CONSENT FORM

CONSENT FORM

 “Positive Change to Promote Mental Health and Wellbeing for Black Canadians in Manitoba”

Study investigators

Principal Investigator: Charlotte Lwanga; Phone: 204-295-2589; email: cklwanga@hotmail.com

Co-investigator: Antoinette Zloty; Phone: 204-798-1694; email: antoinettezloty@hotmail.com

Funding source

This study is funded by the Public Health Agency of Canada (PHAC) through a grant to the Barbados Association of Winnipeg, Manitoba Inc.

Invitation to participate

You are being invited to participate in a research study. Choosing whether or not to participate is entirely your choice. If you decide not to participate, there will be no negative impacts on your relationship with the researchers and your organization. The information provided in this form tells you about what is involved in the research, what you will be asked to do, and any potential risks or benefits. Please read this form carefully and ask any questions you may have.

Consent is an ongoing process. During the research study, we will tell you about any significant finding that could affect your willingness to continue to participate in this study.

Purpose of the research study

A Mental Health Promotion toolkit for Black Canadians was developed by the community. The goal is to conduct an evaluation of a community-based intervention, which will be achieved by engaging Black-led organizations in assessing the effectiveness of the Mental Health Promotion Toolkit for Black Canadians and thereafter using it within the community.

What you will be asked to do

If you decide to participate in this research, you will be asked to attend one (1) orientation session to the Mental Health Promotion Toolkit. This session will take up to 4 hours and will involve taking part in a group with up to 10 organizational representatives. During this session, you will be asked to fill out a survey before and after the orientation. The study seeks to determine the extent to which this newly developed and culturally relevant Mental Health Promotion Toolkit for Black Canadians in Manitoba is effective in promoting mental health and well-being among Black Canadians. After 3 months of orientation, another survey will be available to you and the other representatives of your organization to collaborate in the completion of the organization section. The orientation sessions will be via Zoom and surveys will be completed online within the 4-hour period.

Who can take part in the research study?

To be involved in this study, you must be a representative of a Black-Led organization. We are looking to recruit up to three (3) representatives per organization.

Possible risks and benefits

Risks: As the orientation to the Toolkit will deal with the topic of mental health awareness, it is possible that it may raise issues or feelings that you would like support in dealing with. If this happens, the researcher can refer you to a free counselor, or to other resources in the community that can help you. A counsellor from Canadian Mental Health Association will also be available in a Breakout room for immediate access. You can leave the session at any time, and you do not have to answer any questions that make you feel uncomfortable. You can also withdraw your participation in the project at any time. By agreeing to participate in this research you are not giving up or waiving any legal rights in the event that you are harmed during the research.

Benefits: There is no guarantee that you will benefit directly from participating in this study. However, the study will provide you with the opportunity to share your experiences and will hopefully raise awareness of mental health, wellness and resources especially in Black-led organizations.

Compensation / reimbursement

In order to acknowledge the time that you have taken to be involved in this project, each participant will receive a $20 monetary gift. If you consent to participate, but change your mind before coming to the session, you will not receive this money. If you consent to participate but change your mind during the session, the compensation will be provided regardless of your decision to withdraw.

Privacy and confidentiality

All hard copies of documents will be identified only by code number and kept in a locked filing cabinet. You will not be identified by name in the orientation transcript. Hard copies of any notes or feedback will be stored in a locked filing cabinet in the office of the Co-Investigator and electronic copies will be kept on the local hard drives of team members’ computers – all of which are password protected. Participants will not be identified by name in any reports of the completed study.

Limits to confidentiality: Please be aware that there are limits to confidentiality in a group setting. All members of the group will be asked to respect the privacy of other members and to keep what is said confidential. However, there is no guarantee that they will do so. Please keep this in mind when deciding what you feel comfortable sharing.

No personal information will be shared with anyone outside of the core research team, unless required by law. Instances where researchers are required, by law, to breach confidentiality include the following: child abuse or neglect that is ongoing and unknown to police, cases of imminent risk of physical harm to oneself or another, cases of sexual abuse, sexual assault, or sexual harassment by a health professional.

Reporting of results

Although the project outcomes will be determined by the research findings, possible research products will include: articles in scientific journals, a report for the Public Health Agency of Canada’s internal use, and plain language summaries. We will only report group results, therefore, you will not be identified in any way in our reports. Any quotes will be anonymized and will not be attributed to a specific individual. If you wish to be informed of the results of the research, please indicate this on the signature page below.

Withdrawing from the study

Your participation is completely voluntary, and you are under no obligation to participate. If you decide to participate but change your mind later on, you are free to withdraw at any time without consequence. Your decision to withdraw will not influence your relationship with the researchers or organization in any way. If you decide to withdraw during the orientation, it may not be possible to remove your data, although we will make our best effort to avoid referring to your responses. If you decide to withdraw after the session, your data will already be anonymized and we will not be able to remove your data.

Conflicts of interest

None of the researchers have any conflicts of interest in this study.

Questions and contact information:

If you have any questions about the study or would like more information, please contact:

Charlotte Lwanga or Antoinette Zloty 204 – 202-7197

Email:info@blackmentalhealthpromotion.ca

If you have any questions about your rights as a research participant, you may contact:

Health Canada-PHAC Research Ethics Board Secretariat

70 Colombine Driveway, Room 941C, PL: 0909C

Brooke Claxton Building, Tunney’s Pasture

Ottawa, ON K1A 0K9

Telephone: 613-941-5199

Facsimile: 613-941-9093

Email: hc.reb-cer.sc@canada.ca

This research study was reviewed and approved by the Health Canada-Public Health Agency of Canada Research Ethics Board.

Statement of consent:

By consenting this form, I agree that:

• The study has been explained to me
• All my questions have been answered
• Possible harm and discomforts and possible benefits (if any) of this study have been explained to me
• I have been told that my personal information will be kept confidential
• In addition, I understand that:
• I have the right not to participate and the right to stop at any time
• I may refuse to participate without consequence
• I have a choice of not answering specific questions
• I am free now, and in the future, to ask any questions about the study
• No information that would identify me will be released or printed without asking me first
• I will receive a signed copy of this consent form
• You can still participate in the research if you select no: