HomeMy WebLinkAbout2001- June •
Board of Health
Old Business
Agenda Item # IV. , 1
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Jefferson Health Access
Summit 2001
Meeting Summary
• June 21 , 2001
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Jefferson Health Access Summit
2001
May 22, 2001
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Summary
Prepared by: Kris Locke
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Health Access Summit 2001
Summary
On May 22, 2001 over 50 people met in Port Hadlock to discuss issues related to health
care access in Jefferson County, Washington. The Summit was presided over by
Chuck Russel, Chair, Jefferson General Hospital Commissioners and Jill Buhler, Chair,
Jefferson County Board of Health. Prior to the Summit the Hospital Commissioners for
Jefferson General Hospital and the Jefferson County Board of Health met jointly over a
nine month period to discuss ways to improve local access to care. The joint boards
appointed a workgroup of community leaders to examine the issues more closely and
plan a community Health Access Summit. The workgroup developed a list of ideal
health system goals and a report containing some of the information they discussed. A
summary of the report and the ideal health system goals were distributed to participants
before the Summit.
The purpose of Health Access Summit 2001 was threefold:
1. Gain a better understanding of the problems confronting the Jefferson health
• care system from a variety of perspectives;
2. Assess the level of concern among Jefferson County community leaders about
health system problems;
3. Determine whether or not there is an interest in pursuing a community-based,
cooperative effort to develop and implement specific solutions to identified
problems.
Leo Greenawalt, Washington State Hospital Association, and Greg Vigdor,
Washington Health Foundation, presented information about state-wide health access
and financing issues.
• In the early 1990's Washington State had one of the lowest uninsured rates in the
nation. This is no longer true.
• Costs for health care are expected to increase 15-20% per year into the foreseeable
future.
• Urban areas are better able to weather the storm while rural areas will be hit much
harder.
The financing cycle chart below shows the complicated chain of events that contribute
to current health system problems. The situation is not good right now, is not going to
get better, is probably going to get worse, but people do not seem ready to change.
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S
Thr-: Frne c,in 2000-700!-3
Y J
T Hospital Rates ' ` ,
T Physician Fees •L Insurance
Shedding Losing Lines
Profits
T Rates to
Business
14.
More y Government Pay Dropping
Consolidation Coverage
T Drug Costs k. N. I
T Wages T Uninsured
t. N.
4,Hospital Margins T Bad Debt
4,MD Income T Charity
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Never have so many bright, good people tried to do so much in such a dysfunctional
system.
The Washington Health Foundation's Future of Rural Health Program is a 5-10 year
project to look for new models. The Foundation believes the ingredients for success are
dealing with costs/financing, access, quality of care, the health of the community and
sustainability.
• At least 600,000 people in Washington don't have any health insurance, even more
are underinsured.
• If the state economy takes a downturn, sustaining even the current level will be
difficult.
Tom Locke, MD, MPH, Jefferson County Health and Human Services, discussed the
problem from a public health perspective.
• Even though only about 1% of health funding goes to public health, it has a much
larger role in potential solutions.
• Jefferson County has a rapidly growing population of elderly residents, large
proportion of transfer income (rather than wages), an expanding gap between the
poor and the rich.
• • Jefferson County Health and Human services is a significant service provider with
more than 900 family planning patients and other active direct care programs.
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These programs are vulnerable to the same financing problems destabilizing the
• medical care system.
• 100% access and 0% health disparities is a goal but we need to ask and answer
"access to what?" Can we afford everything or do we need to make conscious and
difficult choices? The Washington State Board of Health has developed a list of
critical health services as a starting point for setting priorities.
• We need to build community partnerships to effectively fill the disparity gaps.
Tim Caldwell, Port Townsend Chamber of Commerce, spoke about his involvement in
local discussions to start a physician hospital community organization after the 1993
state health reform legislation (which was repealed). In reality, health system issues
have many sides. Many businesses in Port Townsend are small - 2 or less employees.
People can see many of the issues but don't know how to fix the problems. The
Chamber is able to offer a KPS group health plan to members and this has been an
incentive for new membership. With many new retirees moving to the area, we've seen
so many different health plans that it's difficult to have the critical local mass to
negotiate contracts. Somehow we need to get people to sit down in the same room and
ask how we can organize something for both workers and retirees.
David Beatty, Olympic Area Agency on Aging, discussed their role in serving older and
disabled adults in the 4 counties of the Olympic Peninsula. Funding comes from the
Older Americans Act and Medicaid. More and more seniors can't pay for prescription
drugs or utilities or home repairs. People are having difficulty finding local doctors or
11111 dentists who take Medicare or Medicaid reimbursement. Access to in-home care helps
seniors remain independent.
Brent Shirley, Brent Shirley and Associates, discussed trends in the local health
insurance market.
• Premiums are rising — 15-33% increase in rates this year (more for some
employers).
• Everyone is being blamed for the problems but the fact is that the system isn't
working well for anyone.
• There are fewer health insurance plans available — many have merged or gone out
of business.
• The pre-existing condition waiting period has increased from 3 to 9 months and
people applying for new individual health insurance policies must fill out a 14 page
health questionnaire. Plans can reject up to 8% of applicants.
• Health care costs are rising again due to increasing prescription drug costs,
technology and expectations of people.
• Benefits mandated by the legislature have also driven up costs.
• Medicaid and Medicare payments are being reduced relative to costs. Medicare
program regulations consist of about 2,500 pages.
• In 1990 the answer to rising costs and access was managed care. Plans were
restructured to meet business needs — not community needs.
. • Focus has been on solving cost problems — not health problems.
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Melanie McGrory, MD, Olympic Primary Care, discussed the unique stresses of
• community physicians.
• The current system is in shambles.
• People need information and reassurance about their health. The current system
makes it increasingly difficult to provide these essential services.
• Primary care physicians need time and technology. It's difficult to give patients the
time and the technology they need in a 10-15 minute visit.
• The costs of regulation for documentation and other administrative demands take up
about 50% of a physician's time.
• Physicians are also required to negotiate contacts with plans, police their peers,
invest in office space and run a business — none of which was taught in medical
school.
• 14% of our gross national product is spent on health care and more and more time is
spent on work not related to patient care.
• Medical practices are failing as businesses across the state. In Olympia 10 primary
care physicians are quitting leaving 20,000 people without a doctor.
• Most physicians went into practice to take care of patients but now the work has
become very dehumanizing and many physicians can't even make a living being a
doctor any more.
Vic Dirksen, Jefferson General Hospital, said we need more people like Melanie to
speak up about the issues.
• • Jefferson General Hospital might be able to capture 1/2 to 1/3 of the hospital care that
is provided in other communities, but some should go to facilities that can provide
services that will never be available locally because of the small number of cases.
• Government financed care is reducing payments relative to costs and is having a
disruptive impact locally. Under the current projections, the Balanced Budget Act
will eliminate the hospital's reserves by 2003. State budget problems may require
cuts in Medicaid and Basic Health eligibility, benefits and reimbursements.
• The charity care provided by the hospital is increasing and is another symptom of
local problems. Last year at this time charity care totaled about a million dollars.
This year it's about 1.5 million dollars out of a 20 million dollar budget.
• An important piece of the access puzzle is finding a way to care for the most
physically and financially vulnerable residents. If we leave them behind, we've
failed.
• Physician recruitment is a looming problem.
• The Commissioners have decided to keep "unprofitable" services, unlike many other
hospitals and health care providers. The hospital has taken a number of steps to
redesign services and work with local physicians to see how everyone might be
more successful.
• The hospital has also been working with the Jefferson County Board of Health to
address some of the health system and financing problems locally.
4) A Summit discussion included the following comments and questions.
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The rising costs of prescription drugs are a complicated problem. Because many of the
11111 major drug companies are multi-national corporations controlling them through
regulatory means is difficult, although some other countries do regulate what they can
charge. The US has chosen not to do this.
One success in the health system has been increasing coverage for kids. Unfortunately
the rate of preventive services has declined. Therefore some kids get diagnosed later.
One reason is that it takes time to do the screening tests but economic pressures don't
always allow adequate time during a visit. An example is that Basic Health says they
cover a particular service, but they don't pay providers an adequate reimbursement to
really do it, so it's not really adequately funded by the state.
Another issue is provider liability. Reform of this system could save money.
In rural communities, everyone is in it together. We need more answers and models for
how health care can work in rural areas. The market based system may work in urban
areas but it can't work in rural areas.
In some areas creative employer based preventive programs have had success.
Health workforce shortage issues are looming. We need the ability to attract top-notch
providers. The health system and providers will also be important for attracting new
business to the area.
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Why hasn't government jumped on the economic development bandwagon in
P p g terms of
sustaining rural health systems? Economic vitality requires a local health system. This
might be a way to get economic assistance.
One issue that can't be ignored is risk. Prevention helps but if there is an insurance
based system or strategy, you need to deal with risk (of catastrophic health costs). The
state will never return to a fee-for-service system and communities that want to be
innovative have to find ways to deal with risk. The state has talked about some models
like the Primary Care Case Management for Medicaid.
The state used to take all risk for publicly funded coverage. When they began
contracting with managed care plans for Medicaid and Basic Health, they washed their
hands of any local problems caused by the plans. They expected the plans to deal with
everything for them. The plans pay local providers what ever they want and the state
doesn't interfere. Before a community could take risk, they would have to be sure that
the payment from the state was adequate to pay for the services. Right now it isn't.
Geoff Masci, Board of Health and Workgroup Member, presented information about the
work that let to the Summit. The workgroup was composed of individuals from:
Jefferson General Hospital, Jefferson County Board of Health, Chamber of Commerce,
0 Area Agency on Aging Director, Port Townsend Paper Mill, Insurance Broker, Physician
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Chief of Staff, United Good Neighbors, Jefferson County Administrator, Washington
411, Health Foundation, Olympic Peninsula Community Action, small business owners, City
of Port Townsend.
The workgroup looked at what could be done at the local level to organize the financing
and delivery of health services. The met and:
• Identified reformed heath system goals
• Researched issues and invited experts to discuss options
• Coordinated a local health summit to educate community and discuss situation.
Health care is big business in Jefferson County:
• $91.2 million spent on personal health care services for Jefferson County Residents
(1997)
• 15% of total economy
• $60 million spent in the County (1997)
35% Federal funds (Medicare and Medicaid)
32% Private health insurance
19% Out of pocket (Self-pay, copay and deductible)
10% State and Local funds (Medicaid, Basic Health)
4% Other funds
Why is our health system struggling?
• • Medical practices across the state are going bankrupt - physicians leaving
Washington.
• Medicaid, Medicare and Basic Health reimbursement is so low jeopardizes hospital
and physician's solvency.
• 53% of hospital revenue comes from Medicare (compared to 33% statewide)
• Medicare will continue to cut payments to hospitals.
• 3,000 — 7,000 residents have no health insurance.
• Employers are having a harder time paying for health benefits.
• Many seniors on Medicare can't afford prescription drugs.
• State budget cuts in health care are expected over the next several years.
The workgroup developed a list of ideal health system goals. The purpose of the goals
is to develop a flexible document that can guide local efforts to improve access to health
care. The goals or desired outcomes of re-designing the financing and delivery of health
care services in East Jefferson County are broad value statements. The goals will be
used to discuss and evaluate the relative merits of models or proposed system
changes.
• Access to Care. The broadest range of services that can be provided locally will be
available to all East Jefferson County residents, particularly the most physically and
financially vulnerable.
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• Quality of Care. The quality of health services will be continually improved.
• • Funding Sources. To the greatest extent possible, funding sources will be
organized to better support the local health care system.
• Spending Impacts. Health care system funding will be directed to improve the
health and quality of life of East Jefferson County residents.
• Medical Practice Viability. East Jefferson County providers will be supported by
the community to ensure the continued availability of their services.
• Incentives to Improve Health. Prevention and public health will be important
components of the model.
• Administrative Functions. A local, publicly accountable entity will manage
administrative functions in a way that improves access, supports local health
services and redirects as much funding as possible to direct heath care services.
• Patient Autonomy. Patients should have the greatest range of choices possible
within the financial limitations of the system.
• Physician Clinical Decision-making Autonomy. Cost containment and clinical
autonomy will be balanced through quality improvement activities.
• External Factors. External factors will be continually monitored to take advantage of
beneficial developments and address disadvantageous changes.
• Future Demographic Factors. Health System changes should be designed to
accommodate the changing demographics and needs of the East Jefferson County
population.
• Personal Responsibility. Incentives should be built into the system to encourage
• individuals to take personal responsibility for their health and the services they need.
• Occupational Support. The system will incorporate special programs and services
that will help impaired and disabled East Jefferson County residents maintain or
regain physical functioning to participate as members of the local workforce and
community.
Summit participants formed four discussion groups. The following is a partial summary
those conversations.
Discussion Group 1 facilitated by Julia Danskin.
• What issues are involved related to Jefferson County's population not being large
enough to be able to create it's own health plan.? Brent Shirley had said in the
morning session that maybe a plan could include other rural communities. Could we
get more information for the joint boards on how many people would we need to
consider creating a local insurance group?
• The number would have to be large enough to cope with the variability in numbers;
KPS is small at 40,000 members. All of Jefferson county is only 27,000.
• Liability is a huge expense that doesn't contribute to client care. Would like some
discussion and ideas on how we could bring this to the legislators for some policy
help.
• • What are the major policy decisions that have unexpected impact at the local level?
What are the larger policies that have forced the health care system to become this
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way? Is there any new legislation that would prevent us from moving ahead with
• solutions we might come up with?
• There were no solutions coming from the state or federal government at this time.
What would the physicians want if we had a magic wand: Less administration cost
or less liability cost?
• What about the underserved. Why don't we have a community Clinic? The
argument about not wanting a 2-tiered system doesn't hold. We already have a two-
tiered system. What is the basic Level of Health Care and what are extras?
(Oregon was able to come up with what it would pay for and what was extra.) How
come Kitsap has 3 community clinics and Jefferson Co. has none? (Actually,
Jefferson has a rural health clinic in Quilcene.) Physicians can get their liability paid
by the government if they work in a federally designated underserved area.
• How was Oregon was able to ration health care?
• Oregon went though a ranking by all the citizens on what health care was most
important and least important to pay for. The legislature priced out the services and
looked at how much money it had then decided what it could pay for. The problem
is they only applied it to the Medical Assistance coverage (Medicaid).
• What is the latitude on alternative sources of funding. What can we build on? The
wrong people are getting beaten up, ie the Doctors. We need to build a fence
around Health Care. Until the Physicians have control we won't have a good health
care system. Local Dr. have to compete with the city.
• Not all agreed. Some thought cost controlled health care. With high deductible
• health insurance policies, can't afford to go shopping for a Dr. that will just give you
want you want.
• What are the macro issues at policy level that are impacting local businesses, like
52% increase in KPS premium for Olycap that had a huge impact on their budget?
Also what about solutions like prevention, triage, and wellness programs like Sandra
talked about in the am?
• Will have to face limiting care, Recognize reality. If a group like this could come up
with what is feasible then (KPS) is willing to talk.
• What about mental health and dental. Many medical problems come from mental
health problems. If we don't treat dental problems they become medical problems.
• Need to look at access and rural. When the Chamber of Commerce looks at
opportunities for higher education they can't get it locally. What is minimum care?
Is transportation the solution? Do we downsize the hospital?
• It would be a failure if Jefferson General Hospital got smaller. When a loved one is
in the hospital it is better for them to be closer to their friends and family to visit.
• It is expensive to have employees have to take a whole day off work to go to an
appointment in Seattle when if they could get the care in town they might only be out
for an hour. Also the care may not be any cheaper in Seattle.
• The State BOH has been working on what essential health services are.
• People have been working on lists of essential services that have been published
over the years. No one ever looks at them.
• There was a time dialysis was rationed. In Europe if you are over 50 years old you
• may not qualify for dialysis. The cost of a liver transplant for an ex IV drug user or
alcoholic is questionable.
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• Rationing is happening now by person not by treatment. Either you get care or you
• don't get care. It would be nice to make the choices consciously not by marketplace.
• Is a community Clinic an option?
• JGH had looked into community clinics and it wouldn't increase reimbursement
because the federal government has no more money to put into community clinics.
• The JGH physicians are now part of the Rural Health Clinic with Quilcene. East
Side Group Health did a franchise in the community with a 5 year agreement.
Again, what are the right numbers? We don't have elements in community to
provide all the services needed.
• Is there a need? What are people willing to commit to? Some people only buy
insurance when they are sick and then drop it when they get well. What would it
take to get a community wide commitment?
• What would it take to guarantee a stable population with controls on extras
(insurance plan)? It would be an interesting idea.
• It would be nice to be able to budget 5 years out for employee premiums
• What part of the community is willing? There are different levels of desire. There
are different levels of commitment. Need leadership from community. We are small
enough to make a difference and what are you going to be willing to pay 5 years
from now?
• There are small ways to reduce administrative cost by paying at time of service.
• Need preventative incentives.
• Can never guarantee that prevention can save money.
• • Are regulations getting worse or better?
• HIPPA is making it worse, regulation are un-integrated ways of solving problems.
• 70 years of policies and regulations. How do you argue compliance, fraud, privacy
and patient record regulation? Can only make changes at the local level on how you
implement regulations. Policies and regulations collide with overall goals
• Complicated billing. Need certain codes with some insurance billing and other
codes with another plan.
• Will the local unions be willing to look at another insurance plan?
• Do we talk to the government first to see what is possible or go ahead with a plan?
• Go ahead with a plan. If you wait for the government you will be waiting a long time.
• The state government is interested in ideas and solutions.
• Specifically regarding Design Goals. Access to Care: what is minimum? On
Spending Impact: "To improve the health and Quality of life" is outside medical care.
• What are Covered Services? That was what she was expecting from the work
group. Also, under Patient Autonomy need to qualify "choices possible."
• Administrative Functions is the only goal that we can work on. One pot payer
system.
• It seems the Goals collide with each other, what are the priorities.
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Discussion Group 2 facilitated by Lorna Stone.
SIs more information needed to understand the problem? Be as specific as possible.
• Rather than the average cost per person, it would be more helpful to know how the
load is distributed (given stats on elderly population).
• Including complementary alternative medicine could double the cost per person.
There is interest in this, but it would be very complicated to include.
• Dental should be included as an access issue.
• How much charity care is being given?
• Is anyone working on a community clinic as an option. The Jamestown S'Klallam
Tribe is looking at setting up a clinic. They are able to get $184 per visit while some
private doctors only get forty cents on the dollar. A clinic has been discussed about
a year ago but it might be competitive with the hospital clinic.
• What about critical mass? Do we have an adequate size population to give a full
range of services? Virginia Mason and Group Health couldn't make it here. The
issue of the high level of transfer payments here influences demand and coverage.
BRFSS study will help give some answers.
• Basic Health covers too many services. It's not as brave as the Oregon Health Plan.
We need to get more information about how Oregon works.
• In the past people paid cash and the system seemed so much simpler. Why can't
cash payments just be used to simplify things? There may be legal reasons why this
won't work. For example some programs require that you can't give discounts for
people who pay in cash.
• • The idea of a local health authority makes sense but how would it work with
employer based model or community clinics?
Do these problems effect you? If so, how?
• Even though there are 31 practitioners in Jefferson, only 13 are primary care doctors
can admit people to the hospital. That's getting to a breaking point. More and more
docs don't want to do on-call or inpatient work. It's burdensome for those who still
do because no pay goes with it.
In general, do you support the health system goals drafted by the Workgroup?
• We should include health education as a goal. Education about both system
financing and health.
• We need a schedule for coverage of services — essential services. The first goal of
access is too broad. Maybe a shuttle to Seattle is more practical. We should just be
doing what we can do really well here —what's feasible.
• The wording of the quality goal seems insulting — it seems to presuppose that we
don't have high quality. Quality is an issue of perception as much as fact. There
needs to be a lot of community education about this issue.
• Even people who should know better sometimes say things like we should have a
cardiologist here. They don't understand that we would need several to handle call,
new equipment and enough volume of procedures to support them and maintain the
level of quality that is required. Expectations are really out of sync with reality.
People need a better understanding of why some services are not available here.
• We need to add "financial" to personal responsibility.
