|Year : 2020 | Volume
| Issue : 3 | Page : 194-201
Influence of student non-mother-tongue language learning on the achievement of intended learning outcomes: Would code-switching help?
Saleh Ali Alrebish
Department of Medical Education, College of Medicine, Qassim University, Qassim, Saudi Arabia
|Date of Submission||27-Aug-2020|
|Date of Decision||03-Oct-2020|
|Date of Acceptance||27-Oct-2020|
|Date of Web Publication||04-Dec-2020|
Saleh Ali Alrebish
Department of Medical Education, College of Medicine, Qassim University, Qassim
Source of Support: None, Conflict of Interest: None
Background: A stressful learning environment can hinder student achievement. Building on sociolinguistic theory, student learning is enhanced wherever the mother-tongue language is the same as the teaching instruction medium language. The present study aimed to evaluate the influence of students' non-mother-tongue language learning in the achievement of learning outcomes. Materials and Methods: The present study is a perception study with interventional, quantitative, and educational research component comparing the learning of 1st-year medical students in pure English with their learning using code-switching. The data were collected during the 2018/2019 academic year through a quiz and a questionnaire. Eighty-six 1st-year students' perceptions were compared to those of 72 4th-year students using the same questionnaire. Both t-tests and Chi-squared tests were used for the data analysis with SPSS for Windows, Version 21; P < 0.05 was considered statistically significant. Results: Code-switching students scored higher in the postsession quiz. One-third of the 1st-year students felt that learning in English was stressful, and they cited language issues as reasons for their low scores on examinations. They realized, however, that learning in English had positive consequences on their future careers and suggested that a bilingual approach be used, especially in the early stages and for complex topics. Fourth-year students were less apprehensive about learning in English. Conclusions: Ensuring appropriate English language proficiency during the admission process to medical schools and the use of simple, clear language during teaching with code-switching when needed are likely to decrease student stress during learning. This is likely to enhance students' achievement of the intended learning outcomes and maximize their performance after graduation.
Keywords: Code-switching, learning outcomes, medical schools, non-mother-tongue language
|How to cite this article:|
Alrebish SA. Influence of student non-mother-tongue language learning on the achievement of intended learning outcomes: Would code-switching help?. Saudi J Health Sci 2020;9:194-201
|How to cite this URL:|
Alrebish SA. Influence of student non-mother-tongue language learning on the achievement of intended learning outcomes: Would code-switching help?. Saudi J Health Sci [serial online] 2020 [cited 2022 Jan 22];9:194-201. Available from: https://www.saudijhealthsci.org/text.asp?2020/9/3/194/302445
| Introduction|| |
Medicine plays a significant societal role; the field is highly competitive, very influential, and carries a high status. The study of medicine is highly demanding and is perceived as stressful by students. Minimizing stress during their learning journeys is likely to help with their achievement of program learning outcomes and produce doctors who meet the expectations of the community in a cost-effective way., For medical students, many studies cite academic activities, per se, as stimuli for stress.,, Others report language barrier, gender, socioeconomic status, and ethnicity as potential factors that may increase student stress during the learning process.,
In the setting of the current study, the College of Medicine at Qassim University (COMQU), gender, socioeconomic status, and ethnicity are mostly controlled; COMQU recruits only Saudi students, provides monthly payments for all of them, and provides separate campuses for men and women. Stress due to the nature of studying medicine may be difficult to resolve;, however, stress caused by the language barrier can be addressed.
Some studies from Saudi Arabia identified the linguistic barrier as the most crucial barrier in the tertiary education system in Saudi Arabia. Al-Mously et al. reported English language proficiency as a significant predictor of academic performance. Observations at COMQU indicate a high dropout rate in the 1st year and that many of those who drop out in their 1st-year return to complete their studies after improving their English linguistic skills. Supporting this conclusion, a study at another Saudi university indicates language problems as more prominent for 1st-year students. A study done in Egypt revealed a similar situation where more than half of students admitted difficulty in following lectures fully delivered in English, and almost one-third of them had difficulty in understanding examination questions written in English.
