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International Students with Disabilities: Evaluating barriers to accessing social and health services on campus
Yazmín Hernández Bañuelas, Zoe Yu Wang, Timothy Shah, Jason Lee, Adam Kebede University of British Columbia Planning 515 April 05, 2011

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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.

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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

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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 UBC‟s 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 office‟s registered users. Definitions for the two categories provided by the A&D office (2011a) are presented verbatim as follows:

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● 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

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(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?

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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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2.0: Literature Review
The literature of fundamental importance to this study pertains to various barriers university students with mental health needs or neurological disabilities face in accessing services. The literature features discussion of students (both undergraduate and graduate) with a particular focus on international students. This section reviews a number of barriers: these include the lack of knowledge about a disability or services offered on campus; institutional barriers causing high demand on a service and thus lowering its quality; financial barriers relating to diagnostic testing and the high expenses of being an international student; the debilitating nature of stigma around mental health; and prominent cultural barriers that affect access to health services. Multiple studies have looked at barriers to health services for those at universities. The subjects of these studies have differed, with recent studies published pertaining to medical students (Chew-Graham et al., 2003; Tjia et al., 2005; Givens and Tjia, 2002), men (Davies et al., 2000), and general student populations (Yorgason et al., 2008). Table 1 summarizes the most common barriers found to prevent access to health services in each of the studies: issues which were prevalent throughout the research were a lack of time, a lack of confidentiality, and a fear for later job prospects. These issues provide a context for the multiplicity of issues faced by students with neurological or mental health illnesses that can be prevalent across university campuses.

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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 doesn‟t 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

Givens & Tjia (2002)

Depressed medical students

Davies et al. (2000)

Men

Chew-Graham, Rogers, & Yassin (2003)

Medical students

Yorgason, Linville, & Zitzman (2008)

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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2.2: Institutional Barriers
In a study of early experiences of university students with disabilities in United Kingdom, Goode (2007) discussed the institutional barriers for students in accessing on-campus health services (pp. 45-46). The slow pace of the bureaucratic process beyond the university and the length of time that students needed to wait for reasonable accommodation constituted large obstacles in students‟ studies and life. The long waiting list for adequate service, cumbersome application forms for service, and the use of unfamiliar bureaucratic terminology have been identified as difficulties in accessing service for adolescents with developmental disabilities (Betz, 2007, p. 106). Similarly, a study led by Wilson (2000) indicated that a lack of coordination and timely service from service centres diminished efficiency, failing to providing support and accommodation to students with minimal disruption in their academic course work (pp. 45, 47). Concerns were also expressed about the lack of formal policy and procedural guidelines, leading to services being provided in an inconsistent manner across disability groups (Wilson et al., 2000, pp. 39, 45, 50).

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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Seeking Health Care

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

Acceptability of Health Care

Health Behaviour

Interactions with Health Providers Source: Lee (2003), p. 3

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 one‟s 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 today‟s 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 person‟s 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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2.5: Financial Barriers
A study by McClaran and Sarris (1985) identified that international students utilize health services less than other students; students identified areas of concern that affect their access to services (p. 3). Some of these concerns include insurance policies, communication between patients and providers, and information about available health care services (McClaran & Sarris, 1985, p. 3). Another study by Sharif (1998) on international students in the United States identified language, financial issues, and stress as barriers to health care utilization. Furthermore, insurance forms and claim procedures also acted as barriers to the use of health care services (Sharif, 1998, p. 13). Lartey et al. (2009) explored the factors influencing the health behaviour of international students at another American university. In their study, surveys were given to 525 international students. The response rate was 81 students (15 percent). On the use of health care services, 56 percent reported not to have used any of the services within the past year; 57 percent of the respondents perceived the lack of understanding of insurance policy while 53 percent perceived co-payment as barriers to health care utilization services (Lartey et al., 2009, p. 136). While this article does not speak directly to personal financial barriers, such as testing and documentation, there is a useful discussion around the complication of insurance policies. On the note of insurance policies and co-payments, the authors conclude that “a better understanding of insurance policies will help students use health services easily when they need them” (Lartey et al., 2009, p. 137). Furthermore, the authors emphasized education as a main means of understanding: because students come from cultures with different insurance systems, Lartey et al. (2009) reason that there is a obvious need to provide students with “a clear

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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).

