Rural Health Policy - TRAINING COMMUNITY HEALTH WORKERS

This publication was funded by the Health Resources and Services Administration's Office of Rural Health Policy with the Frontier Education Center under
Contract Number HHSH250200436014C.

Note: All references to "frontier" use the Consensus Definition of the Frontier Education Center unless otherwise indicated. Counties and/or frontier areas so defined have been developed with the involvement of all of the relevant State Offices of Rural Health (100% response rate). This definition has not been adopted by any Federal programs but has been adopted as policy by the Western Governors' Association and the National Rural Health Association. The Consensus Definition weights three elements - population density, distance in miles and travel time in minutes - which together, generally describe the geographic isolation of frontier communities from market and/or service centers. The Center understands that various programs will establish their own programmatic definitions and eligibility criteria.

Dedicated community members - volunteer or paid - are often the glue that holds the local frontier heath care system together. Some are Community Health Workers (CHWs), caring community members with levels of training that vary from location to location. Depending on the organization they work with, they will have different roles and responsibilities ranging from providing direct services, health education, emotional support and patient advocacy, and intake and referral to higher levels of care.

These providers are often unable to leave their home community for training and education. In response to their travel challenges, education and training programs are more frequently using technology to bring training opportunities into the community.

This paper provides a brief overview of some programs and issues related to the use of technology and distance education to train community health workers in frontier areas. Issues include the use of consistent definitions, the appropriate technology format for the learner and access to that technology, cultural competency /proficiency of faculty, support for faculty and students, and the assurance of quality.

Those entrusted with the responsibility of supporting healthy frontier communities and training the community health workers that serve them might consider the following recommendations:

Community Health Workers (CHW) play a pivotal role in meeting the health care needs of frontier communities. These essential community providers work under many labels, including Community Health Worker, Community Health Advisor (CHA), Promotora, ayudante, and other locality-specific titles. This paper will use term Community Health Worker (or CHW) as an umbrella term, except where specific sources use a different term.

Community Health Workers help increase access to health services (particularly among racial and ethnic minority groups), improve quality of care, reduce health care costs, and contribute to broader social and community development (Witmer et al, 1995). As "in-between people," CHWs "draw on their insider status and understanding to act as culture and language brokers between their own community and systems of care (Satterfield et al, 2002; Love et al., 2004, p. 418)."

Although CHWs are not always accepted by the medical establishment, a number of key organizations support the development of CHW programs, including The American Public Health Association (2002), the Centers for Disease Control and Prevention (2005), and the National Rural Health Association (2000). The Pew Health Professions Commission recommended in its 1998 report Recreating Health Professional Practice for a New Century that public health schools, programs and departments focus some of their resources on training lay health workers and community residents to understand the mission of public health and equip them in basic competence to achieve this mission (Oneill, 1998).

CHWs may be known by many different titles, may be paid or unpaid/volunteer, and have varying levels of job-related education and/or training. According to the National Rural Health Association, "the most significant commonalities of CHA programs are that:

As isolated populations increase, their dependence on these multi-tasking and frequently over-burdened healthcare workers also increases; and providing CHWs with the tools to do the best job possible falls to those who employ, supervise and train them. In one study, access to basic training was found to be a fundamental need of CHAs; researchers concluded that improving access to training was an important element of improving retention (Landon et al, 2004).

Despite the importance of CHWs, the challenges of providing them with high-quality training opportunities can be problematic. In an issue paper on community health advisors, the National Rural Health Association (NRHA) states, "training of CHAs is variable in terms of quality and content" and considers it to be a major challenge to community health advisor programs (National Rural Health Association, 2000).

In frontier communities, training challenges include limited infrastructure, distance from population and technological centers, cultural and social norms that sometimes resist even positive change, and the high turnover of key staff. Use of information and communication technologies (ICT) and distance education modalities are a promising strategy for improving training of CHWs and thus the quality of care provided within frontier communities.

CHWs are organized (or employed) within a number of types of organizations: community-based non-profit organizations, public health departments, and national organizations. Training can be formal or non-formal, occur as pre-employment education or on-the-job training, or self-taught. Because the varied and disparate nature of CHW training is thought to contribute to a certain lack of respect within the health professions, as well as a lack of sustainability in terms of funding programs, there is a movement to formalize and standardize basic training within institutions of higher education.

In a 1998 National Community Health Advisor study, CHWs and their program managers identified a set of essential core roles and competencies (Rosenthal et al, 1998). The seven 'core roles' identified by the national study are:

Rosenthal and colleagues also identified eight core skill clusters including (in order of frequency cited) communication skills, interpersonal skills, knowledge base, service coordination skills, capacity skills, advocacy skills, teaching skills and organizational skills. Clearly the roles played and skills needed by CHWs are complex and multi-dimensional.

As a relatively new "occupation" however, formalized CHW education programs have only recently been developed. Most CHWs receive on-the-job training that targets narrow program objectives. Community Health Works, jointly sponsored by City College of San Francisco and San Francisco State University, developed the first college credit certificate for CHWs in the United States (Community Health Works, no date; Love et al, 2004). The Center for Sustainable Health Outreach (CSHO) has an ongoing project cataloging CHW programs that offer credit, certificates, or degrees at institutions of higher education. Thus far the project has identified 15 programs in 10 states that offer courses, certificates, and/or degrees for generalist CHWs (CSHO, 2005a). The majority of programs are offered in partnership with other agencies or programs, and are frequently offered in off-campus locations. However, of those who responded to the survey, only one reported a distance learning component (University of Alaska Southeast-Sitka). May and colleagues (2005) reported that three states (Alaska, Indiana and Texas) have systematic, state-sponsored certification programs, and seven others (Arizona, California, Kentucky, Massachusetts, Nevada, New Mexico, and Ohio) were considering state-level certification.

Because of CHWs' "in-between" role, there is some tension between those calling to professionalize CHWs as members of the healthcare workforce, and the need to preserve the characteristics that make CHWs effective within the community. Sustainability of CHW programs depends on improved recognition of and respect for CHWs within the health services community; advanced education which socializes and places the CHW within the biomedical community can accomplish this goal. However, "…displacing natural CHW skills and experiential knowledge with the biomedical health system's values and methods may undermine their effectiveness within their communities (Love et al, 2004 p. 419; see also Witmer et al, 1995)." Educational philosophy will influence not only the content of CHW curricula, but the educational model selected to develop the competencies of CHWs. To accomplish both objectives, the Community Health Works' CHW certificate program in San Francisco selected a combined pedagogical approach: a performance-based approach to certification in combination with a popular education model. Through this combination, "CHWs learn to bridge the often-disparate worlds of their communities, and the professional health care system, while maintaining their facility and credibility within both" (Love et al, 2004).