The situation is not unique to native Arabic speakers or to students. Research has shown that Scandinavian family physicians retained knowledge better if the information was given in their mother tongue than if in English, whereas the mode of delivery (paper or computer screen) made no difference. Dhaliwal also reported difficulties in teaching medicine to residents with non-English-speaking backgrounds, which led him to seek assistance from a local interpreter. Students are usually motivated to learn by the need for an in-depth understanding of their subject matter. To enhance this in-depth understanding, students should not be under stress during the learning process. The discrepancy between the student's mother-tongue language and the School's instruction language represents an important unaddressed risk factor for student stress.
A non-mother-tongue language learning environment (wherein the medical school instruction medium is not in the student's mother-tongue language) is one of the underlying risk factors for student stress. Language anxiety, which is “the apprehension experienced when a situation requires the use of a second language with which the individual is not fully proficient” leads the individual to react in a nervous manner when speaking, listening, reading, and writing in the second language. Such an unlucky student is likely to waste time and perhaps peace of mind by working first to understand the college instruction medium's language and second to comprehend the subject matter. Ultimately, language anxiety can have a negative effect such that a stressed student is unlikely to achieve an in-depth understanding of the subject.
The present study sets its stage by building on sociolinguistic theory, wherein language is described as an interactive phenomenon with an impact on understanding in any given environment, such as a learning environment. In this sense, it is assumed that sociolinguistic theory predicts that student learning will be enhanced whenever his/her mother-tongue language is the same as the college instruction medium's language.
Published reports on the relation between students' non-mother-tongue language learning and the extent of achieving the intended learning outcomes (ILOs) are scarce in our region. The primary purpose of the present study was to explore the influence of learning in a non-mother-tongue language on students' achievement of a medical program's ILOs and if the use of a bilingual approach (code-switching) would be helpful.
| Materials and Methods|| |
The present study is a perception study with an interventional, quantitative, educational research component. An experiment was developed by the author using the same principles adopted by Gulbrandsen et al. (2002). It was approved by the Medical Education Department, COMQU that it would not negatively affect student learning. The proposal for this study was reviewed and approved by the Ethics Committee at the Research Center of the College of Medicine in addition to the Regional Research Ethics Committee, Qassim Province (Number: 20170416; dated March 27, 2017). This research was funded by the Scientific Research Deanship, Qassim University.
The experimental component was applied to 86 male 1st-year students with a mean age ± standard deviation (SD) of 19 ± 2 years at the COMQU during the 2018/2019 academic year. All the students were Saudis who spoke Arabic as their native language. They matriculated at the college after completion of the University Preparatory Year Program with a grade point average (GPA) of more than 4.2 (out of 5) and a minimum score of 80% in English language courses. They were divided into two groups, with the first group consisted of 42 students and the second group consisting of 44 students. The two groups were matched for GPA and age.
The experiment was conducted for both the groups during the morning session (8 am–12 noon) on the same day with the same lecture topic and the same teacher. Before the experiment, all students were given a written information sheet explaining the experiment and its purpose. In addition, a brief narration about the process was presented just before the beginning of the experiment.
The first group of students (Group I) was given a 50-min lecture in biochemistry (which was selected since its terminology is not generally translated) in pure English, which is a non-mother-tongue language for the students. The second group (Group II) was given the same topic on the same day by the same instructor but in mixed English and Arabic (code-switching); the medical terms and concepts were given in English, while Arabic was used for the explanation.
Following the session, a quiz to measure the level of the students' understanding of the lesson and a standardized questionnaire developed by the author were distributed to both the groups. The students' satisfaction rate with the learning experience was determined based on their scores on the test and by analyzing their responses to the questionnaire.
The quiz was composed of 10 type 1 multiple choice questions, with one best answer of five options, similar to the usual tests given in the college. The test was prepared by subject matter experts and was reviewed to target the core contents of the session. Each item included a short vignette, a lead-in, and five options. The test was machine scored with 1 mark for each item.
