The Impact of Reading Anxiety of English Professional Materials on Intercultural Communication Competence: Taking Students Majoring in the Medical Profession

Abstract

In most medical universities in Taiwan, English-language professional materials are used in professional courses. Thus, a student’s reading ability is very important for understanding the content of English professional materials. The professional knowledge gained will facilitate intercultural communication in their future work setting. In this paper, the authors explored the impact of students’ anxiety when reading English professional materials on intercultural communication competence (ICC). A mixed method was applied. Firstly, sample data from 312 students majoring in the medical profession were investigated to obtain the results of the exploratory factor analysis (EFA) of two scales: a reading anxiety regarding English professional materials scale (RAEPMS) and an intercultural communication competence scale (ICCS). The RAEPMS, with a total explained variance of 81.67%, included three factors: worry about comprehension, lack of satisfaction with one’s reading ability, and language distance. The ICC, with a total explained variance of 80.02%, included four factors: skill, attitude, awareness, and knowledge. Secondly, sample data from 205 students majoring in the medical profession were obtained to form the confirmatory factor analysis (CFA) of the two scales, and then structural equation modeling (SEM) between RAEPMS and ICCS was created. The results showed that “worry about comprehension” impacts “skills” and “attitudes”; “lack of satisfaction with one’s reading ability” impacts all four ICC factors; and “language distance” impacts “skills”, “awareness”, and “knowledge”. Furthermore, interview results from three teachers were obtained to understand the significant connection between RAEPMS and ICCS. Additionally, pedagogical implementations, based on the interviews’ results, which could decrease reading anxiety and increase ICC were discussed. This paper provides a significant contribution to student education and professional training. The benefit of this research is to think how to design the pedagogy implementation to ensure the education of students and their professional training. Thus, students majoring in the medical profession will be more easily trained to communicate with people of different cultures in their future workplace.

1. Introduction

It is well known that knowledge and technology development have brought people closer and led them to be more interconnected, bringing about a “global village” [1]. This phenomenon leads people with diverse cultural backgrounds and ethnicities to work together and communicate with each other. To interact with those coming from different countries, the English language has been adopted as a means to facilitate international communication. Hence, to become globalized, students must learn the four English language skills—listening, speaking, reading, and writing—to sharpen their grammatical and linguistic competence. Over many years, English language learning has become synonymous with linguistic or grammatical accuracy. Nonetheless, with the emphasis on the communicative approach, the four English language skills, involving knowledge of grammar, vocabulary, reading, and writing, have taken second place in English language learning. Instead, English language learning has prioritized communicating smoothly with those from different cultures [2].

Moreover, with the increasing adoption of EMI (English as a medium for instruction) courses in Taiwan for the acquisition of professional knowledge and academic achievement, college students have been required to use the English language to communicate not only with teachers and classmates, but also with contextual texts or intercultural contexts. While these college students are proficient in language skills, they often encounter communication barriers due to unfamiliarity with sociocultural parameters, unable to develop an appropriate contextual understanding of research or communicating with people from different cultures [3]. Students may need to have communicative language competence such as intercultural communication competence (ICC) to adapt to the so-called “global villages” and conduct intercultural communication [4].

In most of Taiwan’s medical universities, English professional materials are used in professional courses. Hence, a student’s reading ability is very important to understand the content of English professional materials. The professional knowledge obtained will help in cross-cultural communication in their future workplace. In Taiwan, most medical universities’ students only contact with English and only means to learn English are from English professional materials. Therefore, it can be assumed that when students are familiar with these English professional materials, their ICC would increase in their future workplace. For example, if you wish to learn more about American culture, you must learn English as part of American culture. The relation between language and culture was considered direct and indissociable. Language barriers have been identified through intercultural communication [2]. Hence, by avoiding reading anxiety to linguistic barriers with regard to these English professional materials, students can maintain or even augment their interest in reading English, thereby better understanding the world of today and tomorrow, people from other cultures, and even their own worth. Clearly, decreasing reading anxiety will help to increase students’ future ICC.

2. Literature Review

2.1. Pragmatic Competence

Pragmatics, according to [5], is defined as a study of language from the perspective of users, including the choices they make, the limitations they experience in the use of language while socially interacting with others, and the participants’ understanding of the conversation when interacting with others who may come from different countries or cultures. The ability to understand the meaning intended by another speaker is referred to as pragmatic competence, which is a linguistic term coined by Thomas [3], a sociolinguist. Thomas [3] defined pragmatic competence as the ability to use language efficiently and appropriately to be understood in a contextual manner. Hence, in a more contextualized fashion, pragmatic competence is a fundamental component of a more integral component of communicative language competence [4].

Pragmatic competence or knowledge affects all forms of communication, irrespective of what language is being used in its sociocultural or intercultural context [6,7]. In other words, pragmatic competence is about the speaker’s ability to adapt language formulas to the constraints of the social context and to realize the implications of indirect statements, either spoken or written. Hinkel [8] proposed two components that would influence students’ pragmatic competence to use a language to interact with others: the assessment of pragmatic norms and shared cultural understanding. Zarrinabadi et al.’s study [9] indicated that pragmatic competence should include two components: pragmalinguistic knowledge and sociopragmatic knowledge. Pragmalinguistic knowledge refers to linguistic forms and combinations of these forms, which are used for a specific function; sociopragmatic knowledge refers to how and when to use each form in order for sociocultural norms to be observed. Qian et al.’s study [10] showed that pragmatic competence should encompass four key characteristics: to abide by the pragmatic-language-level rules, to be sensitive to cultural differences on a social pragmatic level, to realize the limitation of attitudes and behaviors when speaking on a psychological cognitive level, and to take time and situational constraints into consideration.

