Simmons University - Barriers to Academic Success …beatleyweb.simmons.edu/.../original/cec4be63d8b44b7… · Web viewThe American Dental Association’s (ADA) 2015 Survey of 1st

ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 1

PERCEIVED BARRIERS TO ACADEMIC SUCCESS FOR INTERNATIONAL STUDENTS STUDYING DENTAL HYGIENE IN THE UNITED STATES

Simmons College

The School of Nursing and Health Sciences

A Dissertation Defense

by

SUSAN JENKINS

Submitted in partial fulfillment of the requirements

for the degree of

Doctor of Philosophy

May 12, 2018


Table of Contents

Signature Page 4Committee 5 Acknowledgements 6Abbreviations 7Abstract 8

Chapter 1Introduction 9 Problem Statement 13Purpose 15Research Questions 15

Chapter 2Literature Review

Overview 17Barriers to Academic Success for International Students 19Barriers to Academic Success for Students Studying the Health Professions 21International Students’ Ability to Overcoming the Barriers 24Pertaining to Their Academic Success

Chapter 3

MethodologyOverview of the Study 28Recruitment 31Participant Selection/Setting 32Inclusions & Exclusions 32Data Collection and Procedure 34Data Analysis 36Rigor 36Human Subjects Protection 38

Chapter 4 Results Introduction 40 Participant Demographics and Characteristics 40 Themes 42 Theme One: Language – “I am embarrassed to ask” 42 Theme Two – Communication “Patients are Not Going to 44 Understand Me or I’m Not Going to Understand Them” Theme Three – The Educational System: 45 “What is a multiple choice question”? Theme Four – Culture: “Can I Leave the Classroom 46 without Permission?”


Theme Five: Belonging “Hanging out” 47Theme Six: Diversity: “A Positive Presence” 49

Chapter 5Discussion and Conclusions 52Limitations of the Research 54Implications for Dental Hygiene Education 55Future Research 56Conclusions 56

References 59 Appendix

Appendix A Student Recruitment Flyer 69Appendix B Student Recruitment Email 70Appendix C Informed Consent 71Appendix D Interview Guide 73

Appendix E Survey Monkey© Participant Inquiry to Participate 75 Appendix F Survey Monkey© Demographics 77

Appendix G IRB Project Description Templat3 79 Appendix H Simmons IRB Request for Review 83

Appendix I Simmons College IRB Approval Document 87Appendix J MCPHS University IRB Approval Document 89



Committee Members

I would like to thank my committee for their encouragement and support.

Eileen McGee, PhD, RN, Chair, Associate Professor of Practice Simmons School of Nursing and Health Sciences Jean Christoffersen, PhD, PMHCNS-BC, Associate Professor of Practice Simmons School of Nursing and Health Sciences

Linda Boyd, RDH, RD, EdD - Professor & Dean, Forsyth School of Dental Hygiene MCPHS University


Acknowledgements

To Dr. Eileen McGee, Thank you for assuming the role of chair of my committee in the

midst of my journey. Your no nonsense demeanor was refreshing. You were always positive

and willing to help me complete this journey.

To Dr. Jean Christoffersen, Thank you for joining my committee, also in the midst of my

journey. You were always encouraging and positive.

To Dr. Linda Boyd, my Dean and the only constant on my committee from day one. You

were always there for me as I weathered the ups and downs of my journey. I am forever

grateful.

My sincere gratitude and thanks to my expert readers Dr. Pam Bretschneider, for her APA

expertise and Dr. Craig Mack, for his willingness to participate as a focus group facilitator

and for his constant encouragement. Your input and support throughout my dissertation

journey was greatly appreciated.

To Dr. Dianne Smallidge, not only one of my expert readers, but my colleague and

friend. Our weekly “let’s get our dissertations done” meetings were invaluable. Words

cannot describe my gratitude.

To Robert, my life partner, who has always encouraged me to continue my education,

you always say “no education is ever wasted”. Your love and support though out this

journey was amazing. I am so grateful to share my life with you.


List of Abbreviations

ADA – American Dental Association

BSN – Bachelor of Science in Nursing

GPA – Grade point average

IEE - Institute of International Education

IRB - Institutional Review Board

MCPHS - Massachusetts College of Pharmacy and Health Sciences

TOEFL - Test of English as a Foreign Language

U.S. – United States U.K. – United Kingdom


Abstract

The number of international students coming to the United States (U.S.) for post-secondary

education has been steadily increasing. The research suggests international students

encounter many barriers to their academic success. Research has been done in this area;

however, it has not been conducted for the discipline of dental hygiene. Overlapping

qualitative methods, including focus group methodology and one-on-one interviews, was

utilized to answer the research questions: “What strategies international students employ to

overcome barriers and challenges to their academic success;” and “What strengths do the

international students feel they bring to U.S. dental hygiene programs.” Data collection was

achieved through semi-structured focus group interviews and one-on-one interviews. A

purposive, homogeneous sample of study participants included international dental hygiene

students attending three dental hygiene programs. A flexible interview guide was utilized to

guide group discussion. Transcripts of interviews and field notes were analyzed through

qualitative content analysis. Credibility and dependability was used to demonstrate rigor.

The study found international students studying dental hygiene in the United States have

similar challenges as other international students in other disciplines. The most significant

barrier found to play a role in the academic success of this group of 12 international

students, was comprehension of the English language. Didactically, students found they

needed additional time to study and to process examination questions. In the clinical setting,

some found communication with patients to be a challenge.

Keywords: international students, barriers, academic success, focus group, dental hygiene


Chapter I

Introduction

The character of most United States (U.S.) higher education institutions and those

offering dental hygiene have change significantly since the 1950s (ADA, 2015; Studying in

the U.S.A, 2015;). Changes in the population and available funding for domestic students

has caused institutions to seek out students from other countries.

In recent years there has been an increase in the numbers of international students

enrolled in higher education (p. 347), including dental hygiene studies in the United States.

This trend reflects a larger national trend in enrollment of international students in the

United States. According to Beauchemin (2012):

Enrollment of international students in U.S. universities and colleges has rebounded

following a temporary decline in the early part of the last decade. During the 2010-

2011 academic year there were 723,277 international students on U.S. campuses.

This was a 4.7% increase from the previous year, and 3.5% of the total U.S. higher

education enrollment. (p. 347)

Today, the U.S. has the world’s largest international student population, with over

1,078,822 students choosing to broaden their education and life experience in the United

States (Institute of International Education, 2017). Nearly 4% of all students enrolled in

higher-level education in the U.S. are international students, and the numbers are growing

(Studying in the U.S.A, 2015). From the mid-1950s international student enrollment was

only just reaching 35,000 (Studying in the U.S.A, 2015). The 2015 Open Doors Report on

International Educational Exchange reports the number of international students at colleges

and universities in the United States increased by 10% over the prior year to a record high of


974,926 students in the 2014/15 academic year, confirming once again that the United

States remained the destination of choice for higher education (Institute of International

Education, 2014).

During the academic year 2016/2017, a total of 34,181 international students were

enrolled in health professions education in the United States, a 1.6% increase from the

2015/2016 academic year (Institute of International Education Open Doors: Fields of Study,

2017). The profession of dental hygiene falls under this category. The American Dental

Association’s (ADA) 2015 Survey of 1st year enrollment in allied dental professions for

academic years 2003-2004 to 2013-2014 found the enrollment in U.S. dental hygiene

programs increased by just under 17% (1,398 additional students). For the academic year

2013-2014, just over 13% of all dental hygiene students enrolled in U.S. dental hygiene

programs were not from the United States (ADA, 2015).

The United States hosts more of the world’s 4.5 million international college and

university students than any other country in the world, with almost double the number

hosted by the United Kingdom, the second leading host country (Institute of International

Education, 2015). The overall number of international students in the United States has

grown by 42% since the first International Education Week briefing was held in 2000

(Institute of International Education, 2014). Evan Ryan, Assistant Secretary of State for

Educational and Cultural Affairs (2014) noted “International education is crucial to building

relationships between people and communities in the United States and around the world”

(Institute of International Education, 2014). The continued growth in international students

arriving in the U.S. to pursue higher education has a significant positive economic impact on

the United States. In 2015, international students contributed more than $36 billion to the


U.S. economy, according to the U.S. Department of Commerce (Institute of International

Education, Open Doors, 2017).

International students constitute a diverse and unique group of students at

universities in the United States and countries across the globe (Hendrickson, Rosen, &

Aune, 2011). The number of international students present at a university makes a

significant contribution to the “personality” of that institution, and also to its financial

wellbeing (Hegarty, 2014). Academic institutions need to totally embrace students from

different countries. A truly welcoming educational institution is one that does not merely

tolerate the arrival of international students for financial gain or even provide support to

international students who run into difficulties. Instead, it is one that builds on the diversity

and opportunities for intercultural exchange resulting from the presence of international

students to offer cultural, social, and academic enrichment to international students, host

students, and staff members alike (O’Reilly, Hickey, & Ryan, 2012).

In order to better facilitate the learning experience of international students,

educators need to have a good understanding of the features of international students’

learning behaviors in relation to their academic achievement (Li, Chen, & Duanmu, 2010).

Some educators suggest international students are insufficiently adjusted to higher education

in their host country, both academically and socially (Rientes, Beausaert, Grohnert,

Niemantsverdriet, & Kommers, 2012). According to Diaz, Sanchez, & Tanguma (2012),

admitting students is easy, but there is no benefit to admitting those who may not be able to

succeed due to their lack of prerequisite scholastic aptitude.

International students facing challenges may no be fully prepared for the rigors of a

dental hygiene program. Unsuccessful students also have an impact on their host institution.


The issues of student attrition and retention are of concern to all schools and programs, but

the issues are of special interest to professional health care programs charged with

graduating qualified, competent practitioners who serve to meet the health care needs of

society (Fruedenthal & Bowen, 2010).

A solid understanding of the English language, adapting to a new culture, feelings

of discrimination, financial issues, high anxiety, stress, homesickness, loneliness, having

less social support, and difficulty connecting with other students and faculty pose the

greatest challenges for international students (Andrade, 2006; Chavajay & Skowronek,

2008; Davey, Grant, & Anoopkumar-Dukie, 2013; Gilligan & Outram, 2012; Hotta & Ting-

Twoomey, 2013; Ryan & Dogbey, 2012; Sherry, Thomas, & Chui, 2010; Vardaman &

Mastel-Smith, 2016). Despite the barriers international students face, enrollment in U.S.

universities continues to increase. Obst and Forester (2004), in conjunction with the

Institute of International Education (2015a), surveyed 420 international students from 24

U.S. institutions, seeking information on what motivated international students to advance

their education outside of their home country. Two main reasons surfaced. A majority of

respondents viewed U.S. education as a medium to enhance their career opportunities (78%)

in their home country or abroad, and the reputation and academic qualifications of U.S.

institutions of higher education are highly regarded (88%). In spite of how prepared

international students are academically, how proficient they are in English, or how familiar

they are with U.S. cultural norms, they still face unique challenges to succeed in a foreign

environment away from family and friends (Mamiseishvili, 2012). Ultimately, international

students are prepared to face the challenges of study in a different country simply because

they feel they can obtain a better education abroad which will differentiate them from their


peers upon returning home (Hegarty, 2014). Vardaman and Mastel-Smith’s (2016)

descriptive phenomenological study of international nursing students (n=10) found

international students viewed a nursing degree from the U.S. as highly regarded in their

home country and would allow them a “better future” (p. 37) when they returned home. In

addition, participants believed a degree from a U.S. institution would provide them with a

good paying job and increased chances of securing a position immediately after graduation.