The questionnaire consisted of seven closed-ended questions and two open-ended ones. It was developed to target the issues raised by previous studies. The closed-ended questions inquired about the stressfulness of learning in English and if teaching in Arabic would be helpful, whether linguistic difficulties lead to low scores on or failing examinations, and whether students perceived positive effects of learning in English on their future careers. It also included the following open-ended questions:
- Do you have any comments on the impact of student non-mother tongue learning on the achievement of ILOs?
- Do you have any suggestions on the impact of student non-mother tongue learning on the achievement of ILOs?
The closed-ended questions were quantitatively analyzed, and the responses (agree, not sure, and disagree) were expressed as percentages. The open-ended questions were intended to add a qualitative component. Before its use, the questionnaire was given to some peers in the Medical Education Department and a small group of 2nd-year students, who were not included in the study, for face validation.
The study also included a comparison of 1st-year students' perceptions to those of students at an advanced level in the college program. The same questionnaire was distributed to 72 4th-year male students (Group III) with a mean age ± SD of 22 ± 2 years, and their opinions were compared with those of the 1st-year students.
The obtained data were analyzed using IBM SPSS for Windows, Version 21 (IBM Corp., Armonk, New York, USA). The mean scores of the two 1st-year groups in the quiz were compared using t-test. The Chi-squared test was used to compare students' responses to the closed-ended section of the questionnaire. In both situations, a 95% confidence level was used, and P < 0.05 was considered statistically significant. For the open-ended part, opinions/issues raised by 70% of the respondents were considered.
| Results|| |
The experimental component of the study showed that Group II (code-switching) students had a higher mean score (7.1 ± 1.1) on the quiz following the lecture than their Group I fellows (6.6 ± 1.0). The difference was statistically significant (P < 0.005).
Regarding students' perceptions, the responses of 1st-year students to the closed-ended portion of the questionnaire are shown in [Table 1]. Most students from both the groups agreed that “Learning in both English and Arabic languages during the same activity is useful.” Although the Group II students exhibited more agreement than Group I students (97.7% compared to 90.5%), the difference was statistically insignificant. Almost one-third of each group believed that “Learning in the English language is stressful,” and approximately three-quarter of the students thought that “Low scores on examinations are sometimes due to language issues in understanding the examination questions.”
Group II students were more concerned than their Group I fellows that “Stress created by language difficulties in understanding the examination questions” may lead to low scores (65.9% compared to 42.9%) or cause them to fail examinations (59.1% compared to 28.6%). Of the Group II students, 40.9% considered that “Failure in examinations is sometimes due to language issues in understanding the examination questions,” while only 23.8% of Group I had the same perception. The differences were statistically significant [Table 1].
Students from both groups agreed that “Learning in English will have positive consequences on my future career.” Group I had statistically significant stronger agreement with this perception than Group II (90.5% compared to 70.5%).
When responding to open-ended questions [Table 2], most of the 1st-year students reported that teaching in English is not a barrier for their understanding or achievement of the ILOs. They gave the following comments regarding learning in English:
|Table 2: The main issues highlighted by 1st-year students in response to open-ended questions|
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“Increases the ability to communicate with other persons in the same field,” “makes it easier to take exams, and makes it easier to speak and elaborate,” “is useful because it brings out the concepts in my mind for the questions on the exam.”
Students considered the clarity of using “understandable English,” proper accents, and the ability of the instructor to “talk easily” and “explain the information” as having marked influences on their attainment of information. Most of them preferred the mixed linguistic approach:
“Mixed language is better” and “If doctors speak in English and Arabic, the students will understand better.”
Students suggested that code-switching be used, especially in the early years of school and for complex topics in “difficult lectures.” They also suggested that “Terminology clarification is needed at the beginning of the lecture” and “Doctors should explain terms to students in English.”
Fourth-year students, as shown in [Table 3], were less apprehensive about learning in English. Only 27.8% of them considered it stressful; however, the lower rate compared to 1st-year students was statistically insignificant.