• Can we get a good medical triage/management system built in?
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• We need to emphasize incentives to improve health. Perhaps also rephrase to
• include cost savings.
• We need to deal with value added documentation. Right now the documentation
required is so excessive it takes 50% or more of a physician's time. People want
doctors to spend time with them not filling out forms.
Other issues
• The HRSA Community Access Program grantees are very interested in this work
(federal grant program). There are 120 grantees looking at these issues and trying to
find models that work. HRSA is also funding the Washington State access to
insurance grant.
• The lawyers do a good job of campaigning for access to justice and funding through
legal services. Access to health care.
Discussion Group 3 facilitated by Aaron Katz.
Key statement made by someone: "The health care system should be at least as good
as Domino's Pizza."
Additional information needed.
• Percent of the health care dollar used up by insurance companies
• Outmigration of Jefferson County residents for health care elsewhere
• What are the incentives to leave the area for care (intended and unintended)
• Why do people leave for care (employment? Convenience?)?
• • What is people's perception of the quality of care in Jefferson County?
• Better data on insurance coverage rates for children
• Number of women who lose pensions and health insurance when their husbands die
• What are the challenges to employers in providing health insurance?
• What is the basis of insurance coverage (employment? Other?)?
• What percentage of the health care dollar is responsive to prevention?
• What is the public's expectation for basic health care? What constitutes basic care?
What are the criteria?
• Is there community consensus of priorities?
How do problems affect you?
• Limited access to physicians because mine retired.
• Trouble recruiting physicians, because:
• There are fewer family practitioners out there
• Fewer medical students are going into primary care
• Fewer physicians want to relocate
• The demand to take a lot of call
• Issues are invisible, for example access to dental care due to DSHS low payment
(dentists are forced to say "no" to DSHS patients) or issues regarding seniors
• DSHS's billing system stinks
• Referral processes — both public and private — each has its own rules and hoops
• Affordability — employers are struggling to provide coverage, but premiums are going
up so they have to offer plans with $1000+ deductibles.
• • Not enough choices of insurance products
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• Limited funds generally— how do we decide which services to provide?
• Support health system goals?
• Good statements, but very broad, "boilerplate," "bureaucratic"
• There should be a [community] vision statement that is tangible, about what a
healthy community is; it should connote a "roll up our sleeves and work together"
mentality, like the old barn raisings.
• How much is the public willing to take responsibility for their health?
• Work to make the existing system work better.
• Look at what's happening in other states and rural areas to find good models
• How well do the goals align with the IOM report?
• Develop work groups on each aspect of the problem:
• Financing
• Community voice
• Data
• Etc.
• Have work group members each describe a good model and then see what
elements might work
• Ground rules: There are no dumb ideas; get disagreements out early in the process.
• The process could be a healing process, especially if it's a city-county partnership
• One possible approach — get every child in the community enrolled, then build on
that with adults and seniors.
• Get better information to seniors.
•
Discussion Group 4 facilitated by Debby Peterman.
The group would like more information about the following:
• Number of primary care physicians that are declaring bankruptcy: How big of a
problem is this in our community?
• What inducements are other communities offering physicians to attract them to their
area? How are the offers being made?
• Why is our Medicare reimbursement so low? When was the last time that the
AAPCC was adjusted? What can we do to increase reimbursement levels?
• How many and what kind of physicians does our community need? If national
estimates are made, do these estimates take into account the demographics of our
community and the fact that many of our doctors do not want to work full time or take
call?
• Kris' data show the community spent $60 million on health care yet the community is
saying that this is not enough. What is enough? What would it take to sustain our
community's health care?
• If we created something like a health care trust fund or health care funding pool for
our community, what are the obstacles we would face? E.g. risk, licensing. Who
could provide risk and reinsurance for our small community? What would be the
amount that we would need to seek reinsurance for? How big of a catastrophe?
• Can we do anything effective at the local level? Do we need to go to Olympia?
•
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The problems identified by the group include:
• • There are no incentives for people to take care of themselves. There is no reward
(reduced health insurance) for healthy behavior.
• Employers can't afford to cover their employee's health benefits particularly for lower
wage employees.
• Providers need to join together and communicate with each other when providing
care. In home care providers are not linked to primary care, but they should be.
• The system is not in place to help people make hard choices. When is enough
enough. Who decides who gets which services.
Goal discussion
• The goal, patient autonomy, talks about patient choice. Sometimes assuring choice
is costly and can undermine our ability to do things. Quality is the key issue.
• Patient choice is a matter of degree. We want to be able to pick our physician.
• All of these goals are like motherhood and apple pie.
• Personal responsibility is a number one priority for some.
• Add the following goal: Redefine the health care system to be a coordinated,
collaborative system.
Suggestions from the group on ideas to explore as solutions.
• We need to define a bottom line of services that every one will get. These need to
include primary care and prevention at a minimum. For services beyond this
baseline, the patient will need to pay more. ( A two tiered health care system that
provides a safety net.)
• We need to create a system that links together both health services and non health
services to take advantage of what we have. — i.e new YMCA could do outreach
and education to youth.
• We need to create a system that rewards people for healthy behavior.
• Pool all community health care funds into a common pot of money for community
health care.
• Homogenize what we purchase. Band the community together to be one larger
purchaser or contractor for health care services.
• Develop a report of our findings and share this with other rural areas. Have them do
similar projects. Create a ground swell of rural communities and take our reports to
Olympia.
• Establish a demonstration project and get resources to make changes locally.
Identify ways that the community can be involved and help. Be up front about the
fact that this will take a long time to make change. Don't offer unrealistic
expectation.
Next Steps
There was agreement, and even enthusiasm, to work together to look for local
solutions. In addition to ensuring the necessary leadership to move ahead, there is a
need to develop an adequate communication network to inform everyone about what's
happening. It will be easier and more effective to work together with better
communication about what others are doing.
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• A summary of the Summit will be prepared and circulated.
Work on local solutions will continue over the summer and, if all goes well, a Health
Access Summit II will be held in the fall.
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Jefferson Health Access Summit 2001
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Participants
Ann Avary Economic Development Council
Jean Baldwin, ARNP Jefferson County Health & Human Services
Katherine Baril WSU Cooperative
David Beatty Olympic Area Agency on Aging
Jill Buhler Jefferson County Board of Health
Tim Caldwell Port Townsend Chamber of Commerce
Terri Camp Jefferson General Hospital
Robert Campbell Jefferson General Hospital
Mary Conway Office of Senator Patty Murray
Julia Danskin Jefferson County Health & Human Services
Anthony De Leo Jefferson General Hospital Commissioner
Vic Dirksen Jefferson General Hospital
• Paula Dowdle Jefferson General Hospital
Patsy Feeley Office of State Senator Jim Hargrove
Roberta Frissel Jefferson County Board of Health
Leo Greenawalt Washington State Hospital Association
William Hagens Office of Insurance Commissioner
Tom Hagens, DDS Dentist
Jenny Hamilton Office of Financial Management
Kathy Hill Commissioner Jefferson General Hospital
Tim Hockett Olympic Community Action Program
Janet Huck The Leader
Glen Huntingford Jefferson County Commissioner
Claus Janssen, MD Olympic Primary Care
Jennifer Johnson PT Paper Company
Nadine Jonientz Fleet Marine, Inc.
Aaron Katz Univ. of Washington Health Policy Analysis Program
• Kris Locke Policy Analyst
16
Tom Locke, MD Jefferson County Health & Human Services
• Tom Luce Office of Congressman Norm Dicks
Geoff Masci, DC Mayor, Port Townsend
Bill Matheson, MD KPS Health Plans
Melanie McGrory, MD Olympic Primary Care
Bob Peden United Good Neighbors
Debby Peterman Peterman and Associates
Cory Reddish, ND Olympic Naturopathic Clinic
Bill Riley Jamestown S'Klallam Tribe Health & Human Services
Chuck Russell Jefferson General Hospital Commissioner
Charles Saddler Jefferson County
Ree Sailors Office of the Governor
Jon Shelton Frontier Bank
Brent Shirley Brent Shirley & Associates
Stacie Simmons Bates KPS Health Plans
Sandra Smith-Poling,MD EMS Medical Program Director
• Lorna Stone Washington Health Foundation
Elinor Tatham, MD Physician
Dan Titterness Jefferson County Commissioner
Greg Vigdor Washington Health Foundation
Philip Watness Peninsula Daily News
Sheila Westerman Jefferson County Board of Health
Joseph Wheeler Jefferson General Hospital Commissioner
Vicki Wilson Office of Financial Management
Richard Wojt Jefferson County Commissioner
•
17
0 Jefferson Health Access Summit 2001
Evaluation and Comments
Total number of evaluations = 26
Total number of participants = 52
1. Did you learn new information about health access issues today?
23 - yes 2 - no
What was most interesting to you?
• Doctors are independent. Need to band together and network more with other
health provider groups in town. How about if they get AARP on their bandwagon for
Medicare.
• Physician input.
• Need for clear understanding of how system works, what $ are used for.
• Discussion of various possible solutions.
• Different perspectives presented and level of participation.
• • Good statistics. That the meeting happened at all and the potential collaboration.
• The possibility of a community-wide health care plan.
• The numbers. How physicians are reimbursed, What portion of the local, state,
national economy is actually made up of the health industry.
• The overwhelming will to do something.
• The panelists — they were excellent esp. keeping on time.
• The concept of local socialized medicine was acceptable.
• Medical — health care — continuum of planning and problems, solutions.
• The discussion that has already been going on — the need for further work — political
will.
• All.
2. On a scale of 1-5, to what extent do you think our health system is in distress?
(circle one below)
No distress Minor Moderate distress Serious Critical distress
1 2 3 4 5
Average = 4.2
• There's plenty $/there's plenty interest — Just co create system driven by health and ins.
18
• 3. Do you agree with the health system design goals? (circle one below)
Don't agree Slightly Generally agree Strongly Completely agree
1 2 3 4 5
Average = 3.8
Why?
• Seems logical need to structure bite size steps.
• Not much help — Good win-win ground rules but not motivating as goals.
• Our small group determined that some of the goals collide (i.e. access and quality).
• I do question the administrative functions section. In terms of the formation of an
entity that manages administrative functions.
• Need some "right brain" thinking".
• I guess it is good to start in an idealistic way but it doesn't seem very practical or
realistic (gotta try).
• I'm sure as a first draft we will streamline and detail this list more — It's a great start.
• Model/integrate with Institute of Medicine (national) guidelines for health care system
restructure.
• 4. Should Jefferson County residents look for community based solutions?
26 - yes none - no
Why?
• Power is local.
• We live with consequences of poor health.
• State and federal governments do not have the political will for this.
• As an isolated rural community with a diminishing employer/employee base our
"individual" community members are becoming our health care access leverage.
• A small community is often better equipped to address these issues in a way that
meets the needs of that community.
• It seems the most workable solution — the state and feds aren't doing much.
• What options?
• What other choice do we have?
• I strongly believe in the community access program approach to increasing access
and quality of health care services.
• The expenses are community expenses.
• Demonstration projects can be funded and implemented.
• Things are only going to get worse. We need to find the solution ourselves.
• State and feds don't care — dominated by interest that are contrary to our interest.
•
19
What other comments do you have that you'd like to have included in the written
• Summary from today's Summit?
• I'm looking forward to health access summit II and some action items. Thank you.
• Very well done.
• De-bureaucratize the system.
• Not just another study and report please — create some kind of action process.
• Investing in subscriptions for an on-line health education service like Medline would
be worthwhile.
i
•
20
File Copy
•
Jefferson County
Board of Health
Agenda
•
Minutes
June 21, 2001
•
•
JEFFERSON COUNTY BOARD OF HEALTH
Thursday, June 21, 2001
2:30—4:30 PM
Main Conference Room
Jefferson County Health and Human Services
AGENDA
I. Approval of Agenda
II. Approval of Minutes of Meeting of May 17, 2001
III. Public Comments
IV. Old Business and Informational Items
1. Jefferson Health Access Summit 2001 —Meeting Summary
V. New Business
•
1. Legislative Update Tom (15 min)
2. Community Indicators Workgroup Jean (15 min)
3. Take Charge Program Implementation Julia (10 min)
4. Maternal Child Health —Hear & Say: Reading Jean (15 min)
With Toddlers Program
5. Topics for Local Board of Health Workshop-- Tom (15 min)
Survey Results
6. Jefferson Health and Human Services Charles (15 min)
Director Recruitment
VI. Agenda Planning
1. Future Agenda Topics
VII. Adjourn
Next Meeting: July 19, 2001 —2:30—4:30 PM
Main Conference Room
Jefferson Health and Human Services
II/
w
JEFFERSON COUNTY BOARD OF HEALTH
MINUTES
Thursday, May 17, 2001
DRA5
Board Members: Staf{Members:
Dan Titterness,Member- County Commissioner District#1 jean Baldwin. Nursing Services Director
Glen Hunlingjord, Member- County Commissioner District#2 Larry Fay,Environmental Health Director
Richard U ojt,Member-County Commissioner District#3 Thomas Locke,MD. Health Officer
Geoffrey Masci,Member-Port Townsend City Council
Jill Buhler; Chairman -Hospital Commissioner District#2
Sheila Vesterman, Vice Chairman- Citken at Large (City)
Roberta Frissell-Cititien at Large(County)
Chairman Buhler called the meeting to order at 2:30 p.m. All Board and Staff members were present,
with the exception of Jean Baldwin.
Member Frissell asked for an update on the Linda Sexton case.
Larry Fay responded that there is no update on the Linda Sexton matter. Municipal Research Services
Scontinues
to investigate the feasibility of a uniform compliance procedure that applies to all rules and
regulations adopted in the County.
Member Masci moved to approve the agenda. Vice Chairman Westerman seconded the motion,
which carried by a unanimous vote.
APPROVAL OF MINUTES
Member Masci moved to approve the minutes of the March 13, 2001 meeting. Member Frissell
seconded the motion, which carried by a unanimous vote.
Member Masci moved to approve the minutes of the April 19, 2001 meeting. Member Frissell
seconded the motion, which carried by a unanimous vote.
PUBLIC COMMENTS - None
OLD BUSINESS
On-site Sewage: As directed by the Board at the last meeting, Larry Fay reported that Staff amended
*Section 8.15.140(12), changing "may"to "shall."Even though the meeting about the expedited rule
process was published in the newspaper, no public comments were received.
HEALTH BOARD MINUTES - May 17, 2001 Page: 2
Member Masci moved to approve new sections 8.15.140(12) and 8.15.150(6)c with an effective date •
of May 26, 2001. Commissioner Wojt seconded the motion. During discussion of the motion,
Chairman Buhler asked if Operation and Maintenance (O&M) is defined earlier in the Code and
noted a typographical error in Section 8.15.150(6)c—the word "specialists" should be "specialist."
The motion carried by a unanimous vote.
Crawford Correspondence: Larry Fay reviewed the material included in the agenda packet regarding a
Jefferson County resident's concerns about their neighbor's slow compliance to a septic system
complaint. When asked whether there is a penalty for installing a system without a permit, Larry Fay
said the systems often predate the permitting process. He noted that there are some confirmed violations
that need to be corrected by this particular property owner and that a re-inspection for these should soon
surface in the Department's tickler file.
NEW BUSINESS
Public Health Threats and Emergencies Act of 2000: Dr. Tom Locke briefed the Board on Federal
legislation initially driven by America's lack of preparedness for even a minor bio-terrorist incident. The
Frist-Kennedy Bill,which began as the Public Health Threats and Emergencies Act of 2000, ended up
being called The Public Health Improvement Act of 2000. The bill would define and provide substantial
federal funding to build a set of"reasonable capacities" in public health systems throughout the country. •
The bill acknowledges study findings that there are major deficiencies at the local level and that a
Federal commitment to fund local systems to respond to significant public health threats is needed. He
believes that planning and implementation will occur fairly rapidly.
Chairman Buhler asked whether the Hospital Commission would collaborate on developing a local
strategy and how the oversight of this legislation would occur?
Dr. Locke responded that because the local responsibility will fall to agencies with the most capacity,
oversight will vary among communities. Local jurisdictions may decide how best to spend available
funds and he believes a minimum set of response capabilities will be defined. Also under development
are airlift-ready container laboratories with which to distribute needed drugs and equipment.
Member Frissell suggested that this topic be discussed at the Statewide Local Board of Health
workshop.
Commissioner Wojt said he believes this issue relates to access to care; a disease or outbreak could
occur and not be immediately recognized if spread among citizens who are not regularly seen by doctors.
Dr. Locke agreed this could be a bioterrorist strategy. He referred to bioterrorist scenarios played out in
several cities to measure their response times.
Vice Chairman Westerman asked for a better understanding of the distribution of funding. •
HEALTH BOARD MINUTES - May 17, 2001 Page: 3
•Dr. Locke responded that he is uncertain of the rationale behind the distribution, however, the majority
of the first appropriation went to the Centers for Disease Control (CDC) to modernize the Level 5
containment facility. He said part of the support this legislation enjoys is not only for the rare occurrence
of a catastrophic bio-terrorist event, but also for its use against the far more frequent risk of imported
infectious disease. The U.S. is not prepared for a natural infectious disease disaster such as an influenza
pandemic. He referred to information from a CDC study provided in the agenda packet describing a
hypothetical influenza pandemic in Jefferson County. This information from the State bio-terrorism
exercise was fed into a national database for comparison with other counties. One of the preparations for
an influenza pandemic is to stockpile pharmaceuticals that block penetration of influenza into cells. The
local health department would have responsibility for distributing an anti-influenza vaccination to those
most at risk.
Community On-site Sewage System Financial Assurance Agreement Addendum: Linda Atkins
explained the Jefferson County policy which requires that all community systems have a financial
insurance plan to cover major repairs. The problem with the Olympic Greens Community Drain Field's
agreement was that the property was purchased and the capital account had not been maintained. She
explained that the amended agreement allows them to pay money into an account over a five-year period
instead of requiring that all the funds be paid into the account prior to the property changing ownership.
Staff is asking for the Board's concurrence with the amended agreement since the Department was not
successful in achieving compliance with the original agreement.
Vice Chairman Westerman asked what the tracking and triggering mechanism is for ensuring that funds
are available? She believes these situations need to be handled better administratively.
Linda Atkins responded that this particular situation came to her attention because of a building permit
application. The Department recorded the financial assurance agreement, but she is uncertain what
information is provided to the new property owner about the agreement.
Commissioner Titterness suggested that Staff check with the Deputy Prosecutor about the scope of the
problem and what might be missing in the legislation.
Larry Fay suggested in order to ensure the account is being built, it may be possible for the County to
add a reporting and feedback mechanism to the agreement. This report—or lack thereof—would also
provide an early warning that action is needed.
Commissioner Huntingford suggested it may be fine for there to be a schedule that ensures certain
amounts are deposited over a period, but there should also be a lien on the property, so that the total
amount is satisfied in the event of a transfer of ownership.
Commissioner Wojt said that funds for septic repairs would then be funneled through a bank with the
bank recording the lien.
•Member Frissell said while this may satisfy the situation when the property is sold, what is the
mechanism when payments have not been establishing a fund for system repairs?
HEALTH BOARD MINUTES - May 17, 2001 Page: 4
County Administrator Charles Saddler commented that depending on how the lien is structured, a lien •
could also be triggered at the time of a system failure.
Vice Chairman Westerman suggested that it might be important to receive payment in full up front.
Linda Atkins reviewed the funding situation used at Kala Point, whereby account funds in the
homeowners association can be shifted as needed. The County is still awaiting for Kala Point to present
a proposal to amend the agreement to reflect this proposed funding structure.
Larry Fay said he believes there is less concern with the agreement than with the enforcement
mechanisms such as a lien on the property.
Vice Chairman Westerman recommended that while this owner may be allowed to pay on a yearly basis,
it should be made clear that there is going to be a lien on the property. The Board may then need to
consider whether a change in the process is needed.
Larry Fay suggested that with the creation of a county-wide waste water management plan, it may also
be a good time for a discussion on the management of community drain fields.
County Administrator Charles Saddler clarified that this type of work is not currently in the scope of
services between the County and the PUD.
Commissioner Wojt questioned whether there is a link between the periodic O&M inspection and the •
Financial Assurance Agreement?
