Practice makes perfect

Another thing that I learned but was not a formal part of our learning activities is that when you have to repeat a learning activity because you did something slightly wrong, you learn a lot about that activity the second time around.  I ran into a challenge half way through this course in that my original concept for the course design was not going to work for the intended outcomes of the ETAP687 course.  At first I was disappointed in the loss of time that I put into the original concept but realized as the modules unfolded that the original concept would not have worked.  I had to repeat the earlier activities with a new course concept and found that with the knowledge of the later modules in ETAP687, it actually made the earlier activities more thorough in the second effort.  This was of great benefit to me in that I got to reapply ideas presented in some of the exemplar courses to my new course design.  For instance, my original concept did very little in the way of building class community but the second try allowed me to create reflection blogs that are a way for students to share their experiences of their clinical rotation sties.  Since this course is the last in the curriculum, class community had been built over the previous 8 months and the challenge was to keep the community together when the students separated and went to their clinical rotation facilities.  I think one of the biggest things that I learned was how to develop teaching presence in an online course and how to create class community from Alexandra’s “Understanding Teaching Presence and Class Community Online” presentation.   I found that many of the concepts were discovered and could be applied to my FTF classes in addition to the online course.  In this presentation I learned that students learn their best when 4 major things are addressed in a course design: knowledge centered (developing good objectives and outcomes for the course ), learning centered (create activities that engage the students prior understanding and make the activity applicable to their lives), community centered (create a group environment that fosters learning  through the sense that it is ok to ask questions to the group), assessment centered(create multiple ways to assess student learning and ways to provide feedback to students about their progress through the materials).   These are only a few areas that I found valuable to me in this presentation.  I am pretty sure that I learned this material in how I incorporated these aspects into the design of my course.  Course reviewer’s like the multiple methods that I utilized to assess the students and like the use of group activities that put the student in the center of the learning activities, making them take more of an active role in what they want to learn.   I am utilizing a group activity for developing a procedure and using a student led question and answer session for review of the materials presented in the course.  These activities also help to build class community through group work and presentation of material that the students find confusing or want to learn more about. 

I think another thing that helped my overall learning was the ETAP 687 course manual that was provided to us.  I will keep this for the rest of my career, hopefully adding to it as technology changes or as we find more data to support new ideas to enhance online learning.  I hope to do an Amazon search to find this manual published and hope that mine and my classmates experiences contributed to edits that may take place in the future. 

The only thing that got in the way of learning for me was the blog posts.  I understand the value of reflecting on your work but often forgot about posting to the blog or did not meet blog requirements due to a feeling of me being repetitious in my statements.  I often felt like the things I was saying in the discussions were also required to be posted in the blog reflections and seemed to be duplicate efforts.  To me, the blog might be more valuable as a way to see more of a personal side of the learning process, outside of the content engagement in the different modules.  I see the blog as a way that students can share their feelings, frustrations and ideas about the course content.

Overall, this has been the most challenging course that I have encountered in my educational career and that is saying something since my background includes some biological and chemical science courses that most people dread the mere thought of taking.  However, I feel I have learned more in this course that I can apply to my own life and profession than those afore mentioned courses.  The principles presented and utilized in my online course design made me revaluate my FTF courses and how I will teach them in the future, too.  Good luck to all of my classmates as they prepare to actually teach their course and then evolve their course as they reflect on what worked and what didn’t in the live presentation of the course.  Cheers!

Design of activities helps create class community and fosters learning

I think the most important thing that I learned this week is no matter how clear you think you write instructions, someone is going to interpret them differently than you intended.  I have encountered this in the teaching of my laboratory classes and have wondered how 1 student can interpret something different than the other 13 in my class.  This week, I became that 1 student.  I think that some of my confusion came from my interpretations based on how I have made assignments similar to this one in this module but used the bold face type in a different meaning.  Lesson learned: be specific.  When a mistake is made, review the instructions, make clarifications and try again next year.

Reflecting on this course I have learned how to provide effective instruction in an online environment.  Design is crucial in that you need to address things that we take for granted in a FTF class.  Building community comes easily in the FTF curriculum I teach but in the online environment, you must design activities and discussions that help foster community building, which in turn helps all of the students learn in the online environment.    For example, creating a problem based or case study activity engages the student and helps them apply the information to their own situations.  By having the students post their findings or thoughts about the case study, you encourage student to student interactions that help them see how their classmates engaged the material, noting similarities and differences.  By designing activities that encourage these interactions, students learn not only from the material but from each other.

I have more to report for this last module’s blog but I wanted to get this in before I forgot what I was thinking about tonight.

I feel good about my course, especially since the design reflects how I do things in my FTF class

I didn’t submit a blog last week as I was really involved with reviewing my course and preparing the last of my documents to post to the course. 

I feel pretty good about my course design.  I am very near completion, have tested the areas, printed some pages and checked to make sure that the links work the way that they should.  However, I have forgotten to place an area into the course for the non-online clinical practicum portion of the course.  I will need to create a place for forms and documents that students can use while on clinical rotations. 

I think that I have learned a new way to teach or at least changed my approach so that it will work in an online capacity.  First, I have realized how I can create an online environment that will help continue the community developed while my students are in FTF classes.  Because of this course I realized how the students must feel leaving their close community setting and enter into an isolated and new environment.  I have tried to create a couple of areas within the course like the coffee house and the blog entries as ways that students can share their experiences.  I hope that this area will materialize into something more than just a reflection area but will generate discussions that help students make connections between their different clinical rotation environments.

Second, I think that I have borrowed a couple of different ideas from the exemplar course and this course that will help tap into the cognitive or thinking presence.   Through group activities I hope that the students will be able to help each other learn about new laboratory areas and compare their findings to see the variations that exist in the work force.  It is one thing to understand the theory, laws and procedures but it is another level when they will make connections between the theory to their actual clinical site.  Another activity that I have created is a way for students’ t o help each other review assigned cytology topics in preparation for their board exams.  Letting the students decide which questions to ask will give them the choice on what areas they want to focus or increase their knowledge while helping their classmates understand their subject material.  This is the one part of the course that worries me the most, however as I am not sure how this will work in the online environment.  I want each student to answer the post questions without seeing other student’s answers until they have posted their responses.  I am not sure how much discussion the questions and answers will generate but I am hoping that at least a couple of discussions will begin on confusing areas.

Lastly, there are areas throughout the course that allow me to demonstrate a teaching presence much like I do in my FTF classes.  Through reassuring students in their reflection blogs to clearing up confusion in the question and answer review sessions, I should be able to keep up the same teaching presence that I have provided the entire year in the FTF class. 

My biggest challenge in this course was choosing a course that would work in an online enviroment

I will attempt to expand upon first post concerning this module.  In my current FTF classes the emphasis is on knowledge.  All of our lectures reiterate or explain the important details and criteria needed to diagnose disease.  Students spend 2 to 6 hours each week listening to the criteria that they need to know and apply for making an accurate diagnosis.  All of these introductory lectures contain images of the different types of disease in addition to text that explains the criteria seen in the images.  During our lectures we point out the different criteria in each image that we project to them.  These lectures are intermixed with case presentations that help the students learn how to see and apply the different criteria to a projected image.  In a way, this is part of the assessment centered environment that we utilize in the curriculum.  Another type of assessment takes place when students learn to apply the criteria to the microscope slide in their weekly lab sessions.  The final form of assessment takes place in both weekly written exams and microscope slide exams, which provide a culminating feedback mechanism that shows the students what they have learned.  Throughout all of these assessments, students receive feedback in multiple ways.  For the culminating weekly exams, the feedback is in the form of review of their answers vs. the correct answers.  Microscope slides are reviewed with students as a group where they learn about their mistakes and from each of others mistakes on the slides.  During the lab sessions, small groups of students sit with the instructors and review each of their own microscope slides in addition to their classmates, providing them opportunities to hear feedback about their own cases and others.  All of these lab sessions and assessments also form the community centered environment. 

Turning the focus to some of the questions asked for this blogging assignment, one of the things I have tried to take into consideration is the questions students might ask within the module.  In Pickett’s article, A Series of Unfortunate Online Events, she points out some of the false assumptions about teaching online.  One of the first pieces of advice that she offers in this article is “Assume Nothing” (Pickett, p1).  I have taken this to heart in the design of my course and have tried to be as specific as possible when creating assignments and discussions.  For instance, I have taken care to make sure students know how I want their file submissions named.  A concern arises from this specificity in the sense that Pickett points out that we cannot assume that students will read everything we place in our course (Pickett, p1) so this is sort of a catch 22. 