The academic success of international students is important to the global health

professions (Vardaman & Mastel-Smith, 2016). International students studying dental

hygiene face additional challenges. Not only are these students learning English, but they

also need to learn the language of dental hygiene. The foundational aspects of the dental

hygiene profession are taught during the first professional year of the dental hygiene

program, which include vocabulary-laden courses. The first semester can be challenging for

both domestic and international non-native English-speaking dental hygiene students.

Students may not succeed academically, resulting in possible dismissal from the dental

hygiene program.

For purposes of this study, international student is defined as any student from

a foreign country studying dental hygiene in the United States who has no previous

post-secondary educational experience in the United States Educational System, prior

to beginning their studies in dental hygiene.

Problem Statement

Academic difficulty can be a significant problem for international students in health

professions programs (Szumacher et al., 2007). Anecdotal evidence and attrition rates in

dental hygiene programs suggest international and native students often encounter various


barriers to academic success, yet little is known about this phenomenon. Holt’s (2005) study

investigating retention strategies and practices implemented in associate degree, entry-level

dental hygiene programs (n=25) considered attrition issues. Holt (2005) found the major

reasons for increased attrition occurred due to academic under achievement (88%),

dissatisfaction with career choice (76%), family and personal responsibilities (72%), and

underdeveloped clinical skills (56%). Unfortunately, international students in academic

difficulty often are identified late in the curriculum and risk dismissal if remediation is not

successful (Freudenthal & Bowen, 2010, Szumacher et al., 2007).

Dental hygiene programs in the U. S. are highly structured. Students are required to

progress in a prescribed fashion in the program with little opportunity for individualized

learning. The language and skills particular to dental hygiene may add yet another barrier to

international students who are struggling with language and various other issues of

acculturation (Freudenthal & Bowen, 2010; Hotta & Ting-Toomey, 2013). Early

identification and remediation of these barriers to academic success can potentially lead to

more effective and supportive interventions to promote personal adjustment and academic

success.

Student attrition at universities is a growing problem. Attrition can be defined as “the

difference between the number of students beginning each cohort and the number who

complete that cohort” (Glossop, 2002, p.377). The lock-step nature of dental hygiene

programs limits the options for students who do not meet the standards for progression

(Freudenthal & Bowen, 2010). International students may not only face a higher attrition

rate due to their English language skills, but also encounter additional struggles, as they also

need to learn the language of dentistry (Andrade, 2006; Freudenthal & Bowen, 2010).


Purpose

International students choose the United States as their top choice for their higher

education studies, as they perceive the United States to have a high quality higher

educational system (Institute of International Education, 2015a). Despite challenges and

barriers, international students often choose to study dental hygiene in the United States,

because they believe the quality of education received in this country is superior to that of

their country of origin and that it will improve job opportunities and provide them with a

competitive edge (Hegarty, 2014). A 2015 report in U.S. News and World Report (2015),

ranked the profession of dental hygiene fifth in their list of top health care professions.

Encouraging both international and domestic students to pursue a career in dental hygiene.

Woolfork and Price (2012) noted overall enrollment in U.S. dental hygiene

programs began to increase in the academic year 2009-2010. The American Dental

Association’s 2015 Survey of Allied Dental Education reported the number of non-U.S.

students in U.S. dental hygiene programs has remained constant over the past three

academic years, 2011-2014, with enrollment numbers of 558, 577, and 556, respectively.

The purpose of this study was to investigate international students’ perceptions

related to the barriers that interfere with their academic success as students in a dental

hygiene program.

Research Questions

1: What do international students, studying dental hygiene in the U.S., perceive

are barriers to their academic success?

2: What strategies have international students studying dental hygiene in the U.

S. employed to overcome barriers and challenges to academic success?


3: What do international students perceive to be the strengths they bring to studying

dental hygiene in the U. S.?


Chapter 2

Literature Review

This dissertation seeks to highlight some of the barriers to academic success

international students encounter while enrolled in U.S. dental hygiene programs.

The researcher conducted a literature search using CINAHL, ERIC, and Google

Scholar, and SCOPUS. The following search terms and phrases were used: academic

success; academic success for international students studying dental hygiene in the U.S.;

academic success of international students studying health sciences in U.S. universities;

barriers to academic achievement post-secondary education; barriers to academic success

in college;

international students in health sciences programs in the United States; and international

students studying health science in U.S. colleges university.

In the search for published literature, the researcher located no information on barriers to

academic success for international students studying dental hygiene in the United States

(U.S.). Articles related to academic success in dental hygiene programs focused on the

relationship between grade point average (GPA) and first time success taking the National

Dental Hygiene Board Examination. Dental hygiene literature was limited to predictors of

academic success and successful completion of dental hygiene programs and subsequently

passing the National Dental Hygiene Board Examination.

The goal of dental hygiene educators is to prepare competent oral health care

professionals who can contribute to the profession; thus, determining what predicts success

has been a persistent goal among dental hygiene admissions committees (Alzahrani,

Thompson, & Bauman, 2007). These researchers examined various predictors of academic


success and subsequent passing of the National Dental Hygiene Board Examination at one

U.S. dental hygiene program. They concluded that attrition encountered in dental hygiene

programs impacts the individual, the institution, and the community. These researchers

analyzed various factors for attrition; however, they did not discuss the students’ country of

origin.

Downey, Collins, and Browning’s (2002) conducted a six-year retrospective study

which looked at predictors of success in dental hygiene education. The study participants,

n=134, were comprised of Caucasians, African-Americans, and Asian-Pacific Islander

dental hygiene students. The study found that incoming grade point average (GPA), p< .001,

and total scholastic aptitude tests, p< .004, were the most effective method to predict

success in the program. A follow-up retrospective study (Ward, Downey, Thompson, &

Collins, 2010) evaluated dental hygiene graduates, (n=156), utilizing the same model as

Downey, Collins, and Browning (2002,) yielding similar results. They found a moderate

correlation (r=581, p=.01) to predict GPA at graduation and to predict National Dental

Hygiene Board Exam results( r=.465, p=.01). They took the study one step further to include

reviewing GPA’s at the end of year one. They found a stronger correlation between

predicting graduation GPA (r=957. p=.01) and National Dental Hygiene Board Exam results

(r=.964, p=.01). The limitations of both studies included limited diversity of students and

the samples from single institution.

The first part of this literature review will consider academic success of international

students studying at institutions outside of their home country. The second part will take

into account academic success of international students studying various health professions


at post-secondary institutions outside of their home country, and the third part will review

support available for international students studying health professions.

Barriers to Academic Success for International Student

Perceived barriers to academic success for international students arise in all

disciplines. Sherry, Thomas, and Chui (2010) conducted a qualitative study, n= 121, which

looked at international students at a Midwestern university, and the barriers they faced as

international students. The students acknowledged the importance of language issues,

understanding new cultural norms, financial problems, friendship, and social impact as the

key barriers to their success. The students appreciated the receptiveness of the University

community to their being on campus. As the international students’ understanding of

language, culture, and their sense of connectedness increased, the more successful they

became in their studies.

In a similar study in the United Kingdom (UK), Lillyman and Bennett (2014)

conducted a thematic synthesis of 87 articles related to international student adjustment to

studying in the U.K. The literature reviewed identified how the stressors of being an

international student can be reduced with planning, support, and understanding between the

host universities and the international students. The thematic synthesis identified the

following themes: reasons students study abroad, experiences of students and higher

education institutions, problems faced by students when preparing to leave their country,

culture shock, arriving in a foreign country and studying in a new country, and opportunities

and threats faced by academics due to not having a full understanding of the language. The

researchers concluded building a sense of community between all students, faculty, and

administration were the most important factors for student success.


Rienties et al., (2012) administered the Students’ Adaptation to College

Questionnaire at five institutions in the Netherlands in a cross-institutional study, n=958, of

both local and international students in an effort to determine the impact on academic

performance as it related to international students’ ethnicity, academic success, and social

integration. The study demonstrated that the degree of academic success of international

students was multi-faceted. The more familiar international students are with the Western

practices and the Western educational system, the better they adapted and ultimately

performed. The study had four main findings: positive academic performance was

dependent on the academic integration (p< .01), academic and social integration was related

to the East-West conventions among students (p< .01), there was a compensatory

relationship between academic and social adjustment and study performance, and when

controlling for ethnicity, academic performance predicted grade point average for all

students (p< .01). The study limitations included the self-reported scores of students on

academic and social integration and the clustering of the 79 nationalities and 129 ethnic

identities, of the participants, into four groups, possibly oversimplifying specific cultural

adjustments process across countries, continents, and cultures.

In spite of the many perceived difficulties international students face, they continue

to pursue higher education outside of their home country. Mamiseishvili (2012) investigated

the characteristics of first year international students looking at the reasons they persisted in

U.S. institutions of higher education. Participants (n=18,640) were surveyed in one of the

following manners: a web-based, self-administered interview, a computer-assisted telephone

interview, and a computer-assisted personal interview. Two hundred foreign or international

students were included in the sample. The dependent variable was the cumulative outcome


of persistence at the end of the academic year. The independent variables included in-

college characteristics, first-year GPA, attendance intensity, remediation, housing status,

degree plans, financial aid, financial help from parents, net price of attendance, institution

level, and academic and social integration measures. Pearson’s Chi-square or T-test and

logistic regression were used to evaluate the data. The study revealed the GPA (p< .05),

degree goals (p< .05), and academic integration (p< .05) all significantly impacted first-year

international student persistence. In addition, international students who interacted with

classmates in and outside of class in study groups and other related academic issues were

more persistent. The study showed the persistence of international student studying at U.S.

institutions is multi-faceted.

Limitations for the Mamiseishvili (2012) study were it would have been more

appropriate to use region of origin rather than race/ethnicity as a variable, international

students were from different level institutions (2-year and 4-year institutions), but due to the

small sample size limitation, they could not be reviewed separately. Acculturation, financial

difficulties, lack of social and emotional support were not examined.

Barriers to Academic Success for Students Studying the Health Professions

The issue of student retention is of interest to all academic institutions and programs,

but is of special interest to professional health care programs charged with graduating

qualified competent practitioners that serve to meet the health care needs of society

(Freudenthal & Bowen, 2010).

