Professional Documents
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International Students with Disabilities: Evaluating barriers to accessing social and health services on campus
Yazmn Hernndez Bauelas, Zoe Yu Wang, Timothy Shah, Jason Lee, Adam Kebede University of British Columbia Planning 515 April 05, 2011
Executive Summary
The purpose of this study is to identify and address the barriers facing international students with disabilities at the University of British Columbia (UBC). Specifically, this study addresses the barriers international students face in accessing health services on campus. As a collaborative project between the two UBC departments: the School of Community and Regional Planning (SCARP) and the Access & Diversity (A&D) Office, the research findings are intended for both parties. In particular, the findings in this study are meant to: to help the A&D office better understand the barriers to health services on campus; provide recommendations for enhanced inclusion and to assist the A&D office in their advocacy efforts towards policy advancement and improved service delivery. We employed a case study research methodology. The flexible nature of this exploratory study allowed the researchers to go in more depth through the semi-structured interviews to inquire about how and why the identified barriers are so problematic. We recruited three participants for the study, all of whom were international students and male. We conducted a total of four interviews with three participants; one participant was interviewed twice for further clarification of the data and for an elaboration of the interview questions. A semi-structured interview style was used because it allowed for focused, conversational two-way communication which provided the research team with more information and data beyond the scope of the interview questions which appeared to be limited at times. The major findings in this study pertained to reported barriers from the participants, and the coping strategies they use in everyday life. These barriers included lack of knowledge: one participant did not know about any services on campus, for example; institutional barriers: two participants had issues with institutional rules that inhibited access to a service; stigma: one participant had issues with perceived stigma and two had issues with the public health care system as they are not used to this in their home countries; communication/language: one participant wished for a service to be delivered in his native language; financial: one participant had financial issues around paying for a diagnostic test. The latter half of the findings are the coping strategies used by the participants, these include support networks such as parents, friends, academic/international advisors and residential communities. Combined, these networks act as coping mechanisms to ease the academic and personal challenges associated with neurological disabilities and mental health issues. The coping strategies reported by the participants were powerful and inspiring stories about the mechanisms these students use in everyday life to cope with the neurological or mental health illness they are living with. These stories and experiences were captured in our study but warrant further academic exploration. Our contribution to this area is simply a starting point for the critical research that needs to follow. Section 6 provides a detailed list of recommendations we have prepared for the A&D office.
Table of Contents
1.0: Introduction ...................................................................................................................... 7 2.0: Literature Review ........................................................................................................... 10 2.1: Knowledge .............................................................................................................. 11 2.2: Institutional Barriers................................................................................................ 13 2.3: Culture ..................................................................................................................... 13 2.4: Stigma ..................................................................................................................... 14 2.5: Financial Barriers .................................................................................................... 17 2.6: Communication Barriers ......................................................................................... 18 3.0: Methodology................................................................................................................... 20 3.1: Methods ................................................................................................................... 22 3.2: Research Limitations ............................................................................................... 25 4.0: Research Findings .......................................................................................................... 27 5.0: Discussion & Recommendations .................................................................................... 30 5.1: Knowledge .............................................................................................................. 30 5.2: Institutional Barriers................................................................................................ 33 5.3: Socio-cultural Barriers ............................................................................................ 36 5.4: Communication ....................................................................................................... 40 5.5: Financial Barriers .................................................................................................... 41 5.6: Coping Strategies .................................................................................................... 42 6.0: List of Recommendations ............................................................................................... 45 7.0: Conclusion ...................................................................................................................... 48 Acknowledgements ........................................................................................................ 49 Appendices ............................................................................................................................ 56 Appendix A: Key Informant Interview Guide ............................................................... 57 Appendix B: Additional Interview Guide ...................................................................... 59 Appendix C: Registrations with the Access and Diversity Office ................................. 60 Appendix D: Screening Questionnaire ........................................................................... 61 Appendix E: Consent Form ............................................................................................ 63 Appendix F: Recruitment Letter .................................................................................... 66 Appendix G: Poster ........................................................................................................ 67
1.0: Introduction
The Access and Diversity office (A&D office) at the University of British Columbia (UBC) works to eliminate structural and attitudinal barriers to those with disabilities. The A&D office (2011b) provides disability-related services and accommodations for students, faculty, and staff with disabilities. In 2009, the A&D office (2011a) served approximately 1,248 students with diagnosed or suspected disabilities. As of 2009, UBC campuses (including Vancouver and Okanagan) host 54,125 students, 7,570 of whom are considered international students, accounting for almost 14 percent of the student population (UBC Public Affairs, 2009). The number of international students at UBC continues to grow, as attracting students from outside Canada is a part of UBCs strategic plan to become a globally renowned institution (Hepburn & Pennant, 2011). Within the A&D office (2011a), however, international students are underrepresented: 112 students or 8.9 percent of those registered with the A&D office hold study permits. According to the 2009 National College Health Association (NCHA) survey, 36 percent of UBC students who completed the survey said they felt so depressed that it was difficult to function at least once in the last year (Amos, 2010). According to statistics provided by the A&D office (2011a), neurological and mental disabilities are the most common disabilities reported on the UBC-Vancouver campus. In 2009, the A&D office (2011a) assisted 427 students with neurological disabilities and had 278 cases of mental disabilities; while broad, the two categories account for 57 percent of the A&D offices registered users. Definitions for the two categories provided by the A&D office (2011a) are presented verbatim as follows:
Neurological disabilities refer to disorders that affect understanding or using language, spoken or written, and mathematical calculations, as well as processing speed and memory capacities. This category covers learning disabilities, brain injuries, autism spectrum disorders, attention deficit disorders and attention deficit hyperactivity disorders. The term does not include learning problems that are primarily the result of visual, hearing, or motor disabilities, of mental delay, of emotional disturbance, or of environmental, cultural, or economic disadvantage. Mental illness is a term that describes a broad range of mental and emotional conditions that significantly interferes with the performance of major life activities, such as learning, working and communicating, among others. Among forms of mental illness are generalized anxiety disorders, depression, schizophrenia and other psychiatric disorders. As the A&D office continues to strive towards social inclusion on campus, understanding the experiences of those affected by neurological and mental health disabilities is imperative. During the past two academic years, the A&D office and the School of Community and Regional Planning (SCARP) have collaborated on various community based research projects on the UBC campus. In January 2011, SCARP's qualitative research methods class embarked on six community based community service learning projects with the A&D office. The main objectives of our particular project, focusing on international students and disabilities, are as follows: (1) To understand the experiences of using social and health services on campus for international students with disabilities in order to address any barriers; (2) To make recommendations for enhanced inclusion; and
(3) To produce a report that can be used by the A&D office in their advocacy efforts towards policy advancement and improved service delivery. This report presents the findings regarding the focal research question what are the barriers international students with disabilities face in accessing social and health services on the UBC-Vancouver campus? Other topics investigated throughout this project address the following sub-questions:
What are the experiences of international students in accessing social and health services on campus?