Among the 4th-year students, statistically significant lower percentages agreed with the usefulness of using both English and Arabic languages during the same activity (P = 0.019), and attribution of low scores on examinations to language issues in understanding the examination questions compared to overall 1st-year students [P = 0.002; [Table 4]].
|Table 4: Comparison of responses of 1st-year students and 4th-year students|
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Fourth-year students were closer to Group I students in saying that “Stress created by language difficulties in understanding the examination questions” may lead to low scores (44.4%) and “Failure in examinations is sometimes due to language issues in understanding the examination questions” (25.0%). They gave scores approximately halfway (36.1%) between Group I and Group II in considering “Failure in examinations is sometimes due to language issues in understanding the examination questions.”
Fourth-year students had almost a similar value (88.9%) to that of Group I students (90.5%) regarding “Learning in the English language will have positive consequences on my future specialty career.” At the same time, they were worried that it may decrease their ability to explain medical issues to patients in Arabic: “There is a problem learning in English in that we sometimes cannot communicate medical issues with non-English speakers.”
| Discussion|| |
Stress during learning may cause difficulties for students in achieving the ILOs. Many reports blame academic activities, per se, as stimuli for stress among medical students.,, Others report language barrier, gender, socioeconomic status, and ethnicity as potential risks that may stimulate student stress during the learning process., Khan, in 2011, identified the linguistic barrier as the most crucial barrier in the tertiary education system in Saudi Arabia. The current study was designed to evaluate the influence of learning with a non-mother-tongue language in the achievement of ILOs.
Matching teachers' experiences and previous reports,, the current study showed that students perceived learning in the English language as stressful and considered linguistic issues as contributing to low performance on or failing examinations. A study done in Egypt where more than half of the students admitted difficulties in following lectures fully delivered in English and almost one-third of them had difficulty in understanding examination questions written in English revealed a similar situation. In that same study, a considerable portion of the faculty (40.7%) expected that use of the Arabic language would result in harmony between students' thinking and speaking, and 28.6% believed that it would improve the communication of lectures to students.
The observed better performance of students taught bilingually in the current study's postsession test supports these perceptions. However, the present study revealed that students' concerns about language difficulties decreased as they advanced in the program. This also agrees with the findings of Almoallim et al. (2012) at Umm Alqura University in Saudi Arabia, indicating the linguistic problem to be more prominent among 1st-year students.
In the present study, the use of code-switching through alternating between the English and Arabic languages during the session resulted in better achievement, as shown by better results in the postsession test. The structure of the test, with type 1 multiple choice questions, more closely targeted cognition than short-term memory. This finding is consistent with earlier reports that even physicians experiencing activities in their mother-tongue language were able to retain information far better than when these same activities were conducted in a non-mother-tongue language. This also agrees with the reported effect of code-switching in enhancing deeper understanding during social communications. The beneficial effect of code-switching on learning is likely because of the potential to amplify and emphasize, explain or clarify spoken messages, and help to establish a rapport with the audience.
In the present study, students reported a belief that code-switching is more useful for their learning and suggested that it may be used at the beginning of sessions and for complex topics. Nevertheless, it is promising that 1st-year students realized that learning in English has positive effects on their future career paths, although the students in the code-switching group (Group II) were less sure. The perception became more solid as they advanced in the program.
In this regard, students considered the clarity of using “understandable English,” proper accents, and the ability of the instructor to “talk easily” and “explain the information” to have positive impacts on their retention of information, regardless of the language used. This is similar to earlier findings that lack of fluency in the language of instruction can be a barrier to medical education, especially for students whose mother tongue is not English. The delivery of information in a simple and comprehensive way is beneficial regardless of the language used; this is similar to what is suggested for teaching medicine to learners from a non-English-speaking background and international audiences.,
In the current study, 4th-year students had fewer worries about learning in English than their 1st-year fellows. This observation is similar to the finding of an earlier study who found that preclinical students at both Maastricht University and Universiti Sains Malaysia experienced higher psychological pressures than clinical students. Although no explanatory discussion of this finding was given in their report, the similarity of the situation to learning in a non-mother-tongue language may be the underlying cause. Improvements as students advance in the program are not unexpected. With time, students become more able to comprehend the non-mother-tongue language of instruction.
