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.
TABLE
OF CONTENTS
Definition Of Frontier
EXECUTIVE
SUMMARY
- INTRODUCTION
- Training Community Health
Workers
- Challenges of Training
in the Frontier
- Distance Learning
- TRAINING ISSUES
- Definitions and Formats
- Access Barriers and Limited
Resources
- Cultural Competence/Proficiency
of Faculty
- Electronic Literacy of
Students and Community
- Support Issues for Faculty
and Students
- Quality Standards and
Evaluation
- PROMISING DISTANCE EDUCATION
MODELS
- Generalist CHW Programs
College of Rural Alaska
University of Alaska Southeast at Sitka
Diné College of the Navajo Nation
Maui Community College, Native Hawaiian Health, and the Primary
Care Association of Hawaii
- Specialized Programs
The Arizona Community Health Outreach Worker Network
Community Supports for People with Disabilities Program
Milagros, the Center of Excellence for Migrant Health
- Continuing Education and
Peer Learning
The CHR On-Line Program
The Mary Amelia Douglas-Whited Community Women's Health Education
Center
- NATIONAL INITIATIVES
- Center for Sustainable
Health Outreach
- Community Health Worker
National Educational Collaborative
- CONCLUSIONS
REFERENCES
Appendix A: List of
Contacts
Appendix B: List of Acronyms
Appendix C: Glossary of Distance
Learning Terms
Appendix D: Definitions of Types
of Technology Assisted Learning
Appendix E: Summary Table of
Distance Learning Technologies
DEFINITION OF FRONTIER
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.
TRAINING COMMUNITY HEALTH WORKERS:
USING TECHNOLOGY AND DISTANCE EDUCATION
EXECUTIVE SUMMARY
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:
- Investment in technological infrastructure
is necessary.
- Faculty must be supported to increase their
cultural competence as well as their comfort with new technologies
for distance education.
- Students must be supported to increase expertise
with both their complex provider role as well as new technologies.
- Existing quality standards for distance education
should be adapted to assure their appropriateness for frontier
education programs.
- Current and emerging models of frontier
training should be evaluated using appropriate standards and realistically
achievable competencies.
TRAINING COMMUNITY HEALTH WORKERS:
USING TECHNOLOGY AND DISTANCE EDUCATION
I. INTRODUCTION
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:
- they are focused on reaching hard-to-reach
populations;
- the workers usually are indigenous to the target
population; and
- their expertise is in knowing their communities
rather than formal education" (National Rural Health Association,
2000).
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.
A. Training Community Health Workers
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:
- Cultural mediation between communities and
health and human services systems
- Informal counseling and social support
- Providing culturally appropriate health education
- Advocating for individual and community needs
- Assuring people get the services they need
- Building individual and community capacity
- Providing direct services
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).
B. Challenges of Training in the Frontier
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:
- Less choice of internet service provider (ISP):
more rural respondents (29%) reported using the only ISP available
to them, compared with suburban (9%) and urban (7%) users.
- Rural respondents reported lower broadband
use than others. Between 2000-2003, the home use of broadband
increased from 8-36% among urban respondents, 7-32% among suburban
respondents, and 3-19% among rural respondents.
- In 2002, 25% of rural respondents reported
that broadband was not available to them (compared with 5% and
10% among urban and suburban respondents).
- More rural internet users (9%) than urban (5%)
or suburban (3%) users are dependent on internet access outside
of home or work
- More rural users reported "mixed feelings"
towards computers and ICTs (50%) than urban (32%) or suburban
(27%) users.
Rural Communities and the Internet:
Summary of Findings at a Glance
|
Internet penetration has grown in rural communities,
but the gap between them and suburban and urban communities
has remained constant over time. |
Rural Americans are older and less wealthy
than those in other parts of America and that may account for
some of the differences in Internet penetration between community
types. |
Another factor in lower Internet penetration
may be that many rural residents say they have less choice than
others about the way they access the Internet. |
Rural communities hold larger proportions
of relative newcomers to the Internet than do urban and suburban
communities. Yet rural Americans are often enthusiastic adopters.
|
Broadband adoption is growing in urban, suburban,
and rural areas, but broadband users make up larger percentages
of urban and suburban users than rural users. |
A portion of rural Internet users depend
on Internet connections at places other than work or home. They
are more likely than suburban or urban users to say they depend
on another place for going online. |
Rural African-Americans are significantly
less likely than rural whites to go online, possibly because
of differences in income and education. |
Rural users pursue many of the same online
activities as urban and suburban users, but they are more likely
to look for religious or spiritual information and less likely
to engage in transactions. |
Rural Internet newcomers are wary of technology,
but those with experience embrace it. |
Source: Bell, Peter, Pavani Reddy and
Lee Rainie. "Rural Areas and the Internet." Washington,
DC: Pew Internet & American Life Project, February 2004 |
C. Distance Learning
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:
- Physical distance between instructor and learner.
The distance learning strategy is often given other names-distance
teaching, distance education, distributed education, learning
at a distance. All of these names refer to some form of instruction
in which instructor and learner are physically separated from
one another. This physical separation is the principal-and defining-characteristic
of distance learning.
