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Running Header: INTERNATIONAL STUDENTS WITH DISABILITIES 1

International Students with

Disabilities:

Evaluating barriers to

accessing social and health

services on campus

Yazmn Hernndez Bauelas, Zoe Yu Wang, Timothy Shah, Jason Lee, Adam Kebede

University of British Columbia

Planning 515

April 05, 2011

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INTERNATIONAL STUDENTS WITH DISABILITIES 2

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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 threeparticipants; 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 issueswith 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 illnessthey 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 .......................................................................................................... 275.0: 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 ........................................................................................................ 49Appendices ............................................................................................................................ 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 ofUBCs strategic plan to become a globally renowned institution (Hepburn &

Pennant, 2011). Within the A&D office (2011a), however, international students are

underrepresented: 112 studentsor 8.9 percentof 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 ofthe A&D offices 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 questionwhat are the

barriers international students with disabilities face in accessing social and health services on the

UBC-Vancouver campus? Other topics investigated throughout this project address the

following sub-questions:

What are the experiences of international students in accessing social and health services

on campus?

What are the key health and social services on campus?

How do cultural differences impact the experiences of international students?

What recommendations would international students make to enhance social inclusion?

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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 medicalstudents

1. Lack of time2. Not enough sessions with university care3. Stigma4. Negative career impact5. Fear of diagnosis in academic record

Givens & Tjia (2002) Depressed medical

students

1. Lack of time2. Lack of confidentiality3. Afraid no one will understand problems4. (tie) Stigma / Problems not seen as important6. Cost

Davies et al. (2000) Men 1. Conceal vulnerability, independence2. Lack of knowledge

3. (tie) Lack of time / no perceived susceptibility5. Advisor lacks credibility

6. Advisor doesnt understand culture (gay, ethnic)

7. Cost

Chew-Graham, Rogers, &

Yassin (2003)

Medical students Stress

Shame, embarrassment in admitting weakness

Lack of confidentiality

Later job prospects

Fear of diagnosis in academic recordYorgason, Linville, &

Zitzman (2008)

General population Real behaviours:

1. Lack of time

2. Lack of knowledge3. (tie) Did not think services would help /

embarrassmentHypothetical behaviours:

1. Lack of time2. Lack of knowledge3. Did not think services would help4. Cost5. Did not want to talk to stranger

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 numberincluding many of those

who would benefit from such servicesdo 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 campusesresidence halls and administrative programsare 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.

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Table 2: Five health domains influenced by culture according to Penn et al. (1995)

Health domains influenced by culture Definition

Seeking Health Care Cultural beliefs about disease and majorevents (births and deaths) influencingdecisions about health care

Preferred Treatment Cultural beliefs about health, illness, andtreatment influencing treatment afterdiagnosis

Acceptability of Health Care Cultural familiarity or knowledge affectinghealth care acceptability

Health Behaviour Cultural preferences and values affectingsources of knowledge, use of preventativehealth care, lifestyle

Interactions with Health Providers Cultural relations, processes affectingindividual and intergroup relations

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 ones willingness to access a service, stigma around mental health and

disabilities appears to be highly severe in the literature. There have been a range of studies

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completed on the subject of stigma as it pertains to mental health, neurological disabilities, and

accessing services.

Twardzicki (2008) defines stigma as a sign of disgrace or discredit, which sets a person

apart from others (p. 69); this reflects that that shame, disgrace, and stigma still are associated

with mental illness in todays society. Hyun et al. (2007) also report how the stigmatization of

mental illnesspossibly connected to the decreased recognition ofothers 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 self-

esteem (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 othersthis can include friends,

colleagues, or classmatesresulting in an awareness of negative stereotypes surrounding a

persons condition (Rao et al., 2009, p. 586). Eventually, this can evolve into enacted stigma: this

happens when discriminatory behaviour occurs; when the person with the condition believes in

the stereotypes surrounding his/her condition and internalises them, the stigma evolves from a

public stigma to self-stigma (Rao et al., 2009, p. 586). By accepting the stereotypes, self-esteem

and self confidence tend to drop (Corrigan, 2004, p. 618). As a result, Corrigan (2004) concludes

that self-stigma results in the avoidance of the label causing stigma, and as a result, a vast

decrease in willingness to participate in any sort of treatment (p. 618).