Larry Fay replied that the likelihood of a failure would be reduced by the O&M inspection.
Linda Atkins said the community drain field systems are being monitored, but there is no mechanism
within that O&M that requires anyone to set aside funds to repair it.
Commissioner Huntingford suggested the language in the agreement indicate that a community system
with a single owner bears the responsibility if there is not enough money in the fund at the time repairs
are needed. He believes there should be a way to hold the owner responsible,but allow for incremental
payments to build the fund. He questions the revamping of a policy to deal with isolated cases.
Larry Fay said it appears that the implementation of the agreement is the major concern. Staff will
discuss options with Deputy Prosecutor Alvarez and provide an update at the July meeting. He said that,
as the majority of the community systems are managed by the PUD, only a few are single owner and
Staff does not feel this situation presents an urgent problem.
Vice Chairman Westerman asked how, if there are only a few, can we ensure they are not overlooked
and this situation repeated in the future?
Commissioner Wojt suggested that a June agenda item be to determine how much of the department's •
operations the Board of Health thinks should be covered by fees versus the general fund.
HEALTH BOARD MINUTES - May 17, 2001 Page: 5
•Legislative Update: Dr. Locke reported that the legislature is currently in special session. The status of
Public Health funding looks favorable in the House and Senate budgets, but is always at risk until the
final budget is passed. Although there are significant cuts in human services, the hold-up and battles will
be over the transportation and education areas of the budget. Legislation passed that will appropriate
$10.6 million to continue the universal vaccine distribution system for another two years. A statewide
registry program, developed by Snohomish and King County, was rejected for the fourth time.
Lisa McKenzie added that the current registry is over 40% complete.
Dr. Locke reported that a tattooing and electrolysis bill also passed. Local health jurisdictions will be
responsible for enforcing this state rule. He noted that evidence of actual hepatitis in licensed tattoo
parlors is virtually non-existent and this legislation serves to regulate an area that is not the source of the
problem. Another bill will allow currently licensed massage therapists to pursue a certification for
animal massage.
Commissioner Wojt mentioned that he has heard of a group formed in Seattle for the prevention of
tattooing. Their program is focused on educating young women about tattooing alternatives.
Larry Fay said that a part of the Governor's Omnibus Water bill would expand the watershed planning
process and fund up to $100,000 for each optional planning element. Funds have not yet been
appropriated.
41/Jefferson Health Access Summit 2001: Chairman Buhler asked if the Board felt comfortable having
her co-host the 2001 Health Access Summit with Chuck Russell of the hospital?
Vice Chairman Westerman said her only concern about the summit is that it not turn into a hospital-
driven event.
There was no objection by the Board to Chairman Buhler acting on behalf of/representing the Board at
the summit.
Dr. Locke circulated and reviewed the final agenda and a list of ideas for his presentation on the public
health perspective. His discussion will cover the changing demographics of East Jefferson County,
Jefferson Health and Human Services as a Medical Provider, and a Public Health Role in Assuring
Access. He asked for suggestions on other issues.
Commissioner Wojt asked whether the transition in out-patient mental health services should be a topic
of discussion?
Charles Saddler explained that Jefferson Mental Health has made a business decision not to seek
continued funding under the State contract to provide crisis out-patient services after July 1. There is an
ongoing effort to contract with a different service provider. He suggested that an issue for discussion
•might be, are the current services provided by Community Mental Health adequate to address the
population of the community?
HEALTH BOARD MINUTES - May 17, 2001 Page: 6
Dr. Locke said that following the panel's overview of the issues and a 40-minute discussion period,
•
Member Masci will present the Joint Board and Workgroup Process. He noted that in order not to limit
the discussion to one single option, the section that proposes a specific healthcare authority model was
not included.
Member Masci said that in his summary of the workgroup process, he will list the spectrum of ideas and
options.
Vice Chairman Westerman suggested that some printed materials about those options be available. Her
concern is that there will not be substantive discussions without a list of proposed alternatives.
Dr. Locke agreed to provide information for distribution. He then reviewed the meeting structure for the
afternoon.
Vice Chairman Westerman said her biggest concern is that if the doctors contribute a whole day to the
process and nothing concrete comes out of it, it will be difficult getting them back in the fall.
Member Masci said doctors represented on the workgroup recognized the importance of their
participation in this process. He believes the summit will serve as a multi-level exercise: involving
community leaders and providers, and getting some information out to the general public.
Larry Fay announced that Dave and Gloria Christensen delivered their baby daughter earlier today. •
AGENDA CALENDAR/ ADJOURN
Commissioner Wojt suggested that an agenda item for June be a Discussion of Fees Versus the General
Fund to support the Department's Operations.
2001 AGENDA ITEMS
1. CONTINUED STABLE FUNDING TO REPLACE MVET
2. ACCESS HEALTH CARE
3. PROGRAM MEASURES (Genetic Research and Public Health Implications)
4. METHAMPHETAMINE SUMMIT
5. PERFORMANCE STANDARDS & COMMUNITY ASSESSMENT
6. TOBACCO PREVENTION AND COALITION
7. FLUORIDE
8. TRANSIT AND PUBLIC HOUSING
9. BIOTERRORISM READINESS & PLAN
10. AGING POPULATION
11. WATER
12. MATERNAL CHILD PREVENTION GOALS (0-3)
•
HEALTH BOARD MINUTES - May 17, 2001 Page: 7
• Meeting adjourned at 4:35 p.m. The next meeting will be held on Thursday, June 21, 2001 at 2:30 p.m.
at the Jefferson County Health and Human Services Conference Room.
JEFFERSON COUNTY BOARD OF HEALTH
Jill Buhler, Chairman Geoffrey Masci, Member
Sheila Westerman, Vice-Chairman Richard Wojt, Member
Glen Huntingford, Member Roberta Frissell, Member
Dan Titterness, Member
...
•
v
•
•
•
•
Board of Health
New Business
Agenda Item # V., 2
•
Community Indicators
Workgroup
June 21, 2001
•
•
Memorandum
Date: April 5, 2001
To: Charles Saddler, Geoff Masci, Bill Woolf, Roberta Frissell, Katherine Baril,
Dan Wollam, Chris Hale, Juelie Dalzell, Vic Dirkson, Anne Avery(EDC
Council), David Beatty, Art Clarke, Tim Caldwell, Larry Crockett, Beth Juran,
Mr. Timmons
From: Jean Baldwin
• RE: COMMUNITY INDICATORS WORK GROUP
We will begin the process of evaluating the quality of life and some of the data indicators
of Jefferson County with Dr. Chris Hale on Friday, April 20`h from 9:00 to 11:30 a.m. in
the Jefferson County Health & Human Services conference room. Data regarding
economic indicators, health indicators, substance abuse use, law and justice problems
exist for Jefferson County. How do we, as a community, frame the work to be done and
assure ourselves that we are looking at quality data? The next steps are: finding out what
the numbers tell us about Jefferson County and what other information we need to gather
before we begin to look at the contextual valley quality of life in Jefferson County. This
steering committee can begin to provide an overview of a number of projects going on
and decide how we will indeed interpret the Census data and other data coming to us.
I look forward to seeing you all there,
Jean Baldwin
Director of Community Health
•
• Agenda
Apr; ) Zo
J 0
• Build a DATA Users Group Jean Baldwin
• Welcome to Visioning & Planning Geoff Nlasci
Charles Saddler
• Introduction to Jefferson County Data Analysis
Past & Future Katherine Bari!
• Census Data .... The Sequel Chris Hale
•
• Data & Trends Can Clarify Community Profiles. Needs
& Strengths Chris Hale
• Is this the right direction'? Jean Baldwin
Katherine Baril
• Time Frame for Assessment in Strategic Planning ' Geoff\lasci
Charles Saddler
•
April 20, 2001
Health Indicators Steering Committee Meeting
Attendees: Chris Hale, Charles Saddler, Tim Caldwell, Roberta Frissell,
Geoff Masci, Syd Lipton, Mary Ann Seward, John Elrock,
Bill Woolfe, Katherine Baril, Jean Baldwin
Geoff Macri
- Design data collection systems
- Get a handle on future trends
- Health, law &justice, human services, traffic flow impacts
Charles Saddler
- Knowledge based decisions
- Jefferson County commitment to more information for strategic planning
- This has been a period of rapid growth and change do we know ourselves
- Research
o Knowing what the issues are
o Reality-based Focus Group
- Assessment project completed by the beginning of 2003 to be part of the Strategic
Planning process
Katherine Raril
. 1. Community Deliberative dialogue to view data that is
- Credible
- Consistent
- Comparable
- Comprehensive
2. Rural Sociology provides some barriers to engage discussions
3. Public decision-making process
Chris Hale
1. Review existing data
- THEN go out and look for more data
2. We have all the health data - now what are the priorities?
- Very selective in-migration in the 1990's
o Seniors
o People in their child bearing years (20 - 45)
• Married and childless
• Single and childless
- Real outcome of data analysis is public dollar statements
3. Data to information then in the context of our experience
TRIANGULATION
- Gather every piece of information about an age group you can, then crunch it up
• - Do brief fact sheets to share with the community
BRFSS begins May 1 and finishes calling 600 families in December 2001.
• COMMITTEE WORK PLAN
1. Add Clallam & Kitsap counties as comparison
a. Come back with new questions
2. In charge of processing and transforming data into information
3. Brief text to go out to the community that constitutes information
4. Look at analysis of Census data
a. Oversee the translation
5. Take the information out to the community and tell them to "reflect on this in light of
your experiences"
a. At the end of that process (January 2003), a set of agreed-upon priorities
i. Typically 5 to 7 priorities
ii. THAT is where you put your money
b. Set up a series of working groups to look at 4 or 5 of the indicators
i. Jefferson County relative to Kitsap and Clallam
Phase One
Three county comparison of existing data
New data analysis growing out of that comparison
What stays
What comes off
Phase Two
• BRFSS, Prenatal Risk.... What is it telling us?
Phase Three
Detailed analysis of Census data
Phase Four
Filling out loose ends
Information to the community
***Next meeting scheduled for May 24th from 10:30 to 1:00
•
Agenda
Jefferson County Assessment Committee
21.44. 10:30- 1 :00
Jefferson County Health and Human Services Conference Room
Background
• Bremerton Kitsap and Assessment in other places in Washington
• Census Data update, new Jefferson County Work books
What is going on now
• Grant for traffic safety
• Human Subjects review PRAMS & death certificates
• • Posting data when, how and where
Anticipating needs
• Health Care Access Summit
• Community and Media
Set Calendars
• July
• August
• September
•
Washington Traffic Safe Commission
Project Agreement
• Section 2
Description of Activity
In this section, the following five elements should be defined in narrative form: (1) Problem
Identification, (2) Project Goal(s), (3) Project Activities and Tasks, (4) Project Evaluation and (5)
Budget Narrative (explain how funds will be used and details of any matching funds.)
Please clearly label each element using the titles listed above, and limit Section 2 to three
single-sided pages using nothing smaller than a 12-point font.
Problem Identification
Motor vehicle injuries are the single largest preventable cause of death in Jefferson
County. Between 1994 and 1998, the age-adjusted death rate from motor vehicle
injuries among Jefferson County residents was 26.4 per 100,000 compared with only
13.6 for Washington State as a whole. This year 2000 state study reinforces that motor
vehicle injury morbidity is 50% greater among Jefferson County residents than the state
rate. The National Transportation Safety Board estimates that 50% of all motor vehicle
injury deaths involve substance abuse. If information currently in paper records could
be transformed into a computerized database it would be possible to determine the role
of substance abuse in J.C.'s motor vehicle morbidity and mortality. Such a database
could also identify other potential prevention strategies. The county's prosecuting
attorney has indicated a willingness to make the coroner's records available (provided
human subjects' review ensures their confidentiality). The county's law enforcement
• agencies have also indicated their support for the project. A computerized database
would also help prevention efforts by determining other explanations for the county's
excessively high injury and fatality rate. For example, are certain highway locations
frequently the site of motor vehicle injuries and fatalities? How many injuries and
fatalities are associated with out-of-county residents? Were safety devices properly
used? What other risk factors appear to be important? This proposal asks funding to
build such a database and to document its construction so that other counties in the
state might benefit from the work.
Project Goals
• Create a database from coroner's records and law enforcement reports of motor
vehicle injuries and deaths and analyze it to determine risk factors. These will
include. but not be limited to, substance abuse, failure to use safety devices,
unfamiliarity with the road (by comparing resident and occurrence rates) and
certain road conditions.
• Disseminate the findings to the policy makers and the community.
• Document the entire project in such a way that it can be replicated in other
Washington counties.
Project Activities and Tasks
• Create partnerships between the Jefferson County Health and Human Services,
the county's Prosecuting Attorney (responsible for maintaining coroner's records of
all unexpected deaths), and law enforcement agencies.
• Develop a procedure for protecting privacy as records are transferred to database
and get that procedure approved by the WA State DOH Institutional Review Board.
• Using SPSS (software), develop a database structure.
• Document the use of this database structure so that it can be replicated in other
• counties.
• Review all reports of motor vehicle injuries and fatalities between 1/1/1996 and
12/31/2000 and enter relevant information into the database.
• Analyze data to determine trends and risk factors.
• Use the county's GIS to identify whether certain locations are especially high risk
by mapping accidents by location.
• Convene a steering committee of city and county elected officials, law
enforcement, judges, extension agents, citizens and health providers to review the
results of these analysis and to formulate a community process to disseminate the
findings.
• With the community, use these findings to determine appropriate prevention
strategies which will reduce the county's motor vehicle injury and fatality rates until
they are no higher than the state average.
Project Evaluation
At its conclusion, this project will have at least three products:
1. A manual which will allow any other Washington county to develop the structure
of a database to examine driver characteristics and behaviors, road conditions,
and other factors contributing to motor vehicle injuries and deaths together with
the computer code to analyze these data.
2. A report summarizing the contribution of substance abuse to Jefferson County's
• high motor vehicle injury and death rate and identifying other contributing factors.
3. A community-based plan to reduce Jefferson County's motor vehicle injury and
fatality rate to no more than state average.
•
•
Board of Health
New Business
Agenda Item # V. , 3
• Take Charge
Program Implementation
June 21 , 2001
•
•
Board of Health
New Business
Agenda Item # V., 4
Maternal Child Health
• Hear & Say
Reading with Toddlers Program
June 21, 2001
•
Medical Assistance Administration
Family Planning Waiver Information Fact Sheet
• May 2001
I'LANNING.
What is the TAKE CHARGE Waiver?
• The waiver allows DSHS Medical Assistance Administration (MAA) to create a new program
outside the existing Health Care Financing Administration(HCFA) policy.
• The waiver creates a new 5-year demonstration and research program called TAKE CHARGE.
It allows MAA to increase financial eligibility for"family planning only" services.
• The waiver was approved by HCFA in March 2001. TAKE CHARGE will be implemented on
July 1, 2001.
What does TAKE CHARGE do?
• Expands eligibility for Medicaid pre-pregnancy family planning services for women and men
with family incomes at or below 200% Federal Poverty Level (FPL).
• Defines family planning services as federal Food and Drug Administration (FDA) approved
contraceptives, abstinence, natural family planning, sterilization, and education and support
services.
• Expands an existing payment system and allows more persons needing services to get them.
• • Clients will access family planning services through an approved TAKE CHARGE Provider.
Providers will submit the TAKE CHARGE client application to MAA for eligibility
determination. TAKE CHARGE eligibility cannot be determined at a Local Community
Service Office (CSO).
Why is the TAKE CHARGE program so important?
• The TAKE CHARGE program will decrease the numbers of unintended pregnancies and reduce
costs for state paid maternity care.
— 60% of Medicaid-paid births are from unintended pregnancies.
— $100,000,000: 1998 estimated cost of Medicaid-paid births from unintended pregnancies.
• Waiver will increase the availability of pre-pregnancy family planning services.
• Planning and spacing of pregnancies promotes healthier birth outcomes. Unintended
pregnancies are associated with late or inadequate prenatal care, low birth-weight, fetal
exposure to alcohol, tobacco smoke and other toxins, and maternal depression.
• Unintended pregnancies are also associated with economic hardship, marital dissolution, poor
child health and development, spouse abuse, and child abuse and neglect.
• Revised 5/17/01
DSHS, Medical Assistance Administration,
Beth Brenner, Family Planning Program Manger
(360) 725-1652
Apra 11, 2001
•
TAKE CHARGE
Federal Poverty Level (FPL) Chart
for Income and Family Size
1 Number of People in Family 200% FPL Income
• (includes parents and Limits
children)
1 Up to $ 1 ,432
2 $ 1 ,935
• 3 j $2,439
4 $2,942
5 $3,445
6 $3,949
7 $4,452
8 $4,955
9 $5,459
10 $5,962
More j Add $504 for each
additional family
member
•
I Washington State Department of
; z
•
Health Release
For Immediate Release: June 11, 2001 (01-49-km1-2)
Contacts: John Whitbeck, Center for Health Statistics (360) 236-4321
Phyllis Reed, Center for Health Statistics (360) 236-4207
Linda Jacobsen, Family Planning Program (360) 236-3469
Kate Lynch, Communications Office (360) 236-4078
Teen pregnancy and abortion rates down,
1999 statistics show Washington rate lower than U.S.
OLYMPIA The teen pregnancy and abortion rates in Washington dropped in 1999,
continuing a gradual decline over the past decade. This information is published in a state
Department of Health report released today: Washington State Pregnancy and Induced Abortion
Statistics 1999.
The Washington teen pregnancy rate reflects a national downward trend; however, the rate in
• Washington is lower than the national rate. The National Center for Health Statistics of the
Centers for Disease Control and Prevention reports an overall decline in the number of all
pregnancies, especially among teens.
Of roughly 121,000 females ages 15 to 17 in the state, 4,726 were pregnant in 1999, a rate of
39.2 per 1,000. This rate is 3.4 fewer pregnancies per 1,000 women, compared to the 1998 teen
pregnancy rate of 42.6. By contrast in 1989, 59 of every 1,000 girls, ages 15 to 17, were
pregnant.
The National Center for Health Statistics 2000 Fact Sheet suggests some factors contributing to
the decline may be an increased use of condoms and other contraceptives (birth control pills,
injectable methods) and to a leveling off of teen sexual activity.
(http://www.cdc.gov/nchs/releases/00facts/trends.htm)
"This is good news for us," said Linda Jacobsen, a nurse practitioner with the department's
Family Planning Program. "This is the lowest pregnancy rate for this age group in over two
• decades, and confirms what research shows -- that more programs are making a difference in
encouraging teens to remain abstinent or use highly effective methods of contraception when
-More-
•
Teen Pregnancies/Abortions 1999
June 11, 2001
Page 2
• they have sex."The Department of Health funds 21 family planning agencies in Washington
State.
Abortion Statistics
Not only were fewer teens getting pregnant, fewer teens sought abortion. For teens ages 15 to
17, the abortion rate in 1999 was 16.6 compared to 18.4 in 1998. In 1989, the abortion rate for
this age group was 30 per 1,000.
The highest abortion rate of any age group in 1999 was among women ages 20 to 24, with 47 per
1,000 pregnancies. "This shouldn't be a surprise, when you consider that 20 to 24-year-olds also
have the highest pregnancy rate of all age groups. Birth rates and marriages are also highest in
this group," said Dr. John Whitbeck of the Center for Health Statistics.
Another health department report, with 1999 vital statistics (births, deaths, marriages, divorces),
will be published in mid-June. Tables for 1999 are currently available on the Department of
• Health's web pages: http://www.doh.wa.gov/EHSPHL/CHS/default.htm.
In 1999, there were 1.2 million women in Washington state of the childbearing ages, 15 to 44. Of
that total, about 85 out of 1,000 women were pregnant. Of these 85 per 1,000 pregnancies, 64 per
1,000 resulted in a live birth and 21 per 1,000 resulted in either abortion or miscarriage (fetal
death). There were 25,965 abortions in 1999, which is nearly 15 percent lower than a decade ago;
in 1989, the number of abortions was 30,452.
Abortion Data as Public Health Indicator
The goal of the Department of Health is to decrease the number of unintended pregnancies.