What are the key health and social services on campus? How do cultural differences impact the experiences of international students? What recommendations would international students make to enhance social inclusion?
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Table 1: Summary of prior studies on barriers to health services Study Population Barriers (in rank order where noted)
Tjia, Givens, & Shea (2005) Depressed medical students 1. Lack of time 2. Not enough sessions with university care 3. Stigma 4. Negative career impact 5. Fear of diagnosis in academic record 1. Lack of time 2. Lack of confidentiality 3. Afraid no one will understand problems 4. (tie) Stigma / Problems not seen as important 6. Cost 1. Conceal vulnerability, independence 2. Lack of knowledge 3. (tie) Lack of time / no perceived susceptibility 5. Advisor lacks credibility 6. Advisor doesnt understand culture (gay, ethnic) 7. Cost Stress Shame, embarrassment in admitting weakness Lack of confidentiality Later job prospects Fear of diagnosis in academic record Real behaviours: 1. Lack of time 2. Lack of knowledge 3. (tie) Did not think services would help / embarrassment Hypothetical behaviours: 1. Lack of time 2. Lack of knowledge 3. Did not think services would help 4. Cost 5. Did not want to talk to stranger
Men
Medical students
General population
2.1: Knowledge
The first barrier one must overcome in accessing a service is knowledge: while many university students are aware that services exist, a significant number including many of those who would benefit from such services do not. This is seen in a survey conducted led by
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Eisenberg (2007), showing that just less than half of undergraduate students in their survey would be able to find mental health care on campus, while slightly more (59 percent) knew of available free counselling services (p. 597). Among those who tested positive for depression or anxiety and who did not use campus services, less than one-third could find mental health care, while 53 percent knew of free counselling services (Eisenberg et al., 2007, p. 597). A similar study done led by Yorgason (2008) found similar results: 70 percent of students contacted had never heard of mental health services, and the majority of those who did seek out the information did it on their own (p. 175). A study on graduate student mental health led by Hyun (2006) showed that more graduate students were aware of services. It was found that nearly three quarters of graduate students were aware of these services, and that female graduate students were significantly more aware of these services than males (Hyun et al., 2006, pp. 256-7). Furthermore, graduate students were found to be more likely to seek out information on their own instead of gaining knowledge from friends or advisors, meaning that traditional methods of information dispersion on university campuses residence halls and administrative programs are unlikely to reach then (Hyun et al., 2006, p. 261). However, another study led by Hyun (2007) found that although 61 percent of international graduate students responded that they knew that counseling services were available on campus, a percentage significantly lower than the 79 percent knowledge found of domestic graduate students (p. 113). This gap in knowledge helped result in a gap in the use of counselling services, as domestic students were much more prone to use the services provided by the university (Hyun et al., 2007, p. 114).
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2.3: Culture
One definition of culture considers it an integrated pattern of human behavior including thought, communication, ways of interacting, roles and relationships, and expected behavior, beliefs, values, practices, and customs of a group (Taylor, 1997 as cited in Lee, 2003, p. 3). Penn et al. (1995) argue that intersections between culture and class affect one's behaviour toward health and health care (p. 641). Lee (2003) analyses the findings of Penn et al. (1995) and presents five health domains influenced by culture, summarised in Table 2.
INTERNATIONAL STUDENTS WITH DISABILITIES Table 2: Five health domains influenced by culture according to Penn et al. (1995) Health domains influenced by culture Definition
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Cultural beliefs about disease and major events (births and deaths) influencing decisions about health care Cultural beliefs about health, illness, and treatment influencing treatment after diagnosis Cultural familiarity or knowledge affecting health care acceptability Cultural preferences and values affecting sources of knowledge, use of preventative health care, lifestyle Cultural relations, processes affecting individual and intergroup relations
Preferred Treatment
Health Behaviour
2.4: Stigma
Collins and Mowbray (2008) explain that university students with mental health issues face structural obstacles, ranging from personal discrimination (e.g., lack of awareness or understanding from faculty and peers) to gaps in service provision (e.g., inadequate financial aid, lack of campus-based mental health services, lack of information about campus services) (p. 305), to a fear of stigmatisation for disclosing their illness to faculty or peers. While all of these barriers can impede ones willingness to access a service, stigma around mental health and disabilities appears to be highly severe in the literature. There have been a range of studies
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completed on the subject of stigma as it pertains to mental health, neurological disabilities, and accessing services. Twardzicki (2008) defines stigma as a sign of disgrace or discredit, which sets a person apart from others (p. 69); this reflects that that shame, disgrace, and stigma still are associated with mental illness in todays society. Hyun et al. (2007) also report how the stigmatization of mental illness possibly connected to the decreased recognition of others emotional problems presents a barrier to access of mental health services (p. 116). In discussing the stigmatisation of mental illness, Twardzicki (2008) asserts that young people may hold attitudes which are more ill-informed than the rest of the population (p. 68). Such negative attitudes toward stigma can create a spiral effect, where mental health is further undermined, and making it harder for those with disorders to seek help or treatment; this can further negatively affect relationships and ultimately cause the people with the disorder to be isolated (Twardzicki, 2008, p. 68). Corrigan (2004) discusses how stigma may impede people from seeking or participating in mental health services (p. 614). Further, the threat of social disapproval or diminished selfesteem (Corrigan, 2004, p. 618) that is associated with having a mental health illness can lead to the underutilization of services: this may partially be because those who are labelled mentally ill are severely stigmatized beyond the levels of other medical diagnoses (p. 614). There is also extensive research on public stigma and self-stigma both can impede a student in accessing a mental health or disability service. Corrigan et al. (2006) found that self stigma is a process by which public attitudes lead to personal responses and self stigmatization (p. 882). Self-stigma has been further defined as the internalised impacts of others negative attitudes on a person who possesses a devalued characteristic (Rao et al., 2009, p. 586), and has
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been associated with lower use of services, as well as negative personal impacts, including low self-esteem, depression, and anxiety. Rao et al. (2009) look to ground this term more pragmatically and link it to enacted, or public, stigma. This process begins through discrimination from others this can include friends, colleagues, or classmates resulting in an awareness of negative stereotypes surrounding a persons condition (Rao et al., 2009, p. 586). Eventually, this can evolve into enacted stigma: this happens when discriminatory behaviour occurs; when the person with the condition believes in the stereotypes surrounding his/her condition and internalises them, the stigma evolves from a public stigma to self-stigma (Rao et al., 2009, p. 586). By accepting the stereotypes, self-esteem and self confidence tend to drop (Corrigan, 2004, p. 618). As a result, Corrigan (2004) concludes that self-stigma results in the avoidance of the label causing stigma, and as a result, a vast decrease in willingness to participate in any sort of treatment (p. 618). The way in which people manage perceptions of stigma affects their choice to access health care. An important step to managing perceptions is self-disclosure in this case, telling others about a disorder. For those with disabilities, this is extremely contextual: Olney and Brockelman (2003) list situation, life stage, familiarity, and necessity (p. 36) as factors which are included in a decision to tell others. Therefore, this becomes a complex decision-making process, which allows someone with disabilities to break down stigma by sharing information on his terms (Olney & Brockelman, 2003, p. 49).
