Tl'azt'en Learning Circle: Information Technology, Health and Cultural

1. University of British Columbia. Email: sandra.js@ubc.ca
2. University of British Columbia
3. University of British Columbia
4. Concordia University

Introduction

Canada’s rural and remote First Nations communities face challenges such as lower health status relative to the national population and diminished access to certain health services (e.g., specialists) as a consequence of factors such as geographical isolation and the social determinants of health. According to the Royal Commission on Aboriginal Peoples, there are disproportionately high rates of social and community ill health among First Nations in comparison to the Canadian population in general (Department of Indian and Northern Affairs Canada, 1996). In 2002, Registered First Nations residents had a life expectancy of 73.9 years, compared to 82.2 years for all other residents of British Columbia (British Columbia Vital Statistics Agency, 2004). The Age Standardised Mortality Rate (ASMR) among Registered First Nations was more than twice as high as the ASMR among other BC residents (British Columbia Vital Statistics Agency, 2004). Health encompasses not only health care delivery, but also education, community and family networks, traditional knowledge exchange, linguistic vitality and identity. This approach is not dissimilar to the one used in the Blueprint on Aboriginal Health (2005) produced from the Meeting of First Ministers and Leaders of National Aboriginal Organizations, which states “the term health embraces a holistic approach encompassing the physical, emotional, intellectual and spiritual well-being of people living in harmony with well-functioning social systems in a healthful environment. Health is also grounded in traditional beliefs. The Blueprint focuses on population health strategies that address determinants of health” (Health Canada, 2005 p.7).

Research has revealed that insufficient access to care can be addressed through available and relevant health information and education via the Internet, commonly known as e-health (Ho, Karlinsky, Jarvis-Selinger & May, 2004) and information and communication technologies are often presented as a means of mitigating the challenges unique to health service delivery in rural and remote First Nations communities. According to a report by the First Nations and Inuit Health Branch, First Nations and Inuit communities are well suited to realize the benefits of e-health (First Nations and Inuit Health Branch, 2005). To this end, the Government of British Columbia is committed to ensuring that 366 remote communities are provided with high-speed networks (Network BC, 2006). The Provincial Health Services Authority plans to expand e-health services into these remote communities as they gain connectivity (Provincial Health Services Authority, 2005). Recognizing that communication between community members and decision-makers is a key success factor; e-health projects must be developed and implemented with mutual respect, trust, and synergistic cooperation among all stakeholders.

Yet, recent research suggests that e-health is not in and of itself a standalone solution to these challenges (Ho, Jarvis-Selinger, Dow, Sharman, Steele, Carty, Novak-Lauscher, Gunasingam, 2004). Rather, e-health should be viewed as a strategic addition to a comprehensive approach to community health. Lack of access to health services is only one of many issues affecting Canada’s rural and remote First Nations communities. For e-health to provide optimum support to First Nations communities in British Columbia, it is important to recognize the unique contexts specific to these communities, as well as the historical and present day consequences of marginalization. As such, access cannot be seen as an end in itself . Attempts at improving First Nations health (at both individual and community levels) through the use of information and communication technologies must therefore address the broad issues affecting health, including socio-cultural, geographical, policy and cost factors (Ho, Jarvis-Selinger et al., 2004). These innovative applications should not only actively attract connectivity investments to the community, but also create expanded access to health services when connectivity is established. Moreover, the process of defining health and health priorities must be community-driven. The remainder of this paper is devoted to describing a collaborative rural community-based First Nations e-health initiative that exemplifies the aforementioned principles.

Community Learning Centre Concept

A Community Learning Centre (CLC) is a unique and innovative model of delivering health care and health information based firmly on the idea of holistic community engagement. It is made up of two interrelated components: 1) a community-based facility housing Internet-linked computers accessible to all community members free of charge; and 2) community developed web-based resources relevant to community defined needs and priorities. The guiding vision of a CLC is to create a space in the community where individuals can develop social linkages through the use of information technology. In particular, a CLC can support the acquisition of health information as well as research and technology skills by facilitating access to, and uptake of, relevant health information resources that are developed by and for community members. In this environment, youth are encouraged to share their knowledge of computers with adults and elders; similarly, adults and elders can help youth contextualize information they discover with the use of computers. This environment can also help professional and non-professional community health providers’ access information for continuing professional development and healthcare delivery. As well, it may increase community awareness of, and proficiency in, IT use and research, stimulate job creation, and contribute to a diverse local economy.