The way in which people manage perceptions of stigma affects their choice to access

health care. An important step to managing perceptions is self-disclosurein 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 readers understanding of a

phenomenon by extending the readers experience (VanWynsberghe & Kahn, 2007, p. 4). With

only three participants in the study, we decided to use a case study research approach to focus on

the experiences, behaviours and challenges of the participants in light of our main research focus.

The experiences of the participants allowed our research team to create themes and codes

to categorize the findings, which are discussed at length in the subsequent section. A thoroughly

conducted case study research project recognizes that the involvement of human participants will

generate data and stories upon which the researcher reflects and writes about. As our intention

was to grasp a comprehensive and in-depth understanding of the barriers international students

face, case study research is well justified.

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Outreach Strategy

The process of recruiting participants was a difficult albeit gratifying process. We

received ethics approval for our requested amendments in early February. We requested a series

of amendments to change certain terminology in our recruitment letter and our projects purpose

to make the study as unambiguous and open as possible. We made specific amendment requests

to ethics to include more flexible terminology such as students who self-identify with a non-

dominant Canadian culture. Moreover, we have also included space forstudents who may not

have a diagnosed disability but claim to have an impairment that affects their daily life. In

essence, the need for these changes stemmed from group consensus and deep reflection about

what we would like to get out of this project.

Once we received ethics approval, we proceeded to circulate our recruitment letter to

several academic departments including but not limited to geography, economics, psychology

and engineering. We figured it would be helpful to utilize the networks of our fellow graduate

school friends from these respective departments to circulate our recruitment letter. We also

passed along our study to the listservs of the A&D office and International House. Our ethics

approval also permitted us to utilize posters as a recruiting strategy. We did not put up too many

posters; these were limited to a bulletin board in International House.

Analyzing the Data

We utilized a coding structure that broke down the barriers as themes (see Table 3). We

initially used a comparative case study approach to make connections and relationships. But after

some discussion, we elected not to use this approach to ensure the anonymity and confidentiality

of the research participants. We broke up the reported barriers into themes to present the findings

in a succinct and presentable way, and to maximize the level of analysis.

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3.1: Methods

Semi-Structured Interviews

We completed three semi-structured interviews in our study. All three participants were

male and of Latin American ethnicity. One participant had a mental health problem (depression),

the other participants had neurological disabilities (learning processing disorder and attention

deficit hyperactivity disorder (ADHD). The participant with depression is a visiting international

student who has not accessed any of the social or health services on campus since he arrived.

Only one female student expressed interest in our study but we did not successfully recruit her.

Before we actually conducted the interviews with our participants, we forwarded the interview

guide to our A&D office advisor to review the nature of the questions and to receive feedback on

how to make them clearer and better focused. The ultimate purpose of using semi-structured

interviews was to learn about the various barriers international students with disabilities face in

accessing social and health services on campus (see Appendix A).

Until the interviews, our groups understanding of mental health and neurological

disabilities as barriers to service was constructed through reading the literature and other case

studies across North American campuses. On a more practical level, the semi-structured

interviews provided more of the context to UBC and the participants experiences with accessing

services here. The use of a semi-structured interview style employed an open framework

allowing for focused, conversational two-way communication.

The flexible nature of semi-structured interviews can confirm what is already known but

also provide the opportunity for further learning (Mason, 2002, p. 62). Mason (2002) explains

that semi-structured interviews are conversations with a purpose (p. 62). Our intention was to

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construct or reconstruct knowledge as opposed to excavating it. The use of probing questions

proved to be useful in soliciting information from the participants. When participants seemed

perplexed by certain questions in our interview guide, we resorted to our probing questions to

simplify what we were asking our participants. Our fieldnotes and continuous group debriefs,

allowed group members to reflect about how the interview went and how we can improve for the

next time.

Questions that generated the most data from our interviews included questions 8 and 11.

These questions were are there barriers you have encountered in accessing health and social

services that relate to being a non-domestic/international student?Question 11 was in general,

how do you feel about the experience of approaching/trying to approach the on-campus

social/health services? Both of these questions targeted the very nature of qualitative research

which focuses on the experiences, behaviours and feelings of the research participants, whoever

they might be. As semi-structured interviews are a flexible approach to seek information, we

thought of questions on the spot in light of the conversations we were having with the research

participants.

While we recruited three participants overall, our group decided to interview the first

participant twice. The first interview with the participant, while valuable in that in generated data

and helped build rapport, did not provide us with all of the information we had hoped for. In

essence, going through the interview with this participant allowed the group to test the research

instrument and ultimately give us a better understanding of the clarity and direction of the

questions. We did not provide the participant with enough information about the studys purpose.