To sum up, pragmatic competence involves the speaker’s ability to use language in a variety of ways to express socially acceptable behaviors in a given linguistic and cultural context, and the listener’s ability to move beyond the superficial meaning of that language and determine the speaker’s real intentions, hidden inside [11]. Yin [12] also suggested that computer-aided communication may be an effective approach to encourage students to acquire a foreign language and promote the pragmatic development of EFL learners. Hence, pragmatic competence acts as a crucial factor for interacting in an appropriate manner in communication situations.

Bardovi-Harlig’s study [13] revealed that those versed in pragmatic strategies have better communication competence than those only exposed to linguistic input. However, when they are lacking pragmatic English language information, students may use their own means to develop pragmatic interlanguage by transferring knowledge from their mother tongue or from universal knowledge to their English language performance, which may cause pragmatic breakdowns in English language communication [6]. Without any means to acquire intercultural knowledge, college students are not familiar with the differences in communicative speech acts used in the English language. Moreover, they rarely have access to various cultures and, further, have no idea of how to use pragmatic knowledge to realize the cultural or textual differences between them.

In Taiwan, most national universities and medical universities have used English professional materials to teach students, which serves as a means to acquire professional knowledge and to increase communication competence in their future workplace. Hence, students have been required to use the English language to read contextual texts or intercultural contexts, which requires pragmatic knowledge. Without pragmatic knowledge to fill in the gap between the input of cultural knowledge and the output of communication competence, a breakdown of intercultural communication can arise.

2.2. Reading Anxiety with English Professional Materials

With no pragmatic knowledge while reading English professional materials, college students may unintentionally cause a breakdown in intercultural communication, fearing to use the wrong word. When they are reading or discussing English professional materials with others, they may experience reading anxiety, and further affecting not being able to reach an appropriate level of communication when they are reading or discussing English professional materials with others. Liu [14] studied 162 students who were learning a second language, Chinese, at a Chinese university. They created a cause-and-effect model for Chinese speaking anxiety and willingness to communicate. The results showed that Chinese speaking anxiety is a powerful negative predictor to predict students’ willingness to communicate in Chinese. In addition, Liu and Jackson [15] studied 547 Chinese students who were in their first year and studying English as a foreign language; they found that foreign language anxiety is an important predictor for predicting students’ willingness to communicate. Chu [16] studied 364 Taiwan University students and found that students with a greater anxiety toward learning English have a decreased willingness to communicate with each other in either Chinese or English. Some studies also showed that foreign language anxiety closely predicts one’s willingness to communicate [16,17,18,19]. Furthermore, they may experience additional anxiety symptoms, such as trauma, fear, embarrassment, or timidity. Even worse, they may lose a positive sense of self, suffer a variety of psychological syndromes, or temporarily forget the knowledge they have acquired [20,21]. Moreover, while acquiring intercultural knowledge via reading relevant professional or academic materials, students’ awareness of their cultural inadequacy and lack of pragmatic competence may further affect their ICC.

Though research has paid attention to language learning anxiety in education, there is still little attention paid to reading anxiety and the factors that may cause reading anxiety in higher education [22,23], especially when reading English professional materials. Gradually, while struggling with the reading demands requested by teachers, students may feel incapable of mastering academic or professional English, that is, less competent in language acquisition and in reading English professional materials, and hence experience a higher level of English reading anxiety. Research [24,25,26] has also revealed that there is a significant correlation between reading anxiety and the self-perception of one’s reading proficiency. In addition, Ghaith [27] suggested integrating pedagogical implications, such as the use of humanistic approaches, to teach students’ English reading to improve reading comprehension and lessen English reading anxiety.

2.3. Effects of Reading Anxiety on Intercultural Communication

Those having higher reading anxiety would have a lower self-rating and less comprehension of the literary texts. Moore’s study [28] demonstrated that there is a correlation between students’ language anxiety and intercultural sensitivity. Saito et al. [29] pointed out two components that cause reading anxiety for foreign language learners: an unfamiliar writing system and unfamiliar cultural contexts. Hence, they developed a foreign language reading anxiety scale (FLRAS) to measure students’ foreign language reading anxiety toward the unfamiliar writing system and the unfamiliar cultural context. Zoghi [30] added two more components to the scale in Saito et al.’s [29] study, students’ reading comprehension skills and teachers’ instructional methods. Miao and Vibulphol [31] proposed three potential components that would affect students’ foreign language reading anxiety: personal factors (including foreign language proficiency levels, reading comprehension skills, and background knowledge of the texts), text-related factors, and teacher-related factors. Teacher-related factors refer to the teacher’s correction behaviors and lack of support.

Based on the review, it can be concluded that a strong relationship exists between language and culture, because language is about human life and culture is about making things possible [32,33]. The main reasons for students’ reading anxiety could be that they are unfamiliar with the knowledge of the culture or the experience of reading professional texts in English [29,30,34]. Hence, while reading an academic passage, with no understanding of the cultural background or history, students may be unable to fully interact with the text, since they do not fully understand the intention of the text. Furthermore, students’ English reading ability will demonstrate whether their ICC can communicate effectively or appropriately with others while coping with different cultural contexts in their occupational sites. Students’ learning motivation, their professional knowledge, and their tolerance for their future jobs may affect their ICC [35]. Hence, students’ English reading anxiety will affect students’ reading ability with the interaction of learning motivation, knowledge, and tolerance.

To increase students’ intercultural communication and to help students acquire pragmatic competence, colleges have widely adopted courses with professional English reading materials to give students an opportunity to acquire an advanced English language, along with some inside intercultural knowledge. To sharpen students’ advanced English language skills and to increase their ICC, students must acquire pragmatic knowledge and apply it to the real world and daily academic study; thus, by using pragmatic knowledge while reading English professional materials, they would experience less reading anxiety and hence have better intercultural communication about those materials. With the acquisition of pragmatic knowledge, students in these courses will understand the meanings or implications of the language through a wider intercultural perspective. Indeed, by interacting with the English professional materials frequently, both in linguistic practice and pragmatic practice, students will increase their ICC with these texts and others. Hence, it can be assumed that students who understand the content of English professional materials will experience an increase in their English pragmatic competence. In turn, increasing their English pragmatic competence will increase their ICC in their future workplaces. Van Ek [36] emphasized that teaching a foreign language involves not only teaching the skill of communication, but also social interaction. Thus, the framework for the learners’ objective, to comprehend the content of a foreign language, was created. An evaluation of intercultural competence includes the acquisition of a foreign language and intercultural communication, increasing self-awareness, and so forth [37].

3. Research Questions

Based on the above studies regarding the relationship between foreign language anxiety and intercultural communication, the main research objective of this paper is to explore the relationship between anxiety when reading English and ICC. To address this issue, two scales, a reading anxiety regarding English professional materials scale (RAEPMS) and an intercultural communication competence scale (ICCS) needed to be developed. Then, the relationship between RAEPMS and ICCS needed to be investigated. Lastly, pedagogical implications needed to be explored to decrease reading anxiety with English professional materials and increase students’ ICC. Hence, there are four research questions:

$Q_1$: What is the relationship between RAEPMS and ICCS?

$Q_2$: What pedagogical implementation will decrease reading anxiety in English professional materials and increase ICC?

4. Research Methods

4.1. Research Design

In this paper, the authors used a mixed method, the quantitative method and the qualitative method, to explore the impact between students’ reading anxiety with English professional materials and ICC. RAEPMS and ICCS were developed for the quantitative method. Additionally, structural equation modeling (SEM) between RAEPMS and ICCS was created. The qualitative method involved obtaining teachers’ opinions.

4.2. Participants and Data Collection

In the quantitative method, data from 312 samples majoring in the medical profession were investigated for the exploratory factor analysis (EFA) of the two scales; then, the data from another 205 samples majoring in the medical profession were obtained to run a confirmatory factor analysis (CFA) for the two scales and a SEM between RAEPMS and ICCS. These participants were from a medical university located in the center of Taiwan. They all had experience reading English professional materials.

In addition, three teachers were interviewed to obtain the qualitative data. All three teachers were very interested in exploring students’ reading and speaking in English because they hoped that students could facilitate intercultural communication in their future work context. Therefore, they were willing to join this interview and provide their opinions. Teacher A is an ESP (English for Specific Purposes) teacher with over 15 years of teaching experience in ESP, and Teachers B and C are EMI teachers, each with over 3 years of teaching experience in EMI. Teacher A and Teacher B were asked to adapt or delete the items in the initial developmental RAEPMS and ICCS, and to explain the findings of the SEM. The deletion criterion was to evaluate whether the item was fit for measuring students’ reading anxiety in their English materials and ICC in their future medical job site. Additionally, the interview guidelines followed the results of the path from PAEPMS to ICCS. For example, what is the reason why students “worry about comprehension” to affect their ICC skill?

Teacher B and Teacher C were asked to provide ideas about pedagogical implementations. The interview guidelines included how to design the pedagogy to decrease students’ reading anxiety in English professional materials, and how to implement the pedagogy to promote students’ ICC.

4.3. Instruments

The RAEPMS was adapted from Saito et al.’s [29], Matsuda and Gobel’s [38], and Bensalem’s [23] FLRASs. Teacher A and Teacher B adapted these items and deleted some items. In the end, 18 items with a five-point Likert range, from 1 = strongly disagree to 5 = strongly agree, were obtained. The validities and reliabilities of the related FLRASs, including Saito et al.’s [29], Matsuda and Gobel’s [38], and Bensalem’s [23], are as follows. Saito et al.’s [29] obtained an above-acceptable level of internal reliability (Cronbach’s alpha = 0.86) in the FLRAS with 20 items. Saito et al.’s FLRAS [29] showed a concurrent validity (Pearson correlation coefficient = 0.64) and discriminative validity compared with the foreign language classroom anxiety scale [20]. Matsuda and Gobel [38] adapted Saito et al.’s FLRAS [29] and used the principle component analysis to obtain three factors, familiarity with English vocabulary and grammar, reading confidence/enjoyment, and language distance, with 17 items; their total explained variance is 40.88%. Additionally, Bensalem [23] adapted Saito et al.’s FLRAS [29] and obtained an internal reliability of 0.79, which is a reliable measure. Three factors—worry about comprehension, lack of satisfaction with one’s reading ability, and unfamiliar phonics rules—were obtained from a Varimax rotated EFA with a total explained variance of 49.2%.

The ICCS was adapted from Kazykhankyzy and Alagözlü’s scale [39]. Teacher A and Teacher B adapted these items and deleted some items. In the end, 39 items with a five-point Likert range from 1 = strongly disagree to 5 = strongly agree were obtained. Kazykhankyzy and Alagözlü [39] used Byram’s ICC [40] concepts, including knowledge, skills, attitudes, and awareness, to develop the ICC scale (ICCS). Twenty-one items pertained to skills (factor 1), thirteen items related to attitudes (factor 2), twelve items regarded awareness (factor 3), and six items applied to knowledge (factor 4). The internal reliability (Cronbach’s alpha) for factors 1, 2, 3, and 4 were 0.935, 0.860, 0.807, and 0.764, respectively. The total Cronbach’s alpha was 0.937.