Additionally, in First Nations communities, professional healthcare providers (e.g., nurses, physicians) are in high demand and limited supply. As such, community leaders not formally trained in healthcare have, in some cases, become default health service providers. CLCs in this way can play a role in supporting these individuals by being a trustworthy source of information about issues relevant to their community’s needs and furthermore, to educate all health care providers about community health needs and priorities.

History of the CLC Concept

The concept of the Community Learning Centre (CLC) originated from the Instituto Tecnológico y de Estudios Superiores de Monterrey (Tec de Monterrey), which is a private university system in Mexico. Responding to poverty and poor educational access and levels experienced in that country, the first CLC was established in February 2001 in order to provide quality education to geographically isolated regions and to assist community members to develop new skills and enhance their living standards. A CLC was implemented through collaboration between the University, the provincial and national government in Mexico, and the communities as a social development vehicle to promote the social and economic development of these rural communities and their populations (Carrigan, Milton & Morrow, 2005).

Tec de Monterrey University initiated CLCs to provide multifaceted educational content from commerce to health in order to facilitate knowledge exchange and collaboration between faculty, students, and community members. Strengthening families through online resources for parents and increasing community leadership through leadership skills development were also essential goals of the Tec de Monterrey CLC concept.

Tec de Monterrey’s community-based CLC model is composed primarily of:

• A network of computers connected to high-speed Internet, comprising a hardware and connectivity infrastructure

• A web portal providing educational materials and opportunities for electronic dialogues between participants

• A live facilitator (called “Margarita” in Mexico) at the CLC to assist community members to optimally utilize the CLC for learning, family dialogues, and community enrichment

Since February 2001, Tec de Monterrey has been successful in their CLC implementation, and to date they have more than 1,000 Spanish-language CLC’s located in Mexico, with a few jointly developed centers in the Southern USA – such as the CLC developed through a partnership with Arizona State University (Arizona State University, 2006).

One important reason why this model succeeds is the strong engagement of the academic partner with the communities that this model serves. Because of the university’s social responsibility mission, Tec de Monterrey invested its funding, technological and educational expertise into the establishment of CLCs. Over time, in partnership with and co-investments from regional, provincial and national governments, CLCs continue to expand to more communities. The tripartite partnership between communities, the university, and government has been found to successfully support and address the needs of the communities involved in this initiative.

CLC Modeling in B.C.

The University of British Columbia (UBC), located in Vancouver, BC, considers community empowerment as one of its core values, evidenced by the Trek 2000 declaration¹. UBC Faculty of Medicine’s eHealth Strategy Office (UBC eHealth) has a strong interest in assisting communities in the improvement of access to, and quality of, health. BC rural communities have similarities to those in Mexico in that access to quality care and health education is significantly hampered by geographic isolation. This is particularly true for rural First Nations communities.

Building on a strong institutional relationship between UBC and Tec de Monterrey, UBC eHealth connected with the Monterrey Tec School of Medicine in 2002 looking for opportunities for synergy, and a CLC pilot project in rural BC was one of the first initiatives launched.

UBC and Ministry of Management Services

UBC eHealth’s interest in technology enabled initiatives resulted in the establishment of a relationship with the BC government’s Ministry of Management Services, which has an interest in bringing broadband electronic infrastructure to rural and isolated communities. This relationship is symbiotic in that both infrastructure and content are necessary for the launching of a CLC. The Ministry was able to provide expertise in network connectivity while UBC eHealth provided health and educational content expertise, leading to a comprehensive plan that could be proposed to rural communities. As a result, UBC eHealth and the Ministry jointly envisioned the introduction of high-speed broadband infrastructure and health content to a rural First Nations community that would help achieve the following goals:

• Access of community members to general computer training towards use in e-learning and e-health

• Establishment of a broadband-based e-health curriculum for school students by working with First Nation community leaders and community health nurses

• Scheduled online continuing health education to community health providers (e.g. community health nurses, First Nation elders and leaders, mothers, etc.) on relevant health issues defined by the communities

• Documenting processes to understand and learn for future implementation of CLCs and the potential policy impact of the CLC concept.