We did e-mail all of the participants the interview guide prior to conducting the interview, but

the first participant did not understand the studys purpose, nor did he understand the questions

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we asked him. Upon reflection from the first interview, our group developed another set of eight

questions that were specific to participant one and re-interviewed him (See Appendix B). These

questions were not necessarily a deviation from the original interview guide, but were presented

in a clearer and simpler fashion to allow the participant to digest them and respond in a more

complete manner.

Fieldwork Diary

Following each interview, the interviewers were somewhat consistent in writing a

fieldwork diary. The purpose of this method was to reflect on how the interview went and to

evaluate our relationship with the research participant. Case study research uses afieldwork diary

to record the researchers observations, conversations and maps. Diaries are useful for examining

the researchers engagement in the process (Dowling, 2005, p. 22). In a research process, the

researcher becomes steeped in data, but at the same time cultivates analytical distance to enable

thinking about the data and to allow the imagination to work to see patterns in the detail, or how

apparently unrelated items might be connected (Pratt, 2006).

Pratt (2006) continues with discussing how a variety of devices might be used to aid this

distancing, for example, a research diary containing personal reflections on the research, ones

own involvement in and feelings about it. Fieldwork diaries have helped our research team work

hard to achieve 'analytic distance' from the role, to set aside taken-for-granted assumptions and to

see oneself in the role. Reflexivity has been crucial in the fieldwork diary process.

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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 disabilitywith 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 noteswhile 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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Running Header: INTERNATIONAL STUDENTS WITH DISABILITIES 28

Table 3: Barriers to accessing on-campus services

Barrier to accessing services Sub-themes Participants' insights (Paraphrased)

Communication Language 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.

inancialDifficulties affording a servicehat can help participants cope

with disability

My retesting period lapsed and I needed to get tested again, the lady at the A&D office was nice enough to use herdiscretion 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 givea prescription and that cost me $200 for one months supply. [Insurance] wont cover it without a diagnosis

nstitutional

roblems in the system that makedifficult to access a service

My previous school complied with all the recommendation from the testing centre. UBC only offers someaccommodations 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 onldrop-ins, and they have 2 month waiting lists [...] Two years ago, I met with a counsellor I really liked, but shes gonafter a semester; lack of continuity is the problem.

Lack of informationarticipant is unaware of theervice or do not know how toccess it

Concerning the access to services at UBC, I didnt know that UBC provides help and mental health service to studeWhen I heard of the study, I learned the services existed.

I did not find out through my orien tation, but I didn't tell [my advisor or people around me] about my disability eith

I would have liked to have some information [during the application process]; Im sure the information is availableI got none provided to me during the application process

ocio-Culturalhe influence of peoples health

eliefs, values and perception ofealth problems rooted in one'sulture or society

Transferable

health carebeliefs

I never use public health care services in [my home country or at my undergraduate university] because I have acceprivate 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 t

hospital here.

tigmaPerception ofstigma

If I dont explain to people, they look at my low energy and they will think this guy is lazy... they don't often assocwith a disease, it is often confused with a persons character.

I don't want people to know, if people notice (for example, people will notice me going to a different location for aexam), they will think I am faking my disability. They wont believe me.

I feel that people think I am dumber because I use the services [such as the A&D office].

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Table 4: Coping Strategies

Coping Strategies Participants Insights (Paraphrased)

Previous Knowledge:Use previous knowledgeor experience

I try to recall what I learnt from previous therapy, because I was treated for 1.5 years [] I try to use my previousknowledge from therapy [to cope with disabilities].

Drugs:

Use drugs (medication,cigarette, coffee, etc.)

I take medicines, you get used to medicines when you have disabilities. [] But I also used to smoke. These are mytwo basic supports, friends and cigarettes. [] I use a lot of coffee to cope with that and cigarettes. I dont smoke much[] in a way, I want to make efficient use of this [limited amount of] energy. I try to use it in my work. Just you know,have your cigarettes and coffee and go to work.

Medicine gets rationed []Im almost out now, but Im saving it up for the exams.

Coping through rationing, [I] know when theres going to be a hard day [] [I] learn when to use [the drugs], how touse them.

Family:Seek help from familymembers

In first term I didnt bother to find resources, but I didn't do well with my tests [] and then I spoke with my mom sheencouraged me to look. And I found services online.