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understanding of the insurance system (p. 137) to increase the number of students who would use preventive health services. Hyun et al. (2007) also found financial issues to be a barrier to mental health access for international graduate students. In their study, international students were more likely to report having financial problems and less likely to report having emotional or relationship problems than domestic students (Hyun et al., 2007, p. 117). This underscores the different challenges that domestic and international students face and suggests university health-care administrators should account for these differences in designing counselling programs. Hyun et al. (2007) also found that students with better financial confidence were less likely to access counselling, suggesting that other factors may play a part in access to preventative health services (p. 113).
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skills (p. 57). Additionally, a report on mental health for ethnically diverse communities found that language and cultural factors, along with stigma, a lack of trust, and a lack of understanding of the health system are considerable barriers to accessing mental health care in Canada (Agic, 2003, p. 2). Furthermore, research has found that language barriers are associated with a multitude of negative outcomes, including longer wait times at clinics, a lower frequency in clinic visits, a lower understanding of doctors, an increased number of emergency room visits, and lower satisfaction with health services (Yeo, 2004, p. 59).
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3.0: Methodology
We employed a case study research methodology for this project. The project is meant to investigate a contemporary phenomenon within its real life context: the current barriers international students with disabilities face in accessing social and health services on campus. While our research question gets at the what, the flexible nature of this exploratory study allowed the researchers to go in more depth through the semi-structured interviews to inquire about how and why the identified barriers are so problematic. VanWynsberghe & Kahn (2007) explain how case study research calls for an intensive and in-depth focus on the specific unit of analysis and generally requires a much smaller sample size than survey research. The small sample size in this project makes it difficult to generalize our findings, but case study research is not meant to focus on generalisability. Case studies focus more on contextual detail and extendibility; it also aims to enrich a readers understanding of a phenomenon by extending the readers experience (VanWynsberghe & Kahn, 2007, p. 4). With only three participants in the study, we decided to use a case study research approach to focus on the experiences, behaviours and challenges of the participants in light of our main research focus. The experiences of the participants allowed our research team to create themes and codes to categorize the findings, which are discussed at length in the subsequent section. A thoroughly conducted case study research project recognizes that the involvement of human participants will generate data and stories upon which the researcher reflects and writes about. As our intention was to grasp a comprehensive and in-depth understanding of the barriers international students face, case study research is well justified.
INTERNATIONAL STUDENTS WITH DISABILITIES Outreach Strategy The process of recruiting participants was a difficult albeit gratifying process. We
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received ethics approval for our requested amendments in early February. We requested a series of amendments to change certain terminology in our recruitment letter and our projects purpose to make the study as unambiguous and open as possible. We made specific amendment requests to ethics to include more flexible terminology such as students who self-identify with a nondominant Canadian culture. Moreover, we have also included space for students who may not have a diagnosed disability but claim to have an impairment that affects their daily life. In essence, the need for these changes stemmed from group consensus and deep reflection about what we would like to get out of this project. Once we received ethics approval, we proceeded to circulate our recruitment letter to several academic departments including but not limited to geography, economics, psychology and engineering. We figured it would be helpful to utilize the networks of our fellow graduate school friends from these respective departments to circulate our recruitment letter. We also passed along our study to the listservs of the A&D office and International House. Our ethics approval also permitted us to utilize posters as a recruiting strategy. We did not put up too many posters; these were limited to a bulletin board in International House. Analyzing the Data We utilized a coding structure that broke down the barriers as themes (see Table 3). We initially used a comparative case study approach to make connections and relationships. But after some discussion, we elected not to use this approach to ensure the anonymity and confidentiality of the research participants. We broke up the reported barriers into themes to present the findings in a succinct and presentable way, and to maximize the level of analysis.