4.4. Data Analysis

The data analysis followed the 4-step procedure. The first step was to develop PAEPMS and ICCS. The statistical methods included using EFA to obtain each scale’s factor and items, and then CFA was applied to obtain each scale’s internal consistency and discriminant validity. The second was to create the impact of RAEPMS and ICCS. The SEM was applied here to obtain the relationship between RAEPMS and ICCS. The third was to obtain the results of the qualitative analysis to explain the impact of RAEPMS and ICCS. The fourth was to obtain the pedagogical implementation of the qualitative analysis.

5. Results and Discussions

5.1. The Development of RAEPMS and ICCS

To develop the scales, including RAEPMS and ICCS, the data from 312 samples were used in the EFA, and the remaining 205 samples were used in the CFA. The demographics for the total 517 samples included gender and age. The ages were between 18 and 22 years old. The mean age was 19.12 years old, with a standard deviation of 0.31 years old. In terms of gender, the number of male and female was 168 and 349, respectively.

5.1.1. The EFA and CFA in Developing RAEPMS

The EFA used the initial 35 items of the RAEPMS to determine the factors. The results of the sampling adequacy test showed that the Kaiser–Meyer–Olkin (KMO) test is 0.710, which shows the highest strength of relationships between items [41,42]. Bartlett’s sphericity test was significant (approximately ${\chi }^2$ = 2677.217, degree of freedom (d.f) = 45, p = 0.000 < 0.001) [43]. Hence, the data are suitable, based on the EFA. The Varimax method was applied here, and the selected criteria for each item’s factor loading is above 0.6 [44]. Additionally, factors were chosen based on having an eigenvalue greater than 1. The results showed that factor 1 has 4 items, with factor loading between 0.658 and 0.880, factor 2 has 3 items, with factor loading between 0.713 and 0.895, and factor 3 has 3 items, with factor loading between 0.603 and 0.906. The three factors were worry about comprehension (factor 1), lack of satisfaction with one’s reading ability (factor 2), and language distance (factor 3). The explained variances for factors 1, 2, and 3 are 51.164%, 16.115%, and 14.391%, respectively, and the eigenvalues for factors 1, 2, and 3 are 5.115, 1.612, and 1.439, respectively.

After obtaining the results of the EFA, this study further used CFA of the RAEPMS. The results of the CFA showed a significant path (p < 0.001) between the factors and items, with a factor loading above 0.6. Factor 1 included items 10 and 12, with factor loadings of 0.845 and 0.641, respectively. Factor 2 included items 4, 5, and 3, with factor loadings of 0.876, 0.806, and 0.825, respectively. Factor 3 included items 11 and 16, with factor loadings of 0.856 and 0.648, respectively. Additionally, the CFA of the RAEPMS showed that the ${\chi }^2/d.f$ is 1.139 (p = 0.331), goodness of fit index (GFI) is 0.986, comparative fit index (CFI) is 0.998, Tucker Lewis index (TLI) is 0.995, and root mean square error of approximation (RMSEA) is 0.026, which is above the criteria, since the ${\chi }^2/d.f$ is <2 (p > 0.05) [45], GFI is >0.90 [46], CFI is >0.90 [47,48], TLI is >0.90 [49,50], and RMSE is <0.05 [51]. That is, the CFA shows that the RAEPMS is a model with excellent fit. Appendix A shows the list of statements on the RAEPMS. Table 1 shows the RAEPMS with CFA’s average variance extracted, composite reliability, Cronbach’s alpha square root of AVE, and the square root of AVE and matrix of correlations between factors. The internal consistencies, Cronbach’s alpha, and composite reliability showed that all of the values are greater than 0.7. Thus, the reliabilities are at an acceptable level [52].

To test the validity, firstly, the content validity was analyzed. Each factor’s AVE should be greater than or equal to 0.5, and the value of AVE must be less than or equal to their corresponding composite reliability [53,54]. In Table 1, the “worry about comprehension” factor’s AVE is 0.562 ≥ 0.5 and ≤ its composite reliability, 0.716. The “lack of satisfaction with one’s reading ability” factor’s AVE is 0.699 ≥ 0.5 and ≤ its composite reliability, 0.874. The “language distance” factor’s AVE is 0.576 ≥ 0.5 and ≤ its composite reliability, 0.727. Hence, the three factors have content validity.

Next, discriminant validity was determined. Discriminant validity requires that the correlation coefficient between the two factors be less than the two factors’ √AVEs [55]. In Table 1, the absolute value of the correlation coefficient between “worry about comprehension” and “lack of satisfaction with one’s reading ability” is less than the √AVEs: 0.078 < 0.749 and 0.078 < 0.836. The correlation coefficient between “worry about comprehension” and “language distance” is less than the √AVEs, 0.679 < 0.749, 0.679 < 0.759. The absolute value of the correlation coefficient between “lack of satisfaction with one’s reading ability” and “language distance” is less than the √AVEs, 0.560 < 0.836, 0.560 < 0.759. Hence, the three factors do have discriminant validity.