Friends & Community:Seek help from friends orcommunity

I look for my friends here, Ive made good friends here. Thats the community that I talk about. [] A place like thisis a place for people with disabilities. It is a more tight community. You are surrounded with great people. [] Theactivities of community, because we have breakfast together [] you talk and you expand your social networks. Otheractivities, 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 cantchange the system so you just make fun of it.

[My department]is better because its smaller department, smaller classes. I study better in groups I have a couplefriends to study together with. [] [I study] just on my own or with friends.

Academic Advisors:Seek help from teachers or

Academic Advisor of thedepartment

I have academic advising and international advising. [] I could get a note taker but it costs more money so I dontdo 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 verypersonalized.

Accessing Service:Access service andaccommodations fromservice providers

Socially, I just live with it; with academics, at my old school they just gave me unlimited time. With the SATs I gotdouble 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.

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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,

websitesboth of the university and the facultiescan 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 challengesone 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 ourparticipants 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 ones 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 self-

stigma 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 well-

aware 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 reactionthe

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-stigmathus moving through the stages of

how stigma affects people presented in Rao et al. (2009, p. 586).

We can only speculate on this finding because we did not obtain any more information

from the participant; however, more work must be carried out on this particular topic with UBC

students with a mental health or neurological disability. This should be done both quantitatively

and qualitatively with a larger sample size to generate a holistic understanding of perceived

stigma and the strategies universities could use to better address them. Despite our small sample,

we have come up with some recommendations that we advise the A&D office to consider.

The recommendation regarding stigma is as follows:

In addition to the provision of more information, the A&D office could partner with UBC

Housing and create a section in the August resident advisor (RA) training to better inform

RAs about social and health services on campus. Moreover, RAs should spend some time

when their students first arrive to explain services provided by UBC to all groups,

including students with mental health and neurological disabilities. This can reinforce the

idea of diversity to the student body, generate awareness about these issues, enhance

inclusion, and minimize perceived stigma.

Private and Public Health Care

Strong views on the superior quality of private health care vis--vis the public system

were something which was mentioned during two of the interviews. Two participants held strong

opinions that private health care is better than public health care; however, neither have had a

personal experience with the Canadian health care system. This finding is significant as previous

research has found that unfamiliarity with a given country's health care system discourages use

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by culturally different patients (Hoang & Erickson, 1985, p. 229). For instance, Canada's

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 beliefswhen combined, these issues become a

significant barrier to accessing health care services.

If participants are used to private health care, their perception and expectation of the

public health care system may be inadequate. Furthermore, when participants rely on other

international students or their parents to assess the quality of Canadas care, they may never

receive access to information necessary to familiarize themselves with the way the public system

functions, which may in turn foster dissatisfaction with the system. The 1995 Penn et al. analysis

of the interrelation between culture and class named this barrier acceptability of health care (p.

641); interestingly, when asked directly if they thought culture was a factor in the barriers to

accessing health care, the two participants both said no.

One of the participants who used private health care at home stated that he did so because

it is better; he also mentioned that he does not know if that is true of Canada. He elaborated on

his choice of health care by saying he normally chooses services based on proximity to his on

campus residence. However, the only one time he has felt ill, he went to a private health clinic

off campus. As researchers, we often found ourselves trying to inquire about the reasons behind

the participants actions, choices, and strategies for coping. In this case, however, the participants

were reluctant to share details or did not think those details were relevant to the barriers they

experience in accessing health care.

The recommendations regarding health care provision are as follows:

Further research must be undertaken to investigate the preconceptions and health care

beliefs that international students bring with them when they arrive to Canada. While

much work has been done on immigrants, there is little research looking at

international students in a university setting.

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During orientation, international students should be provided with a description of

what Canada's public health care system offers and the way it functions.

The International Student Handbook should make an effort to explain to students the

characteristics of health provision in Canada such as: the average waiting time for

appointment, the de facto one question per visit policy in clinics, prescription and

refill processes for medicine, referral system for access to specialized doctors, and

other ideas which non-Canadians may not be familiar with.

5.4: Communication

Language was identified by one participant as a significant deterrent from accessing mental

health services. In Canada, the provision of linguistically appropriate health promotion and care

hasbeen 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.

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The recommendation regarding financial barriers is as follows:

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.

