Global theme 2 Shared values

The second global theme is about how insiders value the importance of shared values. Generally, insiders felt outsiders with similar values to their own were better able to contribute more effectively to the development of services for PWCD. The three organising themes focused on how there may be cultural differences in values or attitudes — and in how insiders and outsiders are perceived — but there is a need to be treated equally or fairly.

Table 4.9 Insider global theme 2. Shared values

Organising theme 1. Ideal outsiders

There was a preference for outsiders with certain qualities, skills, or

experiences. Insiders perceived outsiders to typically share specific qualities: volunteers for example were often young, and reflect the SLT profession of their native country (e.g., in the UK, the SLT profession is largely made up of white, female personnel). Insiders perceived outsiders to generally have a higher

Basic themes Organising themes Global themes

1. Age 1. Ideal outsider 2. Shared values 2. Language

3. African outsiders may be better suited 4. Flexibility

5. Motivations

1. Cultural rules 2. Culture 2. Insiders not sharing cultural differences with

outsiders

3. Negotiate cultural differences

1. Superior knowledge 3. Outsider status 2. Outsider value

status in Ugandan culture. Similarities in culture (for example, shared languages) were perceived as advantageous.

BT1. Age

This theme describes insiders’ perception of outsider age and experience. Younger outsiders were often seen as immature: unready for the responsibilities or lacking the commitment to contribute in Uganda.

UG14: “we had a very very young speech therapist who was a bit kind of unstable that she stuck it out she did her two years but she was a bit unreliable sometimes and probably not as mature as you would've wanted”

One participant expanded on this to discuss the potential for tension between relatively young outsider lecturers and older Ugandan students.

BT2. Language

Outsiders came from many different countries to work in Uganda to support services for PWCD. Insiders focused on the difficulties of understanding outsiders’ spoken English based on both theirs and the outsiders’ language proficiency, and the outsiders’ accent. Although English is spoken in Uganda, it is typically learnt as an additional language. When outsiders did not speak English as a first language, this difficulty intensified.

UG18: “And of course it is always their accent … when you think about ‘foreigners' or “outsiders” accents must have something… We’re getting people from everywhere, um, and some who are not even using English, who do not have English as their first language. Ugandans have learned English as their weaker language and for many [it’s] a second language.”

BT3. African outsiders may be better suited

Insiders felt that outsiders from within Africa potentially shared more culture with Ugandans, and were therefore better suited to supporting services for PWCD in Uganda than outsiders from Minority World countries were. Although African outsiders were generally felt to be better suited to working in Uganda, one

participant felt that some African outsiders were reluctant to be involved in supporting services for PWCD.

UG2: “but if someone is from an African country it is actually easier because you understand the language…they relate easy because they automatically know what is available”

BT4. Flexibility

Insiders found certain personality traits and attitudes of outsiders easier to work with or better to collaborate with when working in conjunction to develop

services for PWCD. Ugandans described their culture as friendly and non- confrontational. Insiders described a need for outsiders to be flexible and respectful. Insiders described outsiders who they felt to be less successful based on their attitude. Although some outsiders might have initially struggled to gel with their insider counterparts based on personality differences, it was felt they would generally eventually settle in with the team.

UG13: “they were free with us so you find that you understand and it would make us free to ask them questions and maybe to interact very well…they were flexible”

BT5. Motivations

Insiders talked about their own motivations for working to support services for PWCD, and what they thought outsiders’ motivations were to support services for PWCD in Uganda. Insiders perceived that insiders and outsiders had different motivations (there were also differences based on different insider roles). There were a range of motivations for insiders, including being motivated to work as SLTs as it was a new profession; settling to train as an SLT due to not getting into another course; and wanting to work with a specific client base. Comparatively, insiders’ perceptions of outsiders’ motivations centred on their reasons for working in Uganda, rather than their reasons for working with PWCD. Despite several insider cohorts now having graduated, and regardless of motivations, many used language to suggest that their training had been uncharted and experimental.