The first community with both the educational and the health units being receptive to the CLC model was Tache, a community within the Tl’azt’en Nation located 65km north of Fort St. James² with only one road - often inaccessible in the winter. It was here that UBC eHealth and the Ministry of Management Services chose to implement the pilot project.

Tl'azt'en Learning Circle (TLC): A Pilot CLC Project in British Columbia

The project in Tache began as a CLC implementation pilot and was later renamed the Tl’azt’en Learning Circle (TLC) with the consent of the community. It was guided by an ongoing community engagement process and was supported locally by the community through both commitments of time and energy, as well as collaborative efforts towards accessing additional funding and resources. The pilot phase of the TLC project (November 2003 – March 2004) was carried out by UBC eHealth in partnership with the Tl’azt’en Nation, the BC Ministry of Management Services, and UBC’s Community Liaison for Integrating Study and Service (UBC-CLISS). This pilot phase focused on the following goals:

• Establish a social space for community interaction and sharing of skills and knowledge

• Develop a governance protocol, identifying community expertise and building capacity

• Increase awareness of health determinants and prevention practices, while identifying community health priorities

• Provide youth with training in information technology/web design such that they could create community-based websites and expand the web portal developed during the CLC pilot

• Train youth and other community members in a variety of research skills that could be used to gather and examine community health resources and knowledge

• Increase community-based access to, and use of, health information resources

• Develop a web portal that incorporates both physician-developed content and community-developed content relevant to community-defined health needs

These goals were developed collaboratively among all project team members throughout its early stages. Project goals were informed by the broad goals of the CLC model that inspired the project, but were influenced by the interests and expertise of the project partners. For example, the BC Ministry of Management Services could uniquely address the implementation of information technology, UBC eHealth brought experience in research skills training and health needs assessments, and the Tl’azt’en Nation provided the community impetus and nurtured skill development and capacity building, particularly regarding the health of its communities. Each partner played an important role and made contributions that were possible because of their particular ability and expertise. This collaboration represented a multi-faceted partnership with many individuals and organizations involved. While navigating this type of collaboration can be complex, it was vital that all partners were involved throughout the developmental processes. Thorough documentation of these initial processes may allow streamlining for future applications.

Project responsibilities were divided among the project partners. All partners were responsible for ongoing engagement and overall project implementation (e.g., attending project meetings and events); however, each partner brought specific skills and experience to the project and, therefore, took responsibility for particular aspects, as outlined in Table 1. This paper describes the pilot implementation from the point of view of UBC eHealth researchers and, thus, focuses on UBC eHealth responsibilities

Partner	Primary Responsibilities
UBC eHealth	Research skills training Guiding and supporting web portal development (including mentoring in design, creating of health-related content, uploading content, etc) Maintaining process documents to describe the creation of the CLCs
Tl’atz’en Nation	Defining health priorities Recruiting youth Production/Research assistants (PRAs) Scheduling and arranging for PRA training Securing physical space and furnishings for the CLC/TLC Developing and uploading web content
UBC-CLISS	Community engagement Governance protocol development
BC Ministry of Management Services	Technological infrastructure Technical training of PRAs

Table 1: Primary Responsibilities of Project Partners

During the early stages of project development, an initial community visit was made by members of UBC eHealth and the Ministry to introduce the CLC concept to community representatives and to propose the implementation project as a collaboration between UBC eHealth, the Ministry and the Tl'azt'en Nation. Representatives of UBC eHealth and the Ministry were introduced to members of the Tl’azt’en Nation community (particularly those in the band office and those working in education and health), were given a tour of the community and its resources, and participated in a meeting in the band office (which was broadcast to the community). At this meeting, the Ministry explained its interest in implementing information technology within the community and UBC eHealth presented its ideas for integrating health into that technology implementation process (based upon the CLC model). Tl’azt’en Nation representatives discussed their interest in the project and offered their thoughts on areas of particular interest (i.e., diabetes, cultural preservation). Following the success of this meeting, these groups began work on the pilot project which included ordering hardware and software, seeking further funding and support, and promoting the project within the community.

As the project developed, the Tl’azt’en Nation secured funding from the Prince George Nechako Aboriginal Employment and Training Association, allowing for the hiring of seven community-based Production/Research Assistants (PRAs), and UBC eHealth secured funding from Industry Canada to facilitate additional training and community-based activities. Support from UBC-CLISS was also pledged during this time and a representative worked with the UBC eHealth researchers to plan community engagement activities carried out during community visits (as described below).