2.6: Communication Barriers
According to the literature, language is one of the greatest barriers in access to health promotion programs for people of non-English speaking backgrounds in Canada. A quantitative study conducted by Bowen (2000) correlates official language proficiency with health. Language also interacts with other determinants of health, such as race, culture and ethnicity, and is the means by which people become acquainted with the health and social services active in their community (Agic, 2003, p. 6; Woloshin et al., 1997, p. 476). In turn, effective communication is the foundation for adequate health care provision and the management of disabilities. Communication difficulties, whether due to cognitive, social, physical impairment or because of language difficulties are a significant barrier to accessing health care. Yeo (2004) argues that the “improvement of communication between patients and providers in relation to health disparity consists of cultural competency and communication

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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 reader‟s understanding of a phenomenon by extending the reader‟s 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 project‟s 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 group‟s 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 study‟s 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 study‟s 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 researcher‟s observations, conversations and maps. Diaries are useful for examining the researcher‟s 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, one‟s 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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3.2: Research Limitations
A first limitation we faced was that all three of our participants were male and Latin American. While not all Latin American countries share a culture, they are more similar to each other than they are to other cultures around the world. Furthermore, we lacked a female perspective on the issues; studies have shown that male and female responses to disability and coping can be vastly different from one another (Davies et al., 2000, p. 259). As a result, having only one gender limited the data garnered from the interviews. Another limitation we faced was the inability to transcribe interviews due to the ethics review. Because of this, interviews were recorded by hand, through note taking; thus, some of the rigour was lost before the analysis began, as participants could not be quoted word-for-word, and some meanings may have be inadvertently changed or lost early in the process. As a result, none of the quotes provided are truly quotations, and while we did follow-up with participants in areas where we were unclear, it is possible that interpretation could have been done during the transcription of the interview. In qualitative research there is a process called “participant checking” whereby the interview transcript can be given to the participant for vetting or authorizing (Dunn, 2005, p. 98). This process can not only improve the quality of the transcript but it also “continues the involvement of the participants in the research process and provides them with their own record of the interview” (p. 98). We did not forward the transcripts to our research participants because of time constraints; thus, this can be seen as a limitation in our study. Our ethics approval only allowed for the use of interviews and of mapping as data collection methods. Throughout our research we found out that mapping was not an adequate

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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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4.0: Research Findings
While our initial intent was to explore barriers to both social and health services on campus, our participants focused on discussing barriers to accessing health care services. The various barriers reported are presented in Table 3. These barriers are somewhat consistent with the findings in the literature. Barriers such as financial, institutional, lack of knowledge/information, socio-cultural and stigma all were mentioned in the course of the study. A particular and perhaps unique finding in the socio-cultural category is in regard to the beliefs and perceptions about private and public health care. This issue, along with other findings, are summarized in Table 3 and will be discussed and analyzed in Section 5. Table 4 summarises the coping strategies used by the participants. While coping strategies are not barriers, we feel that coping is an alternative to seeking official care. While participants identified several barriers to accessing health services, they also explained various mechanisms they use to cope with the disability – with accessing services being one of many coping mechanisms. The quotes presented in Tables 3 and 4 are approximations of what the participant said during the interview; as mentioned in the limitations section, we were not allowed to record interviews, and as such, were unable to take down what the participants said word-for-word. We have attempted to reconstruct sentences from the notes – while the results are presented as quotations, we would like to make clear that they are paraphrases, and unequivocally state that despite the appearance of quotation marks, they are not direct quotations.

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Table 3: Barriers to accessing on-campus services
Barrier to accessing services Sub-themes
Communication Financial Difficulties affording a service that can help participants cope with disability Language