I have tried to facilitate discourse in each of my modules, trying to engage the students in discussions through the use of leading questions.  I anticipate that I will also facilitate discourse through encouraging response to student’s posts.  In each of the discussion modules I have tried create a climate for learning by telling the students what they should focus on as part of their learning in the module’s discussions.  In some of my modules, I have created groups for students to work in allowing them to choose a group leader and leaving it to the group on how to best go about completing the assignment.  I am concerned on how to grade or evaluate the group but I have tried to anticipate this problem by having each student in the group document their contributions, which should help me judge the efforts of each student within the group.

My biggest challenge in this course was keeping up with all of the different required responses to discussions and the external blog posts.  I am not sure if this was due to external pressures or the demands of the course development process.  The problems may deal with time management on my part.  Creating a second course design for ETAP 687 did not help with my time management issues.  This was partly my fault as my original course didn’t take full advantage of the objectives of ETAP 687 but I focused on my needs to create an online review tutorial, which does not translate the same as a semester long course would.  This is a good seg way into my problems in choosing a course to place online.  Kassop points to 10 reasons why an online course is better than a FTF course.  I feel like I am a broken record by mentioning this again.  I think that is why I have a hard time with my blog reflections since some of the things I need to state in these posts are also apart of the discussion posts within the course and sort of seem like restatements.  Here is a restatement of a post made to several discussion areas concerning Kassop’s article:

Based on Kassop’s commentary I am not sure that an asynchronous online class is a good fit for most of the topics in my curriculum.  The cytotechnology curriculum has several of the top 10 reasons Kassop states online education is as good if not better than FTF learning. Our curriculum follows a similar format for each body system that we teach.  We provide a lecture that gives students basic criteria for diagnosing diseases. This lecture is followed by a lab session where an instructor uses a 10 head microscope to show students examples of the criteria and diagnostic entities on microscope slides.  Each week, students receive boxes of slides that they must screen, diagnose and bring back to the 10 head microscope during their assigned lab session.  The students’ screening room is oriented in a way that allows for students to interact with each other and their weekly assigned cases before their lab sessions thus helping to facilitate student centered learning (p1).  During the lab sessions, students interact with the instructors, asking questions about their cases.  The 10 head microscope allows all students to see the same image and ask questions or volunteer information about the case/slide. 

Our class size is small with a maximum of 14 students, which results in a 7:1 student to faculty ratio.  Our main focus as faculty is to support student learning and we are available for one on one instruction with dual head microscopes and very open, liberal office hours not to mention email and IM that keeps us connected and addressing On-demand interaction and immediate feedback as defined by Kassop (p.6).  

As mentioned earlier our class size is small and our curriculum spans 8 months of didactic training followed by 12 weeks of experiential education. During the 8 months of didactic training, students are in class Monday through Friday from 8 A.M. to 4 P.M. and we develop a strong sense of community with our students in addition to the student to student relationships.  The student groups are generally very supportive of each other and help each other reach the goals of the courses and personal goals.  This helps address the intimate community of learners (Kassop, p.5).

Our course materials are enriched by short rotations to clinical affiliates where students see firsthand many of the procedures discussed during our lectures.  Students also complete a clinical practicum where they immerse themselves into the daily workings of a cytology laboratory,, providing them the real world experience and practical application of their didactic training.  Lectures are also enhanced by guest lecturers on specific topics that provide a clinician’s perspective on the results that student’s are responsible for providing to them (Kassop, p.3-4)


Building the skills for lifelong learning (Kassop, p.3) occurs from day one in the curriculum but is highlighted by one of our courses, which focuses on new technologies and research studies that highlight the need for students to keep up with current trends in pathology.  We emphasize that what students learn inside of the classroom is just the beginning and that we are always updating our lectures with current information.  The field is always evolving and the use of our journal club helps the student realize this fact and helps teach them how to critically examine research design and results.