The literature review presented many articles related international students coming

to the United States to study nursing. Carty, Moss, Al-Zayyer, Kowitlawakul, and Arietti

(2007) conducted a 10-year, descriptive study utilizing a convenience sample, n=34. This


study examined predictors of success for Saudi Arabian students who completed an

accelerated baccalaureate program leading to a bachelor of science in nursing degree (BSN)

in Virginia. The authors found the admission GPA was significantly and positively related,

p< .001 to the graduating GPA; the higher the admission GPA was, the higher the

graduating GPA. The study also revealed students who entered the BSN program with a

science background, were more successful. The Carty et al. (2007) study reported higher

success was found with male students, those students, male or female, who were married,

and those students, male or female, whose family was with them in the country during their

studies.

In a 2011 descriptive phenomenological inquiry, McDermott-Levy discussed the

obstacles Arab-Muslim female nurses (n=12) faced as they left their home and families in

Oman to complete a baccalaureate in nursing in the United States. Individual, audiotaped

interviews, lasting 1-1.5 hours, were conducted after the students completed 12 months of

the nursing program. Several of the themes that emerged from this study were: English

language immersion, discrimination, learning a new educational system, and having to

become self-directed. Living and studying in the United States was a transformational

experience for these women notwithstanding the obstacles. A limitation of the study was the

researcher was the academic advisor for the 12 participants possibly influencing their

responses. Another limitation was the participants were non-native English speakers and

may not have had full understanding of the English language to fully express their opinions.

In a similar study to McDermott-Levy (2011), Gilligan and Outram (2012)

conducted audio- recorded focus groups of international students in the Master of Pharmacy

(1st year students), Bachelor of Medicine and Biology, and Bachelor of Nursing programs


(2nd year students) at the University of Newcastle, Australia. International students and local

students (convenience sample), n=35, were invited to participate in the semi-structured

focus groups. Participants were asked a series of open-ended questions related to their

experiences with the program. The key themes that emerged from the interviews were:

difficulties with the spoken language, differences in professional roles and expectations,

differences in learning methods, no social interaction outside of the classroom, and

acceptance of different cultural and religious practices.

A retrospective analysis of local, international (on shore), and collaborative

exchange students in Malaysia (n=456) enrolled in a 4-year Australian bachelor of

pharmacy degree program was conducted in 2010 by Davey, Grant, and Anoopkumar-

Dukie. This study assessed the academic performance of the students. The paper-based

survey, consisting of demographic and 14 open-ended questions was administered during

class time to pharmacy students in all four years of the program, yielded close to 100%

return. The authors were looking to assess student motivation, their choice of

discipline/school, and their overall experiences and perceptions as a student. The first

semester was shown to be an adjustment for all students. A retrospective analysis of GPA

was evaluated for the three groups and showed a slightly lower GPA for the international

students. Results common among the groups were the level of independent learning

required by the institution, especially for international first year students, when compared to

local students, impacting their first semester grades (p=< .05). Classes were taught in

English, creating an additional adjustment for the international students, as their command

of the English language was still developing.


Health professions education has both a didactic and a clinical component.

According to the research reviewed, international students encounter barriers to their

success in both components.

International Students’ Ability to Overcome the Barriers Preventing Academic Success

In an effort to help alleviate the perceived barriers for international students, several

academic institutions are employing new strategies to increase their success in health

programs in the United States. Ahmed, Peeran, and Ahmed (2015) studied Libyan dental

and medical students studying in their home country who were taught in English. In Libya,

English is considered a foreign language, even though English is considered a global

language. Libyan students are not taught English until they reach the age of 11 years

(Ahmed, et al., 2015). These students experienced similar difficulties as those non-native

English-speaking students studying in the United States. In following with a current trend,

institutions of higher education in Libya began to teach all science courses in English

(Ahmed, et al., 2015). This affected the academic standing of students who do not have a

full understanding of the English language. An 18-question, multiple-choice survey

administered by these researchers, including one open-ended questions, asking students

about themselves, was administered to medical and dental students, n=254, at one Libyan

university. When asked about the medium of instruction during their schooling, the majority

of students responded that they were instructed in Arabic (p=.011) (Ahmed, et al., 2015).

Findings of their study revealed the majority of the students experienced difficulties

comprehending information taught only in English. Students expressed their preference to

have courses taught in both Arabic and English as a mechanism to facilitate a better


understanding of the information and to increase their English language skills (Ahmed, et

al., 2015).

According to the research reviewed, English and non-native English speaking

students would benefit by seeking help from their institution’s resources if they are having

difficulties. Banjong (2015) administered a Likert scale, three part survey to international

students, n=344, to discover whether academic success increased if international students

took advantage of campus resources available to them. A Pearson correlation, r= (325)

=-.46, p<.001, demonstrated a significant negative relationship between students’ English

proficiency and their academic success. Students who utilized campus resources,

specifically the writing center, success centers, and counseling, had significant positive

outcomes related to their academic success, r (325)=.371, p=<.001; r (320)=.268 p<.001,

and r (331)=.15 p,.001 respectively. These campus services provided a great resource and

were helpful to international students, resulting in improved academic performance and

success (Banjong, 2015).

Some international students who struggle academically are ultimately successful.

Fass-Holmes and Vaughn, (2015) conducted a retrospective study of Test of English as a

Foreign Language (TOEFL) scores of students, n=842 (two cohorts) who experienced

difficulties with English writing and struggled academically, even if they had an acceptable

TOEFL score. Included in their research was whether the TOEFL score should be increased

in hopes of increasing student success. Generalizations were made that if these

undergraduates were struggling academically and were increasingly at risk for academic

probation, disqualification, and/or dismissal from the institution, they also had deficient

English writing skills that did not meet their academic requirements (Fass-Holmes &


Vaughn, 2015). The authors compared SAT scores, TOEFL score, and GPAs. Of significant

note, 90-95% of the students maintained strong academic standing during their first year.

The remaining 10% of undergraduates were not successful and were ultimately placed on

academic probation, became subject to disqualification, or were disqualified from the study

(Fass-Holmes & Vaughn, 2015). A limitation of the study was is the research was

conducted at only at one university. However, it does demonstrates non-native English-

speaking students can be successful. According to these researchers, institutions need to be

mindful as the number of enrolled international students increased, the number of students

who struggle with English also increased.

The academic success of international students studying health professions

disciplines in the U.S. were reviewed in the literature. International students in nursing

programs has been studied extensively. The presence of international students in dental

hygiene programs has not been studied. Dental hygiene education having both didactic and

clinical experiences creates unique challenges for international students. Learning the

language of dentistry can be a challenge for all students. The intent of this research study

was to examine the barriers to academic success international students studying dental

hygiene face during their tenure at U.S. dental hygiene programs. The goal of any institution

is for students to succeed. Although international students may encounter barriers to their

academic success, they bring an important diversity of thought to the institution and they are

a growing presence in the classroom (Hegarty, 2014). International students make a

significant contribution to the “personality” of an institution; in addition, they contribute to

the financial well being of the institution they attend (Hegarty, 2014). The presence of

international students on university campuses provides a unique social forum for enhancing


all students’ understanding and appreciation of the richness of other cultures (Volet & Ang,

2012).


Chapter 3

Methodology

Overview of the Study

This study utilized overlapping qualitative methods of focus group sessions and one-

on-one interviews to investigate the following research questions:

1. Research Question 1: What do international students, studying dental hygiene in

the United States perceive are barriers to their academic success?

2. Research Question 2: What strategies have international students, studying

dental hygiene in the United States employed to overcome barriers and

challenges to academic success?

3. Research Question 3: What do international students perceive to be the strengths

they bring to studying dental hygiene in the United States?

According to Calderon, Baker, and Wolf (2000), “Focus groups are small groups

that have as their objective the acquisition of information based on the perceptions, beliefs,

traditions and values of its participants” (p.92). Carpenter and Spezile (2006) emphasized

focus group participants should be invited to participate based upon their having a “shared

trait or experience on which the group discussion can build” (p. 30). Millward (2012) stated:

It is not the intention of focus group studies to produce conclusions that can be

generalized beyond the context in which they are conducted; so random sampling is

not necessary. Nonetheless, it is important to be systematic when deciding on group

composition. The sample should be chosen to reflect those segments of the

population who will provide the most meaningful information in relation to the

project objectives. (p.414)


It is further recommended focus facilitators be skilled in group processes and focus

group size be limited to no more than ten participants per group (Carpenter & Spezile

(2006) One of the most critical aspects of focus group interviews is the ability of the

researcher to develop a rapport with the group members.

Traditionally most research in dentistry is quantitative (Edmunds & Brown, 2012).

The foundational education dental hygienists receive focuses more on quantitative than

qualitative research (Kanji, 2012). Qualitative research has value in dentistry and dental

education. Qualitative research provides first-hand information from participants that would

not be accessible through quantitative methods as it provides a comprehensive

understanding of beliefs, attitudes, and behaviors (Edmunds & Brown, 2012; Kanji, 2012).

In dental education, qualitative research can provide insight about thoughts, feelings,

attitudes, and anxieties of students and focus groups can yield rich information from the

participants (Edmunds & Brown, 2012). Focus groups are widely used and are central to

the pedagogical interests of many disciplines, including medicine, nursing, and education

(Kamberelis & Dimitriadis, 2013). Focus group methodology is useful in exploring and

examining what people think, how they think, and why they think the way they do about the

issues of importance to them without pressuring them into making decisions or reaching a

consensus (Liamputtong, 2011, p. 5). Focus groups are an informal discussion among a

group of selected individuals about a particular topic (Wilkinson, 2004). Kidd and Parshall

(2002) state:

“focus groups differ from individual interviews as participants relate their

experiences and reactions among presumed peers with whom they share a common

frame of reference” (p. 294).


Focus group research methods are a valuable way to increase knowledge and in-

depth understanding of the topic being investigated; can add tremendous value and uncover

a meaningful understanding of issues, beliefs, opinions, and perceptions that may not be

gained through other methods (Lawrence, 2014; Then, Rankin, & Ali, 2014). Focus groups

are generally used to gather in-depth knowledge about attitudes, perceptions, beliefs, and

opinions of individuals situated within a group regarding a particular topic (Then et al.,

2014). Focus groups are distinctive in that the goal is not to reach a consensus or to

discover a single solution (Krueger, 2006). Focus groups are conducted to hear the range of

feelings or thoughts of the participants (Krueger, 2006). The success of the focus group is

based on the researcher’s ability to stimulate interaction between the participants (Edmunds

& Brown, 2012). In addition, trust between participants and trust between the participants

and the facilitator are vital to the success of the focus group (Edmunds & Brown, 2012).

Research has shown that recorded focus groups, using semi-structured questions to

gather information, demonstrated that each interviewer will need to develop his/her own

technique (Doody & Noonan, 2013). Successful focus groups utilize a semi-structured

interview guide; establish rapport with the participants, and actively listen to participants

(Doody & Noonan, 2013).

Conducting interviews is a common practice in qualitative research (Doody &

Newman, 2013). Individual interviews conducted in a comfortable setting for the

participant may result in more robust responses and may help in establishing trust

between the researcher and the participants (Doody & Newman, 2013; Lambert &

Loisele, 2008).