Participants' insights (Paraphrased)
    “My psychiatrist advised me to treat myself with therapy here [...] language would be a barrier that is difficult for therapy. In psycho-therapy you have to express yourself, and it's very difficult.” “My retesting period lapsed and I needed to get tested again, the lady at the A&D office was nice enough to use her discretion and I was able to sign up again… otherwise it would cost me thousands of dollars.” “UBC wanted me to get re diagnosed, but I am not okay with paying $2000. Plus, I need to convince doctors to give me a prescription and that cost me $200 for one month‟s supply. [Insurance] won‟t cover it without a diagnosis” “My previous school complied with all the recommendation from the testing centre. UBC only offers some accommodations of those recommended for my condition.” “My diagnosis from home is not recognized by UBC” “I have gone for counselling and this service is not equipped for the number of people that use the service. They only do drop-ins, and they have 2 month waiting lists [...] Two years ago, I met with a counsellor I really liked, but she‟s gone after a semester; lack of continuity is the problem.” “Concerning the access to services at UBC, I didn‟t know that UBC provides help and mental health service to students. When I heard of the study, I learned the services existed.” “I did not find out through my orientation, but I didn't tell [my advisor or people around me] about my disability either.” “I would have liked to have some information [during the application process]; I‟m sure the information is available, yet, I got none provided to me during the application process” “I never use public health care services in [my home country or at my undergraduate university] because I have access to private therapy there [...] generally, private health care is better than public where I come from” “I went to the Clinic in the Village, just because I wanted to see if I had a problem. This is private clinic, I am quite satisfied.” “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.” “If I don‟t explain to people, they look at my low energy and they will think this guy is lazy... they don't often associate it with a disease, it is often confused with a person‟s character.” “I don't want people to know, if people notice (for example, people will notice me going to a different location for an exam), they will think I am faking my disability. They won‟t believe me.” “I feel that people think I am dumber because I use the services [such as the A&D office].”

Institutional Problems in the system that make it difficult to access a service

 

Lack of information Participant is unaware of the service or do not know how to access it Socio-Cultural The influence of people‟s health beliefs, values and perception of health problems rooted in one's culture or society

    Transferable health care beliefs   

Stigma

Perception of stigma

 

INTERNATIONAL STUDENTS WITH DISABILITIES Table 4: Coping Strategies
Coping Strategies Previous Knowledge: Use previous knowledge or experience Drugs: Use drugs (medication, cigarette, coffee, etc.) Participants’ Insights (Paraphrased)  

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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 don‟t 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 […] I‟m almost out now, but I‟m saving it up for the exams.” “Coping through rationing, [I] know when there‟s going to be a hard day […] [I] learn when to use [the drugs], how to use them.” “In first term I didn‟t 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, I‟ve made good friends here. That‟s 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 can‟t change the system so you just make fun of it.” “[My department] is better because it‟s 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 don‟t 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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5.0: Discussion & Recommendations
The section will begin with a discussion of the findings. We will draw connections between the findings of our case studies, and relate our discussion back to the literature. After looking at each barrier in our study mentioned in the literature review, we will provide recommendations that are directly relevant to the findings which can help the A&D office with their advocacy efforts. All recommendations are summarized without discussion in Section 6.

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.

5.2: Institutional Barriers
In this case, institutional barriers are defined as issues or problems within UBC which make it difficult for international students to access services. We identified two barriers through our research. The first barrier is associated with non-acceptance of diagnosis documents from foreign countries: one participant failed to receive accommodation from the A&D office, because his “diagnosis from home is not recognized by UBC”. International students with diagnosis documents not accepted by the university must be re-diagnosed in Canada, a costly procedure. In some cases, although documentation of the diagnosis is accepted, institutional barriers continue to persist. As one participant said, “UBC only offers some accommodations of those recommended for my condition”. Mental disorders and illnesses vary in definition and thus, can be diagnosed differently in different cultures (Lin & Cheung, 1999, p. 774). The most used assessment tool for mental health, the Diagnostic and Statistical Manual of Mental Disorders developed by the American

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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 participant‟s 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.

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5.3: Socio-cultural Barriers
Socio-cultural barriers refer to the influence that cultural and social settings have in affecting one‟s beliefs, perceptions, and behaviour. Throughout the three cases we explored, we identified two socio-cultural barriers: stigma and beliefs regarding health care provision. Stigma One participant stated that he did not want his friends or classmates to know that he accessed the A&D office for his neurological disability; he was worried that they would judge him and think he was “dumber” or faking his condition. These beliefs, whether true or not, do not appear to be abnormal for someone with a mental health need or neurological disability. This is related to the threat of social disapproval or “diminished self-esteem” associated with selfstigma of a mental health illness; this has been shown to lead to service underutilisation (Corrigan, 2004). Although the participant accesses the A&D office for his neurological disability, the perceived stigma around this generates negative thoughts including his beliefs around “being dumber” or “faking it”. While we cannot be completely certain in describing the stigma process associated with our research participant, we feel it is similar to a process described by Rao et al. (2009). The participant had mentioned negative comments from his parents; as a result, he has been wellaware of the negative stereotypes regarding his condition. It is possible that he has slowly internalised these stereotypes and led to self-stigma: this is possible because of his reaction – the idea that having a disability could make others perceive him to be “dumber” is something which shows that he has negative feels about his own condition. As a result, it is possible that he has

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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-à-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 Canada‟s 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.