Frontier advocates and trainers are very familiar with the realities of educating truly remote service providers. Challenges include the tremendous cost of travel to regional training hubs and resistance to relocating, even temporarily for such training. Yet institutions of higher education are few and far-between in frontier areas. These training challenges have led to an increased reliance on distance education and technology. As a recent report on the rural health workforce noted, "Distance education is a proliferating response to the demands of rural-based students to obtain in-place education" (Addressing the Nursing Shortage, Frontier Education Center, 2004, p. 15).

The possibility that appropriate distance education provided to community health workers may actually increase the quality of care to frontier residents is the driving force behind some of the most innovative models of technology use in frontier regions. Such goals are consistent with the emphasis on quality of care that is at the heart of the new Institute of Medicine Report Quality Through Collaboration: The Future of Rural Health (IOM, 2005). As Dr. Wayne Myers, former Director of the Federal Office of Rural Health Policy and past President of the National Rural Health Association notes, this new and influential report "recognizes the potential for distance education to help train health personnel in smaller towns, capitalizing on the strengths of place-committed local students (Myers, 2005)."

Internet access in rural communities. Frontier and rural communities are less likely to have access to the internet, affordable internet, or high-speed internet connections, pointing to what the Appalachian Regional Commission (ARC) terms "the connectivity conundrum": those who would benefit the most from a broadband network have the least access to it (ARC, no date). The Pew Internet & American Life Project reports that in 2003, 52% of survey respondents in rural areas used the internet, in comparison with 66% and 67% of suburban and urban residents, respectively (Bell et al, 2004). Low-income respondents in rural areas were less likely to be online than low-income respondents in suburban or urban areas, while middle and upper income residents were equally likely to be online, regardless of residence. Demographic factors contributing to lower internet use rates in rural areas include older populations, lower incomes, and lower educational attainment. Other findings included:

Distance education is "a set of teaching and/or learning strategies to meet the learning needs of students separate from the traditional classroom setting and sometimes from the traditional roles of faculty (American Association of Colleges of Nursing, 2005)."

By most definitions, CHWs are well-established members of a community with a commitment to the people and place that make up the community. Few institutions of higher education are easily accessible to the frontier CHW. Yet leaving the community for training is difficult for a number of reasons. The CHW may have family and community obligations that make it difficult to leave. Also training is removed from the context in which it will be applied. For many CHW programs, it is difficult to gather enough trainees from within a reasonable distance to offer face-to-face training. Distance learning enables learners to participate in in-place education and training. It potentially enables more frequent training as well.

Distance learning has been promoted by the CDC since the 1960s, however the technology revolution has dramatically transformed distance learning. The Public Health Training Network (PHTN), established by the CDC in 1994, "is a distance learning network of people and resources that takes training and information to the learner." According to the PHTN, "whatever you call it, and whatever form it takes, distance learning can be an effective and economical strategy for reaching widely dispersed learners-such as members of the pubic health workforce." Characteristics of distance learning are:

Distance learning is increasingly computer-based (e.g. computer-based training, or CBT), with internet-based modes of delivery. This has lead to the proliferation of web-based courses and curricula. According to a 2000-2001 survey of distance education programs at degree granting post-secondary institutions, 90 percent offered Internet-based asynchronous courses (Waits and Lewis, 2003). Thus in addition to issues of content in CHW training, issues of access to computers, to internet service providers, and computer literacy must be addressed.

Local community colleges are emerging as leaders in distance education, including those colleges serving frontier communities. A 2003 study reported that, "the paucity of quality internet access and the lower adoption rates of information technology in rural areas are frequently cited as barriers to economic growth. Many states have initiatives to spur better, affordable internet access in rural regions, and they should consider the community college as a logical level of redress (Butzen and Liston, 2003, p. 5)."

For frontier communities at a great distance from community colleges, public schools (K-12) should also be considered a potential training site. Increasing numbers of rural and frontier school districts are participating in rural revitalization projects, place-based education, service education, and other programs to increase the involvement of schools in their communities. In rural communities, schools are the center of community activity and the facilities are used for other functions, including adult education programs. Because of initiatives to develop technology networks in K-12 schools, they may be the only viable site in a community for distance education programs.

Distance training for community health workers raises several issues for CHW programs, including developing a consensus on definitions of terms and the best technology format, improving access, cultural competency/proficiency of faculty, low literacy of students, support for faculty and students, establishing quality standards, and the evaluation of training efforts.

Distance education takes many forms. The most important element of any successful training program is the selection of the appropriate format(s) and then ensuring that interested and appropriately selected students have access to the right technology.

Mode of delivery depends on the instructional goals of a course and the desired level of interaction between instructor and students. Although asynchronous course delivery, like most Internet based courses, offers the greatest flexibility for students, some may find the lack of interaction hinders the learning process (American Association of Colleges of Nursing, 2005). Where higher levels of interaction are required, interactive video may be the mode of choice. Appendices C, D, and E provide a glossary of distance learning terminology, definitions of technology assisted learning, and a summary of distance learning technologies from the Rural Trust (Hobbs, 2004).

Because it is costly for any one program or institution to support all the technological infrastructure for a flexible distance learning curriculum, many pool resources and capacities through collaborative distance learning networks. These consortia help make cost-effective use of multiple technologies and increase accessibility to courses that may be infrequently taught, or courses that might otherwise not be offered due to insufficient enrollment. One drawback, however, is the broader range of infrastructure and systems that must be coordinated for compatibility.

Many distance learning curricula make use of multiple media and formats. With technologies constantly changing, it is perhaps not surprising that a significant number of problems can ensue from incompatible technologies or formats. Dedicated technical support to assist students and instructors in resolving technical problems is fundamental to the success of a distance learning course.

Recent reports have highlighted challenges including spotty availability of broadband infrastructure, connectivity issues, and lack of technology integration. The critical steps for future planning are determining hardware, capacity, and connectivity requirements and making existing and planned systems work better together (First Consulting Group, 2002).

American Indian and Alaska Native Communities Have Less Access to Technology. Two groundbreaking studies completed in 1999 found that the basic connectivity of Native American and Alaska Native lands are inequitable when compared to the rest of the US. An Economic Development Administration survey of 48 tribes found that only 39% of households in these tribal communities had basic telephone service (Riley et al, 1999). Among rural native households, only 22% had cable television, 9% had personal computers, and of these, only 8% had access to the internet. The good news was that 90% of Native schools and libraries had computers and internet access. Just a few weeks later, the Department of Commerce issued another sobering report, Falling Through the Net: Defining the Digital Divide. It showed that only 76.4% of rural Native American households had telephone service, compared to 94.1 percent of all US rural households.

These tribal connectivity issues are shared by other frontier communities, and make effective distance delivery of training more complicated and resource-intensive. As a result of these reports, in 2000 the Federal Communications Commission (FCC) supported enhanced Link-Up America (Link-Up) and Lifeline Assistance (Lifeline) programs that allowed tribal consumers not only to connect, but also to subscribe to telephone service at a lower cost.

The National Congress of American Indians commenting to the FCC on the Lifeline and Link-Up Service for All-Income Consumers in December 2001 stated that some American Indian and Alaska Native communities continue to grapple with a "Dial-Tone Divide" reminiscent of developing nations.

Community health worker training is dependent upon the cultural sensitivity and proficiency of the faculty. Mujer Y Corazon: Community Health Workers and Their Organizations in Colonias on the US-Mexico Border, a 2004 report from the Southwest Rural Health Research Center (May and colleagues) described a qualitative and ethnographic study of six organizations in New Mexico and six organizations in Texas. The study had several objectives, including identifying factors that shape the work of Community Health Workers along the border. They concluded that policy and programs for training CHWs must incorporate information about the local community settings in which CHWs will function, and that the training components should include input from local community health worker organizations and local community experts.

At the College of Rural Alaska, new faculty hires are expected to be familiar with rural/Alaska Native cultures as a job requirement, and a cultural component is incorporated into the mentoring process for new faculty (Ruedrich, 2003-04).

For some students, access barriers are more complicated than access to the technology. While appropriate equipment and infrastructure are necessary, they are not the only requirements for student engagement in distance education.

The San Diego Regional Technology Alliance issued a report "Beyond Access-UCSD Civic Collaborative-2001 San Diego Digital Divide." This report is based on an 8-month in-depth qualitative study of new computer users and non-computer users. The report identified three kinds of non-economic obstacles that lead some people to remain computer illiterate: relevance, comfort zone, and self-concept (Stanley, 2001). While about 40 percent of respondents explained that cost interfered with computer ownership, "the vast majority emphasized that one or more of these other obstacles significantly discouraged their initial interest in achieving computer literacy."

The survey investigated factors to help improve technology usage among people with low incomes, and found that:

This report concludes on a positive note calling for "a series of culturally-sensitive, community-based outreach efforts (that)…target adults of all ages, ethnicities and socio-cultural backgrounds - and especially those that are active in the labor force."

The lessons learned in San Diego and the solutions proposed are relevant guidance for programs to train Community Health Workers. These programs should focus on the many educational, economic and social advantages of technological literacy. Effective, culturally sensitive outreach will help reduce barriers to learning new technologies.

Many people engaged in distance education acknowledge the critical role of support for both faculty and students. In 2004, the Rural School and Community Trust (known as 'the Rural Trust) prepared a policy brief on distance learning in rural K-12 education that highlighted several critical issues, including the need to support both faculty and student comfort levels with new technology (Hobbs, 2004).

The Distance Learning Standards and Guidelines adopted by the Missouri Distance Learning Association and others include benchmarks in program design, curriculum and instruction, student support, instructor support, and assessment and evaluation.

The National Education Association (NEA), the nation's largest professional association of higher education faculty, and Blackboard, Inc, a widely used internet platform provider for online education, recently commissioned the Institute for Higher Education Policy to review and validate benchmarks of quality with specific reference to internet-based distance education (Quality on the Line, 2000).

The final outcome of the study is a list of 24 benchmarks that are essential to assure quality in distance education and include indicators related to student support, faculty support, and evaluation and assessment.

While the use of electronic CHW training is just beginning, there are several good programs underway. Some of the most established models of distance education come from the most frontier state: Alaska. This is not unexpected since Alaska has been a pioneer in advancing telecommunications of all types in response to the extreme remoteness of many of its communities and villages. Various funding sources, primarily public, have come together and built this critically important communications infrastructure in Alaska.

College of Rural Alaska (CRA) serves 160 communities through five community campuses: Chukchi Campus (Kotzebue), Northwest Campus (Nome), serving the Inupiaq people of that region, Bristol Bay Campus (Dillingham), Kuskokwim Campus (Bethel) serving the Yupik people of that region and Interior Aleutians Campus stretching to Unalaska. UAF Tanana Valley campus offers the vocational and technical programs, including the Human Services Statewide Distance Delivered program. Other partners in CRA are USDA Cooperative Extension, and the Center for Distance Education and Independent Learning. In 2004, University of Alaska Fairbanks (UAF) College of Rural Alaska (CRA) Executive Dean Bernice Joseph commented: "CRA has an excellent understanding and capacity to respond to the needs of rural Alaska. Community campuses are strategically placed in rural hubs. Local corporations provide scholarships, internships, mentorships and faculty support. Another strength is the College's knowledge of learning styles and cultural background; we tailor our educational offerings while maintaining high standards (Landon, 2004, p. 1)."

The Center for Distance Education and Independent Learning (CDEIL), part of the CRA, is based at the University of Alaska at Fairbanks (UAF). Students can enroll in independent learning (IL) courses without formal admission to a degree program at UAF. While all courses carry credit and can be applied toward degree programs, no degree or certificate program is offered through the CDEIL. Courses are delivered through various combinations of print materials, audio and videotapes, telephone communication with the instructor, fax, CD-ROM, World Wide Web, and/or electronic mail. They can be traditional correspondence courses or web-based, semester-based or independent learning. IL courses are available on a year-round basis and students have one year to complete the coursework. Proctored exams are required; proctors "must be education officials at a university, community college or public school site, other governmental or community officials, or, if such persons are unavailable, other people approved in advance by the Director." The UAF Rasmussen Library has an Off-Campus Services offices to assist distance learning students in accessing on-campus resources. The UAF Writing Center and Math Hotline (tutoring) are other resources with services for distance students. Distance learning instructors are supported through Distance Learning Systems, which provides resources for technical systems components as well as instructional design for "distributed classroom cohorts."

The associate degree program in Human Services is an expansion of a Rural Health Services (RHS) certificate that had been previously delivered from the Interior-Aleutians campus of UAF (Ruedrich 2003-04). A 3-year sequence of coursework leads to the AAS degree. After core courses are completed, students choose an area of concentration in addictions counseling, mental health and developmental disabilities, residential care, supervision and management in human services, or workforce development. Additional coursework can lead to Alaska Substance Abuse Counselor Technician certification (Tanana Valley Campus, 2002; Roberts, no date).

The AAS degree can be completed without moving to a main campus location. All classes (60 credit hours) required for the degree are available both at the UAF Tanana Valley Campus in Fairbanks and through the statewide distance delivery system. Practicum placements are coordinated locally.

The program is designed for flexibility in degree progression. Students who have completed a certificate in Rural Human Services can apply 27 credits toward the AAS; most credits earned for the AAS degree can apply to a bachelor's degree in either social work or rural development. The AAS can also serve to fulfill a minor requirement in other B.A. programs.