Based on UBC eHealth’s responsibilities in this pilot project (namely, research skills training and guiding the community-based web portal development), three community visits were made by UBC eHealth researchers to Tache. Each visit had a particular objective:

1. The first visit (January 2004) focused on engaging the community and determining local interests and needs with respect to the planned project and web design training.

2. The second visit (February 2004) centered on research skills training.

3. The third visit (March 2004) involved community-based web portal development.

These three community visits most clearly reflected the role of UBC eHealth in the pilot project and the following descriptions provide an outline and summary of UBC eHealth activities.

First Community Visit

In January 2004 UBC eHealth researchers and a representative from the UBC-CLISS visited Tache. Prior to this visit, materials were prepared in order to facilitate community engagement including discussing issues of community health and implementation of information and communication technologies in Tache. These materials included a draft information brochure including conceptual background of the Community Learning Centre concept and goals (based on information described in the Mexican CLCs), a graphic that showed a draft “results chain” for the TLC project, and a slide presentation including an ecological model of health in context. These materials were distributed to community members in Tache and were used in meetings to engage and inspire discussion. This visit was instrumental in the project’s development, allowing the university researchers to meet with community representatives and the newly hired PRAs. Meetings with the PRAs involved the UBC eHealth researchers proposing their ideas for the implementation, but more importantly, gave the PRAs an opportunity to suggest their own ideas and to explain their own perspectives on community health status, the research skills they would like to learn, and community health priorities.

In order to build effective relationships and gather information on community health and the health priorities in the Tl'azt'en Nation, a meeting was also held with the health unit staff. Once again, UBC eHealth sought input from the staff, particularly with respect to the notion of community health, health priorities and the potential role of the Health Unit in the project. Open meetings were also held with youth, band administration staff, and elders, where discussions about community health and health priorities helped to further focus the project. In addition, community members helped UBC eHealth researchers to develop the overall vision of community health. An ecological model of health encompassing individual, family, community, health services, social determinants, and environment levels was introduced to the community at various meetings. Discussions about this model resulted in adjustments to ensure the community’s vision was reflected in the project (see Figure 1). While the five levels of individual, family, community, social determinants, and environment remained, new levels of clan and culture/tradition/language were added (health resources were viewed as an overarching concept). In addition, discussions of local challenges regarding treatment and illness prevention as well as contemporary and traditional approaches to medicine reinforced for project team members the importance of these dimensions for the Tl’azt’en Nation. Consequently these aspects were also added to the revised model of health.

Figure 1: TLC Models of Health in Context

This first research visit resulted in a clarification of the project goals and desired outcomes and saw various community members becoming more involved in the project. At the meetings with PRAs, health unit staff, youth, band administration staff, and elders, participants were asked to talk about what they felt were the most pressing community health priorities. A list of the identified health priorities was developed based on community discussions and was circulated back to the community for verification. The top five health priorities (i.e., those mentioned and discussed most often) were:

1. Dealing with addictions (treatment and prevention)

2. Improving diet and nutrition (including information on traditional foods)

3. Treating and preventing diabetes

4. Using and sharing traditional and contemporary information

5. Creating and accessing information about, exercise/recreation and staying active (e.g., skinning, baking, walking, hockey, etc.)

In addition, encouraging and providing opportunities for elder/youth interactions (e.g., transfer of cultural knowledge, computer skills, etc.) and linking traditional and contemporary health information were the 6^th and 7^th priorities, reflecting some of the original project goals.

Second Community Visit

In February 2004, UBC eHealth researchers made their second community visit. This visit focused on training the PRAs in research skills to build community capacity and respond to the research needs identified by representatives of the Tl'azt'en Nation. Prior to this visit two preparatory tasks were completed:

1. A training resource binder focused on community-based research was developed for each PRA. This binder was a guide for training, which was responsive to the needs and skills of the PRAs.

2. The PRAs undertook a research plan on traditional medicine (based on the priorities identified in previous discussions).