5.1.2. The EFA and CFA in Developing ICCS

For the development of ICCS, first, EFA is used to determine the factors and items of the ICCS. The results showed that KMO is 0.589. Hence, the sampling adequacy test showed a high strength between items [41,42]. Bartlett’s sphericity test was significant (approximately ${\chi }^2$ = 5256.067, d.f = 120, p = 0.000 < 0.001) [43]. It showed that the data were suitable for the EFA analysis. The Promax method was used here to obtain the factors and their items. The criteria were that the eigenvalue must be greater than 1 and the factor loading must be greater than 0.6 [44]. Four factors and 16 items were obtained. Factors 1, 2, 3, and 4 were skill, attitude, awareness, and knowledge, and the number of items per factor was 5, 5, 3, and 3, respectively. For factors 1, 2, 3, and 4, the factor loadings were 0.765–0.976, 0.713–0.931, 0.788–0.978, and 0.676–0.939; the eigenvalues were 6.177, 3.099, 1.992, and 1.535, respectively, and the explained variances were 38.607%, 19.370%, 12.451%, and 9.592%, respectively.

After obtaining the factors, CFA was applied. The significant paths (p < 0.001) and factor loadings > 0.6 were set to obtain a CFA of the ICCS. The “skill” factor is composed of items 7, 15, 5, and 10, with factor loadings of 0.727, 0.773, 0.779, and 0.779. The “attitude” factor includes items 20, 21, 14, and 12, with factor loadings of 0.656, 0.714, 0.867, and 0.806. The “awareness” factor incorporates items 32, 26, and 27, with factor loadings of 0.788, 0.762, and 0.863. Lastly, the “knowledge” factor is comprised of items 24 and 22, with factor loadings of 0.698 and 0.774. Appendix B shows the CFA of the ICCS. In addition, the CFA of the ICCS showed that the ${\chi }^2/d.f$ is 1.157 (p = 0.218), GFI is 0.964, CFI is 0.996, TLI is 0.992, and RMSE is 0.028, which are above the criteria, as the ${\chi }^2/d.f$ is <2 (p > 0.05) [45], GFI is >0.90 [46] CFI is >0.90 [47,48], TLI is >0.90 [49,50], and RMSE is <0.05 [51]. Thus, the CFA proves that the ICCS is a model with excellent fit. In addition, Table 2 shows the ICCS with the CFA’s average variance extracted, composite reliability, Cronbach’s alpha square root of AVE, and square root of AVE and matrix of correlations between factors. The internal consistencies of the scales show that the reliabilities are of an acceptable level, with all Cronbach’s alphas and composite reliabilities greater than 0.7 [52]. To verify the validity of the content, in Table 2, the AVEs for factors 1, 2, 3, and 4 are 0.585, 0.585, 0.649, and 0.543, which are greater than 0.5. Additionally, all factors’ AVEs are less than their corresponding composite reliabilities, that is 0.585 < 0.849, 0.585 < 0.848, 0.649 < 0.847, and 0.543 < 0.703 for factors 1, 2, 3, and 4. It also shows content validity for all of the factors [53,54].

Regarding the discriminant validity, Table 2 shows that the correlation coefficient’s value, 0.757, between “skill” and “attitude” is less than the corresponding √AVEs, 0.765 and 0.765. The correlation coefficient’s absolute value, 0.452, between “skill” and “awareness” is less than the corresponding √AVEs, 0.765 and 0.806. The correlation coefficient’s value, 0.456, between “skill” and “knowledge” is less than the corresponding √AVEs, 0.765 and 0.737. The correlation coefficient’s absolute value, 0.558, between “attitude” and “awareness”, is less than the corresponding √AVEs, 0.765 and 0.806. The correlation coefficient’s value, 0.649, between “attitude” and “knowledge”, is less than the corresponding √AVEs, 0.765 and 0.737. The correlation coefficient’s absolute value, 0.341, between “awareness” and “knowledge”, is less than the corresponding √AVEs, 0.806 and 0.737. All of the results showed discriminant validity for the ICCS factors of skill, attitude, awareness, and knowledge [55].

5.2. Impact of RAEPMS and ICCS ($Q_1$: What Is the Relationship between RAEPMS and ICCS?)

To obtain the relationship between RAEPMS and ICCS, that is, to obtain the impact of RAEPMS and ICCS, the SEM was obtained. Figure 1 shows the results of the SEM, particularly, the paths that are statistically significant (p < 0.05). The SEM is an excellent model because the values of the indices are above the criteria: the ${\chi }^2/d.f$ is 1.256 < 2 (p = 0.288 > 0.05), GFI is 0.997 > 0.90, CFI is 0.999 > 0.90, TLI is 0.993 > 0.90, and RMSE is 0.029 < 0.05. In addition, Table 3 shows the coefficients of the paths and their significance (p < 0.05). Below are the interview findings and discussions.

5.2.1. From “Worry about Comprehension” to ICC

From “worry about comprehension” to “skill”, the standardized coefficient is −0.34 (p < 0.000). Teacher A noted that “the students who didn’t worry about comprehending the English professional materials improved their communication skills, including ICC”. Teacher B also observed that “because students have more reading comprehension in reading English professional materials, they will be able to better express their ideas”. Teacher A’s and Teacher B’s opinions correspond to the path’s standardized coefficient, −0.34, that is, those students who worry about comprehension when reading English professional materials may not have enough communicative skills with people from different cultures. Grice [56] thought that communication includes two elements, the processes of encoding and decoding messages. The ICC skill will help students surpass their basic understanding of professional English words by coding and decoding. Students who worry about comprehension when reading English professional materials will find that their pragmatics, i.e., how to convey meaning by language, may be weak [57]. That is, students who worry about comprehension will experience difficulties in using language and, furthermore, will interpret language literally. These results will affect students’ ICC skill.