The College of Rural Alaska also has online materials for the Community Health Aides. Using Denali Commission grant funds, the staff is focusing resources on converting the PreSession course, some Continuing Medical Education (CME) credits and the medical standing orders for the newly revised Community Health Aide Manual (CHAM) released in Fall 2005.

Dean Joseph further commented on the future of distance learning in Alaska:
"Definitely, we will advance our technology. We are seeing more web-enhanced courses. Although we have trouble with connectivity in many of our rural communities, I think we will see more people gaining access. We are coordinating with University of Alaska Anchorage (UAA) and University of Alaska Southeast (UAS) to deliver courses and I think we will see more coordination in the future (Landon, 2004, p. 1)."

The Community Wellness Advocate (CWA) program is a distance program offered statewide in cooperation with the Southeast Alaska Regional Health Consortium. It is designed for village health and human service workers, such as community health aides, community health representatives, and other community-based workers.

The certificate program takes approximately two years to complete. Courses are sequenced so that students take one course per semester, for 3 trimesters per year. Students are required to have access to the internet, and participate in "weekly 1.5-hour audio conference classes". Where necessary, computers, fax machines, and/or audioconference equipment is supplied to students. Two courses require a 1-week residency at the UAS-Sitka campus, but provide scholarships to cover travel, housing, and per diem.

After completing 30 hours of coursework, students have the opportunity to earn a UAS Community Wellness Advocate Certificate that can apply toward an Associate Degree in Health Sciences. Currently, the CWA program has a supplemental Nutritional Specialist tract; future tracts being considered include Injury Prevention, School-Based Health Education, Health Promotion with Elders, and Diabetes Prevention.

Dine College is 'The Institution of Higher Education of the Navajo Nation', and serves nearly all of the 25,000 square miles of Navajo Nation, with campuses at Crownpoint and Shiprock, New Mexico and at Tsaile, Window Rock, Ganado, Tuba City, Kayenta and Chinle, Arizona. Over the past 5 years, a Polycom brand videoconferencing system has been installed at Shiprock, Crownpoint, Window Rock, Tuba City and Tsaile, with the system hub at Tsaile. As of August 2004, a new Associate of Science (AS) degree program in Public Health is available, including an imbedded Certificate option. This option allows students completing all requirements to earn both a Certificate and Associate Degree, although some may opt for completing just the Certificate.

Courses in this degree program originate at the Shiprock campus, and are transmitted via Polycom to Crownpoint, Window Rock, Tuba City and Tsaile. According to Ed Garrison, a Memorandum of Understanding (MOU) between Dine College and the CHR/Outreach Program of the Navajo Division of Health supports a collaboration in which the 160+ staff (including supervisors) of the program enrolls in the Dine College courses and degree program. According to Garrison all courses are open to everyone, but the Community Health Representatives (CHR's) typically comprise 90% or more of current enrollments.

To date (August 2005), only three courses (Introduction to Public Health, Community Health Assessment and Planning, and Introduction to Wellness) have been offered via Polycom, each one multiple times. More courses in the AS degree program via Polycom are expected as the program grows. According to Garrison, at least one of the Shiprock based instructors is on the road almost every week in order to be in the distant classrooms during the class sessions. This assures that the students at all of the distant locations get to meet and personally interact with the instructors at least 3 or 4 times each semester.

Dine College has not yet connected their Distance Education system with external entities, so students outside of Dine College cannot currently enroll in these courses. The current program has been successful in training community health workers throughout the Navajo Nation.

In Hawaii, there are five Native Hawaiian Health Care Systems, and each uses community health workers. Distance learning has long played a major part in the CHW conferences and trainings, developed by the community college system in partnership with the University of Hawaii. Allied health workers at substance abuse and child abuse programs, community health clinics and others participate in training and continuing education. Skybridge, Telecom, V-tech and Polycom are just some of the technology systems used to support in-service trainings, classes and workshops. The Hawaii and Pacific Basin Area Health Education Centers currently lists 68 sites throughout the islands with video teleconferencing (VTC) capacity (Hawaii/Pacific Basin AHEC, 2005).

Maui Community College (MCC) offers a number of community-based health worker certificates through the Departments of Nursing and Community Health, Human Services, and Continuing Education and Training. The Department of Nursing and Community Health offers two levels of certificates of competence for the generalist CHW, and specialist courses including a certificate in case management. In partnership with the Hawaii/Pacific Basin AHEC, MCC plans to offer these courses via distance education within the next 3 years.

The Department of Human Services offers an A.S. degree in Human Services, as well as certificates in substance abuse counseling and child development. The department added a new 9-credit Certificate in Case Management for Health and Human Services in 2004; the certificate was developed with the Department in collaboration with the Hawaii Primary Care Association and a Community Advisory Committee made up of community health workers, supervisors and administrators from community health centers and the five Native Hawaiian Health Care Systems. The Community Advisory Committee identified case management/interpersonal counseling skills as the highest priority for developing CHW capacity. The Case Management certificate was offered in 2004 by MCC on community college campuses on Maui, Molokai, Hawaii and Kauai (MCC hired the instructors from each island, and students registered through MCC Admissions and Records, but classes were held on CC campuses on their own islands). On Oahu, Leeward Community College offers the Case Management Certificate. Three courses are offered every year, one in the spring and one in the fall, with the practicum offered every semester. The Hawaii Primary Care Association is currently working on a project to investigate possibilities of offering some courses statewide through VTC over the next three years.

A new certificate program is being developed by the Community Health Worker Training Program of the Hawaii Primary Care Association, and will be offered by the MCC Office of Continuing Education and Training. This new program is a 100-hour certificate in "Outreach for Health Promotion" with two main segments, a 45-hour section on improving outreach to underserved communities (includes a 3-credit human services community action class), and 55 hours of health promotion consisting of modular training in nutrition/fitness, oral health, behavioral health, and chronic diseases affecting Hawaii's underserved communities.

The Hawaii Primary Care Association is currently working on a project through the recently funded HETC center to investigate possibilities of offering some courses through VTC, statewide over the next three years. These courses will target community health workers in underserved communities that are served by the community health centers and Native Hawaiian Health Care Systems. The 9-credit Case Management Certificate is being considered for this training.

The Arizona Community Health Outreach Worker Network (AzCHOW) is supporting a new project spearheaded by Dr. Ana Maria Lopez of the Arizona Cancer Center. This project, entitled 'Tele-Education in Breast Cancer for Community Health Outreach Workers in Five Southern Arizona Communities', will use the Arizona Telemedicine Program to develop and evaluate a tele-education program on breast cancer for CHWs. Volunteer CHWs will participate in eight sessions, and actively evaluate each session. A focus group of course participants will be conducted by video-conference three months after the series has concluded.