The research training workshops were adapted to meet the PRAs’ needs in completing the traditional medicine research plan as a showcase content area for the TLC web portal (this content area focus was decided on by the PRAs in working with community members, including the health unit staff). Training was focused on relevant research issues and skills, including critical analysis of source materials, focus group and interview strategies, and research ethics. PRAs were invited to add their own ideas and materials to the resource binder in the context of sharing their learning with each other. For example, PRAs added to the list of relevant online resources as they worked on their project.

This second visit resulted in a mapping of the TLC web portal and the TLC space as community resources. In terms of the web portal, PRAs generated ideas for: (1) format and structure, including layout and graphics; and (2) specific ideas related to health and culture for content concerning their traditional medicine work plan. For the physical TLC space, PRAs generated ideas and strategies for: (1) resources such as books (e.g., catalogued resource materials for community members to browse); and (2) convening meetings, support groups, and education sessions (e.g., youth teaching elders how to do Internet searches). Concrete steps were outlined by the PRAs for meeting the project goals of setting up the TLC space, developing the web portal, and engaging the community. Between visits by UBC eHealth, the PRAs were guided and supported by members of the Tl’azt’en community with experience in education and skills in project management. For example, a community member who was an educator and researcher on another project in the community provided mentorship to the PRAs. In addition a 1-800 number was set up so that PRAs could call UBC eHealth staff to problem solve any issues or challenges.

The traditional medicine work plan and project developed by the PRAs was to create a comprehensive database of traditional medicinal plants and their uses, and prepare information for the web portal. The PRAs carried out two main research processes to accomplish this. First they compiled and catalogued existing Tl’azt’en archival material (e.g., tape recorded elders’ interviews, databases, and videotapes related to the topic area). Next, they interviewed key knowledge holders in the community to identify and fill gaps in the information. The PRAs also collected photographs of medicinal plants for the website by taking pictures as well as referencing and acquiring permission to use copyrighted material.

Third Community Visit

In early March 2004 a third community visit was made by UBC eHealth staff, this time with the goal of training the PRAs in web page development and technical skills, as well as determining a final structure for the web portal as part of the implementation project. Prior to this visit, the PRAs had already worked to develop their skills in web development and research, and had begun to develop the content for the web portal. A PRA-selected ‘webmaster’ was chosen and received extended training in web design from UBC eHealth technical staff. It was determined that the web portal would include sections dedicated to health, education, culture, history, elders, and the TLC project, with the initial portal focusing on the following:

• Information on medicinal plants

• Biographies of the PRAs

• History/Context of Tache

• History of the TLC project

• Health Unit information

• Pictures of Tache

• A map of the geographical area

• Family histories

• Elders’ Stories

• Information on the Dakelh language

This stage of the project saw a number of technical difficulties arise as the PRAs began to work more intensively with the equipment. Such difficulties, as well as the looming end of the pilot project and thus of employment for some of the PRAs, resulted in many frustrations. Despite this, by the conclusion of the third visit a web portal template (see Figure 2) had been developed and the content areas mapped out (see Figure 3).

Figure 2: Web Portal Template

Figure 3: Content Areas Map

At the end of the pilot project a “Convergence Workshop" was held in Tache to review the pilot implementation, celebrate the achievements of the PRAs, and plan for future project phases. All project partners, including the government, the university group, and community members, participated in this event and an open house in Tache saw the PRAs present the web portal and reflect on their participation. A community forum featured discussions on community strengths/assets, traditional health, and current community health priorities, while project management-level meetings reviewed the pilot phase results and possible next steps.

Outcomes and Lessons Learned

As previously mentioned, there was a culminating community event at the end of the pilot to celebrate achievements and plan for future development and sustainability. Discussions involved community members, representatives from all community sectors (e.g., Education, Health, Treaties), and funders, as well as community and university project members. Themes drawn from the discussions during this three-day event reflect outcomes related to the pilot project. In addition, lessons learned were highlighted during the community discussions. The remainder of this section will first describe observed outcomes as well as lessons learned and will conclude with a discussion of implications. It is hoped that this discussion will be informative to others engaging in similar community-based projects.

This project set out to achieve the goals of establishing a community learning centre with two components, namely a social space and a web portal. A concrete project outcome was the web portal comprised of community-developed health content that was implemented by community youth (the PRAs) who had an opportunity to acquire skills in community health research methods and web design. The Tl’azt’en Learning Circle as a physical space remains a place where community members can learn to use high-speed internet technology to access health information and resources. The web portal continues to be used and functions as the primary web presence for the Nation (see http://www.tlc.baremetal.com)³. Overall, community members felt the goal of increasing the availability of health resources and information, and use of, health information resources was achieved.