Gill, Stewart, Treasure, and Chadwick (2008) found unstructured interviews

gave participants the flexibility to add their personal thoughts of the topic being

researched, especially if minimal research has been done on the topic.

Some researchers have studied the benefits of combining individual interviews

and focus groups as part of one study. Lambert and Loiselle (2008) researched the

effect of using both methods. They found by combining individual interviews and

focus groups, the information gathered proved to demonstrate one method

complemented the other. In addition, their study found by combining both methods

there was a better understanding of the subject in question. Participants may be more

amenable to one method over another (as cited in Lambert & Loiselle, 2008). Giving

participants the option of either method increase the number of participants (Lambert

& Loisele, 2008).

In a similar study, Guest, Namey, Taylor, Eley, & McKenna (2017) compared

data collected from a randomized study that employed both focus groups and

individual interviews. They found either method produced similar findings and both

methods gave participants the freedom to express their own feelings.

Recruitment

Program directors at 74 entry-level dental hygiene programs, in the United States,

were sent an email explaining the research asking if there were any international dental

hygiene students in their program. Thirty (41%) of the program directors responded. Forty-

four (59%) program directors did not respond. Twenty-six (87%) dental hygiene programs

responded having no international students in their program. Four dental hygiene programs

(13%) expressed an interest in participation. One (25%) of the original four dental hygiene


programs had a change in their international student population and no longer fit the criteria

for inclusion

Participant Selection/Setting

A purposive sampling was utilized to select research participants. Purposive,

sampling is the process of choosing research participants based on the participant’s ability to

answer the questions being asked or choosing those participants who can contribute

significantly to the understanding of what is being researched due to the knowledge the

yahve on the topic being researched (Parahoo, 2014; Struebert and Rinaldi-Carpenter,

2011). In a purposive sample, participants share certain characteristics and will be able to

provide information on the particular topic of interest to the researcher (Holloway &

Wheeler, 2010). Study participants included international dental hygiene students at three

universities, one having an overall international student population of 12% (Pisano, 2015);

one having an overall international population of 20% (New York University, 2017); and

one 6.4% (University of Hawaii Mānoa, 2017).

The researcher worked with the Dean of Students at MCPHS University and with a

contact at University of New York and the University of Hawaii, Mānoa to recruit study

participants. Study participants were recruited using either a face-to-face invitation, flyers

(see Appendix A, Recruitment Flyer) and through email (see Appendix B Student email),

where permitted, to the students.

A face-to-face focus group took place at MCPHS University. ZOOM© video

conferencing was utilized for the remaining focus groups and interviews. The primary

investigator conducted the ZOOM© video conferencing sessions. A facilitator conducted the

focus groups at MCPHS University to avoid the perception of undue pressure on the


students, as MCPHS University participants were students of the primary investigator at the

time of the focus group. The facilitator of this group received his doctoral degree in

Educational Leadership at Johnson and Wales University, and received training in focus

group methodologies. In addition, the facilitator served as a Title III Grant Administrator for

two years at an area community college. As part of his work, he oversaw all focus groups

conducted as part of the grant initiative. For this research study, the facilitator provided

appropriate training for each focus group observer. The focus group interview moderator

asked questions based on the interview guide, establishing a focus on the topic of

importance (Krueger, 2006). During the face-to-face focus group, the moderator created a

welcoming atmosphere, a comfortable place for conversation, developed rapport between

the participants and the participants and the moderator, be trustworthy, and be an active

listener (Breakwell, Smith, & Wright, 2012; Doody, Slevin, & Taggart, 2013; Edmunds &

Brown, 2012; Krueger, 2006; Then, Rankin, & Ali, 2014; Krueger, 2006). An observer

whose role was to take field notes also participated. Prior to beginning the focus group each

participant was signed an informed consent inviting the students to participate. The

informed consent included the details of the research. (See Appendix C).

Inclusions and Exclusions

Inclusion criteria were international students currently enrolled in one of the three

dental hygiene programs at the three universities. Participants were at least 18 years of age.

Participants were English speaking, as the focus groups/interviews were conducted in

English. Exclusion criteria consisted of any dental hygiene student under the age of 18

years, any non-English speaking dental hygiene student, any native-born dental hygiene


student, and any student not studying dental hygiene at the institutions where the research

was conducted.

Data Collection Procedure

Data was collected through semi-structured interviews with focus groups and

individual interviews. Six focus groups/interviews were conducted over a period of seven

months (April 2017 through October 2017). The length of the focus group/interviews was

30- 60 minutes. A facilitator, trained in focus group methodology, conducted the first focus

group/interview. The primary investigator conducted the remaining five.

A face-to-face, audio-recorded focus group (n=4) was held in one location. All other

focus groups/interviews (n=8) were conducted utilizing ZOOM© audio/video conferencing.

A semi-structured interview guide (see Appendix D, Interview Guide) was created, for

purposes of the research by the primary investigator, for consistency in the focus

group/interview meetings. The interview guide was designed based on information garnered

from the published literature.

In the initial focus group informed consent and demographic information was collect

on paper (see Appendix C, Informed Consent). and input to a SurveyMonkey© questionnaire

by the primary investigator. Two SurveyMonkey© questionnaires were created and sent to

other prospective participants. The initial survey asked if students would be interested in

participating in the research project, asked for their availability, and for their email address

(see Appendix E). If students agreed to participate, a second survey link containing the

informed consent and six demographic questions (Appendix F) was sent. Once the day and

time was established participants were sent a ZOOM© conferencing link with the day and

time of the meeting. A professional transcriber was enlisted to create transcripts for three of


the focus groups/interviews. An online password protected, secure transcription service,

HappyScribe©, was used for the others.

A group facilitators recorded observations of the group during the face-to-face

interviews, noting body language, facial expressions, and group interactions. The researcher

did the same during the recorded sessions. The researchers must pay close attention to what

was seen, heard, and experienced during the groups (Liamputting, 2011, 84). Attention was

paid to body language and non-verbal communication, as well as spoken comments.

Immediately after the focus group interview, field notes were written, noting initial

impressions and thoughts. Field notes became a part of the data set that was analyzed.

The number of participants in a focus group can vary from a minimum of 4 to

maximum of 16 and is dependent upon what the researcher sought to accomplish

(Breakwell, Smith, & Wright, 2012; Edmunds & Brown, 2012; Doody, Slevin, & Taggart,

2013; Krueger, 2006; Lawrence, 2014; Then, Rankin, & Ali, 2014). The length of time the

focus group is held is important and can vary from 1-hour to 2-hours, but should not last

longer than2 hours (Breakwell, Smith, & Wright, 2012; Edmunds & Brown, 2012;

Lawrence, 2104; Then, Rankin, & Ali, 2014 ). For purposes of this research, the focus

groups/interviews lasted approximately one hour and included between one to five

participants.

Qualitative research was chosen for this study as the researcher was interested in

gathering the personal experiences of international dental hygiene students. Qualitative

research has value in dentistry and dental education. Qualitative research provides first-hand

information from participants that would not be accessible through quantitative methods as

it provides a comprehensive understanding of beliefs, attitudes, and behaviors (Edmunds &


Brown, 2012; Kanji, 2012). In dental education, qualitative research can provide insight

about thoughts, feelings, attitudes, and anxieties of students and focus groups can yield rich

information from the participants (Edmunds & Brown, 2012). Focus groups are widely

used and are central to the pedagogical interests of many disciplines, including medicine,

nursing, and education (Kamberelis & Dimitriadis, 2013).

Data Analysis

Transcripts of interviews and field notes were analyzed through qualitative content

analysis. According to Merriam and Tisdell (2016), “data analysis is the process of making

sense out of the data and making sense of the data involves consolidating, reducing and

interpreting” (p.202). Once the data was transcribed, the researcher began the process of

immersion in the data. This process of immersion in the data occurred through a reading and

re-reading of transcribed interviews. Immersing oneself within the data will provide the

researcher with detailed insights into the phenomena being explored (Noble & Smith, 2014)

and provide a sense of the whole through reading and rereading the data as cited in

Vaismoradi, Turunen, & Bondas (2013). Data analysis involves thematic analysis;

according to Carpenter and Speziale (2007), “the actual process of data analysis takes the

form of clustering similar data” (p. 36). Clustered ideas uncovered through the reading and

re-reading process are labeled themes. “Themes are structural meaning units (Carpenter &

Speziale, 2007, p. 36). Once the themes emerged from the data, they were presented in a

way that was meaningful to the intended audience.

Rigor

Qualitative research, unlike quantitative research, works with a smaller number of

participants; the focus is breadth and precision, focusing on depth, richness, and context of


the information (Thomas & Magilvy, 2011). According to Plummer-D’Amato (2008),

qualitative research has frequently been criticized for its apparent lack of scientific rigor,

particularly in relation to issues of reliability, validity, and generalizability. It was proposed

that qualitative research be evaluated based on its trustworthiness using the criteria of

dependability, credibility, transferability, and conformability as established by Guba and

Lincoln (as cited in Amankwaa, 2016, & Plummer-D’Amato, 2008). Guba and Lincoln

(1989) created the following protocol to determine the trustworthiness of qualitative

research;

Credibility determines confidence in the truth of the findings;

Transferability shows that the findings have applicability in other contexts;

Dependability indicates if the findings are consistent and could be repeated;

Conformability is a degree of neutrality or the extent to which the findings of a

study are shaped by the respondents and not researcher bias, motivation, or

interest (p. 121; p.123).

For the purpose of this research, credibility, dependability, transferability, and

conformability were used to demonstrate rigor. Credibility, similar to internal validity, is the

element that allows others to recognize the experiences contained within the study through

the interpretation of participants’ experiences (Thomas & Magilvy, 2011). Individual

transcripts were reviewed looking for similarities within the study participants (Thomas &

Magilvy, 2011).

Transferability corresponds to external validity in qualitative research (Thomas &

Magilvy, 2011). Transferability indicates the same processes used in this study could be

replicated in another context or participants (Elo et al. 2014; Thomas & Magilvy, 2011).


Dependability was related to reliability. Dependability occurs when another

researcher can follow the decision trail used by the researcher (Thomas & Maglivy, 2011).

Conformability refers to being sure the voice of the participants is heard and the date

is represented accurately based on information provided by the participants and not created

by the researcher (Elo et al. 2014).

Human Subjects Protection

Informed consent was obtained from participants prior to study participation. Raw,

unedited data was only viewed by members of the research team. Audio-tapes were

transcribed verbatim. Confidentiality of participants was maintained. In focus group

methodology confidentiality of participants was maintained by several methods. The

participant’s name and identifying information was not associated with any part of the

written report. Pseudonyms for participants were used in written reports. Participants were

informed that if quotes are used in written reports, the individual participant will not be

recognizable. The Simmons College Institutional Review Board (IRB) (see Appendix G,

Simmons College IRB document) oversaw the protection of the study participants. Initial

approval from the Simmons IRB was received. Additional approval was received from the

MCPHS University Institutional Review Board (see Appendix H, MCPHS University

Institutional Review document). Approval from other participant institutions was not

formally required due to having received approval from Simmons and MCPHS. Participants

were reassured confidentiality would be rigorously maintained. Reassurance was given to

the participants that their comments and contributions during the focus groups would in no

way identify them to the faculty members or school administrators. Further assurance was

given related to any concerns participants had related to repercussions from any negative


comments made during the focus groups. If, at any time participants were uncomfortable

answering any of the questions they were not required to respond. Participants were free to

withdraw from the study at any time without penalty. Their participation, or lack thereof,

had no impact on their grades in course work or their academic program standing. Each

participant in the face-to-face focus group was given a copy of the signed informed consent.