From “worry about comprehension” to “attitude”, the results showed a negative standardized coefficient, −0.248 (p < 0.000). Teacher A thought that “students worry about reading English professional materials. They [are] afraid to express their opinions. When struggling to communicate, they may develop an aloof, apathetic attitude”. Teacher B noted, “According [to] my observation, students’ attitude is affected by worry. Attitude includes learning and communicative attitude. In addition, the worry factor affects the student’s confidence in learning. Students who are not confident will retreat”. Carrison and Ernst-Slavit [58] observed that English learning students have some shortcomings, such as a lack of reading comprehension or reading skills. This will lead to a lack of confidence in communication with others. Students’ language anxiety has a negative correlation with their communication attitude [15]. Hence, for the ICC attitude, worry about reading comprehension has a negative impact. An interesting phenomenon is that “worry about reading comprehension” does not significantly impact ICC awareness and ICC knowledge (p > 0.05). Teacher A and Teacher B expressed that worry is a kind of awareness. However, it is uncertain whether worry causes more awareness; there is no clear relationship between these two terms. Teacher A and Teacher B indicated another interesting situation: Taiwan’s education system is focused on testing students’ learning knowledge. Nonetheless, students worry about reading comprehension in English professional materials. Indeed, many students still study hard to obtain knowledge, promoting their ICC.

5.2.2. From “Lack of Satisfaction with One’s Reading Ability” to ICC

From “lack of satisfaction with one’s reading ability” to all of the ICC factors, the paths showed statistical significance (all p > 0.05). The order of the standardized coefficients showed awareness > attitude > skill > knowledge (0.516 > 0.461 > 0.298 > 0.148, respectively). That is, when students experience satisfaction when reading English professional materials, their ICC perceptions lead to increasing competence, as follows: awareness > attitude > skill > knowledge. For the path from “lack of satisfaction with one’s reading ability” to “awareness”, Teacher A thought that “[for] students with reading satisfaction, that is, lower reading anxiety, they will increase their cognition about learning professional knowledge. The cognition of professional knowledge will increase their awareness about the ICC”. Teacher B thought that students lacked satisfaction when reading English professional materials; thus, they might dislike reading professional books. In this case, an awareness of ICC is difficult to increase. For the path from “lack of satisfaction with one’s reading ability” to “attitude”, Teacher A stated that “Those students who have high expectations of themselves are more likely to be unsatisfied with their level of reading comprehension”. Teacher B stated that “students lacking satisfaction with reading English professional materials mean[s] that they lack the reading ability to understand the content. Hence, they may show that they lack self-confidence in their ICC attitude”. For the path from “lack of satisfaction in reading ability” to “skill”, Teacher A and Teacher B suggested that, if students experience satisfaction when reading English professional materials, they will increase their self-confidence in reading. By reading and obtaining knowledge, students may be increasing their ICC skill. For the path from “lack of satisfaction with one’s reading ability” to “knowledge”, Teacher A and Teacher B thought that students who were satisfied when reading English professional materials might be eager to obtain the knowledge. However, if students lacked satisfaction with reading English professional materials, they might be disappointed or dejected with reading; hence, knowledge cannot be obtained by these students. Dörnyei and Kormos [59] investigated the individual variables and found that the factor of communication comprehension affects the willingness to communicate in second language learning. Students with communication comprehension will increase their linguistic competence. Teacher A stated that “the higher [the] satisfaction in reading English professional materials, the higher [the] communication comprehension in using English”. Bachman [60] proposed an approach with language performance and language competence. Students with the highest language performance are also predicted to have the highest language competence. Teacher B stated that, to increase students’ satisfaction when reading English, they should be eager to obtain knowledge about how to use English to increase their ICC. Halt et al. [61] pointed out that communicative competence has become much more emphasized, compared with the basic linguistic competence—listening, speaking, reading, and writing. Teacher A and Teacher B thought that increasing students’ satisfaction when reading English professional materials should be the primary job in EMI teaching; students’ ICC will be improved along with it. With an increase in students’ reading comprehension, students’ satisfaction will be increased, and their reading anxiety will be decreased. Canale and Swain [62] stated that learners integrate different forms of knowledge to deliver their ideas. This is the goal of communication in a foreign language: expressing ideas. Simultaneously, as learners read different English professional materials, they are attaining professional knowledge to express their ideas in their future workplace; that is, they are gaining ICC.

5.2.3. From “Language Distance” to ICC

From “language distance” to all ICC factors, the path to “attitude” is not statistically significant (p > 0.05), and the other paths are significant (p < 0.05). The order of the significant paths, based on the standardized coefficients, is skill > awareness > knowledge (Table 3). The path from “language distance” to “skill” showed that students’ ICC skill will be more strongly affected if they have language familiarity and language confidence, as opposed to “awareness” and “knowledge”. Teacher A stated, “If you are familiar with skill in reading English, you know how to use the skill to break through the crux in reading English professional materials; then the skill may improve your ICC skill”. Teacher B stated, “If you become familiar with using English reading materials and you have the knowledge to show the ICC skill”, the path from “language distance” to “awareness” shows a positive significant effect. Teacher A stated that “[if] students have the language familiarly in reading English professional materials, they will expect the communication effect. Hence, they can show their self-evaluation in the ICC awareness”. Teacher B stated, “If the students lack language confidence, they are going to lose the precision of communication. This is a self-efficacy problem. Hence, their ICC awareness may be decreased”. The path from “language distance” to “knowledge” shows a positive effect. Teacher A and Teacher B thought that the higher language familiarity in reading English professional materials leads to higher knowledge being obtained. If students have knowledge of the professional English terms, they can more easily understand the difference between professional materials. Hence, ICC knowledge can be applied in their workplaces. Slangen [63] thought that language distance is a crucial factor in cross-broader communication and noted that language distance represents different languages to be used. However, understanding and familiarizing oneself with language is, indeed, the key component in intercultural communication. Marschan-Piekkari and Zander [64] observed that language plays a crucial role in communication. Teacher A and Teacher B also noted that students with professional English confidence can understand the learning knowledge and display their confidence in their ICC. Barner-Rasmussen and Aarnio [65] thought that language distance is a potential language issue in cross-border communication. If students have ICC, they can predict their language difficulties in their future profession [66]. Teacher A said that, when students use professional English in communication with foreign people, sometimes, they demonstrate their professional identity. In other words, language may be used beyond the basic linguistic competence and with a goal toward communication competence and the development of one’s professional identity [67]. Holmqvist et al. [68] and Van Vaerenbergh and Holmqvist [69] noted that using language correctly is part of a person’s identity. This is true, even with respect to professions. Teacher B stated, “[If] students have a good ability to read English professional materials, in the future, they will show their good ICC in their business when they work with foreign people or work in a foreign company”. Hence, to reduce language distance, for instance, by increasing students’ language confidence, students must perform their language skills and cultural skills when communicating [70].