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3.1: Methods
Semi-Structured Interviews We completed three semi-structured interviews in our study. All three participants were male and of Latin American ethnicity. One participant had a mental health problem (depression), the other participants had neurological disabilities (learning processing disorder and attention deficit hyperactivity disorder (ADHD). The participant with depression is a visiting international student who has not accessed any of the social or health services on campus since he arrived. Only one female student expressed interest in our study but we did not successfully recruit her. Before we actually conducted the interviews with our participants, we forwarded the interview guide to our A&D office advisor to review the nature of the questions and to receive feedback on how to make them clearer and better focused. The ultimate purpose of using semi-structured interviews was to learn about the various barriers international students with disabilities face in accessing social and health services on campus (see Appendix A). Until the interviews, our groups understanding of mental health and neurological disabilities as barriers to service was constructed through reading the literature and other case studies across North American campuses. On a more practical level, the semi-structured interviews provided more of the context to UBC and the participants experiences with accessing services here. The use of a semi-structured interview style employed an open framework allowing for focused, conversational two-way communication. The flexible nature of semi-structured interviews can confirm what is already known but also provide the opportunity for further learning (Mason, 2002, p. 62). Mason (2002) explains that semi-structured interviews are conversations with a purpose (p. 62). Our intention was to
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construct or reconstruct knowledge as opposed to excavating it. The use of probing questions proved to be useful in soliciting information from the participants. When participants seemed perplexed by certain questions in our interview guide, we resorted to our probing questions to simplify what we were asking our participants. Our fieldnotes and continuous group debriefs, allowed group members to reflect about how the interview went and how we can improve for the next time. Questions that generated the most data from our interviews included questions 8 and 11. These questions were are there barriers you have encountered in accessing health and social services that relate to being a non-domestic/international student? Question 11 was in general, how do you feel about the experience of approaching/trying to approach the on-campus social/health services? Both of these questions targeted the very nature of qualitative research which focuses on the experiences, behaviours and feelings of the research participants, whoever they might be. As semi-structured interviews are a flexible approach to seek information, we thought of questions on the spot in light of the conversations we were having with the research participants. While we recruited three participants overall, our group decided to interview the first participant twice. The first interview with the participant, while valuable in that in generated data and helped build rapport, did not provide us with all of the information we had hoped for. In essence, going through the interview with this participant allowed the group to test the research instrument and ultimately give us a better understanding of the clarity and direction of the questions. We did not provide the participant with enough information about the studys purpose. We did e-mail all of the participants the interview guide prior to conducting the interview, but the first participant did not understand the studys purpose, nor did he understand the questions
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we asked him. Upon reflection from the first interview, our group developed another set of eight questions that were specific to participant one and re-interviewed him (See Appendix B). These questions were not necessarily a deviation from the original interview guide, but were presented in a clearer and simpler fashion to allow the participant to digest them and respond in a more complete manner. Fieldwork Diary Following each interview, the interviewers were somewhat consistent in writing a fieldwork diary. The purpose of this method was to reflect on how the interview went and to evaluate our relationship with the research participant. Case study research uses a fieldwork diary to record the researchers observations, conversations and maps. Diaries are useful for examining the researchers engagement in the process (Dowling, 2005, p. 22). In a research process, the researcher becomes steeped in data, but at the same time cultivates analytical distance to enable thinking about the data and to allow the imagination to work to see patterns in the detail, or how apparently unrelated items might be connected (Pratt, 2006). Pratt (2006) continues with discussing how a variety of devices might be used to aid this distancing, for example, a research diary containing personal reflections on the research, ones own involvement in and feelings about it. Fieldwork diaries have helped our research team work hard to achieve 'analytic distance' from the role, to set aside taken-for-granted assumptions and to see oneself in the role. Reflexivity has been crucial in the fieldwork diary process.
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tool to capture the experience of the research participants. Out of the three participants we spoke with, one had never accessed a service at all, one only accessed the A&D office, and the third participant had accessed counselling and the A&D office. Although mapping the existing services on campus would be a great way to promote awareness and allow for the dissemination of information visually, we felt that this was outside the scope of our research.
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Lack of information Participant is unaware of the service or do not know how to access it Socio-Cultural The influence of peoples health beliefs, values and perception of health problems rooted in one's culture or society
Stigma
Perception of stigma
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I try to recall what I learnt from previous therapy, because I was treated for 1.5 years [] I try to use my previous knowledge from therapy [to cope with disabilities]. I take medicines, you get used to medicines when you have disabilities. [] But I also used to smoke. These are my two basic supports, friends and cigarettes. [] I use a lot of coffee to cope with that and cigarettes. I dont smoke much [] in a way, I want to make efficient use of this [limited amount of] energy. I try to use it in my work. Just you know, have your cigarettes and coffee and go to work. Medicine gets rationed [] Im almost out now, but Im saving it up for the exams. Coping through rationing, [I] know when theres going to be a hard day [] [I] learn when to use [the drugs], how to use them. In first term I didnt bother to find resources, but I didn't do well with my tests [] and then I spoke with my mom she encouraged me to look. And I found services online. I look for my friends here, Ive made good friends here. Thats the community that I talk about. [] A place like this is a place for people with disabilities. It is a more tight community. You are surrounded with great people. [] The activities of community, because we have breakfast together [] you talk and you expand your social networks. Other activities, we get together, we play soccer [] If you feel like you belong to a group of people, this is important. Something you are used to, I guess, when you are friends it is something you can joke about. [...] I guess you cant change the system so you just make fun of it. [My department] is better because its smaller department, smaller classes. I study better in groups I have a couple friends to study together with. [] [I study] just on my own or with friends. I have academic advising and international advising. [] I could get a note taker but it costs more money so I dont do that. I ask teachers for their notes. My academic advisor has been helpful. I like being in a small faculty with more one-on-one interaction. It feels very personalized. Socially, I just live with it; with academics, at my old school they just gave me unlimited time. With the SATs I got double time. Here they [the A&D office] give me more time for test. The A&D advisor is helpful, [she] agreed to register me on a semester basis to get benefits.
Family: Seek help from family members Friends & Community: Seek help from friends or community
Academic Advisors: Seek help from teachers or Academic Advisor of the department Accessing Service: Access service and accommodations from service providers
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5.1: Knowledge
Lack of knowledge in this study is defined as not knowing which services are available. Our interviews revealed that there was a gap in knowledge of services when the students first arrived on campus; although the participants had disabilities which they were aware of, and had been treated for in their home country, none were aware of the presence of the A&D office or any other service when they first arrived at university. As a result, none of our participants were officially treated in their first term at UBC: while services were available for them to access, not knowing that they existed was the major barrier in the lack of access. These experiences line up well with a study authored by Goode (2007) on the initial experiences of university students: she found that students had been unaware of what support was on offer and how to access it readily (p. 41), a problem which is exacerbated if a student needs access to a service in the middle of the term. Furthermore, the study states that the accessibility of information sent prior to enrolment is overestimated; as a result, there are unrealistic assumptions placed on newcomers, who are expected to know what insiders already at the school know from being involved in the university (Goode, 2007, p. 46).