Other participant’s informed consent was obtained online. Data was stored in a lock cabinet

accessible to only the researcher. Electronic records are stored in password protected USB

devices and drives on Simmons College computers. All documents will be retained for three

years after the conclusion of the study. At that time all documents and electronic recordings

will be destroyed.


Chapter 4

Results

Introduction

Adaptation to a new country, language and culture can be fraught with difficulties.

For international students the challenges become even greater as they embark on a rigorous

course of study. The participants of this study articulated the profound challenges that they

encounter as international students. The barriers ranged from the practical considerations of

adapting to American test taking practices, to the emotional experiences of feeling

embarrassed and uncomfortable in patient communications. Each of the participants

encountered some form of barrier in their educational processes. Several barriers were found

to play a role in the academic success of this group of 12 international students, with

comprehension of the English language the most prominent. Didactically, students found

they needed additional time to study and to process examination questions. In the clinical

setting, some found communication with patients to be a challenge.

In the practice of dental hygiene, having the ability to communicate with patients is

key. The 12 participants were most comfortable treating patients who spoke their native

language. Regional accents and colloquialisms presented additional challenges.

Participants

Demographics & Characteristics

Participants were from three baccalaureate level dental hygiene programs located in

the following states: Hawaii, Massachusetts, and New York. The participants were in the

second or third year of their dental hygiene program.

Table 1 presents the demographic information for the 12 participants.


Table 1: Demographics

Age

Answer Choices Number of Participants

21-25 years 426-30 years 631-35 years 136-40 years 0Over 40 years 1Total 12

Gender

Answer Choices Number of Participants

Female 8Male 4Total 12

Country of Origin

Country Number of Participants

China 1Cuba 1Egypt 1Ethiopia 1India 2Korea 1Mexico 1South Korea 2Taiwan 1Tibet 1Total 12

English was not the primary language for 10 (83.33) of the participants. None of the

participants were educated in the American educational system prior to beginning their

dental hygiene education. Two of the participants (17%) were foreign trained dentists (India

and Mexico) now studying dental hygiene.


Ten of the participants have progressed in their program without any unexpected

occurrences. Two participants received nonprogression status and needed to repeat courses;

one was successful and is progressing forward; the other has now transferred to another

program within the same institution.

Themes

The intention of this study was to examine the perceptions of a group of international

dental hygiene students related to challenges they faced during their education in the United

States.

Moving to a country is never easy. International student coming to the U.S. to study

are faced with learning a new language, adapting to a new culture, which might seem alien,

and being enrolled in a rigorous college program poses many challenges. The participants of

this study all struggled, at times, with all of these. The overwhelming challenges

international students faced were related to language and communication.

Six themes emerged from the data; these themes were language, communication,

new educational system, culture, belonging, and diversity.

Theme One: Language – “I am embarrassed to ask”

Participants agreed that language was the most challenging barrier to overcome in

both the classroom and, for some, in their clinical activities. Colloquialisms, common in the

English language and regional specific terms added another layer to the language barrier. In

addition, accents, both native and international, and speaking too fast also contributed to

communication issues. One participant commented:

First of all, language is still my barrier to overcome for my career…I feel left out

because I don't understand the language… but sometimes I feel embarrassed to ask,


like slang, they laugh.

For some of the participants translating into their native language was done routinely to

aid their understanding of the material being presented in the classroom and to assist their

answering exam questions. This process added additional time to their studies. During

exams translating back and forth between two languages became an issue, as students were

not always able to complete exams within the allotted time period thus impacting their

grade. One participant shared;

Actually, like, translate everything into Chinese and then figure out the answer and

translated into English, again; because I've been here for many years and I am use to

using English. so I'm not doing that anymore.

Another student said some professors discouraged her from translating into her native

language.

Some of the professors, they suggest me not translated into my language or my own

style because sometimes I ended up like a assuming something that's not, like the way

I understand it, maybe I'm getting it wrong, so the professors suggests me not to do

that but to like look into dictionary and try to understand in English itself so that

would help you better in understanding the terms and the language in the testing so

yeah, been trying that way as well… basically the language itself is a challenge.

The professor’s suggestion has been helpful for the student while studying. However,

students are not able to access a dictionary during exams, so the student still needs to

translate between languages. Participants felt as they progressed in the dental hygiene

program their English skills were improving.


Theme Two – Communication “Patients are Not Going to Understand Me or

I’m Not Going to Understand Them”

Patient care is the primary role of a dental hygienist. The ability to communicate is a

key attribute of dental hygiene practice. This skill includes conversing with patients. In

conversation, with faculty and patients, some participants felt they were viewed as being

intellectually challenged, as they had to process what they were being asked before they

responded. Several of the participants commented they were nervous when seeing patients

because of their English language skills. Students were more comfortable with patients they

were familiar with or those patients who spoke their native language. One participant had

two concerns:

I’m scared also because of my English. They’re not going to understand me or I’m

not going to understand them because even people from New York, they have an

accent that sometimes is hard to understand….. I’ve heard a lot of people speaking

Spanish inside of NYU, the patients. So I hope I get many of those.

Similar sentiments were offered by another participant:

Sometimes I have a hard time communicating my information to the patient to

educate them. I think it is different; the conversation … so yes it is difficult

experience during the clinical.

Some of the students expressed concern when communicating with clinical faculty.

Students perceived faculty were impatient with them as they were not able to respond

quickly to questions since they need to process what they were being asked before

responding.

Theme Three – The Educational System: “What is a multiple choice question”?


The structure of education in their home country was very different from what they

were currently experiencing in the United States. The international students needed to learn

a whole new educational system. Some students had never seen a multiple-choice exam

question or used flash cards. They were evaluated by answering essay questions. For some,

taking an exam online or accessing classroom material online was a new experience. During

class students took notes and examinations were on paper. One participant commented:

It is very, very different to be honest with you. It’s very different from what we had

in India and especially the education system. Everything is on-line. Like even the

exams are on-line, the resources are on-line. In India we were never taught like that.

We had to take notes; we had to write down everything. So I grew up learning

everything that way and we didn’t really have multiple-choice questions. We take

the exams on-line which is a whole different thing for me because I’ve never taken

an exam on-line.

For another :

I’ve never been to high school, middle school in the States. So I don’t know how it

works in the university in the States. So basically I had to learn everything all over

again and I had to accommodate myself into the school.

Learning a new educational system resonated with the participants. The differences

in the delivery of the didactic information, computer versus paper, and the differences in

examination format, multiple choice questions versus answering essay questions, coupled

with comprehension of the English language created additional challenges for the

international students. It was a new beginning for them, like going to school for the first

time.


Theme Four – Culture: Can I Leave the Classroom without Permission?

Cultural differences emerged, not necessarily as a barrier, but as a concern for the

international students. Although cultures were different, the international students welcomed

learning about native customs. Their concerns were related to some of the classroom

practices, of the native students, and were perceived as showing a lack of respect for the

faculty.

One participant found it shocking that:

My first week when I came here, there was this girl, she was sitting in front of the

teacher with her legs on the second chair in front of her facing him… like sort of her

shoes were facing him and she was just sitting in the classroom. So these kind of

things shocked me because there’s a respect, you sit properly and listen to the

teacher, you raise your hand, ask for permission… People coming and going out of

the classroom. One thing that struck me is eating in the classroom. People bring their

whole lunch and sit there and eat their pizza, their burgers and everything… They go

buy coffee and come back… The teacher is standing there. Like what the hell are

they doing? That was also shocking.

Two other participants had similar sentiments:

Just leaving the classroom … I mean, every day, without permission.

Most of the international students felt teachers, in their home countries, had more

authority over the students. Participants shared experiences of coming from cultures where

the role of the teacher is seen in much more authoritarian terms. Educators are figures to be

respected and feared. The casual and collegial relationship that American students have

with educators was surprising to some participants.


One participant shared:

Yeah, the difference between here and study in China, in China students will be kind

of like a afraid of their teachers or professors. Seems they think they have the power

because you know they can give you like a grade that you don't want if they don't

like you; but here, people are more like, you know, equally speaking; you can really

be close friends with their professors. Like he cannot only talk about academic life

but also for your personal life. You know you can experience with the teachers;

here they are more open mind. so they can accept a lot of different ideas.

This radical difference in ways of relating to faculty and different classroom norms left

some participants not knowing how to navigate the world of education.

Theme Five: Belonging “Hanging out”

For participants creating friendship and feeling a sense of community was very

important. Some of the participants developed friendships with their U.S. born classmates

and most participated in study groups with their classmates. Although the international

students participated in study groups, they still felt more comfortable “hanging out” with

other international students. Some of the participants felt the students born in the United

States were younger and perceived to be less mature than their international classmates.

Most of the participants felt they had more in common with other international students.

One participant shared

I don't hang out with the local students, I have local students to talk to but mostly I

don't really hang out with them. But I mostly hangout with the immigrant students…

I feel more comfortable with the international student. I mean not only international

they are immigrants and they are not born here, we have more in common We have


more, both have kind of difficulties studying in America. I have met a lot more

immigrants from other countries then locals.

Similarly another said

Both where available, and to be honest, sometimes I felt it easier to be you know

going around with people from like say my country or my culture but at the same

time there was another time that I was also happy to be surrounded by other people

from different cultures in learn more if it's probably also depends on if you like to be

involved in other you know sort of things or if you want to be kind of closed then

make sure you are satisfied with the situation you have it all depends on the situation

you have, it all depends on what you want.

Some of the international students observed the student groups that were

created, including where students sat in the classroom, tended to be either groups of

U.S. born students or groups of international students.

One participant commented:

Yes. I mean I have some friends; I’ve observed that no matter if it’s a big classroom

or a small, students make groups and most of the groups are like international

students would be on one side of the class and the American students would be on

the other side. I don’t know if they relate more to each other. Probably that’s the

reason. But like my regular group of friends, they’re all international students from

China, Taiwan, Russia, and Mexico.

Another participant shared

For me I tend to get along with Asian Americans I guess because we’re all Asian so

I feel more comfortable talking to them and most of them are the second generation


here. So they understand the struggle that I think to be an international student here.

The other American kids, I also talk to them but we’re not that close compared to the

Asian Americans.

Although all of the participants enjoyed spending time with their U.S. born

classmates they were drawn to other students who were of the same ethnicity or who were

also from outside of the United States. They had a sense of familiarity, comfortableness with

students similar to themselves. It also gave them the opportunity, for some, to speak their

country of origin language. All of the participants felt their dental hygiene program and the

larger institution embraced their presence on campus. Each of the campuses offered social

events everyone was invited to participate in.