5.3. Pedagogical Implementation ($Q_2$: What Pedagogical Implementation Will Decrease Reading Anxiety in English Professional Materials and Increase ICC?)

Reading anxiety regarding English professional materials will affect students’ ICC. Hence, decreasing their reading anxiety can increase their ICC. Most students at medical universities must read their professional books or materials in English. Hence, designing pedagogy to reduce students’ reading anxiety is the first step toward globalization through students’ intercultural communication.

Regarding the design of teaching pedagogy, Teacher B said, “Some materials can [come] from WHO (World Health Organization), such as COVID-19 (Coronavirus disease 2019)-related literatures. Students may feel interested in the contemporary issue”. Teacher C said, “Students may want to know how to apply their knowledge in the practical [world]. Hence, some practical issue, such as COVID-19, can be added [to] the teaching materials”. Kor et al. [71] studied the teaching method in a preregistration nursing program of a Hong Kong university and found that the positive or negative aspects of practical experience may improve students’ cognitive skills. Teacher C thought that, for students, facing COVID-19 is a practical experience. Students can obtain the vaccine-related information about the development of COVID-19. Hence, this promotes students’ cognitive skills in future learning. In addition, Teacher B stated, “Teacher[s] must pay attention to different English reading abilities. Hence, to provide different articles with examples with different English levels, it will help students to choose the appropriate articles fitting for their English levels”. Coelho et al. [72] thought that teachers should know how to use different methods and materials to increase students’ knowledge and skills. Teacher B and Teacher C thought that using practical examples and helping students to choose appropriate articles would help to decrease students’ reading anxiety regarding English professional materials.

To promote students’ ICC, Teacher B stated, “The teacher can ask the student to report their professional knowledge of the platform and to ask other students to communicate with the student. The reporting situation seems like an international seminar”. Teacher C stated, “Asking students questions can help teachers to understand students’ reading ability and their understanding of professional knowledge. Simultaneously, the student replies to the professional question. The teacher can understand the student’s ICC”. Of course, Teacher B and Teacher C thought that teachers must give some points or positive feedback to encourage students’ performance. Thus, students will have the courage to communicate with people from different cultures. Kasper and Rose [73] thought that second language learners faced intercultural communication; the greatest challenge is speaking, as they must think how to integrate the culture and the target language when communicating. Teacher B and Teacher C also expressed the same idea, that is, professional knowledge is also a kind of culture. To express professional knowledge in their workplace, students also must read and understand the content of professional knowledge; then, by integrating English and professional knowledge, students can communicate in their workplace. However, the difference in the integration of the target language (English) and the culture (professional knowledge) may cause miscommunication [3].

Boxer and Pickering [74] stated that, in general, native speakers do not tolerate people with L2 language difficulties very well. Hence, increasing students’ English pragmatic competence will decrease their barriers in intercultural communication with foreign people in their workplaces. Kurpis and Hunter [75] and Zelechoski et al. [76] suggested that the development of experiential learning activities will increase students’ knowledge. With that knowledge, their motivation and confidence will prompt them to communicate with people of different cultural backgrounds.

Overall, the important direction in designing students’ ICC pedagogy involves encouraging students to explore the sociocultural norms through their reading of English professional materials. In addition, increasing students’ English pragmatic competence when they face constraints in their community (workplace) may also be an important factor to consider [7].

6. Conclusions

Students with English reading anxiety will experience poor ICC. The more anxiety a student has when reading in English, the less ICC he or she will have. Therefore, reducing the reading anxiety of students in English will help to promote their ICC. In this paper, samples were from a medical university, and the students had experience in reading English professional materials. To attempt the research goal, firstly, two scales were created: the RAEPMS, which has three factors—worry about comprehension, lack of satisfaction with one’s reading ability, and language distance—and ICCS, which has four factors—skills, attitude, awareness, and knowledge. Then, the path from RAEPMS to ICCS was created by the SEM. The findings showed that “worry about comprehension” impacts “skills” and “attitudes”; “lack of satisfaction with one’s reading comprehension” impacts all ICC factors; and “language distance” impacts “skills”, “awareness”, and “knowledge”. In addition, the results of the interviews with three teachers were obtained to understand the reasons for the significant paths between the RAEPMS and the ICCS. A pedagogical implementation from the outcomes of the interview, including the decrease in reading anxiety and the increase in ICC, was also discussed.