INTERNATIONAL STUDENTS WITH DISABILITIES 

40

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.

5.5: Financial Barriers
In this project, financial barriers are defined as difficulties affording a service that can help a student cope with a mental health need or neurological disability. One participant noted that the cost of diagnostic testing was overwhelming when told that it would cost $2,000 for diagnostic testing in Canada, despite having documentation from his home country. As a result, the participant was discontent and highly stressed. Sharif (1998) found that international students identified language, financial issues, and stress as barriers to health care utilization (p. 11). Hyun et al. (2007) also found financial issues to be a barrier to mental health access for international graduate students; international students were found to be more likely to report having financial problems than domestic students (p. 113). While neither study speaks directly to the financial stress around diagnostic testing, they nonetheless point to stress surrounding finances, which can include higher tuition payments or thousands of dollars in payment toward diagnostic testing. While the A&D office is aware of the high cost of diagnostic testing for students with neurological disabilities, we found that the student was unaware that the documentation from his home country would not be accepted in Canada, and worse yet, it would cost $2,000 to receive proper documentation. This amount can be substantial for any student, domestic or international, but when paying higher tuition fees, it can be even more financially burdensome.

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

42

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.

5.6: Coping Strategies
Coping has been defined as “how people regulate their behaviour, emotion, and orientation under conditions of psychological stress” (Skinner and Wellborn, 1994, p. 112). In our study, we found that participants use a range of coping strategies. Assessing coping strategies and their effectiveness is complicated, as responses to stressors depend on life experiences, as well as other factors, including cumulative mental and physical health. Our research identified six broad coping strategies which are explored throughout this section. Previous Knowledge One participant mentioned that in order to cope with his disability he incorporates the strategies, exercises and suggestions he received from his therapist while he had access to psycho-therapy back in his home country. Drugs The use of drugs – both prescription and non-prescription – was a coping strategy used by two participants; one participant mentioned cigarettes and coffee as his most commonly used strategy for coping. However, the more worrying finding in this topic was to hear the story of a participant who rations his prescription medication as the lack of a Canadian diagnosis prevents

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.

INTERNATIONAL STUDENTS WITH DISABILITIES Academic Advisors

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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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6.0: List of Recommendations
To make it easier for the reader, this section is a collection of all of the recommendations we have listed in the Section 5. Table 5: Recommendations Barriers

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

INTERNATIONAL STUDENTS WITH DISABILITIES
and personal life 

46

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

 Beliefs on health care provision 

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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 student‟s 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. Ponic‟s 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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Pratt, N. (2006). Qualitative Research. Plymouth, England: Faculty of Education, University of Plymouth. Retrieved from http://www.edu.plymouth.ac.uk/resined/qualitative%20methods%202/qualrshm.htm Rao, D., Choi, S.W., Victorson, D., Bode, R., Peterman, A., Heinmann, A., & Cella, D. (2009). Measuring stigma across neurological conditions: The development of the stigma scale for chronic illness. Quality of Life Research, 18(5), 585-595. Sharif, B. (1998). The forgotten world on campus: Acculturation and health issues of international students. Health Educator, 30(1), 11-18. Skinner, E. A. & Wellborn, J. G. (1994). Coping during childhood and adolescence: A motivational perspective. In D. Featherman, R. Lerner, & M. Perlmutter (Eds.), Life-span development and behavior (Vol. 12) (pp. 91-133). Hillsdale, NJ: Erlbaum. Twardzicki, M. (2008). Challenging stigma around mental illness and promoting social inclusion using the performing arts. The Journal of the Royal Society for the Promotion of Health, 128(2), 68-72. Tjia, J., Givens, J. L., & Shea, J. A. (2005). Factors associated with undertreatment of medical student depression. Journal of American College Health, 53(5), 219-224. University of British Columbia Public Affairs. UBC facts & figures (2009/2010). Retrieved from http://www.publicaffairs.ubc.ca/services-for-media/ubc-facts-figures/ VanWynsberghe, R. & Khan, S. (2007). Redefining case study. International Journal of Qualitative Methods, 6(2), 1-10.