UG2: “we didn’t know how it really meant to be a pioneer we had so many challenges here and there even the university didn’t know about the course so we were really guinea pigs”

In some cases, insiders described outsiders as having different motivations for working with PWCD from themselves. When insiders described their

perceptions of their own volunteering, it was described as work. However perceptions of outsiders’ motivations for volunteering, were described in charitable or terms — such as “giving” and “sacrifice” Travel was felt to be a motivating factor for outsiders. Some insiders felt that outsiders used working abroad to enhance their work experience.

Insiders also discussed how some outsiders did not have an initial motivating reason to support services for PWCD in Uganda, as they had not come to Uganda to work in that capacity. These outsiders were perceived to have taken a role in supporting services for PWCD once they were already in-country. One participant described the effects of working with outsiders who were

volunteering with an outsider NGO which apparently offered voluntourism-like packages. The outsider NGO had apparently dissuaded the outsider volunteers from working with insiders by withholding leisure activities for outsiders if they did. This insider perceived differences in motivations resulted from the NGO perceiving collaboration to take more time than lone working by outsiders, and thus resulted in less profit for the organisation.

Organising theme 2. Culture

The second organising theme describes cultural differences (both amongst different ethnic groups in Uganda, and between Ugandans and outsiders) and suggests how these cultural differences may be negotiated.

BT1. Cultural rules

This theme is about how insiders perceived outsiders. Outsiders were seen as being able to better navigate Ugandan society because they were not bound by Ugandan cultural rules. Insiders talked about Ugandan culture not being

homogenous, with different ethnic groups having their own culture. In a multi- ethnic society they felt it was difficult to be aware of all the customs and were

anxious of offending others. Insiders often contrasted this with outsider culture. Outsiders were seen as having more freedom and ability to do what they wanted. Clinically, this meant outsiders were more able to specialise or pursue further CPD training.

UG15: “here it's a lot of respect your elders you don't ask about your elders you don't question why your boss or whatever people say about you er and yet I think for you guys I mean you have the right to question what someone is doing if you don't think it's right”

BT2. Insiders not sharing cultural differences with outsiders Insiders described how they personally and professionally found life within Uganda challenging because of the different cultures. Some insider SLTs described language problems because they did not speak the local language, or they were not comfortable working in other languages. This often had consequences for their clinical practice. Some Ugandans discussed the difficulties from not disclosing personal challenges (e.g., relating to external pressures affecting their work) and difficulties relating to understanding training information. One example of cultural differences that insiders did not share with outsiders was that in some Ugandans’ cultures, it was considered rude to look in their mouths.

UG17: “because for us now in Uganda if I told this person [of a certain ethnicity] to open [their] mouth [they] would really be embarrassed on [their] side but then on my side…it’s embarrassing on my side and also embarrassing like now I am embarrassing [them]”

Not disclosing these challenges was typically due to embarrassment and shame. Due to the status of the teaching roles held by outsiders, insiders felt uncomfortable sharing what would or would not be appropriate in a clinical setting in Uganda. This meant that a portion of the teaching they received had not been culturally appropriate, and outsiders were unaware of this. Resultantly, outsiders may not only have been unaware of specific examples of cultural differences, they may also have been unaware of the “culture” of insiders not sharing information with, or correcting someone of, a perceived higher status.

BT3. Negotiate cultural differences

Insiders noted that having shared aspects of identity helped to mitigate some of the overall cultural differences between insiders and outsiders. However,

addressing aspects of culture that were not shared, insiders discussed the need for both groups to compromise, and the need for outsiders to be patient with Ugandans and Ugandan ways of life — such as different attitudes to time- keeping, expectations of financial compensation for attending training, and Ugandan work procedures. The most commonly discussed cultural difference related to attitudes around time-keeping. Insiders described how they felt the majority of outsiders found it hard to adapt to the flexible attitude to time- keeping, and that the few outsiders who had more laid back attitudes to time- keeping were more desirable. Insiders also felt structural or bureaucratic issues were not always understood by outsiders, who could be frustrated by the