Community Supports for People with Disabilities Program
South Central College, North Mankato, Minnesota
http://online.southcentral.edu/

In the 1990s, the Minnesota governor and State legislature mandated standardized training and skills standards for those working with the disabled, and the Community Supports program was developed to fill this need.

South Central College in North Mankato, Minnesota is a rural site involved in the Community Supports program. Since 2003, South Central College has offered certificate, diploma, and AAS degree programs online (via WebCT platform) (South Central College, 2005). The graduates of this program works with a diverse patient base and in a wide variety of settings, from supported living situations, elder care, behavioral disorders, day treatment, chemical dependency, State Hospitals and the traditional residential/group home settings. Functional English competency is required for participation, but a recent cohort taught by Ms. Nagel included almost half for whom English was a second language.

A consortium of seven colleges teaches the core courses online. On-line faculty participate in a monthly support group that has evolved over time. Students are supported not only by faculty, but also by the consortium technology support staff. Each student receives a CD-ROM with appropriate software and tutorials needed to succeed in distance education; the costs of these materials are included in the costs of the course.

This program was recently identified as a national model, and is benefiting from Robert Wood Johnson Foundation and other private and public funding streams to expand the programs and increase awareness of the critical role paraprofessionals play in service delivery. They are now in the process of expanding this model to reach more culturally diverse community health workers who function in other settings. In 2006, South Central College will begin offering a new generalist Community Health Worker certificate program online.

The Milagros Center of Excellence in Migrant Health was created in September 2003 as a collaborative project between the Georgetown University School of Nursing and Health Studies and the South Texas College Division of Nursing and Allied Health, and with funding from the Office of Minority Health in the Department of Health and Human Services. The objective of the Milagros Center is to "develop, centralize, and disseminate information about what is known, concerning migrant farm workers' health utilizing the latest in digital technology and distance learning." The Center plans to use distance learning to educate both paraprofessionals and professionals regarding specialized care for migrant and seasonal laborers.

The Rural Assistance Center describes the training program as "An adoptable and adaptable curriculum in migrant health and welfare that will be available to all states using web-based online platforms, after assessment of the first two courses are completed". The curriculum will address conditions that place migrant families at risk, as well as teach the protective factors that help overcome health disparities across the life span (Rural Assistance Center, 2004).

The first two classes offered were "Mental Health and the Migrant Family" and "Growing Up on the Border." Initially students will be accepted from states in the Northeastern and Midwestern migrant streams, with Georgetown managing the former and Texas the latter. Program administrators hope eventually to expand to sites in California. The Milagros Center also hosts a virtual library on migrant health.

Use of distance technologies for improving the knowledge and skills of CHWs is not limited to formal training programs. The same technologies can be used to provide post-training follow up and support, create access to formal or informal continuing education opportunities, and importantly, connect isolated CHWs with one another. The networking function of distance technologies creates opportunities for ongoing experiential learning by giving distant CHWs a virtual forum in which they can interact.

Technology also may be used to provide direct support to traditional students after they graduate. As the National Indian and Inuit Community Health Representatives (CHR) Organization noted in their newsletter In Touch in 2001, the CHR On-Line program piloted by Portage College in Lach Le Biche, Alberta, Canada in collaboration with the Community Health Representatives Association of Canada. The project connected otherwise isolated front-line community health workers not only with online resources but with each other. While the ultimate objective of the program was to prepare and equip CHWs for advanced education opportunities, the pilot project was focused on creating distance learning capacity among working CHWs (Parker and Froehler, 2000). The initial cohort completed the one-week "Computers for Distance Education Skill Enhancement" course at Portage College.

The project eventually encompassed 30 different sites in Alberta. By 2001, fifty-three frontline CHRs, with little or no previous computer experience, learned basic computing and Internet skills. Most of the 53 CHRs who participated in the program can now surf the Internet, find reliable and culturally appropriate health information, and communicate by e-mail with their colleagues in other communities (Kuran, 2001). The enthusiasm of the CHRs speaks for itself:

I believe it is a great project. Once we CHR's are connected, it will be great. I sure hope everyone will have connection with a computer, so that the distance will be a thing of the past. (We) can connect by a push of a key and (are) able to share information. This is the future for native CHR's.
Rachel Ermineskine, Southern Alberta CHR Advisor, Siksika

I find it very helpful to be connected online. Just reading someone else's comments helps me realize that there are other CHR's working out there. I know it could be useful when I need the latest information.
Lorraine Cardinal, CHR, Saddle Lake, Alberta

Overall, survey comments received from participants in CHRs On-Line were very positive. The program seems to be particularly helpful in situations where there are lone CHRs in isolated communities. Approximately 38% of those surveyed now use the CHR On-Line website. A full 20% use the site at least weekly.

The Mary Amelia Douglas-Whited Community Women's Health Education Center
New Orleans

The Mary Amelia Douglas-Whited Community Women's Health Education Center in New Orleans has developed a low-tech model of post-training support for community-based health workers that includes a weekly telephone support call. By providing this post-training support, a health educator assists the community health workers to feel more empowered and to create positive behavior changes in their own lives. To date, programs on cardiovascular disease and breastfeeding have been piloted and evaluated, with good results. Such 'low-tech' supports should be used by trainers working with community health workers in frontier regions.

Most models of distance training include explicit attention to support for all of the participants. These programs will potentially be strengthened by the development of national standards.

A. Center for Sustainable Health Outreach (CSHO)
University of Southern Mississippi, Hattiesburg, MS
http://www.usm.edu/csho/

The Center for Sustainable Health Outreach (CSHO) serves as a national point of contact for CHWs and supports them by providing support and technical assistance in public policy, sustainability, education and training, and evaluation and planning (CSHO 2005). Between 1999 and June 2005 the center was operated as a joint project between the University of Southern Mississippi (USM) focusing on education, training, and evaluation, and the Harrison Institute for Public Law at Georgetown University Law Center focusing on policy and sustainability issues. Since June 2005 the projects have been separated, with CSHO remaining at USM.

The Community Health Advisor Network (CHAN) is one program of CSHO. CHAN conducts two different annual training workshops in Hattiesburg; one workshop is on the development and start up of a CHW program, the other is a training workshop for CHWs. CSHO also sponsors an annual Unity conference for CHWs and program administrators. The center communicates with CHWs using a variety of materials including a quarterly newsletter, a website, an email listserv, and direct mailings.

In May 2003 with support from the W.K Kellogg foundation, CSHO began a project to develop a catalog of generalist CHW training and education programs offered by institutions of higher education. Fifteen programs are currently described in the guide, with information on institutional setting, program overview, admission criteria, curriculum, and contact persons (CSHO 2005a).