Highly interactive discussions (Kassop, p.2) take place on days when we provide an alternative to our instructor led presentation of material.  As part of culminating exercises for new material, we provide case studies in two methods.  The first is where an instructor presents images of a case and calls on individual students within the class to describe what they see, using learned criteria and make a diagnosis on the case.  The entire class sees the same image, listens to the student’s descriptions and can agree or disagree with the description and diagnosis.  The instructor then turns to other students in the class that see something not originally described that may have an impact on the diagnosis.  In this sense, the students have now established a teaching presence based on their interactions with each other and the presented case.  The instructor reveals the answer to the case and then initiates a discussion if the diagnosis was incorrect.  A second method used is similar to what I just described but in the second activity, the class is paired and half of the pair turns their back to the projected image and it is the job of the one student who can see the image to describe it in such a way to make his/her partner come up with the correct diagnosis.  I think the second method really establishes a student teaching presence.

At the end of each year I am “rejuvenated” but not like Kassop describes (p.6) with his experiences of faculty developing online courses.  My rejuvenation comes through reflection on each student’s progress through the curriculum.  It amazes me each year to see the transformation that occurs in students over the course of the training program. 

However, I do see possible room for improvement with the current curriculum offerings but perhaps not in an asynchronous setting.  Kassop describes enhanced course materials as reason number five in his commentary (p. 4-5).  Using our current CMS we could create interactive tutorials that are case or scenario based that would enhance a student’s understanding of not only the basic criteria but their application and how diagnostic decisions affect patients and the rest of the medical team. 

Perhaps the best use of an online component in our curriculum would be the development of writing skills and desire for lifelong learning.  As part of our curriculum we have a journal club course which requires a student to search for applicable articles to specific topics.  They are required to present the journal article in a 10 minute oral presentation utilizing PowerPoint.  This portion of the curriculum could very easily be structured to take advantage of the writing intensive nature of an online course as described by Kassop (p.2). 

While enthusiastic about creating online courses for our curriculum, Kassop’s commentary has made me rethink a completely asynchronous offering.

Perhaps the biggest advantage of recreating my course design was knowing where I needed to go.  Recreating the course from the beginning with the knowledge from discussions, reading and viewing the different presentations in the latter modules made the written assignments from the early modules easier to create and more detailed.  I was able to take into account ways to facilitate discourse within the modules.  I was also able to provide more detail that a student might need in order to complete various tasks within each module. (3)

I have learned I need to develop areas that emphasize a learner centered enviroment

Playing catch up half way through a course is not the easiest thing to do.  I feel like I have spent twice as much time in this course than any other that I have taken.  On the bright side, I got to do things twice and the second time around was a little bit easier and I had clearer thoughts on how to go about designing this course online.  I have learned that I have more perseverance to accomplish something than I thought I did.  I have also given a lot of thought about my teaching style in my FTF classes and how I vary the classes to take advantage of different types of learning domains, something that I didn’t realize that I was doing.  So far through this course and in this module, I have given considerably thought to consistency between modules and sequence of modules and activities, trying to anticipate where students might have questions as they interact with the course. 

Perhaps my biggest realization is that I emphasize 3 out of 4 things in my FTF class environments that Bransford, et al. identify as being necessary for students to learn best: knowledge centered, community centered and assessment centered.  An area that I need to develop is the learner centered.  I hope that the online course will help me expand on this area to take advantage of students’ strengths and preconceptions (Pickett, 2008). 

Pickett, Alexandra. Understanding Teaching Presence and Class Community Online”. Sloan C-Workshop. Retrieved 7/10/2008 from

Copyright laws and new ideas for final exams learned in Module 3

Having recovered from the shock of starting my course over from the beginning and having a clearer idea of what I need to do to get caught up, I think I can answer some of the questions for this modules blogging assignment.

I learned a lot of good information concerning intellectual property and copy right laws that pertain to online course development.  Alexandra explained the SLN standpoint and provided an example within the SUNY system, ESC, that is unique in their approach but they own all of the materials and design of their courses.  I did not realize that a college can take this approach and it makes me want to read the currently under revision IP policy at my own institution.   

I also learned about an intriguing approach to providing a final exam.  Stephen Zucker asks his students to write 10 to 15 exam questions based on the discussions and materials within the course.  The questions can be of different formats but they must be structured in a way that demonstrates an understanding of what the answer to the propose question might be.  He states that from the assignment that he can gauge what was most important to each students based upon the questions that they choose to write.