culture. One insider felt that there could be difficulties in the way insiders and outsiders understood training. In Uganda, people who attend training are often financially compensated by the training course “per diem” for being absent at work, and often insiders’ viewed training or contact with outsiders as a way of making money. However, some outsiders instead offered training or supervision with no such compensation. This may have been because of differences

between insiders and outsiders, such as insider SLTs having multiple jobs and more responsibilities, or differing attitudes to who is responsible for a new professions’ CPD.

Overall, insiders felt that where there are cultural differences, that both insiders and outsiders need to adapt and respect each others’ culture. However, cultural differences were not always apparent to outsiders, with insiders not always making outsiders aware of appropriate behaviour or the culture of Ugandans. During an interview with two insiders from different ethnic groups, participants demonstrated some of the cultural differences. Insiders described how they would not bring up cultural differences with outsiders.

Insiders described the challenges and frustrations when outsiders had not adapted to the cultural differences, or offered inappropriate therapy strategies for male SLTs or family members to use. One student SLT reported that advice from outsider SLTs to sit on the floor and sing or play with a child would be culturally unusual and inappropriate for many Ugandans and especially for males. Where outsiders’ methods were culturally appropriate, insiders would “pick" these methods for use; and where deemed culturally inappropriate, insiders would “pick” principles of the theory or method and adapt it for their own practice. This “skill picking” happened without insiders telling outsiders.

UG1: “I pick from people the volunteers and foreigners”

Organising theme 3. Outsider status

The third organising theme in this global theme describes different notions of status in Uganda. Outsiders generally held a higher status than insiders, with insiders perceiving outsiders to have superior knowledge and resources. Outsider-provided services were seen as preferential to services offered by insiders.

BT1. Superior knowledge

Insiders described how they, or other Ugandans, viewed outsiders as superior or as a standard to aim for. Often insiders viewed services for PWCD in Minority World countries as aspirational or needed in Uganda. In the example below, a parent described some of the services for PWCD that she was aware of in Minority World countries and expresses the belief that, if these were available in Uganda, services for PWCD would be improved.

UGPWCDI1: “If they could do that, oh my goodness we would be so OK. we would be very good. Because I know in the western world, mzungu (laughter) I know they have such such uh such um arrangements in schools right?”

Although outsider knowledge was typically seen by insiders as superior, one insider discussed the idea of reconciling Ugandan traditional beliefs with ideas from “western” SLT. They described how they were concerned that a number of

their Ugandan colleagues had beliefs about the causes of communication disabilities that were not founded in evidence based practice. The same participant gave examples of different understandings of the cause of CDs. In this example, they discussed how they reconciled their previous beliefs with knowledge from the SLT course. 


UG1: “I think the thing of the moon I also believe it then but when when we when we went on this course I noticed that there is no link between the moon and the stammering and I mean I can say that I was wrong…I don't know… how can I wrap it up?”

BT2. Outsider value

Insiders felt that outsiders were held in higher esteem than insiders. Insiders often talked about PWCD or their families having a preference for outsider SLTs, often believing their skills to be more authentic. As a consequence of the differences in status of insiders and outsiders, some insiders described

examples of having worked with or in the same clinic as an outsider, and Ugandan PWCD or their parents / carers would choose intervention with the outsider instead of the insider, or be more accepting of the outsider’s

recommendations.

UG1: “[insiders] respect someone from overseas because we expect overseas they have better training better facilities so someone can be trained better than a person who trained from here…I have noticed that it makes it hard for me in speech therapy”

For some, this perception had the consequence of causing insiders to feel substandard compared to outsiders, lowering self-esteem and self-confidence. Alternatively, one insider commented on this difference as making them feel validated because they perceived no difference in how they and outsiders perform SLT, therefore must be as “good” as the outsider.