The project achieved other outcomes such as providing youth with training in ICTs and research skills. After the pilot, two of the PRAs were employed to work in the community applying their research and technology skills (one on a health project related to e-health, and another in the Treaty office). PRAs have also been engaged in various communications activities related to their work at the TLC. For example, the PRAs co-presented at a provincial conference on community and technology. They were also asked to give a presentation at the elementary school, thus contributing to cross-generational learning and sharing.

The TLC project built a foundation for increasing awareness of health determinants and prevention practices, while identifying community health priorities. While much work was done in identifying health priorities and informing the development of the TLC resource, the project did not carry out an evaluation that measured health knowledge pre- and post-implementation. However, it was observed that the TLC project enabled a greater understanding and appreciation of how various groups in the community envisioned health (e.g., how cultural identity and language restoration are related to health). This learning was salient to government partners; community health priorities and a vision of health as holistic were emphasized and reinforced. Further, the model facilitated dialogue and collaboration between youth and elders. Community members and PRAs noted the vast potential of inter-generational learning as well as the value of sharing knowledge with peers, community members and the “world at large” through the Internet. For example, the PRAs expressed pride in the information they were able to share via their web page and hoped “that [their] Nation’s learning might contribute to the health of others.” Another positive outcome – one that was not specifically planned – was that community, government, funders and academia were able to work together with shared enthusiasm around a mutually interesting and beneficial project.

During the pilot, community members identified the ways that information technologies could connect the community and support business ventures as well as create further opportunities for e-health and telehealth. In this project, technology played a role in strengthening the community with the potential of improving health as defined by the community. Health or well-being was often spoken of synonymously with cultural restoration and having a strong cultural identity. The importance of recognizing and sharing talents, knowledge and skills within the community, as well as identifying local resources, was highlighted as a potential outgrowth of the TLC.

One tension that emerged in the project was the importance of teaching youth traditional knowledge in this type of forum while protecting intellectual property or cultural knowledge. An issue that needs to be discussed and planned for with the guidance of the community is this balance between protection and dissemination. In a technology/Internet-based project, OCAP issues (ownership, control, access and possession) including security become even more salient in terms of protecting sensitive heath information as well as working out protocols for potential sharing of traditional knowledge. In this project, this issue emerged in the context of storytelling as a vital part of culture, and the vast potential for learning from elders’ experiences and stories. There was discussion of the PRAs working with elders to build guidelines for recording or disseminating stories, as well as teaching youth how to tell their own stories.

The PRAs consistently expressed their desire and willingness to continue to learn new skills. They felt that their project experience would open doors to other opportunities both within and outside of the community. Within the community, as previously mentioned, two PRAs found employment related to their new skills. Discussion at the Convergence Workshop highlighted the importance of actively finding ways such as this to develop and continue such work in the community. PRAs also spoke of the potential of their acquired skills and work experiences to prepare them for employment or further education outside the community. While the project did not specifically track the impact of the project on youth out it was noted that information technologies, connectivity and the TLC could bring together community groups and connect all community service agencies (e.g., Health, Education, School, Treaty Office, RCMP, Youth Services, etc.). Increased community access to technology resources was a broad community development goal and community members felt that the implementation of the TLC was the primary reason for the community securing broadband network services.

Discussing and prioritizing future TLC applications generated ideas for strategic planning. While future Internet access in all homes was desired, the TLC functions as an “Internet Café” – a social space, which can contribute to community well being as well as economic development. For example, opportunities were identified for training in educational research, research for and promotion of community businesses and ventures (e.g., artisans, etc.), reduction in travel by use of web-based meetings and communication. It was expressed that the design and implementation of these information and communication services, according to community needs and priorities, were facilitated through this project.

Lessons Learned

The remainder of this section outlines several salient lessons that the authors learned through the experiences of challenges and successes throughout the project.