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Our participants experiences with the application and orientation process reflect the latter point: while we are not certain how much information is provided prior to enrolment or the beginning of classes, it is clear that none was retained by our participants at the beginning of the term; as a result, they had to learn which services could accommodate their disabilities further along in their studies. While one participant stated that he is certain that information is readily available, he was not provided any during the application process. Furthermore, two of the participants had attended orientations for international students; neither was aware of any accommodation being mentioned during the orientation process. Finally, for the two participants who accessed services, one did so through a referral from International House, while another found applicable services on the internet. Studies tend to support these ideas, especially for international students. Hyun et al. (2007) found that there are barriers for international students with respect to the transmission of information (p. 117). With respect to how information is found, it is possible that the internet is becoming the norm: a study led by Cam Escoffery in 2005 found that almost three-quarters of students surveyed reported that they used the internet to find health information (pp. 184-5). Given that the use of the internet has increased and become more widespread since that point, websites both of the university and the faculties can play an important role in giving students knowledge about health and social services on campus. The recommendations regarding knowledge are as follows: The A&D office and other health services should provide more information upfront, such as during the orientation process, making services visible, and allowing for students to be aware of the existence of services on campus. While this can be done at larger orientations, it may be preferable to do so in smaller venues with each faculty, so that
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students would be more aware of where to seek help when necessary. We suggest that a student assistant could be hired in order to help raise awareness in the different departments of the university. We recommend that student staff from the A&D office take some time during orientation to inform new undergraduate and graduate students about the A&D office and the diversity of the UBC student body. It should be stressed that there are a number of students with mental health illnesses and neurological disabilities on campus, and to be mindful that universities are diverse, open-minded, and accessible places. To reduce the level of perceived stigma felt by students with mental health and neurological disabilities, it would be useful to increase information and educational efforts about campus mental health and neurological disability services such as the A&D office. As such, we suggest that information provided by the A&D office may take the following forms: A multifaceted approach ought to be used in order to increase knowledge; aside from orientations, there may need to be flyers around campus and in residence halls to raise awareness. Furthermore, the internet should be used in order to raise awareness, with easy-to-access information readily available on university web pages heavily trafficked by students. We suggest the introduction and design of programs for increased education with input from students, including graduate students, international students, and students who are currently using services. This information should include recognition of mental health issues, including symptoms of depression and other disorders, as this may not be readily understood in all cultures. Such information would help in raising awareness and allowing for knowledge regarding mental health, while also giving the
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A&D office and other services a presence on campus beyond just service provision. Further, it would provide information and context about the diversity of students at UBC and the various challenges they have in their academic and personal life Education specific to international students about mental health, including coping and stress relief strategies, and about recognizing mental health problems should be a priority for UBC. Students can also act as peer mentors to not only provide information on how to cope with stress and exam anxiety. This could reinforce that all students have their own personal challenges one of which may be related to mental health.
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Psychiatric Association, has been questioned for its definition of mental disorders and decisions regarding certain conditions and if they can be legitimately considered as a mental disorder (Wakefield, 1992, p. 232). The lack of universal definitions and assessments of mental disorders or illnesses across countries results in the difficulty of accepting diagnosis documentation from foreign medical systems using different or non-compatible standards and measurements. A second barrier identified is the lack of continuity of care in certain health services on campus. Continuity of care, a key indicator of health care performance, relates to both past and present care and its conformity with therapeutic needs of the client (Hermann, 2000, p. 136; Bass & Windle, 1972, p. 110). Cohen and Sanders (1995) further defined the continuity of care as a guarantee that the care is implemented and coordinated by one and the same person (p. 124). One of our participants commented on his disappointing experience with a mental health care service on campus as a counsellor with whom he had a positive experience [is] gone after a semester. The practicum system in this particular UBC service has thus caused a discontinuity of service, which results in negative emotional reactions to some service users, including our participant. Counselling students do not often stay for a long period of time after the completion of their practicum: such constant turnover makes it difficult to guarantee continuity of care, something the participant had to unfortunately experience. The conflict between a high demand for the counselling service and limited personnel was also been pointed out by a participant, a problem which is consistent with an article in the Ubyssey regarding depression in UBC students and mental health services on campus (Wakefield, 2011). The long application process and waiting list for services, mentioned by Goode (2007), is identical to our participants description of the two month waiting list for mental health service at UBC (pp. 45-46).
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Institutional barriers come from the system level and cannot be resolved in a short period of time. In addition, removing these barriers require collaborative actions between different service providers, as well as higher levels of the bureaucracy, since for the most part, institutional barriers are not caused by and cannot be solved by one particular service provider. Thus, we understand that the A&D office is unable to unilaterally change issues found on this front; thus, we suggest some advocacy actions which the office may be able to take. The recommendations regarding institutional barriers are as follows: The A&D office should advocate for funding ensuring continuity of service by providing consistent and adequate service to students. Students should be able to receive all the different services that they need, even if the system is fragmented. Many different service providers must be involved for full accommodation and treatment. In addition, services should collaboratively direct students who are unable to receive service in a timely manner to other same-level, if not better, mental health services on or off campus. The A&D office should collaborate with other health services on or off campus to establish a system to allow for mental health diagnosis documentation from other countries not currently accepted by UBC. We understand that this may have to be done at a level higher than UBC; however, the ultimate goal would be that barriers caused by differences in medical systems do not hinder the access of international students to adequate services on campus. A first step towards this could be the creation of an inventory of the types of documentation that are not accepted by UBC, and the differences in diagnosis.