B. Community Health Worker National Educational Collaborative
Arizona AHEC Program, Tucson, AZ
http://www.chw-nec.org

A new national educational collaborative co-directed by Don Proulx and Lee Rosenthal focuses on community health workers, and is an emerging resource for community health worker training, for both faculty and CHWs. The Community Health Worker National Educational Collaborative CHW-NEC is funded by the Fund for the Improvement of Post Secondary Education (FIPSE) at the US Department of Education. The project has recently launched a website to support a "community of practice" for CHWs and their educational partners.

"this postsecondary innovation supports non-traditional, socio-economically disadvantaged and ethnically diverse students (including U.S./Mexico border health "promotores" and Native American tribal and Pacific Islander "community health representatives" working in rural and urban resource-poor and medically needy neighborhoods). Students in community health work represent a new entry-point in higher education, where the validation of core competencies for this workforce has become a critical national public health and human service issue and where curriculum standards and credentialing are now high on the national agenda. The project is also supported by several nationally recognized experts and by national leaders of active community health worker associations/organizations."

Fifteen college sites are being supported by a partnership of six collaborating universities, colleges, and agencies providing technical assistance. Each partner brings unique expertise to the project. The project shares "best practice materials and methods" for college-supported curricula, core competency assessment, and employment market development. The goal of this project is to develop national programs for the educational preparation of community health workers.

The catalyst for this project was a National Community of Practice Invitational Workshop hosted by the University of Arizona in Tucson in the summer of 2005. Key topics for the National Workshop included:

Several participants in this collaborative currently are, or plan to use distance technologies. Because of its unique focus on training community health workers, the CHW-NEC is an important resource for faculty responsible for CHW training.

State	Core Technical Assistance Institutions	Adaptor Institutions/College Sites
Arizona	The University of Arizona Pima Community College in Tucson	Diné College (Navajo Nation)
Oregon	Multnomah County Health Department's Community Capacitation Center	Portland Community College
Texas	Northwest Vista College in San Antonio	El Centro College South Texas Community College
Minnesota	The State Colleges and University System	Minneapolis Community Technical College South Central Technical College at Mankato Ridgewater College
Florida	The University of South Florida, Lawton Rhea Chiles Center	St. Petersburg College Hillsborough Community College Central Florida Community College
Connecticut	Sacred Heart University Southwestern Connecticut AHEC	Housatonic College Three Rivers Community College
New Mexico		Diné College (Navajo Nation)
Hawaii		Maui Community College Kapi'olani College
Indiana		Ivy Tech State College

This paper has provided a brief overview of some current and emerging issues in the use of technology and distance education in the training of community health workers in frontier areas. The community programs highlighted are meant to be illustrative, not exhaustive. It is likely that there are others doing good work in remote locations, perhaps in isolation from others. Communication among these pioneers should be actively encouraged and supported.

Those entrusted with the responsibility of supporting healthy frontier communities and training the community health workers that serve them might consider these brief conclusions and recommendations for action:

Bell, Peter, Reddy, Pavani, and Rainie, Lee (2004). Rural Areas and the Internet. Washington,DC: Pew Internet & American Life Project. Accessed September 11, 2005.

Centers for Disease Control and Prevention (2004). Distance Learning Primer. Atlanta, GA: Public Health Training Network, Centers for Disease Control and Prevention. Accessed September 13, 2005.

Center for Sustainable Health Outreach (2005a). Report of Colleges and University Programs Awarding Credit, Certificates, and/or Degrees in the Community Health Worker Field. Hattiesburg, MS: The University of Southern Mississippi, Center for Sustainable Health Outreach.

Center for Sustainable Health Outreach (2005b). General Information about CSHO. Hattiesburg, MS: University of Southern Mississippi, Center for Sustainable Health Outreach. Accessed September 11, 2005.

Collins, Timothy and Dewees, Sarah (2001). Challenge and Promise: Technology in the Classroom, in The Rural South: Preparing for the Challenges of the 21st Century newsletter No. 18, March.

First Consulting Group (2002). Rural Health Care Delivery: Connecting Communities Through Technology. Ihealthreport Series prepared for California Healthcare Foundation.

Hawaii and Pacific Basin Area Health Education Centers (2005). Video Teleconferencing. Accessed on 9/20/05.

Hobbs, Vickie (2003). Distance Learning as Alternative to Consolidation. Powerpoint presentation by Telecommunications Policy Analyst for Rural Schools and Community Trust meeting in Hot Springs, AR, March 5, 2003. Accessed July 24, 2005.

Hunter, Jennifer B., Guernsey de Zapien, Hill, Papenfuss, Mary, Fernandez, Maria Lourdes, Meister, Joel, and Giuliano, Anna R. (2004). The Impact of a Promotora on Increasing Routine Chronic Disease Prevention among Women Aged 40 and Older at the U.S.-Mexico Border, Health Education & Behavior 31(4):18S-28S.

Institute of Medicine (2005). Quality Through Collaboration: The Future of Rural Health. Washington, DC: National Academies Press.

Landon, Beth (2004). An Interview with UAF College of Rural Alaska Executive Dean Bernice Joseph. Alaska Rural Health Notes, 5 (3), Winter 2003-4, pages 1-2.

Landon B, Loudon J, Selle M, Doucette S. Factors Influencing the Retention and Attrition of Community Health Aides/Practitioners in Alaska. Journal of Rural Health 20(3):221-30.

Love, Mary Beth, Legion, Vicki, Shim, Janet K., Tsai, Cindy, Quijano, Vickie, and Davis, Catherine (2004). CHWs Get Credit: A 10-Year History of the First College-Credit Certificate for Community Health Workers in the United States. Health Promotion Practice 5(4): 418-428.

Loveland, Elaina (2003). Achieving Academic Goals by Place-Based Learning-Students in Five States Show How to Do It. Rural Roots, 4(1). Accessed July 24, 2005 at http://www.ruraledu.org

National Rural Health Association (2000). Community Health Advisor Programs: An Issue Paper Prepared by the National Rural Health Association, November 2000. Accessed on September 11, 2005.

National Telecommunications and Information Administration, US Department of Commerce (1999). Falling Through the Net: Defining the Digital Divide. Washington, DC: National Telecommunications and Information Administration, U.S. Department of Commerce. Accessed on September 16, 2005.

Oneill, EH and Pew Health Professions Commission (1998). Recreating Health Professional Practice for a New Century: The Fourth Report of the Pew Health Professions Commission. San Francisco, CA.

Quality on the line: Benchmarks for Success in Internet-Based Distance Education (2000). Institute for Higher Education Policy, Washington, DC.

Rosenthal, E.L., Wiggins, N., Brownstein, J.N., Johnson, S., Borbon, I.A., and Rael, R. (1998). Final Report of the National Community Health Advisor Study, Weaving the Future. Tucson, AZ: University of Arizona.

Ruedrich, Lillian (2003-04). UAF College of Rural Alaska Produces Home-grown Health Care Work Force. Alaska Rural Health Notes, 5(3), p. 2.