As for most of the medical schools throughout the world, the language of instruction in COMQU is English, which is the second or third language of our students, whose mother tongue is Arabic. The use of English for medical study is justified by the fact that it is the language used in the medical literature worldwide. It also enables the college to hire teachers from different backgrounds since they can all teach in English.
The current study showed that students perceive that the use of pure English in educational settings helps them to better understand questions on examinations. It also improves their ability to utilize international learning resources for a better understanding of the main concepts and provides them with better skills and opportunities to communicate with their peers at international scientific meetings. It also helps them build their self-learning capacity. However, it may pose some difficulties for short-term knowledge gain and within-class interaction during the early part of their program.
On the other hand, learning in the mother tongue would be advantageous for short-term achievement through the facilitation of the memorization of information and within-class interaction. Nevertheless, students' abilities to utilize international learning resources, which makes their life-long, self-learning abilities questionable, and their consequences for long-term achievement are doubtful.
Medical institutions should create a nonthreatening learning atmosphere for their students, and the language barrier may be one of the stressful issues in class. Approaches to overcome the linguistic issue included teaching colloquial English to students, the use of an interpreter, and the introduction of bilingual medical courses. An interesting study from Saudi Arabia raised the question of whether some medical courses should be taught in the students' mother-tongue language and reported that some colleges had introduced courses in medical terminology that were taught in the students' mother-tongue language.
There is no debate that English should be a language of instruction; a complete shift to Arabic is neither recommended nor needed. The findings of the current study are consistent with earlier reports that learning in a non-mother-tongue language creates some stress for learners,, and that the use of a bilingual modality can be a better approach for teaching.,, In addition, individual linguistic diversity among students might affect their responses to learning in English. It seems that those issues should be considered during program development and reform processes. The ascertainment of English proficiency by recruited students is a justified prerequisite, and the ability of teachers to deliver information in simple, clear, and easily understandable language should not be overlooked.
To reap the benefits of learning in both English and the mother tongue, there is a need for student preparation to achieve appropriate English linguistic abilities. Consideration of this issue in the preparatory year program, augmented by an English proficiency test before admission, and allowing the use of code-switching during teaching in the early years would be greatly helpful.
Code-switching may help to avoid the stress caused by linguistic difficulties, especially in the early phase of medical studies. It is likely to improve the rapid and easy acquisition of knowledge while simultaneously providing the groundwork to use international learning resources for long-lasting achievement. Code-switching during instruction may also help students better communicate with patients during counseling.
Code-switching would also alleviate the issue raised with 4th-year students saying that “There is a problem learning in English that we sometimes cannot communicate medical issues with non-English speakers,” which deserves special consideration. The ability of doctors to explain conditions to native Arabic speaking patients in their own language constitutes a very important component of patient counseling.,
Code-switching between English and the mother tongue does not only necessitate that teachers be fluent in both the languages, but it also requires that they be fully aware of the benefits and drawbacks of using either language. Teachers should be very attuned to class dynamics and be able to read students' eyes and impressions to determine when to switch languages as needed rather than just repeating everything in the mother tongue; faculty training would help.
The limitations of the current study include the inclusion of participants of only one gender, the small number of participants, and the single time point of the experiment, which may have introduced experimental bias. Expansion of the study to include more institutions, both genders, and the opinions of graduates are recommended before any action is taken based on the results.
| Conclusions|| |
The English language should continue to be the medium of instruction in medical education. Ensuring appropriate English language proficiency during the admission process to medical schools and the use of simple, clear language during teaching with code-switching when needed are likely to decrease students' stress during learning, which, in turn, is likely to enhance students' achievement of the ILOs and maximize their performance after graduation. However, this requires teachers to be fluent in both the languages and fully aware of class dynamics and the benefits and drawbacks of bilingual teaching to switch languages as needed rather than simply repeating everything in the mother tongue. Further multi-institutional study exploring the effectiveness of code-switching is highly recommended before any decision is made in this respect.