36
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internalised the idea of stigma, and has led to self-stigma thus moving through the stages of how stigma affects people presented in Rao et al. (2009, p. 586). We can only speculate on this finding because we did not obtain any more information from the participant; however, more work must be carried out on this particular topic with UBC students with a mental health or neurological disability. This should be done both quantitatively and qualitatively with a larger sample size to generate a holistic understanding of perceived stigma and the strategies universities could use to better address them. Despite our small sample, we have come up with some recommendations that we advise the A&D office to consider. The recommendation regarding stigma is as follows: In addition to the provision of more information, the A&D office could partner with UBC Housing and create a section in the August resident advisor (RA) training to better inform RAs about social and health services on campus. Moreover, RAs should spend some time when their students first arrive to explain services provided by UBC to all groups, including students with mental health and neurological disabilities. This can reinforce the idea of diversity to the student body, generate awareness about these issues, enhance inclusion, and minimize perceived stigma. Private and Public Health Care Strong views on the superior quality of private health care vis--vis the public system were something which was mentioned during two of the interviews. Two participants held strong opinions that private health care is better than public health care; however, neither have had a personal experience with the Canadian health care system. This finding is significant as previous research has found that unfamiliarity with a given country's health care system discourages use
INTERNATIONAL STUDENTS WITH DISABILITIES by culturally different patients (Hoang & Erickson, 1985, p. 229). For instance, Canada's
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universal health care system is significantly different from other systems such as the two-tier system or the US-style consumer driven care system (Gladwell, 2005, p. 44). Thus, this can be a large barrier in to use, as there is not an intuitive understanding of the Canadian health care system for many international students. Furthermore, in countries where private or two-tier health care systems are in place, private health care services are seen, in general as superior to the public system (Alves & Timmis, 2001, p. 24). Thus, the public health care system in Canada may be unsettling to international students from countries with such systems. The most striking finding in our interviews was perhaps that neither of the research participants have experienced the Canadian health care system. Both participants referred to horror stories they have heard about the Canadian health care system from third parties. In one case, the stories were from friends personal experience accessing care; for the other participant, the stories came from his parents. This participant said: my parents think that the health care in Canada is really bad [. . .] they would rather fly me [home] than me going to the hospital here despite his parents also never having used the Canadian health care system. His parents' assessment of the quality of care is solely based on their opinion of the performance of Canadian doctors practicing abroad, specifically, in the participants home country. Although there are no studies on health care perceptions and international students access to care, research regarding cultural beliefs and immigrants to Canada has explored this issue at length. In general, studies have shown that immigrants experiences and construction of health care from their country of origin heavily influence their perceptions and expectations of Canadian health care (Carrasco et al., 2009, p. 7). The literature available on this issue points at a
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complex cycle of misinformation and cultural beliefs when combined, these issues become a significant barrier to accessing health care services. If participants are used to private health care, their perception and expectation of the public health care system may be inadequate. Furthermore, when participants rely on other international students or their parents to assess the quality of Canadas care, they may never receive access to information necessary to familiarize themselves with the way the public system functions, which may in turn foster dissatisfaction with the system. The 1995 Penn et al. analysis of the interrelation between culture and class named this barrier acceptability of health care (p. 641); interestingly, when asked directly if they thought culture was a factor in the barriers to accessing health care, the two participants both said no. One of the participants who used private health care at home stated that he did so because it is better; he also mentioned that he does not know if that is true of Canada. He elaborated on his choice of health care by saying he normally chooses services based on proximity to his on campus residence. However, the only one time he has felt ill, he went to a private health clinic off campus. As researchers, we often found ourselves trying to inquire about the reasons behind the participants actions, choices, and strategies for coping. In this case, however, the participants were reluctant to share details or did not think those details were relevant to the barriers they experience in accessing health care. The recommendations regarding health care provision are as follows: Further research must be undertaken to investigate the preconceptions and health care beliefs that international students bring with them when they arrive to Canada. While much work has been done on immigrants, there is little research looking at international students in a university setting.
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During orientation, international students should be provided with a description of what Canada's public health care system offers and the way it functions.
The International Student Handbook should make an effort to explain to students the characteristics of health provision in Canada such as: the average waiting time for appointment, the de facto one question per visit policy in clinics, prescription and refill processes for medicine, referral system for access to specialized doctors, and other ideas which non-Canadians may not be familiar with.
5.4: Communication
Language was identified by one participant as a significant deterrent from accessing mental health services. In Canada, the provision of linguistically appropriate health promotion and care has been identified as necessary to address the existing disparities and ensure equal access to all the resources (Agic, 2003, p. 2). The participant mentioned that he was discouraged from seeking help as the type of therapy he needs would require him to speak in his native tongue for it to be effective. For this participant, psychotherapy was about expressing one's thoughts and feelings; he felt that he would be very limited in his capacity to express those feelings if he were to do this in English. Previous research has also identified language capacity and comfort level for psychotherapy as a barrier to accessing this service (Leong & Lau, 2001, pp. 207-209). International students at UBC possess different levels of comfort and competency in the English language; as such, this barrier may only be applicable for certain students. We do not feel that we have enough information to make a recommendation on the issue of communication and language proficiency. More research is needed to identify possible solutions for this barrier: it is not feasible to provide counselling and psychotherapy in all
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languages; however, varied accommodations can be designed for people in this situation. It would be important to look at best practices among other university campuses, including those in non-English speaking countries, to see how language barriers to accessing health care services have been addressed.
INTERNATIONAL STUDENTS WITH DISABILITIES The recommendation regarding financial barriers is as follows: Create a special fund for diagnostic testing on campus that can provide money for
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students not currently eligible for funding. If students must pay for their testing, look into different payment strategies or financing opportunities that can come out of this funding pool for testing that cannot be paid for upfront as a lump sum.
INTERNATIONAL STUDENTS WITH DISABILITIES his from receiving the same prescription medicine in Canada. Understanding the coping
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strategies of stigmatized individuals requires one to understand their unique experiences and circumstances. While rationing medication seems like a stressor itself, this strategy speaks of the many ways in which existing barriers to accessing health services affects the life choices made by international students. Family One participant mentioned he called her mother once he encountered difficulties functioning within the UBC academic context. It is important to mention this was not the case for all participants: one of our participants clearly stated that his family simply could not help him cope with his disability; thus, he chose to rely on his friends and the community around him instead. Friends and the UBC Community Seeking help from friends and the community is a coping strategy used by all three participants. The participants all mentioned how their friends and the UBC community, either academic or residential, support their studies and life. When they have a couple of friends to study with, have breakfast together in the residential community, or to simply get together with friends, they develop a sense of belonging, which helps them through their respective difficulties. One participant told us that upon transferring from a large department to a smaller one with fewer students, he found that he liked the smaller classes, where he was able to made friends with others in his department.
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Two participants mentioned that they approached advisors when they had problems. One participant commented on his experience with an academic advisor in his department as being helpful. He favoured the one-on-one interactions between students and his advisor, and finding that it was personalized and a better support for him. The A&D Office and Other Services Two participants mentioned their access to the A&D office for accommodations. One participant did not know about the A&D office until he finished his first semester and found information about the A&D office online. He commented on the A&D advisor as being helpful during his registration with the office each semester. Another participant was satisfied with the extended time allocated to his exams as accommodation from the A&D office. Our recommendation involving coping strategies is as follows: The A&D office could promote strategies that focus on healthy and positive coping strategies that incorporate skill development for new students. This could be done through orientations, student handbooks, workshops, roundtable discussions, blogs, newsletters, etc.
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Recommendations
The A&D office and other health services should provide more information upfront, such as during the orientation process, making services visible, and allowing for students to be aware of the existence of services on campus. While this can be done at larger orientations, it may be preferable to do so in smaller venues with each faculty, so that students would be more aware of where to seek help when necessary. We suggest that a student assistant could be hired in order to help raise awareness in the different departments of the university. We recommend that student staff from the A&D office take some time during orientation to inform new undergraduate and graduate students about the A&D office and the diversity of the UBC student body. It should be stressed that there are a number of students with mental health illnesses and neurological disabilities on campus, and to be mindful that universities are diverse, open-minded, and accessible places.