Abortion reports provide information that may help health educators and providers in their work
to reduce the number of unintended pregnancies. Pregnancy and abortion tables are available on-
line: http://www.doh.wa.gov/EHSPHL/CHS/default.htm#Abortion
###
•
--------------
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Hear and SayGO
Hear and Say
in
Reading with Toddlers Reading with Toddlers o
1
Group Tip Sheet
Part I:Tips to Build Vocabulary How to teach Hear and Say Reading
Ask"what" questions
Parents can learn Hear and Say reading directly
Follow answers with another question from this videotape.Another approach parents
enjoy is to learn in small groups. Here are some
Repeat what your child says
tips for teaching Hear and Say Reading in groups.
Help you child as needed
•
Praise and encourage your child Keep group size small
• Meet in a friendly place
Follow your child's interests • Show Part I of the videotape N
HAVE FUN! 0 o
• •tice with each other using children's books al
• Hand-out copies of the tip card included in the 'o
Part II:Tips to Build Sentence Skills video box °
• Encourage parents to practice Hear and Say o
Ask"open-ended" questions Reading with ther children 5 to 10 minutes
Follow answers with another question every day
' Meet again after 3 to 4 weeks' time and water
Expand what your child says
Part II of the videotape
Help your child repeat your longer phrases
• Encourage parents to continue reading daily with
HAVE FUN! Part II tips.
HAVE FUN!
, /1 Z. 1• ,
I i ,f7- -:7'.': ::;-'...1• -il
• ve Helping Your BabyLearn to Talk
, l
?cDies 'eon on amazing nurncer c Things '.n their first two �ecrs. sucn as now to talk. Score scart talking ecny,
ana others co -CT. ,Most!ate talkers are busy 'earring other-rings, cut to De sure, ask a Ccctor, nurse, or other
orofessicro cccut 1 f your accv s not talking nke other ccc es. This chert nelps ycu Cecile wnen to ask.
Age 'Whet to look tor in a growing, healthy baby Talk with a professional-
3 months � _coy "isters fo 'lour voice. He or she coos and gurgles and ✓ if your 3-month-old rices not
fres to mcke the some scunds you mcke. listen to your voice.
8 months Baby picys with sounds. Some of `hese sauna like words. ✓ if your 8-month-old is not
such as 'baba' or 'code." Baby smiles on necnng a happy making different sounds.
voice, and ones or rooks unhappy on necnng an angry
voice.
.
10 months Baby uncerstcnas simple wcras. She stocs to lock at you if v' if your 1O—month-cid does
ycu sCy "No--'o.' If someone asks 'Where's Mommy?" Bcby not lock when people talk
will lock for you. Baby will point, cry, or cc other things to to him or her.
'tell"you to pick her'.;o, or bring a toy.
12 months first wcras! Baty says 1 or 2 Nerds and understands 25 V if year 1-year-old is not
words or more. 3cbv will give you a toy if you ask for it. pointing ct favorite toys or
III even without words. Baby can ask you for something—by things he or she wants.
pointing, reaching for it, or!coking at it and babbling.
18 months Most onilcren con soy 'tt-cnk ycu' and at !east 30 other V if your 18{north-old cannot
words, crd can follow simple directions like 'jump!' say more than 5 wores.
20 months Your child can put 2 words together in a sentence, such V if your 20-month-0Id cannot
as "car go,' or `went juice." He can follow Cirections when fellow simple commends, ,
you say things like 'close the boor.' He con copy you such as'come to Daddy.'
wren you say several words together.
,,24+ months ! Your child cribs encings tc words, such as running,' or V if your 2-year-oid cannot
'picvea." or `toys.' She likes hearing a simcie children's say 50 wores or does not
story. She understands 3 wores about place, such as 'in,' use 2 words together.
'on'or"at.'
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nmtp Y OUl LA-MU IL) I UIK
•
when Do the first activities as long as your child enjoys them. Add new activities as he
to start or she grows older.
birth Help your baby learn how nice voices can be.
✓ Sing to your looby. You can do Tis even before your baby's bcml You bcCY will near you.
✓ Tclk to your bccv Talk•c others Nnen Bcby s near. Baby won't urderstara me words.but will like
your vc4ce ora vctr stale. 3ccy will enjoy hearing and seeing other people. too.
✓ !cn to quiet lime. accv needs time to bobble and play costly wrmalt TV or radio or other noises.
3 months Help your baby see now people talk to each other.
✓ -told your bcty close sc she or tie will lock in you eyes.Talk to Bcbv and smie.
✓ when your Dcbv CaCCles .mrtate me sounds.
✓ 'f 3ccy 'nes to make the some sound you do.soy ms word again.
6 months Help your baby understand words (even if he or she can't say them yet).
✓ play comes like Peek-o-Boo or Pota-Coke. Help Baty move tris hands to match the game.
✓ when vcu give Secy a toy. scv something about it Ike'Feet how fuzzy Teddy Bear a.'
✓ Let your Dabv see riirnseif rt a mirror and ask."Mho's mot?'tf he doesn't answer.say his name.
✓ Ask your acoy cuesstcns.like"Nhsre's Doggie?If he doesn't answer.show ham where.
9 months Help your baby "talk' by pointing and using his or her hands.
•
✓ Show 3ccy new to wove'love-ave." Tell baby"Show me your nose.' Then point to your nose.
She will scan cant o net nose. this with toes.fingers ears eyes.'knees and so on.
✓ :-ice c toy'.vn le 3ccy s Notching. Het Baby find it. Share net delight at finding rt.
✓ .Mien ScCv cctrrs rr cc n es acti;scmemmg. talk abcut'he cheat with her.
12 months i Help your child to say the words she or he knows.
✓ talk ata t .tie trtrgs you,se. ;ike' 'uica.''dots." Give your mild time to none them.
✓ .Ask your olid Questions occur ire pictures it books. Give YOU child time to name things in the picture.
✓ Smile or ctdb your hams caner,your child names the ming'hat he sees. Scy something about it.
15 months Help your child talk with you.
II
✓ Tcik c cut ,vnct your".lid wants most to talk about.Gore hum time to tell you all about It.
i
✓ Ask scout tangs icu cc each Cay—"Which shirt whey you tick today?''Do you want milk or juicer
✓ When vont c^iC says;1st' word. Ike"„ad.'recect t"Kith a ittte extra—"That's Baby's ball.'
✓ Pretend your allies favorte cot or toy primal can talk.Have conversattcrs with the toy.
18 months 'Help your child cut words together and learn how to follow simple directions.
✓ .A.si<your crud tc pec you. ;Cr excmcle. ask her to put her cup on the tette.
✓ Teach your crdc smote songs crd nursery rnymes. Recd to your child.
✓ Srccu:cge your=lc to tale to mends^ond fcmiN. A c rid cot tell them about a new toy.for example.
✓ '_et your c illi'cu y teiecnone.'-+ave a pretend teiecnone conversation.
2 years Help your child out more words together. Teach your child things that are important to know.
✓ Tecan your child to soy nis or her first and last name.
✓ .ask occur me numcer. size. w c srce of things your onto;r.cws you. :f it's worms.you could say:
"Nkat`at wiggly worrrsl How many ore mere?. . Where.re they going?''Nat watch,and listen to
re drswer. Suggest an answer f neecec:fi see rive. . . . Are they gctrg to the park or the store?
✓ Asx your child to tell you the story that goes with d favorite bock.
✓ Check your local'Ibrery for programs to toddlers. Ask at your hearth Clinic for other guides.
✓ Don't forget what worked earlier. For example.your child still needs quiet line. This Is not Just for naps.
Turn otf tine TV and radio and let your ch lit enloy Quiet clay, singing, and'alldng.
For other does on now to nolo your oaby develop.ask al your'oat nealth c+antc for Frantcenourg's Denver Devsioomenral Activities(1987). For More ideas on rings childr,n
might leu to do,wine to C.;nsumer rnformanon Cataaog,Pueblo.CO 31009 and asx for a ocy of Mie free Consumer lntormaaon Catalog.
Remmsson to reproduce this guile for educational ouroosae and tree dtstnbution is granted and encouraged. •
0;�4•♦,,y ILL Ds,sewua l al Education
This guide was developed by Coueen Monssat of Me UnNersiry of Washington and Ponca ones of tie �i ^ �1`� Fdvure w'Aesy
U.S.Department of Equation. Matenai was oaseo on ZERO TO T rREE/Nattonal Center`or Clinical Infant t'
Programs(1992): Fenson et al.(1991): Thai and Bates(19891:Bayisy(19691:and other sources cited in full oleos el Earsetiow^ewers^'"d t'"ere'ea"•"t
n Colleen E.Monsset.'Language ono Emotional Mi Sharon P.Robinson
Milestones on me Road to Readiness:1993,report no.18, Anrarrtr Seatiosry,
Center on Families.Communities.Schools,and Children's Learning. The cartoon is used with permrsson of
Ray Billingsley.The Department of Education extends as appreciation to Ray Billingsley for the generous gift OR 94-3046r
of his wont.For more information about OERI researon.statistics.and oublicatons.call 1-806-42a-1616.
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� � • • C) • • .... • • • •
• Promoting Toddlers' Language
Development Through
Community- Based Intervention
COLLEEN E. HUEBNER
University of Washington
This study evaluated an adaptation of a developmentally based. 6-week parent—child
reading program (-dialogic reading") demonstrated to facilitate vocabulary and syntactic
skills of toddlers. including those at risk for language problems. In this study. dialogic
reading was modified for broad dissemination through four branches of a city library
system. Children's librarians taught parents the reading techniques in two 1-hour sessions.
The study design was an efficacy trial with two thirds of families randomly assigned to
the dialogic reading condition In = 88) and one third to a comparison condition. The
comparison condition was comprised of existing library services for parents and children
(n = 41). Analysis of baseline to post-test change showed a significant intervention-group
effect on parent—child reading style and children's expressive language. In addition. at a
• 3-month follow-up assessment.parents in the dialogic reading group reported less parenting
stress. specifically stress resulting from characteristics of their child.
Studies of social interaction between parents and young children have identified
many ways in which everyday conversation supports the child's task of language
learning. Among the most common examples are parents' use of expansions. repeti-
tions, extensions, responses. and questions that follow the child's interest (Barnes,
Gutfreund. Satterly. & Wells. 1983: McDonald & Piens 1982: Messer. 1978; Morisset,
Barnard. & Booth. 1995: Murphy, 1978: Ninio & Bruner. 1978: Ninio. 1980: Snow,
Barnes, Chandler. Goodman. & Hemphill. 1991: Snow. Perlmann. & Nathan, 1987;
Wells. 1985). In addition to encouraging development implicitly. parents also en-
courage language explicitly by teaching social routines with prompts such as "say
thank you." providing object labels, asking the child to name objects. and correcting
errors in word meaning or linguistic form (Gleason. Perlmann. & Greif. 1984;
Messer, 1978: Moerk, 1974: Murphy. 1978: Ninio & Bruner. 1978: Ninio, 1980;
Sokolov. 1993).
Direct all correspondence to: Colleen E. Huebner. Maternal and Child Health Program. Box 357230.
Department of Health Services. School of Public Health and Community Medicine. University of
Washington. Seattle. WA 98195. <colleenh@u.washington.edu>.
• Journal of Applied Developmental Psychology 21(5): 513-535 Copyright 2000 Elsevier Science Inc.
ISSN: 0193-3973 All rights of reproduction in any form reserved.
513
514 HUEBNER
Shared picture book reading appears to be an excellent activity for drawing
forward the types of verbal exchanges that support young children's language
development. Descriptive studies of book reading with toddlers and preschool •
children show that many parents naturally intersperse reading with conversation
about the pictures that accompany the story. In doing so. parents capitalize on
opportunities to teach new vocabulary and sentence-level skills through the use of
tutorial questions (i.e.. what-. when-. where-. and why-type questions), directive
pointing. object labeling, fine-tuning utterances to the child's level of understanding,
and corrective, informative feedback ( Beals. De Temple. & Dickinson. 1994: Deme-
tras. Post, & Snow. 1986: MIoerk 1974. 1976: Nelson. 1973: Newport. Gleitman. &
Gleitman. 1977). Interestingly. studies of social class differences in mother—child
conversation find that working-class mothers are more apt to use a language-
facilitating speech style during shared reading than in other interactive settings
(Dunn. Wooding. & Herman. 1977: Hoff-Ginsberg. 1991: Snow. Arlmann-Rupp.
Hassing. Jobse. Joosten. & Vorster. 1976). One reason may be that the simple story
line and imaginative illustrations of picture books evoke "optimal motherese. ready-
packaged and presented in a stimulating way for mothers who might not have the
capacity or inclination . . ... (Moerk. 1985. p. 563).
Studies of shared reading over time have identified progressive changes in the
demands made on children from ages 1 to 4 Years (e.J.. DeLoach. cited in Brown.
Bransford. Ferrara. & Campione. 1983: Wheeler. 1983). Labeling routines directed
by relatively concrete questions (e.g.. "What's that?") are more characteristic with
children at the younger ages. whereas at the older ages. mothers tend to ask more
open-ended questions that go beyond the immediate scope of the book (e.g.. "Do •
you think George will get in trouble'"). Evidence from cross-sectional research
with 4- and 5-year olds. with and without communication delays. indicates that
progressive changes in shared reading interactions are the result of adults' adjust-
ments to children's burgeoning language skills. rather than differences in children's
age (Pellegrini. Brody. & Sigel. 1985).
Taken together. over 20 years of correlational research suggests that shared
book reading can be a valuable context for oral language development. particularly
if the reading is collaborative rather than passive, and if the nature of the interaction
supports the child to achieve just beyond her current level of mastery. Experimental
support for these assertions is just beginning to accumulate (i.e.. Scarborough &
Dobrich. 1994: Bus, van IJzendoorn. & Pellegrini. 1995). Causal links between
aspects of shared picture book reading and 2-year-old children's oral language
development were demonstrated first by Whitehurst and his colleagues in a study of
a shared reading program called dialogic reading (Whitehurst et al.. 1988). Dialogic
reading integrates and amplifies the language-facilitating behaviors described above.
The program is based on three general principles: (a) the use of evocative techniques
that encourage the child's active participation in telling the story. (b) use of feedback
to the child in the form of expansions. corrections. and praise. and (c) progressive
change to stay at or beyond the child's current level of independent functioning
(Arnold & Whitehurst, 1994). Instruction in dialogic reading consists of as few as
two brief sessions: the techniques are straightforward and easy to demonstrate. •
The results of multiple, independent studies have demonstrated positive effects
of dialogic reading on the expressive language skills of 2- and 3-year-old children
from lower- and middle-income homes: in daycare and home-based programs,
and with children with normal development and developmental disabilities (Dale,
Notari. Craine-Thoreson. & Cole. 1993: Lonigan & Whitehurst. 1998: Whitehurst
• et al.. 1988: Valdez-Menchaca & Whitehurst, 1992). The most consistent positive
findings are from implementations that include home reading. with or without a
concomitant school or daycare dialogic reading component (Lonigan & Whitehurst,
1998: Whitehurst et al., 1994). Perhaps as Bronfenbrenner speculated. engaging the
mother—child dyad as an interactive system generates a momentum that becomes
independent of the formal intervention (Bronfenbrenner. 1974. as reported in Lev-
enstein. Levenstein. Shiminski. & Stolzberg, 1998).
The goals of the present study were to adapt dialogic reading for broad-based
implementation through neighborhood public libraries and to evaluate the effect
of these modifications with parents and their 2-year-old children. Public libraries
were chosen as the place to reach families with 2-year-old children because, unlike
younger children who have frequent contact with the health care system or older
children who are in school daily. 2-year olds are not within the purview of any
specific institution. A second goal was to test the hypothesis that dialogic reading,
designed to enhance young children's oral language skills. would have an added
beneficial effect on self-reported parenting stress during this period of childhood
characterized by rapid developmental change. often accompanied by heightened
resistance and negativity (Kopp. 1992). and more commonly known as the "terrible
two's."
The study was of a randomized. controlled design in which two thirds of partici-
pating parents received group instruction in dialogic reading and one third were
• assigned to a comparison parent—child reading condition.
METHOD
Recruitment and Participants
Community Context. The setting of the study was Seattle. Washington. Com-
pared with the state and nation as whole. Seattle's residents are on average well
educated. More than 86% of adults more than 25 years of age have completed high
school, and 38% have a 4-year college degree. Although many enjoy a comfortable
income, at the time of this study. 16.5% of the children less than 6 years of age
lived in poverty (City of Seattle. 1992). At the last decennial census. in 1990. there
were more than 7000 births to city residents. Most were to white mothers (66%).
followed by births to Asian mothers ( 14%) and to African American mothers (13%;
Washington State Department of Health. 1991).
The program described in this study took place at four different branches of
the Seattle Public Library. Two of the four libraries were located in south and central
area neighborhoods where the proportion of minority residents in the adjacent zip
code regions was 50% to 75%. and the median household income was in the range
of $7500 to $45.000 per year. In contrast. the two other library sites were in north-
Alk
end, predominately white. middle-income neighborhoods with a median yearly
516 HUEBNER
income in the range of $15.000 to S30.000 dollars (Seattle Office for Lona-Range
Planning. 1990).
Recruitment. To maximize sample size. yet minimize the size of the parent- •
training groups and limit study demands on library staff, the program was conducted
in four successive -waves" at each of the four library locations. Recruitment into
the four successive waves was continuous throughout the study. Announcements
were posted in neighborhood businesses and brief articles describing the program
were placed in local newspapers. Informational fliers that included a telephone
and address contact form and a brief developmental screening questionnaire were
available at participating libraries and in other nearby locations including children's
health clinics and daycare. community, and activity centers within a low-income •
housing facility. Most parents indicated their interest by completing the contact
information requested in the flier and returning it to the project office. Alternatively,
some interested parents were referred to the project by community agencies and
then project staff initiated contact by phone.
Criteria for inclusion in the study were: (a) signed informed consent. (b) parent's
self-report of adequate reading skill. confirmed later by observation of their ability
to complete written questionnaires. (c) a child 24 to 35 months of age at the pre-
test date who scored at or above age level on a developmental screening test. (d)
the family residing in the vicinity of the participating libraries, and (e) English
being the primary language spoken in the home. Eligibility was determined by
telephone interview. Interested families who did not meet the criteria received a
children's book as a token of appreciation and, if indicated, were referred for •
appropriate services such as developmental testing or alternative library programs
for younger, or older. children. One hundred eighty-four families were recruited
and interviewed: of these. 89% ( 164) met the eligibility criteria. The reasons for
exclusion were: children were too young or too old, were bilingual. were language
delayed (and attending speech therapy), or lived outside the study area. No family
was excluded because of parent's low reading skill.
Run-in. Families who met the eligibility criteria were contacted in the month
before the first parent group session to arrange a meeting at the library for child
language pretesting and baseline data collection. Because in this study instruction
in dialogic reading was modified for community-based implementation. it was essen-
tial to determine whether these changes diluted the effect of the training to change
parents' reading style. Thus the 1-month span between child pretesting and group
assignment was used as a run-in period during which parents who did not read very
often could be excluded from randomization into one of the study groups. That is,
to continue eligibility. parents were expected to complete the appointment for child
pre-testing and report parent—child reading of four or more times per week.
Twenty-three of 164 eligible families were dropped before the pre-test appoint-
ment. Most could not be contacted by phone. had disconnected phone numbers,
or had moved out of the area. A few mothers reported they had returned to work
recently and were no longer interested in participating in the study. No one was
dropped because of infrequent reading.
PROMOTING TODDLERS' LANGUAGE 517
Table 1. Sample Size by Assessment and Study Period
Screened Pretested Sz Follow-Cp
, II
& Eligible Randomized Post-tested Assessment.'
Family Background
Sociodemographics and Family
Composition 165 — — —
Parenting Stress Index (PSI) and Life
Stress Scale — 123 — 49
Child Characteristics
Developmental Status (R-PDQ) 165 — — —
Age. Sex. Birth Order. Health Status.
Child Care — 129 — —
Child's Language Ability
Peabody Picture Work Vocabulary Test
(PPVT) — 126 117 50
Early One-Word Picture Vocabulary Test
(EOWPVT) — 125 117 49
Illinois Test of Psycholinguistics Abilities,
Verbal — — 117 48
Expression Subtest (ITPA V.E.)
