individual level. Instead of a cultural sensitivity training being given at a single moment in time, interpersonal and classroom-level cultural education needs to take place at different times in ways aligned with the course material. Additionally, culturally based cognitive and learning styles must be taken into consideration by the instructor in order to provide a more fulfilling experience (Moses and Chang, 2006). Within the context of reflective writing, students should determine how their cultural outlook may have changed due to interaction with others. Self-reflective material can be integrated with subject matter so that culture-related discussion can be made relevant.