Bill Pelz also presented some interesting findings about objective exams.  He no longer uses them because there was no correlation between student scores and their knowledge being displayed in the discussion and written assignment areas.  He also does not provide a final exam but instead uses each discussion as an examination of sorts to gauge how much the student has learned based on individual student posts.  This brings up a couple of questions for me to investigate further:  Are objective exams necessary?  Does a student’s understanding presented in a discussion area test knowledge transfer that can be ascertained in a vertical or longitudinal study?  Meaning, when a student takes the next level of class, do they have a set of knowledge in place that they can build on or does the knowledge exist mostly within the context of the previous online class? 

Amanda Tombari points out how motivating students in her F2F classes are difficult at certain times of the year and I too share this fear of being able to motivate my students in the online classroom. 

I cannot really answer the other question for this blog assignment as I am in the process of rethinking my course and what I plan to do in it.  My main concern in the new course is to keep the class community going that was built during the previous 8 months in the FTF classes.  (2)

Starting over again

There have been a lot of challenges over the past two weeksin this course and personally.  I have been advised that my choice for online course design is not appropriate and I need to start over with a different course.  This presents a great challenge for me. A challenge that I have wrestled with since the beginning of this course and reading Kassop’s article.  Our curriculum is designed in a way that really addresses 8 of the 10 reasons that Kassop states as benefits to an online course.  Not that our curriculum is perfect, it always is being refined but we do not have many of the problems that Kassop states an online course addresses.  This was a shock to me since I had every intention to put more of our curriculum online.  In fact, I chose to pursue a master’s in CDIT based on how many colleges have moved some of their curriculum to an online delivery system.  I still think I made a wise choice to pursue a degree in CDIT but now I am not certain that all courses can be placed online or should be placed online.   I am strugglng with how I am going to start all over yet still keep on top of all of the materials that will be due in the coming modules.  Not to mention still needing to develop the original course that I proposed for my work. 

On a personal note, I have had some health issues that have presented some challenges in keeping up with the course materials over the last week. 

I realize that this is not what the blog assignment stated that we should address but I still think that a blog should be about my personal reflections on the course.  Also, it was a little tough to think about all of the questions being asked in the assignment while trying to retool your entire project half way through the course.

Frustrated and behind but moving on to develop my course

This module didn’t start off any better than the last.  I was able to download, read and listen to the articles and presentations in the module early but was interrupted by work and family commitments that has prevented me from posting as soon as I wanted to the discussion areas. 

After viewing the different exemplar courses and listening to the corresponding audio, I see a reinforcement of many of the concepts listed in Alexandra’s ETAP 687 manual.  The design of each of the courses is similar concerning the course information documents and the “chunking” of material into modules.  In the audio commentary by Piorkowski he explained why ice breakers are used in a course.  I had thought that it was a good way to teach students how to navigate an online course but had not thought about the time frame that it is open and how students add and drop courses during this introductory module.  This was good information to me and is definitely an area that I will develop for all of my courses.  In fact, I will need to extend the date ranges by a week to account for this orientation module.  Another particularly good finding from Piorkowski is the development of his discussion grading rubrics.  It is somewhat complicated with the 4-4point posts required to obtain an A in addition to the 31 points required to receive an A but the ultimate point that he makes is that students should teach each other something in their posts.  Piorkowski’s explanation for the need to change the subject posts was also helpful as I had not made the connection of how this makes students emphasize high order thinking like summaries and synthesizing material.

Another exemplar course which was of great benefit to me was Bill Pelz’s.  He explained his design of the community space and the components of each, which is intended to promote a sense of community within the online class.  However, it did not appear that the shared references area was used too often and perhaps could have been utilized in each of the course modules as a way to build communities and still keep it topic specific.  I particularly like the Coffeehouse section of his course as it contained areas that students could release their gripes and opinions with each other and relates to Scorza’s idea of a coffee shop area (p. 49 of Do Online Students Dream of Electric Teachers).  Pelz also briefly alluded to research into why 6 posts are minimum requirements for discussions and the need for a minimum log in requirement.  I would like to hear more about this research and will need to search for more material to support these findings.  Another cool little tool that Pelz provide was an IE spell checker tool. He also provides an excellent summary document called “The 2 Cardinal Rules” which I hope that I can use in the development of materials for my course. (Do I need permission for using some of his ideas?) 