Audiotapes of Language During Reading
with Parent — 127 — 48
Child's Exposure to Reading
Frequency and Enjoyment — 179 113 50
III 'votes: Dashes indicate the data were not collected during this period.The study involved four different library locations
and four successive waves of families at each site.Within each cohort.pretesting occurred before randomization
(up to 6 weeks before the first parent group session), and post-testing occurred within 6 weeks after the
intervention.Of 184 families screened,a total of 164 met eligibility criteria for the study.Of these. 131 completed
the pretesting appointment and 129 with pretest data were randomized. Of these. post-test data were collected
for 117. Follow-up data were collected for 50 of 62 eligible families.
'For families in the first two waves of the study. follow-up data were collected approximately 3 months after
the post-test appointment.
'Audiotapes of parent-child reading in the home were collected during the intervention between the pre-and
post-test periods: data were available for 11' families after the first parent training session and 103 families
after the second training session.
Of the remaining 1.11 families. 131 completed pre-test appointments. During the
pre-test appointment, parents (usually the mother) and children were audiotaped
reading a book of their choice. After the reading, children completed a language
assessment while parents filled out a sociodemographic survey and a stress inventory
(see Table 1 for a summary of all parent and child assessments and time of data
collection). At the end of the pre-test appointment, parents were given a gift of a
children's book and asked to read at home with their child daily. Parents were
telephoned weekly to maintain contact and to remind them to read with their child.
The interval between child pre-testing and the first parent group session varied for
individual families but did not exceed 6 weeks. This interval was a practical necessity
• to complete all scheduled child testing and establish an adequate group size for the
parent meetings.
518 HUEBNER r
One week before their first parent-group session, parents were telephoned and
informed of the date and time of the meeting. An additional two families were lost
between pre-testing and this telephone call because they moved out of the area. •
Randomization. At the time of the phone call to schedule the first parent
meeting. families were assigned to either the dialogic reading or comparison group.
Allocation to the two study conditions was random and determined by an individual
who had no knowledge of the baseline or pretest data. Two thirds of the families
(ii = 88) were assigned to the dialogic reading group and one third (ii = -1.1) was
assigned to the comparison group.
Content of the Intervention. The intervention was based on the dialogic read-
ing program as described by Whitehurst and his colleagues (Whitehurst et al., 1988).
Training in the dialogic reading method consists of two 1-hour parent-training
sessions (session I and session 2) that occurred 3 weeks apart. Typically. instruction
in dialogic reading is conducted by University-based research staff on a one-to-one
basis. In the present study. children's librarians were taught to conduct parent
training at the library sites. and training procedures were modified to accommodate
small groups of 6 to 12 parents at a time.
The content of the training followed the recommendations of Arnold and
Whitehurst ( 1994). Parents were asked to diminish reading behaviors that minimized
the child's verbal participation in favor of evocative techniques that facilitate the
child's active participation in telling the story. Adult reading behaviors to diminish
included: reading (without the child's participation) and asking the child pointing
questions. yes/no questions. and criticism. Specific dialogic reading behaviors taught
11111
during session 1 included the use of "What?" questions. questions about function
and attributes. praise. and repetition. In session 2. parents were shown how to use
verbal expansions of child utterances and open-ended questions to help children
build more sophisticated sentence-level skills. During each session. videotape illus-
tration was used to provide real-life examples of the new reading techniques. fol-
lowed by interactive stop-action segments that asked. "What could this parent have
done differently?" or "What else could this mother have done?" The videotape
was complemented by one-to-one practice that included role-play and corrective
feedback. At the end of each session. parents received a single-page review of the
dialogic techniques and were asked to use the new way of reading with their children
daily. 5 to 10 minutes per day. during the following 3 weeks.
The experience of parents in the comparison condition was similar to those in
the dialogic-reading group except they did not receive any instruction to change
their reading style. Instead, the curriculum drew from the library's regular services
for parents and young children. Several activities were combined to form two 1-hour
sessions that took place. like the dialogic reading training sessions. in weeks 1 and
4 of each wave of the intervention. At each comparison group meeting. the children's
librarian described story books and related craft projects that are appropriate for
2-year olds. Each meeting was thematically related to a children's book that all
parents (dialogic and comparison) received during the parent meetings. •
To review, all aspects of the dialogic and comparison programs were identical
except that for parents in the dialogic-reading group. parent sessions focused on
' PROMOTING TODDLERS' LANGUAGE 519
learning the dialogic-style of reading. Parents in both groups participated in two
group sessions approximately 1-hour in length. conducted by the resident children's
• librarians and held at the library. Each session was offered on at least two occasions
to accommodate parents' various work and caregiving responsibilities: the sessions
were scheduled to occur approximately 3 weeks apart.
Monitoring Program Integrity and Strength. To monitor the integrity and
strength of the program. as modified in this study, parent—child reading was coded
from audiotapes at four successive points in time: baseline (taped in the library),
during the intervention period after parent training session I and after session
(taped in the home). and at follow-up testing (taped in the library). The purpose
of the coding was to determine the extent to which parents actually used the targeted
techniques. either spontaneously or as a result of training, and whether parents'
dialogic reading behavior had the intended effect to increase the child's verbal
involvement in shared reading. To facilitate audiotaping at home. small battery- -
operated tape recorders were provided to parents at the group meetings. Parents
in both the dialogic and comparison groups were asked to read daily with their
children and to audiotape at least one reading session per day. Families were
contacted weekly to answer questions. to problem solve. and to remind them to
continue reading.
Measures
Parent questionnaire data and assessments of children's language ability were
collected during four periods: screening (by telephone). baseline and pre-test (up
to 6 weeks before the intervention). post-test (within 6 weeks after the intervention
period). and follow-up (3 months after the post-test appointment). Because of
budget and time constraints. only families enrolled in the first two waves of interven-
tion were included in the follow-up testing. An overview of measures by time and
type of assessment is provided in Table 1 each is discussed in turn below.
Adult's Reading Ability. Parent's skill level was assessed during the tele-
phone-screening interview by asking them about their reading habits. particularly
their ability to read the newspaper. Experts in adult literacy estimate that a fifth-
grade reading level is required to read the newspaper and that asking adults general
questions about their functional reading skills gives a better indication of reading
difficulty than brief screening tests (R. Allen. personal communication. 1991). Par-
ents' self-assessment was confirmed later by observing the ease with which they
completed written questionnaires in person. at baseline.
Developmental Status. The Revised Denver Prescreening Developmental
Questionnaire (Frankenburg. 1986) is a parent-report questionnaire that provides
information about four domains of development: personal—social. tine motor, lan-
guage. and gross motor. Children are considered to be developing normally if they
pass all items that correspond to their chronological age. In the present study. age-
• appropriate items from the Revised Denver Prescreening Developmental Question-
naire were included in the information Miers used to announce the reading program.
Parents reported their responses during the telephone-screening interview. The
520 HUEBNER
Revised Denver Prescreening, Developmental Questionnaire was used to screen
out children with obvious developmental delays. Children whose parents reported
they had one language delay and those reported a total of two or more delays were
excluded from the study and referred to their health care provider for further
evaluation.
Sociodemographics. Information about child health status, family composi-
tion. and social status was ascertained at baseline and follow-up by parent question-
naire. Questions included the child's age and sex, birth status (recollection of gesta-
tional age), and whether the child had noticeable speech or language problems.
Questions about family composition included: the number of adults in the home
and their relation to the study child: the number of children in the home and their
ages and relation to the study child: and parity of the study child. Additional
questions were asked about ethnicity and what languages other than English were
spoken in the home.
Children's Reading Exposure. Children's exposure to books in the home was
based on a survey developed for Whitehurst's original study of dialogic reading
(Whitehurst et al.. 1988). The questions include who reads to the child. how fre-
quently. and whether the child enjoys being read to.
Parenting Stress. Self-reported parenting stress was assessed with the Parent-
ing Stress Index (PSI: Abidin. 1990). The PSI consists of items that tap parent,
situation, and child characteristics. Responses reflect the degree to which the state-
ments are true for oneself or one's child (e.g.. "I enjoy going to the movies." "My •
child is not able to do as much as I expected"). The items are divided into two
domains: parent's personality and pathologic status, and stress resulting from par-
ent's perception of child characteristics. Each domain comprises several subscales.
the parent domain (54 items) assesses: depression. attachment. restrictions of role,
sense of competence. social isolation. relationship with spouse. and parent health.
The child domain (47 items) assesses: adaptability. acceptability. demandingness,
mood, distractibility or hyperactivity. and reinforces parent. The PSI contains an
optional 19-item life stress scale. The life stress scale reflects the accumulation of
recent stressful events including divorce. loss of job. and change in residence. The
PSI takes approximately 20 to 30 minutes to complete and can be understood by
mothers with at least a fifth-grade education. In this study, the PSI was completed
in its entirety at baseline and at follow-up.
Percentile scores are used to interpret an individual's PSI scores. The percentile
scores are derived from a norming sample of over 2600 mothers with children ages
1 month to 12 years. Scores within the 15th to 80th percentiles are considered in
the normal range. High scores. at or above the 85th percentile. indicate a need
for clinical assessment and. possibly. intervention. The PSI has been shown to
discriminate between typically developing children and clinical groups (Abidin,
1990). It is widely used in evaluation research to identify changes in parent—child
dyads experiencing, or at risk for, parenting problems and child behavior disorders
•
Caughy. Grason, Guyer. Hughar. Jones. & Strobino. 1996: Mathematica Policy
Research & Administration on Children Youth and Families. 1997).
PROMOTING TODDLERS' LANGUAGE 521
Standardized Tests of Child Language. Standardized assessments of child
language ability were identical to those used in Whitehurst's previous studies (see
• Whitehurst et al.. 1988; Valdez-Menchaca & Whitehurst. 1992). They are: the Pea-
body Picture Vocabulary Test, the Expressive One Word Picture Vocabulary Test.
and the verbal expression subtest of the Illinois Test of Psycholinguistic Abilities.
Language testing was conducted at the library by evaluators trained for this project;
where possible. a different version of the test was used at pretest than at post-test
and follow-up. Descriptions of the measures are provided below.
The Peabody Picture Vocabulary Test—Revised ( PPVT-R: Dunn & Dunn,
1981 ) is a standardized. multiple-choice test of receptive vocabulary. Testing encom-
passes both recognition and visual comprehension skills: the child is asked to look
at a plate of four pictures and point to the object named by the examiner. The
PPVT has two forms. L and M. with 175 plates in each form. The two forms are
highly correlated (Pearson r coefficients range from .65 to .89: Braken. Prasse. &
McCallum. 198I). In the current study. Form L was used at pretesting,. and form
M was used at post-test and again. 3 months later. at the follow-up testing,.
The Expressive One-Word Picture Vocabulary Test ( EOWPVT: Gardner. 1979:
EOWPVT-R: Gardner. 1990) is a test of expressive vocabulary that asks the child
to name pictures of common objects. Test items fall into four categories: general
concepts. groupings. abstract concepts. and descriptive concepts. Concurrent corre-
lations with scores of receptive language. as measured by the Peabody Vocabulary
Test, range from .67 to .78. with a median of .70 (Gardner. 1979). The two forms
. used in this study are the older 1979 version and the revised 1990 version. The two
forms are highly correlated; coefficients range from .84 to .93 and the average
correlation across all age groups is .87 (Gardner. 1990). The EOWPVT was adminis-
tered at baseline. the revised version was used at post-test and follow-up.
The third standardized test used in this study was t.iie verbal expressive subtest
of the Illinois Test of Psycholinguistic Abilities (ITPA: Kirk. McCarthy. & Kirk.
1968). This subscale assesses children's ability to put ideas into words by asking
them to describe simple objects. For instance. the child is handed a button and
asked. "Tell me all about this." If the description is incomplete. the examiner
encourages the child with prompts such as "What do we call it?" or "What can you
do with it?" Scoring focuses on the number of discrete concepts expressed by the
child (e.g.. label and classification. shape. function. color). Because there is only
one version of the ITPA. it was not administered at baseline to avoid potential
item familiarity. It was administered at post-test and follow-up.
RESULTS
Sociodemographics
Family sociodemographics and characteristics of the study children are pre-
sented in Tables 2 and 3. Similar to the city as a whole. most mothers (81%) were
• white. The largest minority group to participate in the study was of African Ameri-
can mothers (12%). the next largest was Asian (3%). Mothers' average age was
34 years. Most (88%) were living with a spouse or partner. It was not uncommon
522 HUEBNER
Table 2. Baseline Sociodemographics and Family Stress for the Randomized Sample .
Combined Group Dialogic Reading Comparison S
IN = 129). In = 88), (n = 41),
Nil (SD) or % M (SD) or °G% M (SD) or %
Mother's .Age (yrs) 34.08 (5.28) 34.41 (4.68) 33.337 (6.40)
Mother's Education (yrs) 15.65 (2.09) 15.7 (2.07) 15.39 (2.15)
•
Mother's Race or Ethnicity
White 81% 82% 81%
African American 12% 11% 12%
.Asian3oio 3% 0 2oi
Other and Mixed 4% 4% 5% .
Living with Spouse or Partner (yes) 88% 92% 78%
Mother Works Outside Home (yes) 49% 47% 54%
Source of Family Income (government
assistance) 10% 8% 15%
No. Children in Home 1.74 (1.05) 1.76 (1.02) 1.71 (1.12)
No. Adults in Home 2.08 (0.68) 2.10 (0.68) 2.02 (0.69)
PSI Parenting Stress Totala 215.39 (37.03) 213.55 (33.91) 221.05 (43.19)
PSI Parent Domain 117.95 (22.16) 117.07 (20.39) 119.39 (25.33)
PSI Child Domain 97.93 (17.29) 96.48 (16.26) 101.16 (19.20)
PSI Life Stress Scale 6.37 (6.02) 6.19 (5.95) 6.79 (6.25)
.bores: Tests for differences between groups were not statistically significant except for the proportion of mothers
living with versus without a spouse or partner f k- = 5.04.p < .05).
.Ni = 129 for the combined group on all variables except the PSI. n = 122. •
for households to include extended family and unrelated adults: 10% of households
had three or more adults, the number of adults in the home was reportedly as
high as six. Approximately half the study children were first-born children without
younger siblings. Only 6 households (5%) had four or more children. The most
common source of income was from two wages: nearly half the study mothers
worked outside the home. Ten percent reported government assistance as their
main source of income.
As may be expected from the neighborhood demographics presented earlier,
families that comprised the north- and south-end library groups differed significantly
(p < .01). Proportionally more of the south-end mothers were minority women
(39% vs. 5% in the north end), more were single parents (26% vs. 4% in the north
end). and proportionally more of the south-end families received public assistance
(20% vs. 4%).
Parenting Stress and Life Stress at Baseline
At intake to the study, the average PSI total score was 216 points: 12% of parents
scored above the recommended cutoff for high parenting stress. The separate parent
and child domain subscores indicated that characteristics of the child most frequently •
contributed to overall stress. The two subscales that were most frequently elevated
were related to parents' view of their child's mood as unhappy (child mood, 13%)
or their interactions with their child as unrewarding (child reinforces parent, 20%).
PROMOTING TODDLERS' LANGUAGE 523
Table 3. Child Characteristics of the Randomized Sample
Combined Dialogic
• Group. Recding. Comparison.
N1 (SD) or ";> NI (SDI or NI 'SD) or %,
Chronological Age (mos) 25.71 (3.32) 25.61 (3.21) 25.93 (3.59)
Sex (male) 61% 64% 56%
Birth Order (firstborn) h8"4, 700/ 63°%
Premature Birth (yes) 1°, 5%
3%
Health or Speech Problem (yes) 7 7%
Ear Infection or Pain (yes) 66% 63% 5690
In Preschool or Daycare (yes) 59% 60 56%
Read to 4 or More Times per Week (yes) 91% 93% 88%
Enjoys Reading Very Much or "Loves It" 92% 93% 90%
Standardized Language Tests
PPVT Standard Score 11)5.19 (16.71) 106.42 ( 17.35) 102.55 (15.10)
EOWPVT Standard Score 110.74 (25.05) 114.39 (24.44) 102.97 (24.94) •
�nrr:
.V = 129 for the combined group on all sociodemographic and health variables. For the standardized tests.n =
126 for the PPVT and is = 125 for the EOWPVT: three children declined both tests: one declined only the
EOWPVT. Within the dialogic reading group. sample size for child variables ranged from '44 to 58: sample size
ranged from 38 to 41 in the comparison group. Tests for differences between groups based on baseline child
characteristics were not statistically significant except for the:-test of differences in EOWPVT t= 2.-12.p <.051.
The sum of all six child subscales form an overall child domain score: it exceeded
the recommended high-stress cutoff for 1200 of sample.
• Parent domain scores were elevated for 7% of the sample. The two parent
subscales most frequently elevated were related to poor health (parents' health.
21%) and a stressful relationship with their spouse or partner (relationship with
spouse subscale. 13%). In addition to overall and domain scores. the PSI contains
a subscale that reflects defensive responding: this subscale was elevated for 11%
of the respondents.
At baseline. the average score on the PSI Life Stress Scale was approximately
6.4 points: total scores ranged from 0 to 27 points. Only 7% of families earned
scores above the recommended cutoff for high life stress (see Abidin. 1990).
Child Characteristics and Language Ability at Baseline
The average age of the study children at pretesting was 28 months: the age
range spanned the inclusion criteria. from 24 through 35 months. Sixty-one percent
were boys. and 68% were firstborn. Only 4% of the sample was reportedly born 4
or more weeks early. Mothers reported health or speech problems for 7% of the
study children: 66% had been medically treated for ear infections or ear pain. Fifty-
nine percent of the children attended preschool or daycare programs outside their
own homes. Most parents (81%) reported reading with their child four or more
times per week.
Not surprisingly. given the eligibility criteria and screening process. few children
• evinced speech or language problems of the degree to warrant professional services.
There was. however. considerable variability in baseline test scores and baseline
524 HUEBNER
parent—child reading. For example. of the 126 who completed the PPVT test of
vocabulary comprehension (3 children declined). 43 scored below 100. Of these,
22 children ( 17% of the total sample) could be considered "at risk" for language •
problems because of below-average test performance and one or more of the
following concomitant psychosocial risk factors: maternal education less than 12
years: mother single: family poverty: PSI parent. child, or life stress score above
cutoff: or high defensive responding.
Intervention Group Differences at Baseline
Random assignment resulted in study groups that were roughly equivalent in
terms of intake family and child characteristics. Table 2 shows a tendency for the
families in the comparison group to be at slightly greater social disadvantage;
however, statistical tests of differences between groups were significant only for
one demographic variable, marital status. Compared with mothers in the dialogic-
reading condition, mothers in the comparison group were less likely to report living
with a spouse or partner (92%o vs. 78%. p < .05).
One test for differences in baseline child language scores reached statistical
significance. The difference. in EOWPVT. was approximately 11 points, equivalent
to nearly one half of one standard deviation (r = 2.42. p < .05) and favored the
dialogic-reading group. Pretest PPVT scores were also higher in the dialogic group,
but the difference was not statistically significant (Table 3). In contrast. analyses
of language skill during baseline reading favored children in the comparison group,
but did not reach statistical significance (Table 4). •
Analysis of Parent—Child Reading Over Time
Coding Method Audiotapes of reading sessions at baseline, after sessions 1
and 2. and at follow-up were used to monitor reading style over time. The purpose
was to identify parents' use of interactive behaviors that characterize dialogic read-
ing. The coding scheme was a time-interval based scheme in which coders listened
to10-secondintervals of taped reading and indicated the frequency of parent and
child behaviors that occurred in that period. Coders were unaware of families' study
group assignment and all other assessments. Five minutes of reading were coded
from the baseline and follow-up audiotapes (recorded in the library), and 10 minutes
were coded from the intervention-period audiotapes (recorded in the home).