Knowledge
Strategies to include information may take the following forms: A multifaceted approach ought to be used in order to increase knowledge; aside from orientations, there may need to be flyers around campus and in residence halls to raise awareness. Furthermore, the internet should be used in order to raise awareness, with easy-toaccess information readily available on university web pages heavily trafficked by students. We suggest the introduction and design of programs for increased education with input from students, including graduate students, international students, and students who are currently using services. This information should include recognition of mental health issues, including symptoms of depression and other disorders, as this may not be readily understood in all cultures. Such information would help in raising awareness and allowing for knowledge regarding mental health, while also giving the A&D office and other services a presence on campus beyond just service provision. Further, it would provide information and context about the diversity of students at UBC and the various challenges they have in their academic
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Education specific to international students about mental health, including coping and stress relief strategies, and about recognizing mental health problems should be a priority for UBC. Students can also act as peer mentors to not only provide information on how to cope with stress and exam anxiety. This could reinforce that all students have their own personal challenges one of which may be related to mental health. The A&D office should advocate for funding ensuring continuity of service by providing consistent and adequate service to students. Students should be able to receive all the different services that they need, even if the system is fragmented. Many different service providers must be involved for full accommodation and treatment. In addition, services should collaboratively direct students who are unable to receive service in a timely manner to other same-level, if not better, mental health services on or off campus. The A&D office should collaborate with other health services on or off campus to establish a system to allow for mental health diagnosis documentation from other countries not currently accepted by UBC. We understand that this may have to be done at a level higher than UBC; however, the ultimate goal would be that barriers caused by differences in medical systems do not hinder the access of international students to adequate services on campus. A first step towards this could be the creation of an inventory of the types of documentation that are not accepted by UBC, and the differences in diagnosis. In addition to the provision of more information, the A&D office could partner with UBC Housing and create a section in the August resident advisor (RA) training to better inform RAs about social and health services on campus. Moreover, RAs should spend some time when their students first arrive to explain services provided by UBC to all groups, including students with mental health and neurological disabilities. This can reinforce the idea of diversity to the student body, generate awareness about these issues, enhance inclusion, and minimize perceived stigma. Further research must be undertaken to investigate the preconceptions and health care beliefs that international students bring with them when they arrive to Canada. While much work has been done on immigrants, there is little research looking at international students in a university setting. During orientation, international students should be provided with a description of what
Institutional barriers
Socio-cultural barriers
Stigma
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Canada's public health care system offers and the way it functions. The International Student Handbook should make an effort to explain to students the characteristics of health provision in Canada such as: the average waiting time for appointment, the de facto one question per visit policy in clinics, prescription and refill processes for medicine, referral system for access to specialized doctors, and other ideas which non-Canadians may not be familiar with. More research is needed to identify possible solutions for this barrier: it is not feasible to provide counselling and psychotherapy in all languages; however, varied accommodations can be designed for people in this situation. It would be important to look at best practices among other university campuses, including those in non-English speaking countries, to see how language barriers to accessing health care services have been addressed. Create a special fund for diagnostic testing on campus that can provide money for students not currently eligible for funding. If students must pay for their testing, look into different payment strategies or financing opportunities that can come out of this funding pool for testing that cannot be paid for upfront as a lump sum. The A&D office could promote strategies that focus on healthy and positive coping strategies that incorporate skill development for new students. This could be done through orientations, student handbooks, workshops, roundtable discussions, blogs, newsletters, etc.
Communication
Financial barriers
Coping strategies
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7.0: Conclusion
This project has been an academically fulfilling experience. The use and application of qualitative research methods to a real-life and salient issue on campus has reinforced the importance of conducting such research. We had the opportunity to learn about some of the barriers international students with disabilities experience in accessing health services on campus. Disabilities in this study constituted neurological and mental health illnesses which as reported in the literature and in the findings of this study, can greatly affect a students academic, social and personal well-being during their university journey. The barriers students face can be extensive and wide-ranging. However, the barriers we found in this study are perhaps more unique to the experiences of international students. These barriers ranged from financial challenges around diagnostic testing, to the troubling aspects of perceived stigma, to discussion around the cultural differences between public versus private health care, language issues and the lack of information and knowledge around a disability or more generally to what services are offered on campus. Our findings were broken up into barriers and coping strategies. The coping strategies reported by the participants were powerful and inspiring stories about the mechanisms these students use in everyday life to cope with the neurological or mental health illness they are living with. These stories and experiences were captured in our study but warrant further academic exploration. Our study differed from others in this academic area in that we used a qualitative approach. Future research on this topic at UBC need not be exclusive to qualitative or quantitative research but an integration of both to gather the most useful data that can lead to substantial changes on campus. We are grateful for having the opportunity to carry this project
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out and hope that the recommendations we have put forward are instructive for assisting the A&D office in improving their advocacy efforts towards policy advancement and improved service delivery, and for enhanced inclusion on campus. The topic of international students with disabilities is an under-studied one that needs more attention in university environments. Our contribution to this area is simply a starting point for the critical research that needs to follow.
Acknowledgements
We would like to thank our course instructor, Dr. Pamela Ponic for her time and dedication to this campus service learning project. Dr. Ponics comments and feedback throughout the process were most useful in helping our group with recruitment strategies, methodology and structuring our ideas. Dr. Ponic also helped our group overcome difficult situations which brought stress and anxiety to the research team. We would especially like to thank Sarah Knitter from the A&D office who was very supportive in this research project. Sarah helped reinforce optimism in times when we were having difficulties with recruitment. Sarah also provided excellent feedback for out interview guide on how to make it clearer and more focused. Last, we would like to thank our three research participants in the study whose participation made this project possible. Their stories and experiences as students with neurological disabilities or mental health illnesses taught the research team a lot about the subject matter and how complicated and multifaceted the issues are. Thank you again for you precious time and interest in our study.
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Appendices
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How did you hear about the service? Were there any challenges in accessing the services? (e.g. financial? cultural? language? lack of needed service? etc.) Were cultural differences a factor? How did you deal with the challenges you faced? (by yourself?; ask for help from anyone?; borrow money?------ did your strategy work?
If NO, what were the reasons? Have you ever tried to approach? When did you try? Does the nature of your disability affect Was there any barrier? What were the barriers? (financial? cultural? language? lack of needed service? etc.)