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Appendices

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Appendix A: Key Informant Interview Guide
1) What country are you from? / ----What is your ethnic background? 2) When did you arrive to Canada? 3) What year are you in? 4) Have you been diagnosed with any type of disability (e.g. physical, mental, learning, etc)? 5) What barriers, related to your disability, do you encounter in your environment? 6) What social services have you accessed on campus? 7) What health services have you accessed on campus? 8) Timeline: When did you access the service e.g. first year, fourth year? How long did it take you to access the service? b) How long did it take for you to hear about the services? 9) Are there barriers you have encountered in accessing health and social services that relate to being a non-domestic or International student? 10) If you can design an ideal service to accommodate your disability, what would it be? b) What would it take to come into practice? PROBING QUESTIONS:
   

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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  

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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 doesn‟t 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 haven‟t?  If you know where they are located, please point them out to me on this map.

3. Why haven‟t you used these services? Do you face barriers to access? If so, what are they?

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Appendix B: Additional Interview Guide
This interview guide was used for the second interview of a participant: 1) What would constitute ideal treatment or accommodation for your disability on campus? 2) What would it take to be realized? 3) Do you access support systems or use coping mechanism that involve reaching out to people back home? (eg. Calling your therapist, family, friends, etc.) 4) During our last interview you mentioned that you often feel tire and lazy. But then you dais lazy was not the right word to describe that feeling associated with depression. Could you explain what you meant by lazy? 5) Let say you are going through a difficult time ....do you seek help? 6) If yes, who do you turn to? 7) In our first interview you mentioned that people in your home country seemed less knowledgeable or understanding than Canadian. Yet you seem to be very open and willing to speak about your disability. Were you as open minded toward disabilities before you were diagnosed? 8) In our last interview you mentioned that in your home country you had access to a private therapist and that in general public healthcare offered through the university is not that great. What do you think of the public vs. Private health care in Canada?

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Appendix C: Registrations with the Access and Diversity Office
Type of Disability Chronic Health Disability Hearing Disability Mental Health Disability Neurological Disability Physical Disability Suspected Disability Temporary Disability Visual Disability Total Count 154 31 278 427 123 76 119 40 1,248

Neurological Disability – breakdown by type Learning Disability ADD/ADHD Neurological Dis. – Other Traumatic Brain Injury Total

Count

201 122 75 29 427

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Appendix D: Screening Questionnaire
Are you an international student? YES NO

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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in sharing this information with the research team.

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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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Appendix E: Consent Form

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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Purpose

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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 Investigator’s 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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This is the only known risk at this time. Consent

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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.

_______________________________________________________________________ Participant Name - Printed

_______________________________________________________________________ Participant Signature Date

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Appendix F: Recruitment Letter
Dear UBC student: A group of graduate students in the School of Community and Regional Planning are conducting a community service learning study on the barriers that students who self-identify as being part of a non-dominant Canadian culture (e.g. international students) face in accessing social and health services on campus. We are interested in the experience of students who have a medically diagnosed or undiagnosed disability. Social services on campus might include but are not limited to Speakeasy, SafeWalk, the office of Access and Diversity, Advocacy Office, AMS resource groups, and the International Peer Program at I-House. Examples of health services may include counselling services, Nurses on Campus, UBC Psychology Clinic, and the Wellness Centre. Your participation in our study can reveal important insights into what the barriers are and how the UBC campus can be more accommodating. The Office of Access and Diversity may use the information in its planning work with the campus. The study will involve a 1-2 hour interview in a location and at a time of your convenience. Two group members will be present at the interview. If you would like further information regarding participation in this study, please contact the course instructor, Dr. Pamela Ponic, by e-mail at pamela.ponic@nursing.ubc.ca. Participation in this study is voluntary and you are allowed to terminate your participation at any time. More information about this is provided in the consent letter. We hope that the results of this study will be of interest and benefit to those involved and the wider UBC community. We very much look forward to speaking with you and thank you in advance for considering this request.

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Appendix G: Poster

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