Rural Assistance Center (2004). New Distance Learning Program for Migrant Health, The Rural Monitor, 11(1), p.9.

Satterfield, Dawn, Burd, Chris, Valdez, Lorraine, Hosey, Gwen, and Shield, John Eagle Shield (2002). The "In-Between People": Participation of Community Health Representatives in Diabetes Prevention and Care in American Indian and Alaska Native Communities.
Health Promotion Practice 3(2): 166-175.

Stanley, Laura (2001). Beyond Access-UCSD Civic Collaborative-2001 San Diego Digital Divide, as follow up to report of Regional Technical Alliance-Mapping a Future for Digital Connections: A Study of the Digital Divide in San Diego County, February 2001, p. 1-25.

Witmer, Anne; Seifer, Sarena D.; Finocchio, Leonard; Leslie, Jodi; and O'Neil, Edward H. (1995). Community Health Workers: Integral Members of the Health Care Work Force, American Journal of Public Health 85(8): 1055-1055.

Nancy E. Collyer
Senior Program Coordinator
Arizona AHEC Program, Tucson, AZ
(520) 629-4300 ext 121
collier@u.arizona.edu

Agnes Hilton
Professor of Community Health
University of Southern Mississippi-Hattiesburg, Hattiesburg, MS
601-266-5859
agnes.hinton@usm.edu

Nancy K. Johnson
Nursing & Health Program Coordinator
Maui Community College. Maui, HI
808-984-3250
nancyjoh@hawaii.edu

Susan Mayfield-Johnson
Program Coordinator
Center for Sustainable Health Outreach (CSHO)
University of Southern Mississippi-Hattiesburg, Hattiesburg, MS
601-266-6266
Susan.Johnson@usm.edu

Kellie J. Miller Nagel
CSP/CHW Instructor, Community Supports Program
South Central College, North Mankato, Minnesota
507-389-7407
Kellie.Millernagel@southcentral.edu

Don Proulx
Co-Director (with Lee Rosenthal)
Community Health Worker National Educational Collaborative
Arizona AHEC Program, Tucson, AZ
520-629-4300, ext. 121
dproulx@u.arizona.edu

Lillian Ruedrich
Program Coordinator
College of Rural Alaska
University of Alaska-Fairbanks, Fairbanks, AK
907-474-2669
fnlr@uaf.edu

Napualani Spock
Community Health Worker Training Coordinator
Hawai'i Primary Care Association, Honolulu, HI
808-280-0984
nspock@hawaiipca.net

Cindy S. Tsai
Director of Special Projects and Training
Community Health Works
415-338-3034
chw@sfsu.edu

Anne Willaert
Community Health Worker Project
Healthcare Education - Industry Partnership
Minnesota State Colleges and Universities
Mankato, MN
507-389-2590
anne.willaert@mnsu.edu

Note: Not all contacts were interviewed.

APPENDIX B: LIST OF ACRONYMS

AAS	Associate of Applied Sciences
AS	Associate of Science
AHEC	Area Health Education Center
AIHEC	American Indian Higher Education Consortium
BSW	Bachelors of Social Work
CBT	Computer Based Training
CD-Rom	Compact Disc-Read Only Memory
CHA	Community Health Advisor
CHAM	Community Health Aide Manual
CHR	Community Health Representative
CHW	Community Health Worker
CHW-NEC	Community Health Worker-National Education Collaborative
CME	Continuing Medical Education
CRA	College of Rural Alaska
CSHO	Center for Sustainable Health Outreach
CSP	Community Support Program
CWA	Community Wellness Advocate
FCC	Federal Communications Commission
FIPSE	Fund for the Improvement of Secondary Education (US Department of Education)
ICT	Information and Communication Technology
ILT	Instructor- Led Training
ISP	Internet Service Provider
LAN	Local Area Network
NRHA	National Rural Health Association
RHS	Rural Health Services
VTC	Video Teleconferencing
WAN	Wide Area Network
WBT	Web Based Training

APPENDIX C: GLOSSARY OF DISTANCE LEARNING TERMS
(Source: Hobbs, 2004)

Asynchronous (Not Synchronous)
With reference to video and data signals and devices, asynchronous transmissions are those in which local and remote communication is not precisely in step, not of the same frequency, or does not happen together in time.

ATM - Asynchronous Transfer Mode
An international high-speed, high-volume, packet-switch-ing transmission protocol standard. ATM uses short, uniform, 53-byte cells to divide data into efficient, manageable packets for ultrafast switching through a high-per-formance communications network. ATM is the first packet-switched technology designed from the ground up to support integrated voice, video, and data communication applications. High costs often make this transmission mode impractical for K-12 I-TV networks.

Bandwidth
The capacity to transfer data over telecommunications lines, usually measured in bits per second. The necessary bandwidth is the amount of spectrum required to transmit the signal without distortion or loss of information.

Broadband
A high capacity communications network that can enable the simultaneous transmission of voice, data, and video. Broadband networks are usually defined as operating at greater than T-1 speeds (1.544Mbps).

CODEC
COder - DECoder. A digital device for the coding and decoding of video and/or audio signals usually to permit them to be transmitted in compressed and/or encrypted form.

Continuous Presence
A video processing, transmission, and display technique that electronically combines parts of two (or more) separate video images for transmission in a single data stream. At the receive location, two or more images may be viewed in quadrants on a single monitor or separated for viewing on side-by-side monitors.

DS-3
A telecommunications line (or digital transmission system) operating at 45 Mbps. A DS-3 line is approximately 30 times the bandwidth of a T-1 line.

DSL - Digital Subscriber Line
A generic term including a family of moderate speed access technologies that use sophisticated modulation schemes to pack data onto copper wires. They are sometimes referred to as last-mile technologies because they are used only for connections from a telephone switching station to a home or office, not between switching stations.

E-Rate
A telecommunications discount program for schools and libraries begun as part of the Telecommunications Act of 1996. Telecommunications services, Internet access, and internal connections are eligible for 20-90% discounts based on the free and reduced-price lunch rate of students within a school-or schools within a library district.

Fractional T-1
One or more channels of a T-1 service. A full T-1 carrier contains 24 channels; each provides 64 Kbps. Most phone companies, however, also sell fractional T-1 lines, that provide less bandwidth but are also less expensive. Typically, fractional T-1 lines are sold in increments of 56 Kbps (the extra 8 Kbps per channel is used for data management).

Fractional T-3 or DS3
A telecommunications service that uses a portion of a 672channel T-3 circuit for any mix of voice, data, or broad-cast-quality video.

IP - Internet Protocol
The set of rules that allow the transmission of data among all computers. IP specifies the format of packets and the addressing scheme. Most networks combine IP with a higher-level protocol called Transmission Control Protocol (TCP), which establishes a virtual connection between a destination and a source. IP by itself is like the postal system. It allows you to address a package and drop it in the mail, but there's no direct link between you and the recipient. TCP/IP, on the other hand, establishes a connection between two hosts so that they can send messages back and forth.