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Were cultural differences a factor? Is language a barrier? How did you deal with the barriers? (by your self? ask for help from anyone? borrow money?) Did your strategy work?
11) Have you approached any off-campus social/health service? Why did you chose to go off-campus for help?
12) What would make the A and D office a more accessible and accommodating place? b) Or, what would make it less accessible? PROBING QUESTIONS
Could you please share with us what you know about his/her story? (In case the interviewee doesnt want us to know that the story of his friend is actually his own story)
Last resort question--13) In general, how do you feel about the experience of approaching/trying to approach the oncampus social/health services? 14) Do you know if there is someone else who has similar/different experience of approaching on-campus social/health services?
PROBING QUESTIONS
Did this experience encourage you to approach social/health services in the future? Have you recommended or not recommended services to others due to your experiences?
15) Do you have any recommendations for improving on-campus social/health services for international students with disabilities? Mapping Exercise 1. Please, show us where on campus these services are located on this map. 2. Are there any health or social services on campus that would like to access but havent? If you know where they are located, please point them out to me on this map.
3. Why havent you used these services? Do you face barriers to access? If so, what are they?
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Neurological Disability breakdown by type Learning Disability ADD/ADHD Neurological Dis. Other Traumatic Brain Injury Total
Count
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Please specify with which culture you self-identify: _____________________ Have you been diagnosed with a disability? YES NO
If you have not been diagnosed, do you self-identify as a person with a disability? YES NO (Note: Participants were told verbally when given this sheet that the following two questions were optional.) If yes, please explain: _____________________________________________________________________________________ _____________________________________________________________________________________ __________________________________________________________ Please, describe the nature of your disability? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _________________________________________________
Participant Information Form IMPORTANT NOTES: 1) This information will be collated for all participants in order to describe the participant group as a whole (e.g. to determine the average age of participants, the number who live on/off campus, etc). 2) This information will not be communicated in the research findings in a way that discloses your identity 3) This information may also be used to provide background information in the description of your quotes (e.g. This 22-year old Mexican student said ). 4) This contact details page will be filed separately from interview transcripts. Furthermore, all other information and contributions you make to this research will herein be labelled using your participant ID number. 5) You have the choice to answer any, all or none of the below questions depending on your comfort level
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Contact Details Name:________________________________________________________________________ Address:______________________________________________________________________Phone number(s):____________________ Email address:______________________________ Preferred means of contact: Phone Email Other ______________________________________________ Is it ok to leave a message on your phone? YES NO Participant ID: __________ (Only for researcher's use)
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Office for Access and Diversity and School of Community and Regional Planning PLAN 515 Qualitative Methods Project Consent for Participants
Research Team Leads Dr. Penny Gurstein, Professor and Chair, School of Community and Regional Planning Ph: 604-822-6065; e-mail: gurstein@interchange.ubc.ca Dr. Pamela Ponic, Adjunct Professor, School of Community and Regional Planning and Postdoctoral Researcher, School of Nursing Ph: 778-938-3313; e-mail: Pamela.ponic@nursing.ubc.ca Individual Project Leads Team Leaders, PLAN 515 (to be named once course begins)
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Your participation is being sought in a service learning project being undertaken by graduate students from the School of Community and Regional Planning in conjunction with the Access and Diversity Office of UBC. The students are enrolled in PLAN 515: Qualitative Methods, and will be undertaking defined projects related to accessibility issues. Your participation will contribute to an enhanced understanding of student experience related to issues of social inclusion in public UBC spaces; Access and Diversity may use the information in its planning work with the campus. Invitation to Participate in an Interview Your participation is being sought for a 1-2 hour interview because you have self-identified as a UBC student who is a part of a non-dominant Canadian culture (e.g. international students) who has a medically diagnosed or undiagnosed disability and we want to discuss your experiences of accessing social and health services on UBC Vancouver campus with you. You will be asked questions regarding what serves you have used or would like to use, any barriers you might face (including cultural differences) to accessing the services, and how these barriers may be addressed. We appreciate your time as this information will help us understand how to make campus more inclusive of its diverse population. Confidentiality Confidentiality means that the information you share will not be reported or used in a way that would identify you. Although we cannot guarantee anonymity because these are group projects, your identity will not be revealed in any reports or public documents and this will help maintain public anonymity. Further, your identity as a research participant will not be disclosed to the Office of Access and Diversity or any other service providers on campus. As a service learning class, the primary course instructor is the Co-lead Principal Investigator and is responsible for ethical conduct. As a classroom project, your contributions cannot be used for any purpose other than course reports. By arrangement with the Access and Diversity Office, these reports will be delivered to their Office for their use. Data, including transcripts and field notes, will be retained for two years after the project finishes in a locked cabinet in the Principal Investigators office, as required by University ethics regulations. After two years the data will be destroyed. Benefits/risks This research will provide important and missing information which will help UBC in creating a more inclusive campus. We hope you will experience the associated benefits. You may experience a negative emotional reaction to the content of the interview, if the topic area is sensitive to you. In such cases, the Access and Diversity Office is available to provide you with support and referrals as needed.
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Your participation in this research is entirely voluntary. You may refuse to participate or withdraw from the project at any time. You have the right to refuse to answer any questions or stop the interview or your participation while it is in process. Your participation or lack thereof will have no impact on the services you receive from Access and Diversity or any other services on campus. If you choose to withdraw later, we can stop utilizing the materials you contributed, but we may be at a stage of report writing and analysis where it is impossible to separate our learning from you from the collective learning. Any further questions may be directed to Principal Investigator or Co-Principal Investigator. IF YOU HAVE ANY ETHICAL CONCERNS ABOUT THIS RESEARCH, PLEASE CONTACT: Principal Investigator: Dr. Penny Gurstein, Associate Professor, School of Community and Regional Planning, UBC. Ph: 604-822-6065; e-mail: gurstein@interchange.ubc.ca or Co-Principal Investigator Dr. Pamela Ponic, Adjunct Professor, School of Community and Regional Planning and Postdoctoral Researcher, School of Nursing Ph: 778-938-3313; e-mail: Pamela.ponic@nursing.ubc.ca If you have any concerns about your treatment or rights as a research subject, you may contact the Research Subject Information Line in the UBC Office of Research Services at 604-822-8598 or if long distance e-mail to RSIL@ors.ubc.ca.
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Appendix G: Poster