Coders were trained on 17 audiotapes that included multiple examples of read-
ing behaviors that parents in the dialogic group were asked to increase (e.g.. "What?"
questions. questions about function or attributes, repetition. labeling, imitative
directives, praise. open-ended questions. and expansions) and to decrease (e.g.,
reading without including the child, use of yes-or-no questions. pointing questions,
and criticism). Counts of children's language behaviors included the frequency of
nonlexicalized vocalizations, one-word utterances, and multiword phrases. Coding
proficiency, between the coder and an "expert" (the project coordinator), was
demonstrated on a second set of 12 tapes. Intraclass correlations between the coder •
and expert ranged from .75 to .98 and averaged .91 for 10 of the 12 parenting
behaviors. Two parent behaviors (pointing questions and criticisms) were omitted
PROMOTING TODDLERS' LANGUAGE 525
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526 HUEBNER
from the computation because they rarely occurred. Intraclass correlations for
child behaviors were .61 for vocalizations. .98 for one-word utterances. and .97 for
1111
multiword phrases. Because vocalizations were not a targeted child behavior. vet
one-word and multiword utterances were, this level of agreement was judged to
be adequate. Training to this level of proficiency took approximately 90 hours.
Inter-rater reliability was computed for 20% of the tapes chosen at random over
the coding period. The average intraclass correlation for parents' reading behaviors
was .92: the range was .78 to 1.00. Coefficients for the three child behaviors were
.98 or above.
Three coders unaware of all other assessments transcribed the child's spoken
language from the same set of audiotapes used for behavior coding. The written
transcripts were used to compute a free-speech measure of children's syntactic
maturity. mean length of utterance (MLU). The measure used in analyses reported
here. MLU-5. was based on words (Nelson. 1977) rather than morphemes. and on
the longest five utterances rather than the entire speech sample. because in this
study, the amount and clarity of child speech varied greatly. Mean length of
utterance was computed based on the child's longest five utterances from tran-
scripts of the in-library reading sessions and from the first 5 minutes of the home
reading sessions.
Training to compute MLU-5 took place on a subset of 30 practice tapes. Profi-
ciency was demonstrated on a set of 10 tapes. Inter-rater agreement. indicated by
Pearson correlation with an "expert" (the study investigator) was .98 for coder A
and .97 for coder B. Training to this level of proficiency took approximately 40 •
hours. Inter-rater reliability between coders A and B was computed for 10% of
the tapes chosen at random during the coding period: the correlation was .90.
Changes in Parent—Child Reading Over Time: Table 4 summarizes the con-
tent of parent—child reading over time by intervention group. At baseline. parents
were remarkably similar in their lack of dialogic reading behaviors. At baseline,
the sum of dialogic reading behaviors over the 5-minute period was 20 for parents
in the dialogic group and 2-4 for parents in the comparison group. The groups were
also similar inthefrequency of behaviors the dialogic-reading group would be
instructed to diminish. On average, these nondialogic reading behaviors occurred
53 times (in 5 minutes) among parents in the dialogic group and 51 times among
parents in the comparison group. The most common behavior in both groups was
for parents to read the text without engaging the child in conversation about the
story.
After the parent sessions. the reading behavior of parents and children in the
dialogic-reading condition changed dramatically. Audiotapes of home reading in
the weeks after each of the two training sessions showed that the frequency of
dialogic-reading behaviors among dialogic-group parents increased to approxi-
mately 2.5 times their own baseline level, which was more than 2.5 times the
concurrent level of the comparison group (Table 4). Likewise. dialogic-group par-
ents diminished nondialogic reading behaviors to two thirds of their own baseline, .
a level that was approximately one half that of their comparison-group counterparts.
In contrast. the reading style of comparison-group parents changed little during
the intervention period.
PROMOTING TODDLERS' LANGUAGE 527
Table 5. deans of Child Language Test Scores at Post-test and
• ANCOVA by Intervention Group
Diah ,ic Rcm1ing G'mparistm
L.rn;ruai;r T sr NI !SDI n VI (SDi it .-1.VCOV,1 p
PPVT I15.00 ( 15.;31 ,u 111.11 ( 12.03) 36 F( 1.112) = .6, .41
EOWPVT 117.3h ( 16.22) ,S 114.03 ( 17.4 ) 36 F(1.111) = 27 .60
ITP.V V.E. 40.7; (5.001 75 34.44 (6.11) 36 F(1.1111 = 0.46 .003
�.'rcc: O0 of each .tud% `-'roup Was lot Crum contact between pre- and post-testlhg.
Analyses of children's language during reading also revealed group differences.
Compared with the comparison group. during book reading the dialogic-reading
group children used almost twice as many multiword utterances. more one-word
utterances, and had longer MLU-5s.
Pearson correlations were computed to assess the strength of concurrent rela-
tions between parent's behavior and child language during shared reading. The
association between dialogic reading behaviors and the frequency of multiword and
one-word utterances was highly significant after training sessions 1 and 2 (r ranged
from .55 to .64, p < .001). Likewise correlations between the sum of nondialogic
behaviors and child language were consistently strong and negative (r ranged from
—.39 to —.66. p < .001).
IIIIntervention Group Differences at Post-Test
Having established that training in dialogic reading achieved the goal of chang-
ing the interactive behavior of both parents and children. the next step was to
examine group differences in postintervention scores on the child language tests:
the PPVT, the EOWPVT, and verbal expression as measured by the ITPA. Post-
testing took place at the library within 6 weeks after the end of the 6-week interven-
tion period.
Analyses of differences between the dialogic-reading and comparison groups at
post-test were by "intent to treat." meaning that families were grouped as originally
assigned to the dialogic or comparison condition regardless of their actual reading
style or home reading habits. This analytic approach preserves the value of random-
ization to control baseline confounders that could be related to compliance with
the intervention (Hulley & Commings. 1988). Although possibly attenuating the
magnitude of the intervention effect, the advantage of this analytic approach is
that it increases the generalizability of these findings to other community-based
implementations of the dialogic reading program. Post-test data were available for
93% of the dialogic reading group and 93% of the comparison families.
Because of the imbalance in language scores between groups at pretesting,
differences in post-test scores were determined by analysis of variance: pretest
• scores were used as covariates to correct for initial differences. The results are
presented in Table 5. Differences, favoring the dialogic reading group. were signifi-
cant for one of the three standardized tests. After adjusting for differences in
expressive language at pretest (using pretest EOWPVT scores). the average post-
528 HUEBNER
test ITPA verbal expressive subtest score was 41 points for the dialogic-reading
group and 34 points for the comparison group (F(1,111 ) = 9.46, p < .01). The
difference, equivalent to more than one half of one standard deviation, is considered •
a medium effect size (Cohen. 1977). Differences in post-test PPVT and EOWPVT-R
scores also favored the dialogic-reading group. but did not reach statistical signifi-
cance.
Intervention Group Differences at Follow-Up
Parents who participated in the first two waves of the intervention were con-
tacted approximately 3 months after their post-test appointment for additional
follow-up testing. Fifty of the 62 eligible families (81%) returned for the follow-
up evaluation.
As before. analysis of the child language test scores showed no intervention-
group effect on the follow-up PPVT or EOWPVT-R scores. In addition, at follow-
up. the difference between groups on the ITPA verbal expressive subtest had
diminished and was no longer statistically significant. Between post-test and follow-
up, the mean score of both intervention groups increased. The adjusted mean for
the dialogic reading group was 41.03 points, a negligible increase over the adjusted
post-test mean of 40.73. The adjusted mean for the comparison group was 38.78
points. 4 points higher than the adjusted post-test mean for that group.
At first glance. it appears that dialogic reading gave children a boost in expres-
sive skills. but that by follow-up. comparison group children had begun to catch
up. Perhaps catch-up was the result of maturational gains within the comparison
group: however, two alternative, or additional, explanations are also likely. Inadver-
tently, there was group mixing in the 3-month interval after post-testing and before
the follow-up. As soon as the formal intervention period ended. librarians and
parents relaxed their allegiance to group secrecy and information about the two
conditions was shared casually. No data were available on the frequency of this
practice. although the extent to which dialogic-group parents continued using dia-
logic reading and to which comparison group parents adopted the dialogic style on
their own was assessed with families who participated in the follow-up testing.
Analyses of audiotapes of parent—child reading recorded in the library at the follow-
up test appointment showed persistent group differences in parents' reading style,
vet the means were more similar than before. The mean number of dialogic reading
behaviors among the trained dialogic reading group was 39 (SD = 14): the mean
of the comparison group was 27 (SD = 18. p < .05: data not tabled). Compared
with all three prior data points, for the first time. dialogic reading increased among
comparison-group parents. Presumably this change was brought about by their
recent exposure to the intervention techniques.
Group Differences in Parenting Stress at Follow-Up
An a priori hypothesis of this study concerned the effect of the intervention
on self-reported parenting stress. Because the techniques of dialogic reading are •
similar to the play skills taught in interventions with parents of behaviorally difficult
preschool children (see Webster-Stratton. 1991, for a discussion of these treatment
• PROMOTING TODDLERS' LANGUAGE 529
Table 6. Means of Parenting Stress Scores at 3-Month Follow-Up and
ANCOVA by Intervention Group
f Ltrc'trtim Stress
Diatlo�ic• R�•uclitt. CHmpurisnn
Itrtl'.r t PSI,' N1 (SD) n N1 (SD) n ,1NCOl
Total Score 206.00 (32.8) 34 220.86 (47.32) 14 Fl 1.45) = 4.48 .04
Parent Domain 111.47 (211.12) 34 116.86 (25.79) 14 F(1.45) = 2.33 .13
Child Domain 94.53 ( 16.68) 34 11)4.00 (25.00) 14 F(1.45) = 5.89 .02
•
.yute•s: Only families who were among the tirst and second waves to participate in the intervention
were eligible for the follow-up assessment: PSI follow-up data were available for 18 of these
n2 eligible families.
strategies). it seemed likely that dialogic reading could alleviate or prevent parenting
stress. especially stress emanating from characteristics of the child. Comparisons
of PSI parenting stress scores at baseline and follow-up suggest this was so.
Analysis of variance with baseline PSI as a covariate revealed significant group
effects on overall parenting stress and the child domain score (see Table 6). Analyses
based on the proportion of high scores in the two groups showed a similar pattern.
The proportion of high child domain scores in the two groups was not significantly
different at baseline for the full sample or for the subset who participated in follow-
up testing. However, at follow-up. there was a five-fold difference between the two
groups' child domain scores (p < .05. Fisher's exact test). Twenty-nine percent of
• comparison-group families and 6% of the dialogic-reading group families scored
above the cutoff for high stress. For the follow-up subsample as a whole. the three
most frequently elevated child subscales were related to negative mood. difficulty
adjusting to changes, and the parent's view of the child as rewarding. Only 4% of
parent domain scores were above the recommended cutoff for high stress: the most
frequently elevated parent subscale reflected feelings of emotional closeness to the
child (i.e.. parental attachment).
Effect of Recruiting Method on Sample Composition
Despite widespread recruiting and the participation of four different neighbor-
hood libraries. relatively few families of lower socioeconomic status volunteered
for this study. Lack of variation within the sample precluded the opportunity to
examine potential socioeconomic status differences in baseline home reading prac-
tices or in the effects of dialogic training on parents' reading style. Interestingly,post-
hoc analyses revealed that family sociodemographics were related to the success of
various recruiting methods. When the recruiting methods were categorized by
source. a different pattern emerged for the central and south-end participants than
for the north-end participants (see Table 7). Although the manner of recruiting
was similar in all four library sites, the passive methods (e.g.. posting fliers in
community centers, grocery stores, newspapers) were notably less successful in
attracting families in the central and south-end (mixed-income) neighborhoods.
• Most of the lower-income. central, and south-end families who expressed interest
in the program came as a result of personal contact with study personnel or as a
530 HUEBNER
consequence of participating in other library activities. That is. for these parents,
establishing a relationship with project personnel preceded their involvement. In
contrast, approximately half of the north-end parents came to the program having
heard about it second-hand through a friend, a Hier in a store. coffee house, or
community center.
Discuss1UN
This study tested the usefulness of a simple and effective shared reading method
that helps facilitate young children's language development. Dialogic reading, as
modified here, led to favorable changes in parent—child reading style. in children's
language use during reading. and as measured by a standardized test of expressive
language skill. These findings encourage further dissemination and evaluation of
the dialogic-reading method within other programs for parents and their "pre"
preschool-age children.
Because this study modified the original dialogic-reading program to reach
more parents via community-based trainings. the integrity of the intervention was
monitored closely. Audiotapes of parent—child reading at home and at the library
were coded to determine parents' reading style before. during. and after the inter-
vention period. Analyses of the baseline tapes showed that parents typically did
not use an interactive. dialogic style. The result of brief instruction by neighborhood
librarians was remarkable. Dialogic-reading group parents changed their reading
style dramatically after only one 1-hour training session. Audiotapes of home read-
ing showed they used the new dialogic techniques at home and continued to do so
3 months after intervention, at the follow-up assessment. In contrast. during the •
intervention period. comparison group parents continued reading as they had at
baseline. Within the dialogic-reading group. changes in parent's manner of reading
were associated with changes in the child's reading style. During book reading,
children in the dialogic-reading group became more involved in telling the story:
they spoke more often and used more multiphrase utterances and more complex
speech.
Future research is needed to learn whether training in dialogic reading changes
the interaction style of parents and children in settings other than shared book
reading. In this study. assessment of its effects on vocabulary knowledge and conver-
sational skill outside the context of reading was limited to the children's performance
on three standardized tests. Two tests. moderately correlated with each other (the
PPVT and the EOWPVT-R). were of single-word vocabulary. whereas the ITPA
verbal expressive subtest elicited the use of language to express ideas. Analysis of
pre- to post-test change showed significant intervention-group differences on one
test, the ITPA verbal expressive subtest. In light of the initial skill level of the
children in this study. this finding is not entirely unexpected. Recall that at baseline,
all children were talkative. intelligible. and capable of combining words: on average.
their maximum sentence length during reading was between 3 and 4 words (Table
4). It is likely this level of proficiency limited the ability to document increases in
vocabulary as measured by a brief standardized test. For younger or less mature
groups of children in the midst of the vocabulary growth spurt. one could expect .
PROMOTING TODDLERS' LANGUAGE 531
program effects to he more apparent in tests of single-word vocabulary. In fact.
previous studies of dialogic reading with less highly functioning children reported
• significant intervention-group gains as measured by the EOWPVT and PPVT, but
not the ITPA verbal expressive suhtest ( Lonigan. 1993: Whitehurst. Arnold. Epstein,
Angell. Smith. & Fischel. 1993).
It is perhaps surprising that within this study of relatively advantaged families.
there were children who could he considered at risk for future language, and possibly
school. difficulties. Although a single test or testing series can not be considered
diagnostic, a nontrivial subset of study children did earn lower than average test
scores. At baseline. 34% scored less than 100 on the PPVT. a receptive vocabulary
test, including 10% who scored 4 or more months below age level. Of those who
scored below IUU, more than half (or 17% of the total sample) could be considered
at risk for language delay by virtue of having PPVT scores below average and one
or more family risk factors such as low maternal education or high family stress
(Levenstein et al.. 199$). The fact that so many children were identified as early
as age 2. even within this low-risk sample. underscores the value of this inexpensive
parent—toddler reading program as a universal preventive intervention activity.
Widespread community-based programs such as this, designed for Young children
in a stage of rapid maturation, can serve three related goals: to promote the language
development of all children, to identify those at risk for language problems. and
to refer those in need to ameliorative services early and during a developmental
period that is particularly amenable to intervention.
An unusual hypothesis explored in this study was that an interactive. language-
focused• intervention would have an additional positive effect on self-reported par-
enting stress. It is well recognized that throughout the lifespan, but particularly in
early childhood. physical. mental. and emotional capacities are functionally inte-
grated such that maturation in one domain can be associated with advances in
another (Zeanah. Boris. & Larrieu. 1997). Conversely. delays and difficulties can
also affect multiple areas of development. Specifically, among preschool and school-
age children. language and behavior problems are highly correlated (Benasich.
Curtiss. & Tallal. 1993: Cohen. Davine. Horodezkv. Lipsett & Issacson. 1993:
Purvis & Tannock. 1997: Stevenson & Richman. 1975). Thus it seemed likely that
the dialogic reading could benefit parents and children negotiating the "terrible
two's" because it offers parents a way to let their child practice autonomy and
independence within a developmentally appropriate and widely valued context:
shared book reading. The data supported this proposition. Analyses of follow-up
scores on the PSI showed a five-fold difference between the study groups after
controlling for baseline scores. Parents in the comparison group were most likely
to report elevated stress because of acceptability of the child and child's negative
mood. Both sources of stress threaten parents' availability to a child who is perceived
as demanding and unrewarding. Because brief community-based programs such as
dialogic reading are intended for all families, and thereby do not stigmatize selected
groups. they could be a way to help parents smooth out difficulties that are common
• in the preschool years. while offering a first step to more intensive services for
families experiencing more persistent problems.
A limitation of the program. as carried out here. was that it was difficult to
532 HUEBNER
recruit families and children at greatest socioeconomic risk for language problems.
Analyses of study enrollment by recruiting method yielded an important lesson— •
lower-income mothers and those with less formal education were more likely to
join the study as a result of in-person. one-to-one recruiting methods. This finding
has important implications for those interested in providing parenting-support ser-
vices to lower-income, higher-risk families. Considerable time and resources may be
needed, in advance of program enrollment. to build personal relationships between
program staff. community leaders, and parent participants.
Findings from this study are being used to generate ideas about how to reach
families who were not eligible, or did not volunteer. for the present program,
including parents with low literacy skills. those who read infrequently. and those
who find trips to the library too inconvenient (Huebner, in press). In families whose
parents have difficulty reading or are in distress, overwhelmed. or socially isolated,
children are at highest risk for communication and behavior problems (Morisset,
Barnard. Greenberg. Booth, & Spieker. 1990). For them especially, simple book
give-away programs and public service announcements to encourage reading are
not enough. Young children need adults who can help them make the most out of
book-reading experiences.
To bolster the cognitive and social functioning of children in low-resource. high-
risk families requires comprehensive, intensive. two-generational. individualized
programs (Levenstein et al.. 1998: The Infant Health and Development Program,
1990: Ramey & Campbell. 1984: Ramey& Ramey. 1998). including on-going instruc- •
tion in parent–child literacy activities (Cronan. Cruz. Arriaga. & Sarkin, 1996).
Children whose parents are unable to provide home learning experiences,
including reading. may gain even more from one-to-one interaction with other
caregivers. such as child care workers, preschool teachers, or volunteers. Whether
parents and professionals who work with very young children can find time, daily,
for 5 to 10 minutes of one-to-one reading depends on their priorities and beliefs
about the value reading (DeBaryshe. 1995). Dialogic reading is an interactive read-
ing style that is inexpensive. simple to teach, and easy to adopt. Even more impor-
tantly. it is a potent intervention that can maximize the benefits of shared reading
for language development right from the start.
Acknowledgments: This research was conducted while the author was a post-
doctoral fellow at the University of Washington and was supported by grants from
the John D. and Catherine T. MacArthur Foundation. Major support for this study
was provided by the John D. and Catherine T. MacArthur Foundation through
grants to Kathryn E. Barnard under whose mentorship this work was completed.
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Developmental Psychology. 24. 552-559.
Zeanah. C. T.. Boris. N. W.. & Larrieu. J. A. (1997). Infant development and developmental risk: A
review of the past 10 Years.Journal of the American:academy of Child and Adolescent Psychiatry.
36. 165-178.
•
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• C p,n,ht C 2000,Lawrence Erlbaum Associates.Inc.
Community-Based Support for Preschool
Readiness Among Children in Poverty
Colleen E. Huebner
Department of Health Services
School of Public Health and Community Medicine
University of Washington
This study tested the feasibility of an intervention designed to increase the frequency
and quality of shared reading among low-income parents and their young, 2- and
3-year-old children.The program was based on an interactive reading method known
to facilitate children's receptive and expressive language skills. Study participants
were 61 children and their parents;they resided in 1 of 2 socioeconomically disadvan-
taged communities. Prior to the intervention, few parents reported frequent home
reading,and most children's language skills were at or below that of others'their age.
411111 Atter the intervention,the frequency of home reading more than doubled,and signifi-
cantly more parents reported their children enjoyed shared reading.This study dem-
onstrates that relatively simple,inexpensive,community-based programs can change
the home language and literacy activities of families with young children,including
those most likely to begin school less"ready"than their middle-class peers.