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 drugsboth prescription and non-prescriptionwas 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

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his from receiving the same prescription medicine in Canada. Understanding the coping

strategies of stigmatized individuals requires one to understand their unique experiences and

circumstances. While rationing medication seems like a stressor itself, this strategy speaks of the

many ways in which existing barriers to accessing health services affects the life choices made

by international students.

Family

One participant mentioned he called her mother once he encountered difficulties

functioning within the UBC academic context. It is important to mention this was not the case

for all participants: one of our participants clearly stated that his family simply could not help

him cope with his disability; thus, he chose to rely on his friends and the community around him

instead.

Friends and the UBC Community

Seeking help from friends and the community is a coping strategy used by all three

participants. The participants all mentioned how their friends and the UBC community, either

academic or residential, support their studies and life. When they have a couple of friends to

study with, have breakfast together in the residential community, or to simply get together

with friends, they develop a sense of belonging, which helps them through their respective

difficulties. One participant told us that upon transferring from a large department to a smaller

one with fewer students, he found that he liked the smaller classes, where he was able to made

friends with others in his department.

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Academic Advisors

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

Knowledge

The A&D office and other health services should provide more information upfront, such asduring the orientation process, making services visible, and allowing for students to be awareof the existence of services on campus. While this can be done at larger orientations, it maybe preferable to do so in smaller venues with each faculty, so that students would be moreaware of where to seek help when necessary. We suggest that a student assistant could behired 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 toinform new undergraduate and graduate students about the A&D office and the diversity ofthe UBC student body. It should be stressed that there are a number of students with mentalhealth illnesses and neurological disabilities on campus, and to be mindful that universitiesare diverse, open-minded, and accessible places.

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 raiseawareness. 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 fromstudents, including graduate students, international students, and students who are currentlyusing services. This information should include recognition of mental health issues, includingsymptoms of depression and other disorders, as this may not be readily understood in allcultures. Such information would help in raising awareness and allowing for knowledgeregarding mental health, while also giving the A&D office and other services a presence oncampus beyond just service provision. Further, it would provide information and contextabout the diversity of students at UBC and the various challenges they have in their academic

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and personal life

Education specific to international students about mental health, including coping and stressrelief 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 withstress and exam anxiety. This could reinforce that all students have their own personalchallengesone of which may be related to mental health.

Institutionalbarriers

The A&D office should advocate for funding ensuring continuity of service by providingconsistent and adequate service to students. Students should be able to receive all the differentservices that they need, even if the system is fragmented. Many different service providersmust be involved for full accommodation and treatment. In addition, services shouldcollaboratively direct students who are unable to receive service in a timely manner to othersame-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 asystem to allow for mental health diagnosis documentation from other countries not currentlyaccepted 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 donot hinder the access of international students to adequate services on campus. A first steptowards this could be the creation of an inventory of the types of documentation that are notaccepted by UBC, and the differences in diagnosis.

Socio-culturalbarriers

Stigma

In addition to the provision of more information, the A&D office could partner with UBCHousing and create a section in the August resident advisor (RA) training to better informRAs about social and health services on campus. Moreover, RAs should spend some timewhen their students first arrive to explain services provided by UBC to all groups, includingstudents with mental health and neurological disabilities. This can reinforce the idea ofdiversity to the student body, generate awareness about these issues, enhance inclusion, andminimize perceived stigma.

Beliefs onhealth careprovision

Further research must be undertaken to investigate the preconceptions and health care beliefsthat international students bring with them when they arrive to Canada. While much work hasbeen done on immigrants, there is little research looking at international students in auniversity setting.

During orientation, international students should be provided with a description of what

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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 thecharacteristics of health provision in Canada such as: the average waiting time forappointment, the de facto one question per visit policy in clinics, prescription and refillprocesses for medicine, referral system for access to specialized doctors, and other ideaswhich non-Canadians may not be familiar with.

Communication

More research is needed to identify possible solutions for this barrier: it is not feasible toprovide counselling and psychotherapy in all languages; however, varied accommodationscan be designed for people in this situation. It would be important to look at best practicesamong other university campuses, including those in non-English speaking countries, to seehow language barriers to accessing health care services have been addressed.

Financial barriers

Create a special fund for diagnostic testing on campus that can provide money for s tudentsnot currently eligible for funding. If students must pay for their testing, look into differentpayment strategies or financing opportunities that can come out of this funding pool fortesting that cannot be paid for upfront as a lump sum.

Coping strategies The A&D office could promote strategies that focus on healthy and positive co

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