1. Personal identity and cultural identity are pathways to health and well-being. For this community, cultural identity and restoration, opportunities for youth to learn the Tl’azt’en language, and cross-generational sharing were all aspects of the community-created TLC. Training and research that occurred during the project focused on recording and sharing traditional knowledge and understanding cultural pathways to healthy living. Health priorities outlined in planning discussions related to individual identity, competencies, self-worth, self-awareness, pride and unity. Through the planning processes, community members also helped healthcare providers to better understand the context for community health and well-being as illustrated by Figure 1.

2. Relationship building is central to community development. In the context of building the TLC, the importance of recognizing and sharing talents, knowledge and skills within the community were highlighted. Identifying and increasing awareness of local resources was seen as a central goal of the TLC. Beyond, the development and content of the TLC web portal, the TLC space in the Elders’ Centre resulted in building relationships within the context of the project. Awareness of the TLC space as a local resource grew during and after the project as evidenced by organized community activities and learning sessions held there as well as informal or casual use of the facilities by youth.

3. Knowledge sharing is reciprocal in nature. Sharing knowledge – traditional, technical, cross-generational – is mutually beneficial to all involved. For example, UBC and Tl’azt’en engaged in community learning activities and connected with community members to discuss and work together on wider knowledge sharing. It is also essential to recognize the central role of the community in contributing knowledge, as well as the community’s ownership of that knowledge.

4. Capacity building and training must be authentic (i.e., applied as opposed to theoretical) and meaningful to the participants. No formal certification was available through this project. The PRA position offered on the job training through paid employment. However, it is vital to recognize that training and work done in capacity building projects, needs to have a meaningful reason to occur. It is also necessary to ensure opportunities for trainees to apply their skills both within and beyond pilot implementations to concrete tasks that contribute to the overall goal.

5. Community leadership and governance is essential for sustainability. Community development projects – even when they are multi-stakeholder – must be community-driven as well as collaborative. A challenge in this project was the lack of a mechanism for broad based community governance. That is, there was no formal community steering body that represented all sectors of the community. As a result, it became easy for certain community groups to have more influence and contact with the decision making processes and resources because they had more involvement in the day to day operations of the TLC. For example, because the PRAs were supervised by education staff, it was less likely for health staff to benefit from the PRAs’ assistance. It is clear that an organized process for establishing inclusive community governance would have ameliorated such challenges, and contributed to sustainability through maximizing usage and flexibility of the resource across sectors.

6. Tripartite involvement of community, government, and academia is essential to CLC success. This project validates the Mexico experience that joint involvement, planning and implementation of the CLC are essential to its success. Each partner brings unique authority, resources, and perspectives to the collaborative process, which is necessary to develop the CLC. It is through this iterative cooperation that the CLC succeeds through its many steps, from infrastructural establishment to defining community health priorities, content and technical development, capacity building, and evaluation.

Overall, according to feedback gleaned at the project wrap-up, the TLC project was considered successful in the community. The web portal, physical space and community experts remain in Tache. The feedback received from community and organizational partners was that the Community Learning Centre (CLC) concept was a worthy undertaking and the partnership created between UBC eHealth and the Tl’azt’en Nation continued and has fostered new technology projects. For example, Tl’azt’en Health was a partner in conducting a community end-user consultation to understand potentials and needs relating to the delivery of clinical telehealth programs. One of the PRAs was hired by Tl’azt’en Health as the research assistant who conducted community interviews and focus groups. One of the needs identified in this project was for wound management. To that end, Tl’azt’en and UBC eHealth recently partnered in a pilot implementation and evaluation of a tele-wound care system.

A major limitation of the project was the lack of a formalized evaluation process. Funds were used to train and develop capacity for community based technology and TLC personnel. A lesson learned was that some of the resources for capacity building in training and support could have been wisely allocated to community-led evaluation of the processes and outcomes of the TLC project.

A key success factor for future CLC projects is to be community-driven. There is a need for all partners to work actively together to ensure that such a project remains community-driven, and that a community-driven governance model is established early in the process. Engaging in this project helped illuminate how various groups in the community envision health. Collaboratively, this community-university partnership developed a way to look at health that includes not only individuals, but also community, culture, the environment, and other factors. It was valuable to us at UBC eHealth to look at health in this broad and holistic way. This vision of health can inform the future of the TLC so that it will continue to meet a variety of community needs and purposes. What has been learned in this collaboration will inform future partnerships between First Nations, government, funders, and academia.