Despite the national goal that"by the year 2000 all children in America will start
school ready to learn" (Goals 2000: Educate American Act, 1994), an alarming
number of the nation's children are not prepared for academic lessons when they
enter formal schooling.The reasons are complex. One contributing factor may be
that increasingly harsh social and economic circumstances provide fewer opportu-
nities for parents to feel supported,competent,and able to meet the day-to-day de-
mands of family life.In the past 25 years the proportion of children who live in pov-
erty has risen steadily. This is especially true for very young children; currently
nearly one child in four under 6 years of age lives in poverty (Lamison-White,
Requests for reprints should be sent to Colleen E.Huebner,Maternal and Child Health Program,Box
357230.Department of Health Services,School of Public Health and Community Medicine,University
of Washington,Seattle,WA 98185.E-mail:colleenhla,u.washington.edu
292 ER:EBNER
1097). When parents are not able to meet basic economic needs,it is especially dif-
ficult for them to provide socially and emotionally for their young children
(Barnard. Morisset, & Spieker, 1993;Conger et al.. 1992; McLoyd, 1990; Ramey
&Ramey. 1990: Schor, 1995).The cumulative effect of unremitting economic dis-
tress is reflected in a less stimulating,less responsive and more punitive parenting
style that is more common among lower-income parents and parents who are
young, less educated, and raising their children alone (Conger, McCarty, Yang,
Lahey, & Kropp, 1984: Culp. Culp, Osofsky, & Osofsky, 1991; Dodge, Pettit. &
Bates, 1994: Hashima&Amato, 1994;Haskins, 1986:Kelley,Power.& Winbush,
1992;McLovd, 1990).Given the hardship of poverty and the accompanying social
and personal stress, perhaps it is not surprising that children whose families are
poor are less likely to be ready for kindergarten,more likely to fall behind in grade
school, and more likely to drop out of high school (Duncan, Brooks-Gunn, &
Klebanov, 1994; Hare & Castenell, 1985; Krein & Beller, 1988; Schweinhart,
1994; Zill, Collins, West, Hausken, 1995).
A second impediment to parents'ability to prepare their children for school re-
Iri
lates to recent changes in the labor market that require more time in the workforce
for nearly all parents to adequately support their families and maintain their em-
• ployment. One result has been a new "poverty of time" (Fuchs. 1988). Working
parents, but especially working-poor parents who cannot afford to purchase mate-
rial resources and help with basic household chores, are short on time for their
families(Smith, 1989). Lack of time can limit parents'ability to provide for the in-
strumental, emotional, and educational needs of their children. A recent national
poll of over 1,000 parents of infants and toddlers found that nearly half the parents
surveyed end most days having spent less time than they wanted to with their chil-
dren(ZERO TO THREE, 1997).
The social and economic conditions that have created a steady increase in the
number of families who are struggling, including an additional 1.4 million new
working-poor families between 1989 and 1996. show no signs of reversal (Annie
E. Casey Foundation, 1998). Thus, although social and health service profession-
als advocate for the policy changes necessary for long-term improvement,we must
acknowledge that the problems of too little time for parenting and too little money
for adequate child care are daily realities for millions of American families.As in-
terventionists, and in program planning, the education and service communities
must be ready to function within the constraints of limited time and limited money.
In short, we must work "smarter" on behalf of families and young children
(Barnard. 1995). To do so requires that we articulate the models and assumptions
that support our intervention efforts and evaluate our programs and practices with
scientific rigor.To do less insults the hard-earned time and trust of families we in-
tend to help (Morisset, 1996).
No single intervention will ameliorate the disadvantages faced by young chil-
li/ dren from poor families. Individual families' needs and resources must be con-
iii
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SUPPORT FOR PRESCHOOL READINESS 293
sidered when determining the timing, intensity, and duration of supportive
services. With regard to educational intervention programs, some children, for
instance those of mothers with limited intellectual abilities, respond favorably to
intensive. continuous educational interventions that begin in infancy (Ramey,
Bryant. Campbell, Sparling, & Wasik, 1988; Ramey & Ramey. 1990). Other
children can benefit from relatively less intensive center-based programs, in-
cluding Head Start (Barnett. 1995; Schweinhart, 1994). Home-based family sup-
port programs can also have positive effects on opportunities for children's
learning and on the quality of parent—child interaction (Booth. Barnard, Mitch-
ell, & Spieker, 1987; Seitz. 1990; Yoshikawa, 1995). As these illustrations
show, formal preventive intervention programs vary in focus, intensity, and du-
ration of services.
Neighborhood and community networks can shape the lives of children and
families also, but they do so through more informal means (Bronfenbrenner,
1986).The"ecology"of the community affects families through the concentration
and persistence of poverty and violence;the richness of resources, such as family
centers and parent-support groups; and the number and function of local institu-
tions, such as churches, public transportation, schools, and health and child wel-
fare(Young& Marx, 1992). Natural support networks, such as extended family,
religious groups,merchants,or social clubs,benefit children indirectly by provid-
ing parents with instrumental and emotional support (Delgado, 1992; Dunst,
Trivette. & Deal. 1988). They can also affect the quality of parent—child interac-
tion directly,through social expectations and by modeling desirable parenting be-
• havior(Cochran& Brassard, 1979: Cotterell. 1986).
Experts in early child development emphasize home reading as one way parents
can support their children's learning and readiness for school (Boyer, 1991). The
relations between home reading and later school achievement are multiple and
complex (Snow, Barnes, Chandler. Goodman. & Hemphill, 1991). At the youn-
gest ages, there is general agreement that parent—child reading can add substan-
tively to children's vocabulary and emergent literacy skills(Bus,van IJzendoom,
&Pellegrini, 1995;Lonigan, 1994).Differences in the frequency of shared reading
are apparent as early as the child's first 3 years of life and are strongly associated
with parents'education and income(Young,Davis,Schoen, &Parker, 1998). So-
cioeconomic differences in home literacy activities persist throughout the pre-
school years. For example, the 1996 National Household Education Survey
identified a strong linear relationship between parent education and home reading
with preschool-age children. Among parents with less than a high school educa-
tion, only 59% reported reading three or more times per week with their 3- to
5-year-old children; the percentage was 77%among those with a high school di-
ploma or GED,87%among those with some college,91%among those with a col-
lege degree,and 96%among parents with a graduate or professional degree(Wirt
et al., 1998).
I.
294 HLEBNER
This study tested the feasibility of a community-based intervention de- _
signed to increase the frequency and quality of home reading among lower-in- ten
I come, less well-educated parents and their young, 2- and 3-year-old children. anc
I The program was based on an interactive "dialogic" reading method known to T
facilitate the expressive language skills of children from lower- and middle-in-
I come homes; and children with normal development and developmental dis-
abilities(Dale, Craine-Thoreson, Notari, &Cole, 1996; Lonigan& Whitehurst,
1998; Whitehurst et al., 1988). Dialogic Reading differs from typical reading
in that it emphasizes active involvement of the child in telling, and retelling,
the story. Instruction in Dialogic Reading consists of as few as two brief ses-
sions. The techniques, which include asking questions, expanding the child's If
responses, and giving praise, are straightforward and easy to demonstrate. In a
randomized controlled study of Dialogic Reading in Seattle, Washington, anal- ma
yses of audiotapes of home reading showed marked changes in parents' read-
ing style after attending each one of two I-hour training sessions with a• 319.
children's librarian. Compared with parents in a comparison condition, and
•
with their own baseline reading, parents in the Dialogic Reading intervention
group quickly learned to read with more questions, more expansions and repe- Sc
titions, and gave more praise. In turn, children in the Dialogic Reading group
'I used more one-word and multiword utterances during reading and showed Tv
'1
more sophisticated language skills on a standardized test of word use
(Huebner, in press). go
The results of the Seattle study are particularlyusmost co
ar-
ents began the program with a strong tradition of family readingcandethe major- I na
a
fir of the children were developing apace. That the intervention could enhance
the language abilities of these children testifies to the potency of the reading en
techniques. However, this unintended design "strength" limits the bt
generalizability of the Seattle findings to less socioeconomically advantaged st<
groups. In the Seattle study, only I O°% of the participating mothers were receiv- lit
ing government assistance or had not gone beyond 12 years of formal schooling.
Analysis of recruitment by recruiting method yielded an important lesson.In Se-
attle,lower income, less well-educated mothers were more likely to enroll in the
study if they had an opportunity to discuss the value of the home reading with p'
program staff and witness other parents' enthusiasm. In contrast, middle-in- pi
come, higher educated mothers were willing and eager to "sign up" and did so di
without the additional personal contact. Sociodemographic factors and
St
self-identified parenting stress were associated with parents' participation dur- i rr
ing the intervention, too. Parents with fewer social and financial resources were ft-
less likely to adopt regular reading as a family routine. Perhaps for some, spo- st
radic reading reflected their own discomfort with reading or the relative unim- n
III portance of literacy compared to more pressing family and neighborhood v,
problems(Gadsden, 1995).
illI )II'
II
l II
SUPPORT FOR PRESCHOOL READINESS 295
•
The purpose of the present study was to learn whether the Dialogic Reading in-
ter,entton could be adapted to communities characterized by widespread poverty
and reiati‘e!y low levels lit adult education. The primary questions were
Can the intervention he modified to titwithin existing systems of commu-
nity-based family support services?
2. Does the intervention change the home literacy activities of families in
socioeconomically disadvantaged communities in ways that are pleasur-
able and desirable to parents and their young "pre.'preschool children?
If successful, the results of this study will have significant implications for more
widespread use of the intervention. In particular. the findings can contribute infor-
mation to the national school readiness goal.ideas for Even Start programs,and de-
signs for other two-generational family literacy programs.
METHOD
Setting
Two communities IFC and NLi represented by local family resource centers'
governing councils chose to participate in this study. The resource centers were
contacted and offered participation because of their recent past involvement with
a community case study of child and family service systems conducted by the
national organization. ZERO TO THREE (View & Amos. 1994). The opportu-
•
nity to work cooperatively with ZERO TO THREE. a well-respected par-
ent—professional advocacy and education group. allowed the current project to
build on established relationships within the communities and gain a rich under-
standing of local services, service delivery systems. and the experience'of fami-
lies with young children.
FC. FC is a rural county in the western Lnited States. The county encom-
passes approximately L500 square miles and had a population of about 32.000 peo-
ple,including 1,771 children under 5 years of age(1990).According to U.S.census
data. in 1990 the poverty and unemployment rates were higher in FC than for the
state as a whole(http://www.census.gov).At the outset of the present study in 1994,
many FC families were receiving Aid for Families with Dependent Children.Most
families who received government aid were never-married mothers or families
supported temporarily because of periods of unemployment. Medium-sized busi-
nesses were scarce. and it was difficult to find ajob that paid more than minimum
wage.Residents of FC were predominately White.non-Latino in ethnicity(View&
Amos. l994).
296 HUEBNER
NL. tit, is a community that encompasses two census tracts of an urban Mid-
western city. It was the ninth poorest of that city's 77 communities. Former major
employers have left the area,and the rate of violent crime was high.more than double
that of the city as a whole. In 1995, at the time of the present study, many of NL's
streets were lined with boarded-up and burned-out shops and housing. Census data
from 1990 reported employment at about 25°'o; among those who were working,
many were underemployed,in low-wage jobs.The ethnic make-up of the community
was predominately(96%)African American las reported in View &Amos. 1994).
Recruitment
Recruitment to the study was organized by the participating family centers and took
the form of informational posters,announcements in the local newspaper,and word
of mouth.The program was open to all parents of 2-and 3-year-old children.Thus,
within each site, the intervention was universal in scope. This decision was based
on each community's insistence that the program be promoted as a special opportu-
nity for all families and not stigmatized as a remedial program for families and chil-
dren "at risk." Extra effort was made to include parents who, because of limited
economic and educational resources,might be less likely to read with their children
on a regular basis,as well as children observed to be slow in language acquisition.
In addition, a few families with children outside the preferred age range were in-
cluded at the request of parents and family center staff who felt they would benefit
from the reading program.
Content of the Intervention
The goal of the intervention was to encourage frequent parent-child reading and
teach parents a way to guide children's verbal participation during book reading
through the use of specific conversational devices, such as frequent•.:hat, where.
and why questions, open-ended questions.corrective feedback,and praise.The in-
tervention, based on the Dialogic Reading program for toddlers developed by
Whitehurst et al.( 1988),consists of two 1-hour parent-training sessions that occur
approximately 3 weeks apart.The training includes videotaped illustration.model-
ing,role play,and corrective feedback.In this study,paraprofessionals were taught
to conduct the parent-training sessions by the study investigator,who received her
training from the developers of the Dialogic Reading program.
Community adaptations of the intervention. In the original Whitehurst et
• al. (1988)study, parent training sessions were conducted one-to-one. In this study,
I
WNW
SUPPORT FOR PRESCHOOL READINESS 297
1110 -
the format was mom tied to accommodate individuals as well as small groups of par-
ems. When groups met,they viewed the videotape and then broke into pairs for the
one-to-one training. All parent-training sessions began with a discussion about the
value of books and reading for young children's development and ended with a ques-
:ton and answer penod:.a summary of goals for that phase of the intervention: re-
minder sheets for parents' use at home:reading logs to keep track of their home read-
ing sessions:and a magnet to display the reading logs in a prominent place,such as
their refrigerators.dost parents spent 3 weeks working with each set of reading tech-
niques for a total intervention period of 6 weeks.Occasionally,when family obliga-
tions conflicted or parents requested that their child go on.the increments were short-
ened to 2-week intervals. In both FC and NL,parents received three children's books
over the course of the study:one book at each of the two parent-training sessions and
a third book at the posttest data collection visit. In addition,parents who completed
both training sessions received a"certificate of excellence."
Other program adaptations were tailored with respect to the strengths and limi-
tations of the individual sites. As mentioned. paraprofessionals employed by the
participating family centers were responsible for recruitment and parent training
within each community. In FC. a rural, sparsely populated area with no public
transportation,the majority of the 25 parent participants received at home instruc-
tion in Dialogic Reading. Four of seven Even Start families learned the reading
techniques as part of their center-based Even Start literacy classes. Ail instruction
in Dialogic Reading was provided by one trained community resident. Parent
training, in home or at the center, was offered four successive times over a
10-month period.
In contrast. in densely populated SIL, all 33 parents began the intervention
within the same month.To accomplish this,parents met in small groups on several
different days at the family resource center. Child care was provided on site.The
parent-training sessions were conducted by pairs of paraprofessionals who worked
for the family center regularly as paid home visitors. A total of nine staff members
received training in Dialogic Reading. NL study families were drawn primarily
from the staffs existing case loads. Baseline and posttest data were collected as
part of their regularly scheduled home visits.
Remuneration. Each community received 53.000 to compensate for the ex-
penditures of time and resources required by the research activities.The governing
councils,with the family center staffs input, chose how to spend the money.The
NL center chose to purchase cellular telephones and air time for their home-visiting
teams' use. As described previously,NL was a very poor,often violent, inner-city
area.The telephones were a welcome safety measure. In NL.the remaining funds
were spent on a Dialogic Reading"graduation"celebration for study parents,chil-
dren.their other family members, and the reading program staff.
298 HUEBNER
In FC. approximately half the funds were used to establish parent-child book
nooks, one at the family center and another in the children's section of the county
library. One third of the money was used to hire a part-time Dialogic Reading in-
structor who also served as the project coordinator.This person.a community resi-
dent and mother of two preschool boys. took responsibility for all aspects of the
intervention, including recruiting, parent training, and data collection. The re-
maining funds went toward additional staff training and supplies necessary to con-
tinue the reading program beyond the study period.
Data Collection and Instruments
Data collection was organized in two time periods: pretest (or baseline) and
posttest.To facilitate parent and staff cooperation with the study protocol and mini-
mize respondent burden, primary data collection was kept to a minimum. Where
possible,and with parents'consent,routine information,such as marital status and
family size,was obtained from existing family center tiles. Information about chil-
i dren's literacy activities and language skills was obtained at baseline and posttest
from interviews with parents or self-administered written questionnaires. Parent
satisfaction was ascertained in the posttest interview through a series of
open-ended questions. Each type of data will be discussed in turn.
Sociodemograpnics. Information about the mother's age, education.
marital status, income,and household composition was abstracted from family
center records at baseline.The father's age and education were recorded only if
the father was living in the child's home. Additional information was collected
about family ethnicity and what languages. other than English, were spoken in
the home.
Children's interest in literacy. Children's interest in books and reading
was assessed from pre i baseline)and posttest parent interviews.Parents were asked
about the child's exposure to reading, including the age at which the parent began
reading with his or her child,who reads to the child,how frequently, and whether
the child enjoys being read to (Whitehurst et al., 1988). One item, Things Your
Child Likes to Do, was added based on the work of Needlman, Fried.Morely,Tay-
lor, & Zuckerman (1991). This was an open-ended question that asked parents to
name their children's three favorite activities.In this study,parents'responses were
scored yes or no based on whether reading was among the three items named.
Finally, to reflect the community-based context of this study, parents were asked
about visits to their public library and to children's storytimes.
1
fTTTTTTT
SUPPORT FOR PRESCHOOL READINESS 299
• Assessments of children's language abilities. Two methods that are rel-
atively brief and straightforward were used to collect pre- and posttest information
about expressive language skill.The first occurred as part of the baseline interview:
Parents were asked to recall the three longest sentences,or phrases.they had heard
their child say. Phrase length is considered a proxy for grammatical skill because,in
the early stages of multiword speech.increasing length is one sign of increasing syn-
tactic maturity(Fenson et al., 1993).The average length of the child's longest three
phrases was computed based on the number of grammatical units(morphemes)and
based on words. Relatively few children had more morphemes than words.To mini-
mize errors because of parent recall, the average length of utterance was based on
words rather than morphemes(e.g.. grammatical markers of plural and past tense).
After the interview,parents were asked to complete the MacArthur Short Form
Vocabulary Checklist: Level II (CDUSF II; Developmental Psychology Lab,
1993)as the second method of measuring expressive language skill. The CDUSF
II is a parent-report inventory of words typically said by children in the age range
of 16 through 30 months. Parents were asked to indicate which of the 100 words
they have heard their child say and whether or not their child has begun to combine
words(e.g.,"more juice").The CDUSF II toddler version is available in two paral-
lel forms (Form A and Form B). The inventory can be completed in less than 10
min by most literate parents or.as an alternative,it can be read aloud. In the present
study, parent preference determined the method of administration. Parents who
were obviously capable readers and grew impatient with the interview format,that
is,by reading ahead over the interviewer's shoulder, could complete the form on
i
their own.
The CDUSF is intended to identify children's expressive language skills and be
• ' sensitive to changes caused by maturation or intervention. In addition,by desig-
nating the 50th percentile as the average number of words typical of children at
monthly age increments. CDUSF norms can be used to estimate age equivalents
for developmentally delayed children whose chronological ages are beyond the
specified age ranges (Fenson, Pethick. & Cox. 1994). It was for these rea-
sons—brevity,availability of pre-and posttest forms,and the potential to interpret
the vocabulary skill of delayed children—that the CDUSF was chosen for this
study.
yr ( Parent satisfaction. As part of posttest data collection,parents were asked
`.- about their and their children's experiences in the intervention.The questions were
,o open-ended and asked. "what did you especially like, what didn't you like, what
was useful to you,and is there anything you'd like to change about this program."
Parents were also asked if they would continue to use Dialogic Reading in the fi1-
c1 tore.As before.parents could respond to the questions in an interview or as a writ-
ten questionnaire.
300 f-[ EBNER
RESULTS
Program Participants
Study participants included a total of 61 children and their families: 26 children
from 25 different families in FC,and 35 children from 33 different families in NL.
Sociodemographics of study participants are provided in Table 1.Recruiting meth- •
ods were successful in attracting a wide range of parents, including teens and par-
ents who had not completed high school,and families living in poverty.Compara-
•
tively,the families in NL experienced a relatively greater degree of socioeconomic
hardship: 52% were teens at the birth of their first baby, 53% had not completed
high school,88%were single parents,and 94%lived below the annual(1995)Fed-
eral Poverty Level. All participating NL mothers were African American. In FC,
88% of study mothers were White, non-Hispanic, and 12%were bilingual Span-
ish-speaking mothers who completed the program in English.In FC.20%were teen
•
parents, 32% had not graduated high school, 20% were single parents, and 40%
lived below the Federal Poverty Level.