- Independent study or study groups. Distance
learning may be set up to have learners participate either individually
or in groups-or both.
- Many delivery options. Instruction may be provided
in a variety of media, from printed materials to live satellite
videoconferences to electronic messages on the Internet (CDC,
2004).
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.
II. TRAINING ISSUES
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.
A. Definitions and Formats
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.
B. Access Barriers and Limited Resources
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.
C. Cultural Competence/Proficiency of Faculty
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).
D. Electronic Literacy of Students and Community
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:
- Low income respondents were more likely to
'express negative feelings toward computers as reasons for not
owning one.'
- 2/3 of all Hispanics and those earning less
than $15,000 per year believe that "we have come to rely too much
on technology."
- 1/3 of respondents earning $75,000 or above
agreed with this statement.
- Cost is a primary ownership barrier for
some, but other formidable obstacles contributing to computer
literacy are fear and self-doubt.
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.
E. Support for Faculty
and Students
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.
F. Quality Standards
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.
Student Support Benchmarks
- Students receive information about programs,
including admission requirements, tuition and fees, books and
supplies, technical and proctoring requirements, and student support
services.
- Students are provided with hands-on training
and information to aid them in securing material through electronic
databases, interlibrary loans, government archives, news services,
and other sources.
- Throughout the duration of the course/program,
students have access to technical assistance, including detailed
instructions regarding the electronic media used, practice sessions
prior to the beginning of the course, and convenient access to
technical support staff.
- Questions directed to student service personnel
are answered accurately and quickly, with a structured system
in place to address student complaints.
Faculty Support Benchmarks
- Technical assistance in course development
is available to faculty, who are encouraged to use it.
- Faculty members are assisted in the transition
from classroom teaching to online instruction and are assessed
during the process.
- Instructor training and assistance, including
peer mentoring, continues through the progression of the online
course.
- Faculty members are provided with written resources
to deal with electronically accessed data.
Evaluation and Assessment Benchmarks
- Educational effectiveness and the teaching/learning
process is assessed through a multifaceted evaluation.
- Data on enrollment, costs, and successful/
innovative uses of technology are used to evaluate program effectiveness.
- Intended learning outcomes are reviewed regularly
to ensure clarity, utility, and appropriateness.
III. PROMISING MODELS
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.
A. Generalist CHW Programs
College of Rural Alaska
Human Services Statewide Distance Delivered Program
http://www.tvc.uaf.edu/programs/HSV/hsv-rural.htm
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)."
Community Wellness Advocate (CWA)
University of Alaska Southeast (UAS)-Sitka
http://www.uas.alaska.edu/sitka/CWA.html
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.
Diné College of the Navajo Nation
Arizona and New Mexico
http://www.dinecollege.edu/
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.
Maui Community College (MCC)
http://www.maui.hawaii.edu/
Native Hawaiian Health
http://www.nativehawaiianhealth.net/index.cfm
Hawaii Primary Care Association
http://www.hawaiipca.net/index.php
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.
B. Specialized CHW Training Models
Breast Cancer Education
for CHWs
The Arizona Community Health Outreach Worker Network
http://www.publichealth.arizona.edu/azchow/
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.
Milagros, The Center of Excellence in Migrant
Health
http://elearn.stcc.cc.tx.us/milagros/
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.
C. Continuing Education and Peer Learning
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.
The CHR On-Line Program
Portage College, Alberta, Canada
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.
IV. NATIONAL INITIATIVES
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.
According to the CHW-NEC website,
"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:
- Students New to Higher Education
- Navigational Skills for Non-Traditional Students
Community Health Worker Employment Market Assessment Strategies
- Community Health Worker Core Competencies Defined
- College Credit by Assessment, Prior Leaning,
and Experience
- Literacy, Language, and Cultural Diversity
in Higher Education
- Community Health Worker Credentialing
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 |
V. CONCLUSIONS
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:
- Investment in technological infrastructure
is necessary.
- Faculty must be supported to increase their
cultural competence as well as their comfort with new technologies
for distance education.
- Students must be supported to increase expertise
with both their complex provider role as well as new technologies.
- Existing quality standards for distance education
should be adapted to assure their appropriateness for frontier
education programs.
- Current and emerging models of frontier training
should be evaluated using appropriate standards and realistically
achievable competencies.
REFERENCES~
American Public Health Association (2002). Policy
Statements Adopted by the Governing Council of the American Public
Health Association, October 24, 2001. American Journal of Public
Health 92(3):451-483. Accessed September 12, 2005.
American Association of Colleges of Nursing (2005).
AACN
White Paper: Distance Technology in Nursing Education. Accessed
September 15, 2005.
Appalachian Regional Commission (no date). Telecommunications:
Wireless Broadband Access in Appalachia. Appalachian Regional
Commission, ARC Online Resource Center. Accessed September 11, 2005
at http://www.arc.gov/index.do?nodeId=1813
Bell, Peter, Reddy, Pavani, and Rainie, Lee (2004).
Rural
Areas and the Internet. Washington,DC: Pew Internet & American
Life Project. Accessed September 11, 2005.