Theme Six: Diversity: A Positive Presence

The international dental hygiene students shared several thoughts on what they bring

to their dental hygiene program and to their campus. The overwhelming theme that emerged

was diversity. Within diversity, a subtheme of changing stereotypes of different

cultures/ethnic groups also developed. The international students found comfort in seeing

other international students in their dental hygiene program and seeing the large number of

diverse international students, in general, at their university. They got a sense “they were not

alone”. Some of the international dental hygiene students felt their country of

origin/ethnicity has not been portrayed favorably in print media or on television/movies.

They felt their presence could help to dispel preconceived notions and stereotypes related to

their ethnicity. Although they are just one person, the international students felt they could

make a difference. One participant shared


So coming here, you are representing your country, your culture, your religion… so

many things… people may have different misconceptions about you without

knowing you; that exposure is helpful I think especially in today’s environment

where everything is politically charged and if you don’t know someone you become

ignorant about them and you judge an entire culture without knowing them, but

when you have one person, one example, that might put things in perspective for you

and that will shatter stereotypes and generalizations. …. I think my presence gives

them a different perspective and I can correct some misconceptions they may have.

Another participant commented

For me as a Mexican with all the things that have been happening and all the bad

things that people are talking about Mexicans, I feel I’m proud to be a Mexican. I

want to show that we are smart, we don’t have to be in this country especially illegal

or taking someone else’s spot… It doesn’t mean like what you see in the movies, it’s

just about stereotypes, that I’m glad that I could be changing some stereotypes about

Mexicans and Latinos because I don’t know, they say Mexicans are lazy, they say

Mexicans… so many bad things that I feel I have to okay, I have to step up and

change that idea of people’s minds.

The sharing of culture also was seen as a benefit. The participants enjoyed learning

about different ethnic practice, sharing ethnic food, and learning more about different

countries. The international students welcomed the opportunity to talk about their home

country in a positive light.

The real life experiences of this group of international students studying dental

hygiene in the United States were similar to other cohorts of international students, as found


in the literature, from various disciplines. First and foremost, a solid understanding of the

English language was key to their academic success and their communicating with faculty

and patients. Another areas of concern was adapting to a new educational system where

study tools and examination format were very different from their previous schooling.

Students having the freedom to come and go during lectures was very unnerving for the

participants and took some adjustment. There were many opportunities for the international

students to interact with their U. S. born classmates, however, they tended to associate with

other international classmates. One finding, not previously discussed, was respect or lack of

respect, for faculty. The participants had come from educational systems where they felt

teachers were held in higher regard, teachers were authority figures. They felt, in some

instances, this was missing.

Each participant approached the challenges of their dental hygiene program to the

best of their ability. Ten of the participants progressed in their program without any

additional challenges. One participant was placed on nonprogression status, repeated the

course where they were unsuccessful and has continued in the program successfully. One

participant continued to have challenges and ultimately transferred into another health

professions program.

Chapter 5

Discussion and Conclusion

International students constitute a diverse and unique group of students at

universities in the United States and countries across the globe (Hendrickson, Rosen, &


Aune, 2011). The number of international students present at a university makes a

significant contribution to the “personality” of that institution, and also to its financial well-

being (Hegarty, 2014). International students are a vital component of an institution and

have an increasing presence in the classroom (Hegarty, 2014). Academic institutions need to

totally embrace students from different countries. A truly welcoming educational institution

is one that does not merely tolerate the arrival of international students for financial gain or

even provide support to international students who run into difficulties. Instead, it is one that

builds on the diversity and opportunities for intercultural exchange resulting from the

presence of international students to offer cultural, social, and academic enrichment to

international students, host students, and staff members alike (O’Reilly, Hickey, & Ryan,

2012).

Findings of this study found the biggest challenges for this group of 12 international

students studying dental hygiene in the United States was having a solid understanding of

the English language. Dental hygiene education is very vocabulary laden. It is a language in

and of itself, adding yet an additional dimension to academic achievement.

Student success in dental hygiene programs has previously been measured based on

first time success rate when sitting for the National Dental Hygiene Board Exam looking at

all dental hygiene students. No studies were found looking at the specific barriers to a

student’s academic success in a dental hygiene program based on country of origin. While

qualitative studies are not generalizable, this study hoped to shed light on some of these

questions.

The results of this current study paralleled previous findings from all disciplines.

Previous research found a solid understanding of the English language, adapting to a new


culture, feelings of discrimination, financial issues, high anxiety, stress, homesickness,

loneliness, having less social support, and difficulty connecting with other students and

faculty, posed the biggest challenges for international students across all disciplines

(Andrade, 2006, Hotta & Ting-Twoomey, 2013; Sherry, Thomas, & Chui, 2010; Andrade,

2006; Davey, Grant, & Anoopkumar-Dukie, 2013; Chavajay & Skowronek, 2008; Ryan &

Dogbey, 2012; Gilligan & Outram, 2012; Vardsman & Mastel-Smith, 2016).

Sherry, Thomas, and Chui’s (2010) qualitative study found once international

students had an understanding of language, culture, and sense of connectedness, the more

successful they became. Mamiseishviil (2012) also found international students who

interacted with their classmates in and outside of the class in study groups and other

academic related issues were more persistent, thus more successful. The participants in this

study became more successful as they became acclimated to their dental hygiene program.

In addition, once the participant’s English language skills improved, their communication

skills with faculty and patients also improved. As a result, the other challenges the

participants faced began to diminish.

The study participants felt they brought great diversity and a positive attitude to their

dental hygiene program. The international students welcomed the opportunity to share

information about their home country and to learn about the United States. Several of the

participants felt they were able to change other’s preconceived stereotypes regarding their

ethnicity.

One finding, not discussed in previous literature, was classroom behavior. Several of

the international students felt the native students exhibited a lack of respect for faculty. The


international students were accustomed to more structured classrooms. Their teachers were

more authoritarian, some, actually, feared their teachers.

Limitations of the Study

Qualitative research does not lend itself to the large participant pool of quantitative

research. Millward (2012) states, “It is not the intention of focus group studies to produce

conclusions that can be generalized beyond the context in which they are conducted.”

There are several limitations to the current study. The study is not generalizable to

other groups due to the purposive sampling of the 12 participants who provided only their

insight at a specific point in time. However, for most research that aims to understand a

common perception and experience among a group of relatively homogeneous individuals,

twelve participants should suffice (Guest, Bunce, & Johnson, 2006).

The limited number of participants in this study does not represent the feelings of all

international students studying dental hygiene in the United States. In dental education,

qualitative research can provide insight about thoughts, feelings, attitudes, and anxieties of

students (Edmunds & Brown, 2012). Theoretical saturation criteria was used to justify the

sample size, in qualitative research, as saturation has become the gold standard by which

purposive sample size are determined in health science research (Guest, Bunce, & Johnson,

2006).

Participants may have been hesitant to discuss their true feelings due to the nature of

the focus group research.

Even though a facilitator conducted one of the focus groups, participant bias may

have played a role in some of participant’s willingness to be included in the research, as

some participants knew the primary investigator.


Implications for Dental Hygiene Education

The participants of this study expressed their concern, when taking

examinations, of the need for additional time due to their translating exam questions

into their language and then back to English. This is time consuming and impacts

student’s ability to complete exams, resulting in a low score. Dental hygiene faculty may

consider extending exam time which will ultimately benefit all students. Students in any

discipline can struggle academically. Their country of origin may not play a role. Faculty

strive to educate all students to be successful. Students who have struggled

academically in their dental hygiene program have a higher first time failure rate.

When possible, extending exam time may be beneficial for all students.

In order to better facilitate the learning experience of international students,

educators need to have a good understanding of the features of international students’

learning behaviors in relation to their academic achievement (Li, Chen, & Duanmu, 2010).

Unfortunately, international students in difficulty often are identified late in the curriculum

and risk dismissal if remediation is not successful (Freudenthal & Bowen, 2010, Szumacher

et al., 2007). Dental hygiene programs need to have remediation programs, in place, to assist

both international and native students struggling academically.

Future Research

As international students continue to come to the United States other barriers may

arise. An area of interest may be how changes in the political environment have impacted

the number of new international students coming to the United States. Current international

students may not be permitted to renew their educational Visas or may face deportation.


This puts added stress on students. Prospective international students, wanting to come to

the United States, may face restrictions in obtaining an educational Visa. If new

international students are denied access to the U.S. educational system, what countries are

they going to.

Another areas of future research might be following international students though

out their academic program as a way to learn how specific individuals have adapted and

adjusted to a new country and to the barriers they faced. Another area of interest may be

researching international dental students to see if they experience similar barriers to their

educational endeavors.

In addition, a study that addresses the learning behaviors of international students

could help identify areas where additional interventions/remediation could be implemented.

If interventions/remediation are implemented, a study comparing the international student’s

academics pre intervention/post intervention is another area of future research.

Conclusions

Currently there is uncertainty to the numbers of international students who will

continue to come to the United States for their education. As previously mentioned, IIE

Open Doors 2017 Fast Facts notes a 3.3% (300,743 to 290,836) decrease in enrollment of

new international students, at United States institutions, for the fall of 2016 from the

previous year. Overall, though, for the academic year 2016/2017, 1,078,822 international

students were enrolled (National Center for Education Statistics, 2017) at US institutions, an

increase of 3.4% from the previous year. For the academic year 2016/2017 3.2% (34,395) of

international students were enrolled in health profession programs, a 1.3% increase from the

previous year (Institute of International Education, 2017). Although there was a decrease in


new international students the numbers are still high. International students are coming and

remaining in the United States to complete their education.

The goal of dental hygiene educators is to prepare competent oral healthcare

professionals who can contribute to the profession (Alzahrani, et al. 2007). It is the ultimate

goal of every dental hygiene program to have a 100% first time pass rate. Sadly, students,

who struggle academically throughout the program are not successful. This occurrence is

devastating for the student. It results in increased stress and puts a huge financial burden on

the student.

To assist in achieving this goal of 100% first time pass rate, when possible, dental

hygiene educators should work closely with admission departments to ensure qualified

students are accepted (Alzahrani, et al. 2007). Dental hygiene programs should evaluate the

procedures, in place, at their institution to assist all students experiencing academic

difficulty. Remediation programs, such as peer-tutoring, professional tutors, English

language centers, writing centers, math centers, and supplemental clinical help will benefit

all students. Ensuring student success benefits both the dental hygiene program and the

academic institution. The issue of student attrition and retention is of interest to all schools

and programs, but is of special interest to professional health care programs charged with

graduating qualified, competent practitioners that serve to meet the health care needs of

society (Alzahrani et al. Fruedenthal & Bowen, 2010) today and in the future.


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Woolfolk, M. W., & Price, S. S. (2012). Dental education: Evolving student trends. Journal

of Dental Education, 76(1), 51-64.