There are limitations to this paper. First, the samples are from the students majoring in medical professions; hence, if the samples belong to other majors, the SEM’s results may differ. Second, the two scales, the RAEPMS and the ICCS, may be adjusted when they are applied to different samples and different research sites. Third, the pedagogical implementation may be adjusted by different universities. The future study may consider different factors which have affection in reading anxiety and ICC, such as learning motivation, leaning expectation, learning behavior, and so on. For example, motivation, including intrinsic motivation and extrinsic motivation, will enhance a person’s ICC [77]. Furthermore, teachers’ ICC levels may affect students’ global perspectives on understanding different cultures [39]. Hence, the factor of teachers’ ICC levels may be worth exploring in the future study. This paper provides important input to students majoring in the medical profession in their future places of business, where they may communicate with people from different cultures. Furthermore, the benefit of this research is to think about how to design the pedagogical implementation to ensure the education of students and their professional training. The true beneficiaries of this research are those in charge of student education and professional training.

Author Contributions

Conceptualization, H.-C.L.; methodology, H.-C.L. and S.C.H.; software, H.-C.L.; validation, H.-C.L.; formal analysis, H.-C.L.; investigation, H.-C.L.; resources, H.-C.L.; data curation, H.-C.L. and S.C.H.; writing—original draft preparation, H.-C.L.; writing—review and editing, H.-C.L. and S.C.H.; visualization, H.-C.L.; supervision, H.-C.L.; project administration, H.-C.L. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

This study complied with the Declaration of Helsinki. Participation in this study was voluntary. The participants were told about the purpose of the survey. Informed consent was obtained from the participants. Confidentiality and anonymity were ensured in this study. Additionally, this study did not include any interaction or intervention with human subjects or include any access to identifiable private information; then this study did not require IRB review [78].

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The data used during this study are available from the first author, upon request by e-mail.

Acknowledgments

We would like to thank all the participants in this research.

Conflicts of Interest

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figure and Tables

Figure 1. The SEM from RAEPMS to ICCS.

Table 1

(RAEPMS with CFA) Average variance extracted, Cronbach’s alpha, composite reliability, and square root of AVE and matrix of correlations between factors.

Factor	1	2	3	AVE	Cronbach Alpha	Composite Reliability
worry about comprehension	0.749			0.562	0.706	0.716
2. lack of satisfaction in reading ability	0.078	0.836		0.699	0.873	0.874
3. language distance	0.679 **	−0.560	0.759	0.576	0.711	0.727

The values shown in bold are the square root of AVE; ** p < 0.001.

Table 2

(ICCS with CFA) Average variance extracted, Cronbach’s alpha, composite reliability, and square root of AVE and matrix of correlations between factors.

Factor	1	2	3	4	AVE	Cronbach Alpha	Composite Reliability
Skill	0.765				0.585	0.858	0.849
Attitude	0.757 **	0.765			0.585	0.869	0.848
Awareness	−0.452 **	−0.558 **	0.806		0.649	0.839	0.847
Knowledge	0.456 **	0.649 **	−0.341 **	0.737	0.543	0.748	0.703

The values shown in bold are the square root of AVE; ** p < 0.001.

Table 3

The SEM’s paths and their significance.

Path		Standardized Coefficients	C.R.	p-Value
From	To
worry about comprehension	skill	−0.344	−6.721	<0.000
worry about comprehension	attitude	−0.248	−5.128	<0.000
lack of satisfaction in reading ability	skill	0.298	5.689	<0.000
lack of satisfaction in reading ability	attitude	0.461	8.091	<0.000
lack of satisfaction in reading ability	awareness	0.516	9.985	<0.000
lack of satisfaction in reading ability	knowledge	0.148	2.477	0.013
language distance	skill	−0.535	−12.664	<0.000
language distance	awareness	−0.430	−9.596	<0.000
language distance	knowledge	−0.249	−4.323	<0.000

Appendix A. RAEPMS with CFA

Item	Initial Item	Question
Factor 1: Worry about comprehension
1	10	I like to read English professional materials. (reverse question)
2	12	Once you get used to it, it is not so difficult to read English professional materials. (reverse question)
Factor 2: Lack of satisfaction in reading ability
3	4	I feel nervous when reading unfamiliar English professional materials.
4	5	When reading English professional materials, I feel nervous whenever I encounter grammar I don’t understand.
5	3	Whenever I see a full page of English professional materials, I get flustered.
Factor 3: Language distance
6	11	When I read English professional materials, I feel confident. (reverse question)
7	16	At present, I am satisfied with my English professional materials reading ability. (reverse question)

Appendix B. ICCS with CFA

Item	Initial Item	Question
Factor 1: Skill
1	7	I am able to properly interact and communicate with people from different cultural backgrounds in the workplace.
2	15	I can use English when communicating with people from other cultures.
3	5	When I meet people from different cultures, I am able to start conversations.
4	10	I can handle communication barriers due to different cultural backgrounds.
Factor 2: Attitude
5	20	I always try to get in touch with people from other cultures.
6	21	I would like to participate in cross-cultural events in the workplace.
7	14	I feel confident when interacting with people from different cultural backgrounds.
8	12	I am able to build cross-cultural friendships.
Factor 3: Awareness
9	32	My English is not good enough to communicate with people from other cultures. (reverse question)
10	26	I get overwhelmed when it comes to expressing myself in front of people from different cultures. (reverse question)
11	27	I find it difficult to make friends with people from different cultures. (reverse question)
Factor 4: Knowledge
12	24	I am eager to meet colleagues from different cultures and countries.
13	22	I would like to learn about education and training in different cultures or countries.

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