Future Directions

The Tl’azt’en Learning Centre was conceived as an implementation project with no scope (or funding) for a systematic evaluation. Therefore, other than anecdotal feedback and researcher reflection, this project had no evaluation focusing on the impact of the learning centre in terms of language restoration or improved health perspectives. But the lessons learned from this project were invaluable to the project team and led to the creation of another project with a full evaluation component.

Building on the technology and implementation lessons learned here, the authors have partnered with the Ktunaxa Nation to create four learning centres in each of their British Columbia communities. Funded by a grant from the Canadian Institutes of Health Research, the project team includes university and community co-investigators. Known as the Ktunaxa Community Learning Centres (or KCLC) this emerging project will continue the momentum begun with the Tl’azt’en Nation project and use the lessons learned to support building these new community learning centers. In addition the KCLC project will engage community researchers over a three year period to evaluate the process of implementation and measure the impact on community members’ health perspectives, interaction with the learning centres, and language restoration.

The evaluation of the KCLC initiative spans four phases over three years. The first phase focuses on training and preparation. Community advisory committees will be set up, community research and technical personnel will be engaged and training will begin in preparation for the launch of the CLCs. This phase will draw on the lessons learned in the Tl’azt’en Nation project. For example, storytelling was an integral component in the Tl’azt’en project and will be supported as an evaluation method in the Ktunaxa project. In the second phase, the overall evaluation framework and data collection strategies will be co-developed with community researchers and with community advisories. The intent of the second phase is for community researchers to collect baseline data on perceptions of community wellness, technical skills related to the CLCs, health concerns, and awareness of health resources. This phase will also focus on creating the technical infrastructure and preparing to upload the health content. Phase three will be the ‘go live’ phase, involving the finalization of the health content and uploading it to the CLCs.

Once the CLCs are live, community researchers will engage in evaluation processes (for example, focus groups and interviews) to understand and document the impact of the CLCs on the aforementioned topic areas, as well as other significant themes that may have emerged over the course of the project. Other more technology-related theme areas may also be explored, including assessing the level of accessibility and usability of the CLCs’ information and tracking the number of user hits on specific portal pages, etc. The final phase will focus on data analysis, report writing, and communication of results with full engagement from both community and university partners. Strategies that include sharing results of the final report will be supported through town hall meetings as well as formal opportunities such as conferences and forums.

Through the Tl’azt’en Nation project and now with the emerging Ktunaxa projects we believe that providing culturally relevant health information online and engaging community members in building the content will lead to improved health outcomes in the community. Further, the health of a community is highly influenced by that community’s social determinants of health. Potential positive outcomes and progress in community wellness include:

1. Revitalization of traditional knowledge and practices (such as use of traditional language);

2. First Nations’ control of community programs;

3. Increased employment chances via research, technical and interpersonal skills training; and

4. Improved awareness of, and access to community health resources through the community learning centre.

In understanding the potential of improved availability and access to health information via the learning centres it is important to keep in mind that… “access in itself is insufficient. Rather it is what is and can be done with the access that makes ICT meaningful” (Gurstein, 2008, pp. 12-13). The TLC project represents one step towards locally relevant public health information available online as well as through the TLC physical space. The project addressed what van Dijk (2003) characterized as successive, cumulative, and recursive stages of access. The community consultation processes addressed issues of mental access (overcoming anxiety around technology). Material access was made possible through funding for connectivity, and hardware first placed in the community space. Skills access (strategic and instrumental skills) was fostered through training, and finally, opportunities for usage access in the community were developed by the PRAs. In addition to better health information, we believe the CLC model which, was piloted in Tl’azt’en and is being evaluated in Ktunaxa can lead directly to improved social strengths and opportunities for the community.

Acknowledgements

We wish to thank the community of Tache, the Tl’azt’en Nation, and especially the Production Research Assistants whose hard work, resourcefulness and creativity were instrumental in developing and promoting the TLC web portal. The Directors and Staff of Tl’azt’en Education and Health were integral to moving this project forward.

We are grateful to the members of the entire TLC project team including Deborah Page, Vince Verlaan, John Rowlandson, Michal Fedeles, and Chris Steele. Finally, we wish to thank John Webb for his vision and support.

Funding for this project was provided by the BC Ministry of Management Services, Industry Canada, and the Prince George Nechako Aboriginal Employment and Training Association.

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