Butzen, Sarah and Liston, Cynthia (2003). Rural
Community Colleges and the Digital Divide. Learning Abstracts,
6(5), p. 1-5. Accessed July 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.
Centers for Disease Control and Prevention (2005).
Diabetes
Projects: Community Health Workers/Promotores de Salud: Critical
Connections in Communities. Atlanta, GA: Centers for Disease
Control and Prevention, CDC Division of Diabetes Translation and
Division of Adult and Community Health, Community Health Worker
and Promotora de Salud Workgroup. Accessed September 11, 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.
Community Health Works (no date). Community
Health Worker Certificate. Accessed September 15, 2005.
Community
Wellness Advocate (CWA) Program at University of Alaska Southeast
(UAS). Accessed April 12, 2005.
United
States Distance Learning Association. Distance Learning Glossary.
Accessed July 24, 2005.
Riley, L.A., Nassersharif, B., and Mullen, J.
(1999). Assessment
of Technology Infrastructures in Native Communities. Washington,
DC: Economic Development Administration, US Department of Commerce.
Accessed September 16, 2005.
First Consulting Group (2002). Rural Health Care
Delivery: Connecting Communities Through Technology. Ihealthreport
Series prepared for California Healthcare Foundation.
Frontier Education Center (2004). Addressing
the Nursing Shortage: Impacts and Innovations in Frontier America.
Accessed July 17, 2005.
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.
Hobbs, Vickie (2004). The
Promise and the Power of Distance Learning in Rural Education.
Rural Trust Policy Brief Series on Rural Education. Arlington, VA:
Rural Schools and Community Trust,. Accessed September 8, 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.
Johnson, Susan (2002). Report
of College 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, February 2002. Accessed September 11, 2005.
Kuran, Heidi (2001). First
Nations and Inuit Health Information Systems: Are We Ready for Technology?
In Touch: Newsletter of National Indian and Inuit Community Health
Representatives Organizations, Vol. 19, Summer. Accessed on September
29, 2005.
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
May, Marlynn L., Contreras, Ricardo B., Callejas,
Linda, and Ledezma, Elvia (2004). Mujer
Y Corazon: Community Health Workers and Their Organizations in Colonias
on the US-Mexico Border. Final Report. The Southwest Rural Health
Research Center, School of Rural Public Health, Texas A&M University
System Health Science Center. Accessed September 14, 2005.
May, Marlynn, Cash, Bita, and Contreras, Ricardo
(2005). Community
Health Worker (CHW) Certification and Training: A National Survey
of Regionally- and State-based Programs. Southwest Rural Health
Research Center, School of Rural Public Health, Texas A&M University
System Health Science Center. Accessed September 14, 2005.
Miller, Bruce (1995). The
Role of Rural Schools in Community Development: Policy Issues and
Implications. Portland, OR: The Northwest Regional Educational
Laboratory, Rural Education Program. Accessed September 27, 2005.
Myers, Wayne (2005). Institute of Medicine Comes
to Rural: Now Read the Book! The
Rural Monitor, Volume 11, No. 3, Winter 2005. Accessed September
11, 2005.
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.
Parker, Nancy K., and Froehler, Carrie (2000).
Voices
in the Wilderness: Processes for Identifying and Resolving Internet
Access Barriers Among Aboriginal Health Promotion Professionals.
Paper presented at the 9th Annual Conference of the Canadian Institutional
Research and Planning Association (CIRPA-ACPRI), Saskatoon, Saskatchewan,
October 15-17 2000. Accessed on September 29, 2005.
Quality on the line: Benchmarks for Success in
Internet-Based Distance Education (2000). Institute for Higher Education
Policy, Washington, DC.
Roberts, Larry (no date). Request
for Human Services (HSV) Resources. Accessed September 14, 2005.
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.
Rural
School and Community Trust (2005). About us. Accessed September
27, 2005.
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.
South Central College (2005). Community
Supports for People with Disabilities. Community Supports Program
website, Accessed September 28, 2005.
South Central Technical College (2005). CSP
Looks for Diversity: New Community Health Worker Certificate Pilot
Program. Community Supports Newsletter, March 2005, p.7. Accessed
September 28, 2005.
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.
Tanana Valley Campus (2002). Human
Services Statewide Distance Delivered Program. University of
Alaska Fairbanks, Tanana Valley Campus. Accessed September 14, 2005.
University of Wisconsin-Extension (2005). Distance
Education Clearinghouse. Accessed September 16, 2005.
Waits, Tiffany and Lewis, Laurie (2003). Distance
Education at Degree-Granting Postsecondary Institutions: 2000-2001,
NCES 2003-017, Washington, DC: U.S. Department of Education, National
Center for Education Statistics. Accessed September 28, 2005.
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.
APPENDIX A: CONTACT LIST
Nancy E. Collyer
Senior Program Coordinator
Arizona AHEC Program, Tucson, AZ
(520) 629-4300 ext 121
collier@u.arizona.edu
Ed Garrison
Dine College, Shiprock, NM
(505) 368-3522, 3518 ext 3583
ergarrison@dinecollege.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
Valerie Starkey
Community Health Worker, Molokai, HI
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)
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