The author gratefully acknowledges Qassim University, represented by the Deanship of Scientific Research on the material support for this research under number (1530-med-2016-1-12-S).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dowell J. How do we select students with the necessary abilities? In: Routledge International Handbook of Medical Education. New York: Routledge; 2015. p. 112-25.
Hunter L, Leahey E. Collaborative research in sociology: Trends and contributing factors. Am Sociol 2008;39:290-306.
Yee LY, Yusoff MS. Prevalence and sources of stress among medical students in Universiti Sains Malaysia and Universiteit Maastricht. Educ Med J 2013;5:34-41.
Yusoff MS, Abdul Rahim AF, Yaacob MJ. Prevalence and sources of stress among Universiti Sains Malaysia medical students. Malays J Med Sci 2010;17:30-7.
Kaliyadan F, Thalamkandathil N, Parupalli SR, Amin TT, Balaha MH, Ali WH. English language proficiency and academic performance: A study of a medical preparatory year program in Saudi Arabia. Avicenna J Med 2015;5:140.
] [Full text]
Yamada Y, Klugar M, Ivanova K, Oborna I. Psychological distress and academic self-perception among international medical students: The role of peer social support. BMC Med Educ 2014;14:256.
Meydanlioglu A, Arikan F, Gozum S. Cultural sensitivity levels of university students receiving education in health disciplines. Adv Health Sci Educ Theory Pract 2015;20:1195-204.
Khan IA. An analysis of learning barriers: The Saudi Arabian context. Int Educ Studies 2011;4:242-7.
Al-Mously N, Salem R, Al-Hamdan N. The impact of gender and English language on the academic performance of students: An experience from new Saudi medical school. J Contemp Med Educ 2013;1:170-6.
Almoallim H, Aldahlawi S, Alqahtani E, Alqurashi S, Munshi A. Difficulties facing first-year medical students at Umm Alqura University in Saudi Arabia. East Mediterr Health J 2012;16:1272-7.
Sabbour SM, Dewedar SA, Kandil SK. Language barriers in medical education and attitudes towards Arabization of medicine: Student and staff perspectives. East Mediterr Health J 2012;16:1263-71.
Gulbrandsen P, Schroeder TV, Milerad J, Nylenna M. Paper or screen, mother tongue or English: Which is better? A randomized trial. JAMA 2002;287:2851-3.
Dhaliwal G. Teaching medicine to non-English speaking background learners in a foreign country. J Gen Intern Med 2009;24:771-3.
Yang Z, Xi J. Bilingual medical education: Opportunities and challenges. Med Educ 2009;43:613-4.
Imam AM, Al-Salloom AA, Ibrahim MI, Elsanosi BH, Al-Wabel AH. Student presentation: A conceptual model. Educ Med J 2014;6:57-61.
Al-Hourani M, Qasim A. The Use Code Switching Between Arabic and English Languages Among Bilingual Jordanian Speakers In Malaysia: Universiti Sains Islam Malaysia; 2016.
Esen S. Code Switching: Definition, Types, and Examples: Owlcation; 2019.
Chur-Hansen A, Barrett RJ. Teaching colloquial Australian English to medical students from non-English speaking backgrounds. Med Educ 1996;30:412-7.
Gerard DR. Teaching overseas. Emerg Med Serv 2004;33:60-2, 66.
Alshehri MY. Medical curriculum in Saudi medical colleges: Current and future perspectives. Ann Saudi Med 2001;21:320-3.
Chan A, Purcell A, Power E. A systematic review of assessment and intervention strategies for effective clinical communication in culturally and linguistically diverse students. Med Educ 2016;50:898-911.
Abi Raad V, Raad K, Daaboul Y, Korjian S, Asmar N, Jammal M, et al
. Medical education in a foreign language and history-taking in the native language in Lebanon – a nationwide survey. BMC Med Educ 2016;16:298.
[Table 1], [Table 2], [Table 3], [Table 4]