Appendix A

Recruit Flyer


Appendix B

Letter Inviting International Students to Participate in the Focus Group

Dear International Dental Hygiene Students,

I hope your academic year is going well. My name is Susan Jenkins. I am a dental

hygiene educator pursuing my PhD in Health Professions Education from Simmons College

in Boston. I am conducting a research study using focus group methodology. A focus group

is a planned discussion on a particular topic. The topic of the focus group is perceived

barriers to academic success for international students studying at dental hygiene programs

in the United States. I am interested in your thoughts about this important topic.

I am writing to invite you, as an international student, to participate in a focus group

to be held at the University of New York Dental Hygiene Program (date to be determined).

I hope to have between five and ten participants in each group. I know that your schedules

are very busy so I anticipate that this group should take approximately one to one and a half

hours of your time.

If you agree to participate, you will be asked to join in a one to one and a half hour

focus group session at your institution. Your participation in the focus group is completely

voluntary. Measures will be taken to ensure your privacy. Come let your voices and

thoughts be heard about what it is like to be an international student studying dental hygiene

in the United States. Information about a date, time and place will follow.

Sincerely,

Susan Jenkins, RDH, MS


Appendix C

Informed Consent for Participation in Research

PurposeYou are being invited to participate in a research study. Research is a way of getting

new knowledge. The purpose of the study will research perceived barriers to academic success for international students studying dental hygiene in the United States.

ProceduresIf you agree to participate, you will be asked to participate in a one to one and a half hour focus group session at your institution. Follow-up meetings for clarification may be needed.

RisksThere are no physical or inherent risks to your participating in this research study. You will be asked to share your personal views related to your studying dental hygiene in the United States at your institution.

BenefitsThe main benefit of participating in this research is the opportunity to help future international students studying dental hygiene in the United States.

ConfidentialityThe information you share will be kept confidential. No personal identifiers will be used. The information shared during the focus group will be recorded using an audio recorder. The audio recordings and any transcripts will be kept in a locked cabinet that only the researcher can access. These documents and audio recordings will be securely stored for three years after the research is completed, at which time they will be destroyed.

Contact informationIf you have questions about this research at any time, please contact the Primary Investigator of the research:

Susan Jenkins, RDH, [email protected]

If you have questions about your rights as a participant in research, please contact the Institutional Review Board (IRB) at the Simmons College

Valerie BeaudraultHuman Protections AdministratorOffice of Sponsored Programs, at Simmons College617-521-2414


Participation is voluntaryYou do not have to participate in this research study. There is no penalty for refusing to participate. If, at any time, you are uncomfortable answering any of the focus group questions you are not required to respond. You are free to withdraw from the research study at any time without penalty.

By signing this document you are indicating that you are willingly agreeing to participate in this research study. You understand that your comments will be audiotaped during the focus group meetings. Your signature indicates that you have had a chance to read and understand this consent form and all of your questions have been answered to your satisfaction. In addition, you have received a copy of this form and you are not waiving any legal claims, rights, or remedies.

Signature of research participant: _____________________________________________

Name of research participant: _________________________________________________

Date: ________________________


Appendix D

Interview Guide

Demographic Questions

Demographic questions1. Age

a. 18-20b. 21-25c. 26-30d. 31-35e. 36-40f. over 40

2. Gender a. Femaleb. Male c. Other d. Prefer not to answer

3. How long have you been studying in the United States?a. 1 yearb. 2 yearsc. 3 yearsd. 4 yearse. 5 yearsf. over 5 years

4. Is English your primary language?a. yesb. no

If not, what is your primary language? ___________________

5. What is your country of origin? _________________

Focus Group Questions

Interview QuestionsInitial Question

1. Please describe what it is like for you, as an international student, to study at this university

2. Explain the language and cultural differences you face as an international student?3. Have you encountered any barriers in the classroom in your dental hygiene program?

For example, understanding terminology?


a. If so, what were the barriers?b. How did you overcome those barriers?c. Did you speak with a faculty member/administrator about the barriers you

were having?d. Were all of the barriers you were experiencing addressed by a faculty

member or administrator? If not, please explain. 4. Please describe your clinical experiences.5. Have you encountered any barriers in your clinical experience? 6. While in the dental hygiene program did you create friendships with your American

classmates? a. If so, where those friendships helpful in your becoming successful in the

dental hygiene program?7. How well did the University accept you as an international student? For example,

have you felt part of the university community?8. How do you feel your perspective as an international student contributed to a

positive learning environment?9. Is there anything else you would like to share about your dental hygiene educational

experiences?


Appendix ESurvey Monkey© Inquiry to Participate

Perceived Barriers to Academic Success for International Students Studying Dental Hygiene in the United States focus group inquiry

1. Would you be interested in participating in a focus group, for a dissertation research, titled Perceived Barriers to Academic Success for International Students Studying Dental Hygiene in the United States.

yes

no

maybe

2. If you are interested in participating in the focus group what day of the week is best?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

3. If you are interested in participating in the focus group what time of day do you prefer?

9:00-10:30

10:00-11:30

10:30-12:00 noon

11:00-12:30

12:00-1:30

1:30-3:00

2:00-3:30

3:00-4:30

5:00-6:30

6:00-7:30

4. If you are interested in participating in the focus group please provide your email.


5. Thank You for your time.

thank you


Appendix FSurvey Monkey© Demographic Questions

1. Age

18-20

21-25

26-30

31-35

36-40

over 40

2. Gender

Female

Male

Other

Prefer not to answer

3. How long have you been studying in the United States?

1 year

2 years

3 years

4 years

5 years

over 5 years

4. Is English your primary language?

yes

no

5. What is your primary language?


6. What is your country of origin? _________________


Appendix G

IRB Project Description Template

The project description should be approximately 5 single-spaced pages in length, not including consent forms and instruments.

General Description. Briefly describe the overall goals of the proposed research and the general procedures to be used.

In recent years there has been an increase in the numbers of international students enrolled in dental hygiene studies in the United States. This trend reflects a larger national trend in enrollment of international students in the United States. Academic institutions need to totally embrace students from different countries. In order to better facilitate the learning experience of international students, educators need to have a good understanding of the features of international students' learning behaviors in relation to their academic achievement (Li, Chen, & Duanmu, 2010). The issue of student attrition and retention is of interest to all schools and programs, but is of special interest to professional health care programs charged with graduating qualified, competent practitioners that serve to meet the health care needs of society (Fruedenthal & Bowen, 2010). The overall goal of the research is to gain an understanding of what international students studying dental hygiene in the United States feel are barriers to their academic success. The literature review found no information related to the academic success of international dental hygiene students. Focus group methodology will be utilized to gather information. Participants will be chosen through a purposive snowball sampling at two private dental hygiene programs in New England.

Significance of the Study. Provide a brief theoretical and empirical rationale for why you believe this study is important.

Despite challenges and barriers, international students often choose to study dental hygiene in the United States because they believe the quality of education received in this country is superior to that of their country of origin (Hegarty, 2014). They also believe an education received in the U.S. will improve job opportunities and provide them with a competitive edge (Hegarty, 2014). In a recent report, the profession of dental hygiene ranked fifth as one of the top health care professions in the United States (Taylor, 2015). This information may encourage both international and domestic students to pursue a career in dental hygiene. Woolfork and Price (2012) noted overall enrollment in U.S. dental hygiene programs began to increase in the academic year 2009-2010. The American Dental Association's 2015 Survey of Allied Dental Education found the number of non-U.S. students in U.S. dental hygiene programs has remained constant over the


past three academic years, 2011-2014, with enrollment numbers of 558, 577, and 556, respectively. Academic difficulty can often be a significant problem for international students in health professions programs (Szumacher et al.,., 2007). Anecdotal evidence and attrition rates in dental hygiene programs suggest international and native students often encounter various barriers to academic success, yet little is known about this phenomenon. Holt's (2005)study investigating g retention strategies and practices implemented in associate degree, entry-level dental hygiene programs (n=25) looked at attrition issues. Holt (2005) found the major reasons for attrition occurring were academic under achievement (88%), dissatisfaction with career choice (76%), family and personal responsibilities (72%), and underdeveloped clinical skills (56%). Unfortunately, international students in difficulty often are identified late in the curriculum and risk dismissal if remediation is not successful (Freudenthal & Bowen, 2010, Szumacher et al.,., 2007). Dental hygiene programs are highly structured. Students are required to progress in a prescribed fashion in the program with little opportunity for individualized learning. The language and skills particular to dental hygiene may add yet another barrier to international students who are struggling with language and various other issues of acculturation (Freudenthal & Bowen, 2010, Ting Toomey, 2013). Early identification and remediation of these barriers to academic success can potentially lead to

Subject Population: Describe the characteristics of the subject population.

A purposive, snowball sampling will be utilized for choosing research participants. The sample will include international dental hygiene students enrolled in three dental hygiene programs. Inclusion criteria will be any international student currently enrolled in three specific dental hygiene programs. The minimum age of the participants will be 18 years. Participants will be English speaking, as the focus group will be conducted in English.

Sources of Research Material. Identify the sources of research material obtained from individually identifiable living human subjects in the form of specimens, records, or data.

The information gathered in the semi-structured focus groups will be audio-taped. An observer will also take field noted during the focus group sessions.

Subject Recruitment. Describe plans for the recruitment of subjects and the consent procedures to be followed.


The researcher will work with the Dean of Students at MCPHS University andwith aa contact at the University of New York and the University of Hawaii Mānoa to recruit study participants.Study participants will be recruited using f a c e - t o – f a c e i n d i t a t i o n , flyers and through email, where permitted, to the students. At the beginning of each focus group/interview participants will be given the informed consent to review and sign. The informed consent will inform the participants that the information they share will be kept confidential. No personal identifiers will be used. The information shared during the focus group/interview will be recorded using an audio recorder. Field notes will be taken by an observer. The audio recordings and any transcripts will be kept in a locked cabinet that only the researcher can access. These documents and audio recordings will be securely stored for three years after the research is completed, at which time they will be destroyed.

Risks. Describe any potential risks (to confidentiality, physical, psychological and social well-being, legal and financial risks, for example) and assess their likelihood and seriousness.

There are no anticipated potential risks to the study participants. Participants will be informed that efforts will be made to ensure their confidentiality. Since the research will be conducted in a focus group/interviews, complete confidentiality will not occur within the group.

Protection Against Risks. Describe the procedures for protecting against or minimizing any potential risks and assess their likely effectiveness. Where appropriate, describe provisions for secure storage of data.

Participants may be concerned comments made during focus group/interviews discussions could have a negative impact on their academic standing in the institution. Participants will be reassured confidentiality will be rigorously maintained. Reassurance will be given to participants their comments and contributions during the focus groups will in no way identify them to dental hygiene faculty or school administrators. In focus group methodology confidentiality of participants is maintained by several methods. The participant's name and identifying information will not be associated with any part of the written report. Pseudonyms for participants will be used in the written report. Participants will be informed that if quotes are used in written reports, that the intent is the individual participant will not be recognizable. Participants will be informed they are free to withdraw from the study at any time without penalty. Their participation or lack thereof will have no impact on their grades in course work of their academic program standing. Each participant will be given a copy of the signed informed consent. Data will be stored in a lock cabinet accessible to only the researcher. Electronic records will be stored in password protected USB devices and drives on Simmons College computers. All


documents will be retained for three years after the study has been conclude. At that time all documents will be destroyed.