While I understand the rubrics involved and the reasons they are used based on my observations of the exemplar courses, I find the self evaluation part of our posts and blogs a little annoying.  Am I alone in feeling that the posts that I write are generally worthy of a 3 in most cases.  This sort of required rating really is troublesome to me since I am my toughest citric and rarely think I deserve a 4 with any of my posts.  The same goes for the peer reviews.  I think my peers write extremely well and their posts are highly contributory.  I think we all gather a general sense of whether we are helping and adding to a discussion by the responses that we receive to our posts.

I honestly am learning more from my classmates’ contributions to the discussions than I feel I am contributing to this class and easily think I am one of the worst students enrolled in this course.  I feel like I have 7 or 8 instructors in this course providing helpful links and information that I would not have thought of or found on my own, which is in direct contrast to what I have been able to provide.  However, I am starting to see a recurring theme between this course and a book by Tisha Bender that I started reading while taking this course.

I am feeling extremely frustrated by the multiple tools utilized in this course.  I have the feeling of being lost as there are some many locations, discussions and blogs that are in isolated places.  This is something that I do not see within the course design of the exemplar courses.  The instructors of those courses all seem to direct students to outside areas for researching their discussion posts but all of the information from the discussions to the reflections are done within the frame work of the course and do not seem to be scattered about in different program tools.  At one point I really considered dropping the course despite I would lose my entire tuition.  These thoughts quickly subsided as the course administrator was able to restore my course after I tinkered with the theme settings and all of my work had disappeared.  I guess the take home message from that is one that Alexandra has stated a couple of times;  get the material and design in and make it look pretty later.  I feel like I am spending more time trying to locate things and remembering to check outside the course technologies instead of focusing on my course design.  I guess I would change the location of the reflections to be within the Moodle course instead of navigating to a separate web site. 

I have also started reading a second book by Jairath and Mills that pertains to Online Health Science Education since some of my concerns seem to be discipline specific.  This book seems to be more narrowly focused and may help me apply some of the general online pedagogical themes presented in the course reading material in a more accurate manner.


Jairath N, Mills M. Online Health Science Education, Development and Implementation. Philadelphia: Lippincott Williams & Wilkins; 2006.



Reflections on the last 2 weeks

I have found that the first module of this course was laid out pretty well within Moodle.  However, I have felt a little overwhelmed by the other programs that we signed up for and are required to use for the course.  I have completely forgotten about the Diigo account and will need to check this web site more frequently.  I like the edublog area but find the color choices of Prof. Pickett a challenge to read the entries that are contained on her site.  While the colors are pleasing, they lack contrast between the text and background to make the information appear clearer.  I enjoy reading the entries of my classmates.  I have never taken an online course where the discussions were so tightly defined with instructions on how to post.  I assume this must make things easier from an instructor’s view of the discussion forums.  So far, I am not a fan of Moodle.  I do not like the lack of a “cookie trail” to help navigate back through pages.  Navigation within Moodle is not as easy as other CMS’s that I have utilized.  I am looking forward to what the next module has to offer. (3)

Thoughts on “Did you know” video and SLN Statistics

The video “Did you know” is not new to me, however, this version has been updated.  One of the most striking parts of the video is the statement that the fastest growing age group for using the Internet is 2 to 5 year old (Netday News, 2005).  I see this in my own home with my 3 year old.  Just turning 2 years old, he has used the tablet functions of my laptop to draw amazing paintings in a digital medium.  He is now approaching 3 and he regularly uses our laptop to play games, drawing and navigate mazes on the internet.  What will his world look like when he reaches school age and how will educators design activities that will keep him interested in learning.  Other interesting statistics show how large of an economy China has but how much challenge the country faces with their growing population.  Interestingly, nurses are paid less than teachers in China but the video does not state if this is a result of supply and demand or if China places more value on education than on health related professions.

Reading through the SLN statistics the first thing that pops out to my eyes is the high percentage of women taking online classes.  Another statistic stat that draws my attention is the main reason that people take online classes due to personal schedule conflicts and that 43% of people are employed fulltime.   Flexibility of an online class does seem to be of great benefit when you consider these stats.  From this information, I should expect students to most female, married, and fulltime employees needing flexibility within their courses.

From the statistics it seems that the majority of students that I could expect in an online course would be from the US and would have access to high speed internet connections.  This is an important consideration when designing an online course since I would expect that content rich in streaming media would not work well with slower band widths and probably would not attract students from developing countries that lack this access. (4)