IP Address
An IP number is a numerical address consisting of several numbers separated by periods. Each IP address uniquely identifies a certain computer on the Internet.

ISDN - Integrated Services Digital Network
An international communications standard for sending voice, video, and data over digital telephone lines or normal telephone wires. ISDN supports data channel transfer rates of 64 Kbps (64,000 bits per second), but multiple channels can be purchased to increase bandwidth. There are two types of ISDN lines: Basic Rate Interface (BRI) and Primary Rate Interface (PRI). ISDN charges are typically incurred for each call or connection made. Costs increase as the number of channels used increases.

ITV - Two-Way Interactive Television
An audio and video link between two or more remote locations with live, moving image transmission and display. Two-way interactive television allows all locations to see and hear the people and presentation materials at other locations. I-TV is the term usually used to signify videoconferencing in an educational setting. It should not be confused with Instructional Television (ITV), which is the one-way transmission of educational programming by television.

Kbps - Kilobits per second
Refers to the data speed of a telecommunications line. Data is transmitted in bits per second. A bit is the smallest unit of information on a computer network, a binary digit (0 or 1). A kilobit is 1000 bits.

Mbps - Megabits per second
Refers to the data speed of a telecommunications line. Data is transmitted in bits per second. A bit is the smallest unit of information on a computer network, a binary digit (0 or 1). A megabit is one million bits.

Point-to-Multipoint
A circuit that connects a single node to a switch. In continuous presence I-TV, it is a single site connecting to up to three additional sites, such that all sites can see all other sites at all times. In a switched I-TV network, it is a single site connecting to any number of additional sites. In a switched mode, each I-TV site will routinely see only the presenter or the site having last spoken.

Point-to-Point
A non-switched, dedicated communication circuit. In I-TV, a single site connecting to only one other site.

Real Times
Rapid transmission and processing of event-oriented data and transactions as they occur, in contrast to being stored and retransmitted or processed in batches. I-TV is a "real time" technology because it is broadcast live, as it occurs.

Synchronous
With reference to video and data signals and devices, synchronous means being precisely in step, or happening together at the same time. I-TV involves synchronous communication because the teacher and student interact at the same point in time through the same medium.

T-VDSI
A telecommunications line (or digital transmission system) operating at a speed of 1.544 million bits (megabits) per second (1.5Mbps). A T-1 line consists of 24 individual channels, each of which supports 64Kbits per second. A T-1 line is a preferred means of transmitting I-TV, taking both cost and quality into account. T-1 lines, though transmitting lower quality, compressed video signals than DS-3 lines, for instance, are much less expensive and more widely available.

Tariff
A public document filed with a state public utility commission that outlines services and rates of telecommunications carriers. Usually, all customers are offered the same rate for a specific service, based on published constraints. In some states telecommunications carriers have filed special distance learning tariffs available to K-12 schools.

Teleconference
Live, two-way audio transmission between two or more locations. Usually includes speaker phones and microphone amplification systems.

Universal Service
The public policy that helps compensate telephone companies or other communications carriers for providing access to telecommunications services at reasonable and affordable rates throughout the country, including rural, insular, and high cost areas. Companies, not consumers, are required by law to contribute to the Universal Service Fund. The law allows companies to pass this charge on to customers. The E-Rate program is a separate part of the Universal Service Program.

Video Conference
An audio and video link between two or more remote locations with live, moving image transmission and display. Two-way video conferencing allows both locations to see and hear the people and presentation materials at other locations, although not necessarily in a continuous presence mode. I-TV is the term usually used to signify videoconferencing in an educational setting. Videoconferencing most often refers to the business application of the technology, e.g., video meetings. Increasingly, the terms are used interchangeably.

Wireless
Radio waves, cellular, satellite, microwave, etc. are alternative modes of telecommunications transmission to land lines. I-TV via wireless transmission is possible, but is in its infancy.

APPENDIX D:
DEFINITIONS OF TYPES OF TECHNOLOGY ASSISTED LEARNING

The following definitions are a synthesis from several sources, all or some of which have been, or could be, used for training community health workers in frontier communities (accessed August 9, 2005 from the Distance Learning Glossary).

Asynchronous Learning - Any learning event where interaction is delayed over time. This allows learners to participate according to their schedule, and be geographically separate from the instructor. Could be in the form of a correspondence course or e-learning . Interaction can use various technologies including threaded discussion.

Computer Based Training (CBT) - Training or instruction where a computer program provides motivation and feedback in place of a live instructor. CBT can be delivered via CD-ROM, LAN or Internet. Its creation is done by teams of people including instructional designers, and often has high development costs.

Correspondence Course - A course completed from a distance using written correspondence for interaction and also to submit assignments. Correspondence classes became popular in the 1890's and remain popular today.

Distance Education - The formal process of distance learning . This term has traditionally implied higher education, post-secondary.

Distance Learning - Learning where the instructor and the student(s) are in physically separate locations. Can be either synchronous or asynchronous . Can include correspondence , video or satellite broadcasts, or e-Learning . Usually implies higher education.

Distance Training - A reference to distance learning for the corporate or professional levels. More commonly referred to as distributed learning , WBT or e-Learning .

Distributed Learning - Distance learning that makes use of information technology. Includes most types of distance learning but not plain correspondence (very similar to e-Learning )

e-Learning - Any learning that utilizes a network (LAN, WAN or Internet) for delivery, interaction, or facilitation. This would include distributed learning , distance learning (other than pure correspondence ), CBT delivered over a network, and WBT . Can be synchronous , asynchronous , instructor-led or computer-based or a combination.

e-Learner - Any learner taking part in an e-Learning course or program.
Instructor-led Training (ILT) - A learning event which is led by an instructor , and either held in a physical location or delivered via a network ( WBT , e-Learning ). Usually implies the professional or corporate level and synchronous learning.

Online Learning - e-Learning over the Internet (as opposed to a local or wide area network).

Online Training - Same as online learning , only it implies the professional or corporate level.

Synchronous Learning - Any learning event where interaction happens simultaneously in real-time. This requires that learners attend class at its scheduled time. Could be held in a traditional classroom, or delivered via distributed or e-Learning technologies.

Threaded Discussion - a type of on-line interaction in which discussion postings are automatically 'threaded' typically by topic area or author.

Web Based Training (WBT) - Training which is delivered over a network (LAN, WAN or Internet). Can be either Instructor-led or Computer Based . Very similar to e-Learning, but it implies that the learning is in the professional or corporate level.

APPENDIX E: SUMMARY TABLE OF DISTANCE LEARNING TECHNOLOGIES
(Source: Hobbs, 2004)