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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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 2
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?”
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 3
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 4
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 5
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 6
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.
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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
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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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 9
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 10
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
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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.
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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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 13
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
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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).
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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?
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3: What do international students perceive to be the strengths they bring to studying
dental hygiene in the U. S.?
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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
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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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 19
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.
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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
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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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 22
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 23
(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.
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 24
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 25
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 &
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 26
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 27
all students’ understanding and appreciation of the richness of other cultures (Volet & Ang,
2012).
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 28
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)
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 29
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).
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 30
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).
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 31
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 32
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 33
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 34
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 35
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 &
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 36
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 37
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).
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 38
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 39
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.
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 40
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.
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 41
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.
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 42
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,
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 43
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.
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 44
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”?
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 45
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.
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 46
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.
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 47
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 48
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 49
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 50
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 51
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, &
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 52
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 53
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 54
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.
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 55
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.
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 56
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 57
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.
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 58
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remedial programmes of the medical radiation sciences programme at University of
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Toronto and the Michener Institute for Applied Sciences, Toronto, Ontario, Canada.
Annals Academy of Medicine Singapore, 36(9), 725.
The International Student, (2015) Studying in the U.S.A. Retrieved from
http://www.internationalstudent.com/study_usa/
https://www.internationalstudent.com/study_usa/
Then, K. L., Rankin, J. A., & Ali, E. (2014, Winter). Focus group research: What is it and
how can it be used? Canadian Journal of Cardiovascular Nursing, 24(1), 16-22.
Thomas, E., & Maglivy, J. K. (2011, April). Qualitative rigor or research validity in
qualitative
research. Journal for Specialists in Pediatric Nursing, 16, 151-155.
doi:10.1111/j.1744-6155.2011.00283.x
University of Hawaii. (2017). UH, Mānoa: At a glance. Retrieved from:
http://www.hawaii.edu/campuses/Mānoa.
US News and World Report. (2016). The 100 best jobs. Retrieved from
http://money.usnews.com/careers/best-jobs/rankings/the-100-best-jobs
Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content analysis and thematic analysis:
Implications for conducting a qualitative descriptive study. Nursing & Health Sciences,
15(3), 398-405.
Vardaman, S. A., & Mastel-Smith, B. (2016). The transitions of international nursing students.
Teaching and Learning in Nursing, 11, 34-43. Retrieved from:
http://dx.doi.org/10.1016/j.teln.2015.12.008
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Volet, S. E., & Ang, G. (2012). Culturally mixed groups on international campuses: An
opportunity for inter-cultural learning. Higher Education Research & Development,
31(1), 21-37. doi:10.1080/07294360.2012.642838.
Ward, S. T., Downey, M. C., Thompson, A. L., & Collins, M. A. (2010). Predictors of
success in dental hygiene education: A follow–up study. Journal of Dental Hygiene,
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Wilkinson, S. (2004). Focus Group Research In Silverman, D. Qualitative Research:
Theory, Method and Practice (pp. 177). London: Sage.
Woolfolk, M. W., & Price, S. S. (2012). Dental education: Evolving student trends. Journal
of Dental Education, 76(1), 51-64.
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Appendix A
Recruit Flyer
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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
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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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 71
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: ________________________
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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?
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 73
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?
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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.
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 75
5. Thank You for your time.
thank you
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 76
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?
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6. What is your country of origin? _________________
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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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 79
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.
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 80
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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 81
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
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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.?
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 83
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?
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 84
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.
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 85
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
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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
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 87
Simmons College IRBApproval to Continuing Review
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 88
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.
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 89
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
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.
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 90
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]
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.
From: Jenkins, Susan Sent: Friday, March 9, 2018 1:32 PMTo: Richman, Kenneth <[email protected]>Subject: IRB continuing request
ACADEMIC SUCCESS INTERNATIONAL STUDENT U.S 91
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]
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.