Benefits: Discuss any specific benefits to the subjects.

There a no anticipated benefits to participating in this study. However, participants may benefit from having the opportunity to share thoughts, feelings and perceptions of the experience of being an international student. They may obtain a sense of personal pride in the contributing to the body of knowledge of this topic


Appendix HRequest for Review by the MCPHS Institutional Review Board

For Research Protocols

Date:

Principal Investigator (PI), title and campus mailing address: Susan Jenkins, RDH, MS, Associate Professor Forsyth School of Dental Hygiene Boston

Other key study personnel:Dr. Eileen McGee, Associate Professor of Practice, NursingSimmons College and Health Sciences Dissertation Committee Chair

Dr. Jean Christoffersen, PhD, PMHCNS-BC , Associate Professor of Practice, Nursing Simmons College School of Nursing and Health Sciences

Dr. Linda Boyd, Professor & Dean, Forsyth School of Dental HygieneMCPHS University

Study Title: Perceived Barriers To Academic Success For International Students Studying Dental Hygiene in the United States

Expected study dates:Start date for data collection: Spring 2017 End date for data collection: Spring 2017

Start date for data analysis: Spring 2017 End date for data analysis: Spring 2017

1. What research question does the proposed study seek to address? What hypothesis does the proposed study test? (If a hypothesis is not appropriate for the study, please explain.)

Research Question 1 - What do international students, studying dental hygiene in the U.S., perceive are barriers to their academic success?

Research Question 2 – What strategies have international students, studying dental hygiene in the U. S. employed to overcome barriers and challenges to academic success?

Research Question 3 - What do international students perceive to be the strengths they bring to studying dental hygiene in the U. S.?


2. How will the study contribute to existing knowledge? How does it add to the literature? (Provide references to the published studies that are most similar to the proposed project. If there seem to be no similar studies, describe the research leading to this finding.)

After an extensive search of the literature information was found related to other disciplines, but no literature was found related to international students studying dental hygiene in the United States. The presence of international at US institutions continues to increase. Institutions need to understand perceived barriers to academic success for this population to help ensure their academic success.

3. What journals, publishers or conferences might be interested in receiving the results of this study?The following journals might be interested in this information:

Journal of Dental EducationACCESS the Journal of the American Dental Hygienists’ Association

The information could be presented at the following conferences:Nationally

American Dental Educators Association Annual Meeting American Dental Hygienists’ Association Annual Session

LocallyThe Conference – Massachusetts Dental Hygienists Association Annual MeetingYankee Dental Congress

4. What population of human participants (subjects) do you wish to study? (Identify any vulnerable populations, such as prisoners, fetuses, pregnant women, the seriously ill, or mentally or cognitively compromised individuals.)

The population to be studied will be any international student enrolled in three specific US dental hygiene program.

5. How many participants will be recruited?

A group of 10 to 20 participants will be recruited between the three locations where the information will be gathered.

6. How do you plan to recruit participants for the study? (Attach any flyers, letters, phone scripts or e-mails to be used.) Who will communicate with potential participants in the recruiting procedures? (Recruitment procedures should minimize coercion—pressure for individuals to participate.)

Participants will be recruited by using a purposive snowball sampling. Flyers, fece-to-face invitaitons, and email invitations (where permitted) sent from the PI.

7. Will participants be compensated for participating in the study? If so, how?


Participants will not receive monetary compensation. Food will be provided during the focus group sessions.

8. Does the research protocol involve any manipulation or intervention (including education, treatment, etc.) other than data collection? (Describe in detail any interventions that are implemented as part of the research. Attach educational materials, treatment procedures, etc.) NA

9. If a manipulation or intervention is involved, are benefits expected from it? If so, what evidence is available to support this expectation? NA

10. In your judgment, what risks does the manipulation or intervention pose? (Consider physical, psychological, social and legal risks.) NA

11. What data will be gathered from human participants? (Attach any data collection instruments. Describe how the instruments will be administered.)

Research will be conducted in a focus group/interview setting. Data will be collect using an interview guide of semi-structured questions. Each participant will be provided a paper or electronic demographic questionnaire prior to the start of the focus group/ interview session. The focus group/interview will be audio recorded along with field note taken by an observer. The PI will do the transcription.

12. In your judgment, what risks to participants are involved when working with these data? (Consider physical, psychological, social and legal risks that may arise due to generating and sharing this information.)

There are no anticipated potential risks to the study participants. Participants will be informed that efforts will be made to ensure their confidentiality. Since the research will be conducted in a focus group, complete cofidentiality will not occur within the group.

13. Who will have access to the data as it is collected and analyzed?

Only the PI will have access to the collected data.

14. What procedures will be used to protect participant data? How will data be stored? How and when will it be destroyed?

Data will be stored in a locked file cabinet that only the PI has access to. All documents will be retained for three years after the study has been concluded. At that time all documents and electronic recordings will be destroyed.

15. What methods will be used to analyze the data collected?

Data will be collect using an audio recording devise and hand written field notes.


16. What are the qualifications of the project personnel, including the principal investigator, to conduct this work?The PI is a registered dental hygienist employed as a full time associate professor at MCPHS University Forsyth School of Dental Hygiene.PI is completing her PhD program. The information collected will be used in the PI’s dissertation.

17. Is the proposed study funded by any intramural or extramural grant or contract? If so, who is funding the study? NA

18. Have the project personnel completed any training in the protection of human participants of research? (If so, give training name and date of completion)

CITI Human Subject Training was completed on1/22/2017 and will expire1/21/2020.

The information provided on and with this document accurately represents my intended research plans. I understand that participant recruitment and data collection may not begin until I receive official approval from the MCPHS IRB and that any changes to protocol procedures or documents must be approved by the IRB prior to implementing these changes.

Principal Investigator (signature) Date


Appendix ISimmons IRB Research Approval

[email protected]/28/17

March 28, 2017

Susan JenkinsPhD Health Professions EducationSimmons CollegeBoston, MA 02115-5898

RE: Your application dated 3/23/2017 regarding study number 16-126: Perceived Barriers to Academic Success for International Dental Hygiene Students Studying Dental Hygiene in the United States

Dear Ms. Jenkins:

I have reviewed your request for expedited approval of the new study listed above. Your study is eligible for expedited review under the DHHS (OHRP) designation 45 CFR 46.110 (7).

This is to confirm that I have approved your application. The protocol is approved through your protocol dated 03/23/2017. The consent form 3/23/2017 has been approved. You must obtain signed written consent from all subjects. Valerie Beaudrault, Human Protections Administrator, will send you a stamped electronic copy of your informed consent document under separate email cover.

You are granted permission to conduct your study as described in your application effective immediately. The study is subject to continuing review on or before 3/27/2018, unless closed before that date.

Please note that any changes to the study as approved must be promptly reported and approved. Some changes may be approved by expedited review; others require full board review. Contact Valerie E. Beaudrault (617-521-2415; fax 617-521-3083; email: [email protected]) if you have any questions or require further information.

Sincerely,

Nicole UsherIRB member and primary reviewer


Simmons College IRBApproval to Continuing Review


Appendix J

MCPHS IRB Approval Letter

Dear Professor Jenkins:

Thank you for submitting your protocol, "Perceived Barriers to Academic Success for International Students Studying Dental Hygiene in the United States", to the MCPHS Institutional Review Board. Because the research study involves interview procedures carrying minimal risk to participants, it has the status “exempt” in accordance with 45 CFR 46.101(B)(2). Your project is now approved and has been assigned protocol number IRB# 041017J. Please refer to this protocol number in any future correspondence regarding this project. You may begin recruiting participants and collecting data.

Please also make careful note of the following:

RECRUITING: University policies prohibit using MCPHS e-mail services to invite MCPHS students to participate in research. Announcements, paper flyers, and online postings are allowed.

ADVERSE EVENTS: You are responsible for reporting to the IRB any adverse events, including unintentional distress or loss of confidentiality experienced by any participants.

AMENDMENTS: Any substantial changes to the goals of the project or to the study documents should be submitted as an amendment for approval before proceeding with the change. Substantial changes include, but are not limited to, changes in the data collected, changes in key personnel, changes in the number of expected participants, changes in recruitment procedures or changes in the research question being investigated. CONTINUING REVIEW: IRB approval is for one year. If you expect to recruit subjects, collect data or analyze data more than one year from the date of this notice, you must apply for continuing review. Please allow adequate time for review and approval prior to the expiry date.

ACCESS TO PARTICIPANTS: You are responsible for respecting the rules and procedures of the research sites. Approval by the MCPHS University IRB does not guarantee access to participants and does not indicate compliance with human subjects protections or other requirements at any off-campus site. The original ethics approval originates with Simmons College. It is your responsibility to maintain communications between the Simmons College and MCPHS IRBs. Examples include and are not limited to approval changes.

Thank you for submitting your protocol to the IRB. I wish you good luck for a successful project.


Yours sincerely,

Jeff Fong, PharmD

Vice-Chair, Institutional Review Board

...

Jeffrey

Fong, PharmD, BCPS

Associate Professor of Pharmacy PracticePharmacy PracticeMCPHS University

19 Foster Street

| Worcester

MA

01608

T [email protected]

Confidentiality Note: This e-mail, and any attachment to it, is intended to be confidential and might be legally privileged. It is intended solely for the use of the addressee. If you are not the intended recipient, you are hereby notified that reading, copying, disseminating or distributing this email is strictly prohibited. If you have received this e-mail in error, please immediately return it to the sender and delete it from your system. Thank you.

http://www.mcphs.edu/

mailto:[email protected]

tel:508.373.5672



MCPHS IRBRequest for Continuing Approval

Hi:

We no longer need continuing review for exempt studies, so you are all set!

You still need to submit amendments if the protocol changes or anything like that.

Thanks,

K

...

Kenneth Richman

, PhD

Professor of Philosophy and Health Care EthicsSchool of Arts and SciencesMCPHS University

179 Longwood Avenue | Boston MA 02115T 617.732.2927 F [email protected]


From: Jenkins, Susan Sent: Friday, March 9, 2018 1:32 PMTo: Richman, Kenneth <[email protected]>Subject: IRB continuing request



tel:617.732.2959

tel:617.732.2927




Hi Ken,

I hope you are having a good spring break.

I am submitting my request to continue my research. I am in the final revision stages.

Please let me know if there is anything else you need. Thank you.

Regards,

Susan

...

Susan Jenkins, MS, RDHAssociate Professor of Dental HygieneForsyth School of Dental Hygiene - Celebrating 100 yearsMCPHS University

179 Longwood Avenue | Boston MA 02115T 617.735.1046 F [email protected]




tel:617.732.2225

tel:617.735.1046


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