Table I also provides information about the children participants.As intended,
the majority were between 2 and 3 years of age. In FC, only 39%of the sample
were boys: the ratio of boys to girls was about even in NL sample (51% boys).
•
Roughly one third of children in each sample were firstborn.
Children's Reading Exposure and Language Skills at
Baseline
Exposure and interest in literacy. At the baseline interview most parents
described books and reading as present in their homes(see Table 2).In both FC and
Ni,well over half said they began reading to their child before the children were 12
months of age (63% and 59%; average age 8.7 months and 9.9 months. respec-
tively). Children's books were currently available in all but one home. Most fami-
lies had at least five children's books. Relative to NL families, proportionately
more of the FC families had many, 11 or more.children's books.Within each of the
two communities,a greater number of children's books was associated with moth-
ers who were married,high school graduates.and with families supported by wages
rather than government assistance. At baseline, virtually all parents had observed
their young children looking at books, and two thirds or more said their child
"liked"or"loved" reading.
Despite positive descriptions of their home environment and of their child's
• past experience with books, few parents reported many current literacy activities.
Only 8%of FC children and 28%of NL children had been read to frequently,five
or more times,in the prior week.Only one third of the children had ever been to the
; -
Ili
A
SUPPORT FOR PRESCHOOL READQvESS 301
• TABLE 1
Descriptive Statistics of Study Participants by Site
FC Site .VL Site
.tf SD a bf SD °�
Mother's age(years) 23.3 4.6 25.6 -.1
Teen at first birth 20 57
Mother's education(years) 12.5 2.5 1 1 4 1.4
Not a high school 32 53
graduate
Mother's race or ethnicity
Black.not Hispanic 0 100
Hispanic 12 0
White.not Hispanic 38 0
Marital status(single) 20 88
Family income
Receiving government 20 79
assistance
Below federal poverty 40 94
level
Household size(adults and 4.5 1.6 4.3 1.5
children)
Child's age(months) 30.1 5.2 31.6 7.2
<2 years 3 0
2 years 62
80
3 years
35 14
4 years 0
6
4111) Child's sex(male) 39 51
Birth order(first born) 35 29
.dote. FC group included 26 children from 25 families:NI.group included 35 children from 33
families.
public library,and just one fourth had attended an out-of-home literacy event(e.g.,
a storvtime at the family center or visit to the children's section of the public li-
brary)in the previous week.
Association between reading exposure and family characteristics.
The availability of books and reading activities was related to baseline family char-
acteristics in some interesting ways.In FC,mothers who reported reading with their
children in infancy(under 1 year of age),were better educated,had fewer children
living at home, and were more likely to be participating in the intervention with
their firstborn child. There were no significant relations between family back-
ground characteristics and initiation of reading among the NL families. Like FC
families, approximately 60%reported reading with their children since infancy.
302 HCEBNER
TABLE 2
Child's Reading Exposure and Language Skills at Intake by Site
PC Site \L Site
.11 SD 'o Range 11 SD ,Runge
Child';Home Reading Experiences
Parent began reading to child 3.7 3.3 I-I5 9.9 6.5 L24
months)
Parent read to child last week y? N,
i_es)
Parent read to child 5-times last 323
.seek
Many 1 I I-i children';books in 35 1?
home
Chid looks at books on his or her 96 9"
ow n
C iild-likes-or 'loves"reading
Reading is among top three 12 13
tasorite activities
Child has exec been to public 33 36
library
.wended library or storytime last 23
week
Expressive Language Skill
CDL SF)
cabulary total is at or above 14 13
lsg. for age
Vocabulary total is 1 to 3 months 19 i3
nelow average
Vocabulary total is 4-months n' "4
nelow aserage
C.'mbines....ords in conversation _ -0
"often"
Combines isoros"sometimes" 23
"Not yet"combining .cords 4
-1•.erase length of longest three 3.3 ! I—i 4.5 Li -s
phrases in words
\'re CDI SF = Communication Development Inventory Short Form Level II. Statistics retlect the
maximum sample size.The FC sample ranged from 21 f for the CDL SF Vocabulary.)to 26:Ni ranged from 23
for the CDL SF Vocabulary.)to 30.
f n both communities,there was a negative association among reading exposure,
• marital status, and income such that married mothers were less likely to have read
frequently I Live or more times)in the past week with their children. This finding is
somewhat surprising and most likely illustrates the lack of time among the mar-
ried, working poor. In both community samples, most of the married mothers
Tr1n/►1/7T T/rmm7T►11TTTTTf7T►►T7tTTTrn►Tn7n m71TTTT7TT►TTTT
•
SUPPORT FOR PRESCHOOL READINESS 303
worked outside the home:all were supported by wages rather than government as-
sistance, and their family income was above the Federal Poverty Level.
Expressive language skill. The average age of children in the FC and NL
samples at baseline differed by just 6 weeks, with NL children being somewhat
older. Of the combined`roup.only 25 children were of chronological ages appro-
priate for the CDLSF II inventory and its vocabulary percentile scoring (16-30
months). Because all scores could be interpreted in terms of language age equiva-
lents. the CDUSF II scores will be discussed in these terms instead of percentile
ranks.
Relatively few children participants earned CM/SF II vocabulary scores com-
parable to children in the sample provided by Fenson(1996),a sample of markedly
higher socioeconomic status. Among the FC sample, only 3 children scored at or
above age level;4 scored 1 to 3 months below age level,and the remaining 14 chil-
dren (67%) scored 4 or more months below age level. In NL. 3 of 23 children
scored at or above age level:3 scored 1 to 3 months below age level,and 17(74%)
scored 4 or more months below age level (see Table 2).The maximum number of
months below age level was greater than 12 months and was true of 7 children:3 in
FC and 4 in NL.
An alternative way to interpret the CDUSF data makes use of readily observ-
• able markers of potential language delay. Among children 24 months of age these
include an expressive vocabulary of less than 50 words total or no combinatorial
speech (Morisset& Lines. 1994; Thal & Bates, 1989). In this study. 47 children
were 24 months or older at the time of the baseline CDUSF. Nine of them were
combining words only"sometimes," and one, "not at all."Eleven of the 47 chil-
dren had vocabulary scores less than 50. They ranged in age from 25 months (a
child with a score of 3 words)to 39 months(a child with a score of 36 words).The
numbers of children who showed either sign of potential delay included 5 children
with both signs—not combining "often" and a vocabulary score of less than 50.
Children in this subset were considerably older than the 24-month threshold; their
ages ranged from 27 to 35 months.Certainly,some children used words that do not
appear on the CDUSF list:however, the overall impression of the vocabulary data
•
suggests a sample at considerable risk for language guage delay.
Additionally,as shown in Table 2,parents'examples of their children's longest
sentences and phrases were consonant with their report of limited vocabulary size.
Among FC children,the average length of the longest three phrases(MLU-3)was
3.3 words (SD= 1.1; range 1-6). Among NL children, the average was 4.8 (SD=
1.6; range 1-8). Few children's scores increased when MLU-3 was computed
based on morphemes, and of those that did increase, the gain was less than one
point. MLU-3 comparison data, based on norms established for the long
full-length CDI (Fenson et al.. 1991), indicate that the average MLU-3 score of
304 HUEBNER
children ages 26 months and above is at least 6.0. This comparison supports the
conclusion that the combinatorial skills of most children in this study were also be-
low
those of their middle-class peers.
To summarize the baseline data, the study participants included many low-in-
come parents with relatively low levels of educational attainment. At baseline,
most parents reported the presence of children's books in the home,but infrequent
parent-child reading. When asked about their children's expressive language,
most described skills that suggest the children's development was slower than oth-
ers their age.
Changes in Reading Exposure and Language Skill
After the intervention period, parents completed CDL SF II, Form B. and were
asked a subset of the same questions about books and reading that they answered at
baseline. Quantitative analysis of their responses focused on those variables most
likely to reflect changes over time in parents'attitudes and behaviors:parents'per-
ception of the child's enjoyment of reading, frequency of in-home shared reading,
and frequency of out-of-home literacy activities.Variables were excluded from the
analyses if virtually ail participants showed the behavior at baseline (e.g., child
looks at books on his or her own)or if improvement could reflect nothing more than
passive participation.For example,the number of children's books in the home was
expected to increase over the course of the study because each family received three
children's books as a consequence of participation.
Because the data from FC and NL were reasonably similar at baseline and
posttest, the sites were combined for the purpose of statistical analysis. Doing so
increased the total sample size and thus the statistical power of detecting pre- to
posttest differences. The results of the statistical analyses for the combined group
are presented in Table 3. Parents' responses to the posttest questionnaire indicated
two important changes: atter the intervention more children enjoyed reading and
were read to more often.
After the intervention, significantly more parents in FC and in Ni. included
reading among their children's top three favorite activities. For the combined
group,the percentage of parents who listed reading as a favorite activity increased
from 14%at baseline to 39%at posttest,X-(1..V=51) =6.36,p< .01 (Table 3).In
addition, the number of children who were read to frequently more than doubled.
The proportion read to frequently, defined as five or more times in the previous
week, increased from 16°o at baseline to 47°'o at posttest.X=(1,.V=43)=3.47,p<
.01 (Table 4). In contrast to substantial changes in in-home experiences.there was
little change in the frequency of out-of-home literacy activities (e.g.. visits to the
• library or family center storytimes [data not tabled]).
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•
306 HUEBNER
TABLE 4
Parent Feedback at Posttest by Site
FC Site,%) .VL Site (%)
What did you especially like or find useful?
The extra time I spent with my child -,
Helped my child's learning(e.g..memory) 54
68 !
6I
Helped my child talk often,more clearly or better 56 18
Influenced other family members'reading to child 16
Gift of children's books 23 214
What did you not like or would like to change?
I could have used more children's books 4 I I
It was difficult to change my old reading style 3
Will you continue to read this way:'
Yes.Yes!and Yes,definitely 100 100
.Vote. Summary of parents'answers to open-ended questions are grouped by theme. Data reflect
feedback from 25 FC parents and 23 NI parents.
In this study it was not possible to assess change in vocabulary as measured by
the CDIiSF II because many children grew beyond the age range and language age
equivalencies provided by the comparison data. Recall that at baseline most chil-
dren were already beyond the age level of the test. In addition to having even fewer
children within the age range of the norms at posttest,it is not possible to interpret
change scores based on age equivalency because age equivalency scores do not
conform to a known mathematical distribution.
Changes over time in children's sentence-level skills were noted by parents in
that, at posttest.slightly more children were reportedly combining words"often."
Improvement was most evident in the length of children's spoken phrases.The av-
erage length of the longest three sentences and phrases increased from baseline to
posttest, particularly for children in the tiL sample(recall Table 3).
Stability and Change in Home Reading Experiences
Additional analyses were conducted to understand more about the effect of the in-
tervention on home reading. Families were grouped by whether children's home
reading experiences improved,remained unchanged,or apparently worsened over
the intervention period. This approach,to examine potential unintended negative
consequences directly, is often overlooked in intervention research. In the current
study, the analysis revealed little of serious concern. A total of eight children's
scores on one,and only one,of the three reading outcome variables declined from
• baseline to posttest.The most common change for the worse was the elimination of
reading on the list of favorite activities. This was true of four children who other-
717777717 117111717171117 77 7771777777177777777777777 '
•
SUPPORT FOR PRESCHOOL READINESS 307
wise gained or maintained their enjoyment of reading:that is,although reading was
omitted from the list of three favorite activities,parents reported their children did
enjoy reading. In three of the four cases. reading as a favorite activity was sup-
planted by outdoor activities: "basketball,""bike riding,"or"go outside."The de-
motion of reading as a favorite pastime is probably best explained by concomitant
improvement in the weather. In two other cases, reading frequency diminished
from more-than-five to less-than-five times per week.It is not obvious why this was
so. Indicators of these children's enjoyment and their parents'comments about the
reading program were all positive. Finally. one 20-month-old boy reportedly en-
joyed reading less at posttest than at baseline. Interestingly, this child and his
39-month-old sister were both participants in the intervention. At baseline, their
mother reported that they both"loved"reading.However,at posttest,she described
her son as liking it"pretty much"and her daughter as continuing to"love"it. It is
possible that the intervention helped this mother become more aware of differences
between her children.
Parent Satisfaction
The final segment of the posttest interview asked parents general questions about
the program—things they liked and things they would like to change. After the
II/ posttest data were collected,all parents'comments were read,sorted,and grouped
by several themes that emerged(see Table 4). This qualitative assessment of pro-
gram effects,in the parents'own words,provided rich supplementary information
to the questionnaire data summarized previously.
Parents'responses were overwhelmingly positive.They all said they planned to
continue using the Dialogic Reading techniques with their children. When asked
what they liked about the reading intervention, the most frequent comment was
that they liked the time they spent reading with their children: they enjoyed the
physical closeness and the positive involvement.Comments that represent this cat-
egory of responses include, "[I liked]the time we spent together, we don't do that
all the time,""[It was useful] learning to spend a few minutes with my child every
day,"and"[I especially liked] holding my baby while reading to him."
The second most frequent positive comment was that parents liked the interven-
tion because it motivated their child's learning or directly helped their child learn
new things. For instance, one mother commented, "It was very interesting—she
[daughter]kind of took over,asking to be read to."Others said,"[It was useful be-
cause]it helped her memory,"and"I especially like when my son brings the book
for me to read every day."Some comments referred to children's learning new vo-
cabulary and language skills, such as "[It was useful because] he pronounces
words better,""The way I read to him—it caused him to talk more,"and"It helped
my daughter learn more words." Other comments were specific to the Dialogic
I.
H308 .,EBNER
Reading techniques, such as "The program taught me that it's okay not to finish
reading the book because this gives the child a chance to ask questions."
An unintended,but welcome,benefit of the intervention was its apparent effect
on other family members.Several parents offered comments such as"This encour-
aged my [older] 5-year-old to read to her sister with my assistance," "It got my
husband involved as well," and "It encouraged more reading and more talking."
Still others appreciated the children's books they received, for example, "[I liked]
my daughter getting the book. She likes to read."
Parents were also asked about aspects of the program they did not like or
would like to change. The most common feedback in this category was that they
"could have used more books." .A few also admitted :hat the new conversational
reading style was unfamiliar and sometimes conflicted with their old reading
style. Three parents commented that it was "difficult :o change my old reading
style." The most common reason was, "I'm used to asking all the questions and
doing all the reading."
Through discussions with parents about their child's language and home activi-
ties, the intervention created an awareness about early language development and
about toddlers' interest in books and reading. It also asked parents to change exist-
ing habits.Specifically,parents were asked to look at books frequently(daily)with
their toddlers, to read in a new way, follow their child's interest in the story, and
praise their talk about the book. Change, even positive change, can be stressful.
Along this line, one parent lamented "that's all she[my daughter] wanted to dol"
Another mother's comment,"I wish the program would continue."is an important
reminder that when successful, applied research creates changes for children and
families that extend well beyond the limited period of data collection.
Benefits of the Intervention DISCUSSION
The results of this study demonstrate that Dialogic Reading can change the home
language and literacy activities of families with young children,including:hose at
greatest risk of school failure. Whether these changes in family practices will be re-
lated to eventual school achievement,particularly in literacy knowledge and read-
ing, is beyond the scope of this study. Several other desirable outcomes.conceiv-
ably fostered by shared reading and more appropriate to the age range of children in
this study.were identified.Specifically,the intervention increased the frequency of
home reading and parents' perception of their toddlers'enjoyment of shared read-
ing.Moreover,the style of Dialogic Reading brought the question-and-answer lan-
guage of formal schooling into the everyday experience of the home.
r.nnn,,,n,•, TT+++TT1+T
•
•
SUPPORT FOR PRESCHOOL READINESS 309
For the subset of families for whom both pre-and posttest data were available,the
proportion of FC children who were read to five or more times in the previous week
increased dramatically,from 8°n)baseline)to 40%. In NL.the proportion doubled,
from 260.0 to 53°O.Thus,after the intervention,many children were read to more of-
ten.and as often,as more socioeconomically advantaged preschoolers whose par-
ems reportedly read to them 4.5 to 10.5 times per week (Scarborough& Dobrich,
1994).Parents also reported chances in their children's readine pleasure.This is not
to say all children enjoyed reading;some did not.At baseline, I 1°°were reported to
like reading"a little"—the lowest intensity response for that item.In another study
of preschoolers. Wells (1985) also found that about 1 I% of the children enjoyed
reading"not at all"or"not much."Although the effect of the intervention on increas-
ing children's enjoyment ofreading was not universal,it was dramatic.After the in-
tervention, only two children(3%)enjoyed reading only"a little."
It seems likely that Dialogic Reading gains its potency from the fact that shared
book reading, and especially this interactive style of reading. is developmentally
salient for young preschoolers and for parents of young preschoolers (Morisset,
1996). Two lines of reasoning suggest this is so. First, shared book reading offers
parents and their mobile, increasingly independent young children a new way to
strengthen emotional ties. Evidence of the rich affective dimensions of shared
book reading have been identified by Bus and van IJzendoorn (1988, 1995),who
observed that the interactions of securely attached dyads tend to be more sensitive
. to the child's needs and less negative,controlling,and inattentive than those of in-
secure dyads.
Second.simultaneous with the opportunity for emotional closeness,book read-
ing provides a context for the young preschool child and parent to negotiate the
child's budding independence and urgent need to "do it myself"This is particu-
larly true of Dialogic Reading interactions because the techniques specifically in-
struct parents to let the child set the pace, take the lead in telling the story, and in
turning the pages. Whether Dialogic Reading would be an effective therapeutic in-
tervention for conflicted or avoidant mother–toddler pairs is an intriguing question
for future research.
It is tempting to discount the finding that all parents in this study said they
would continue Dialogic Reading on their own. To the extent that they do con-
tinue. it is likely that these reasons—the opportunity for emotional closeness,
the encouragement of developmental advances, and the fact that even parents
with low reading skills feel comfortable with the conversational methods of
Dialogic Reading—will be involved. A habit of pleasurable talk about books
and everyday events could go a long way toward diminishing the striking dis-
parities observed between middle- and lower-income toddlers' experience with
language, vocabulary growth, and preparation for school entry (Hart & Risley,
1995).
•
310 ill:EBNER
Cautions and Limitations
Se'.oral potential limitations should be noted in considering the results of this
stuw. First, because the program was 'oluntarv, and no comparison condition
was included. it is possible that parents attracted to the intervention were those
parents more likely to carry out program requirements. Without random selec-
tion and use of a comparison condition, or repeated observations of par-
ent—child reading,we have no way of knowing if the strength of the intervention
was overestimated because of possible favorable preintervention characteris-
tics of the parents. Although the design does limit the generalizability of the
study findings. sociodemographics of the participating families described a
group slightly less advantaged than the community as a whole and a group for
whom shared reading,,.vas not a frequent acti',ity. For these reasons.the findings
are relevant to other families within these and other equally diverse high-risk
communities.
A second caution pertains to the magnitude of the inter:ention effects. It was
not possible to know if parents responses were honest reflections of their home
reading practices or it they were biased to meet the expectations of the program
staff. Two arguments against this possibility are germane. First, there was consid-
erable variability in parents' responses to the posttest questions about reading fre-
quency and enjoyment. Second. in most cases parents had long-standing, trusted
relationships with the paraprofessionals who delivered the intervention and col-
lected the satisfaction data—relationships in which parents felt comfortable dis-
cussing choices and life experiences that were much more personal than the
content of this simple home reading activity.
The third caution concerns :he Dialogic method itself. In :his study it was not
possible to separate the benefit of gift books and encouragement from the effects
unique to the Dialogic method. Anecdotal evidence suggests there was something
special about Dialogic Reading: many parents said they'.vere relieved by not hav-
ing to do "all the reading;' and they enjoyed watching and helping their child's
growing language facilities. Recall, too, that at baseline. few parents 1a) reported
frequent reading, despite saying they had read with their child in the past: (b) had
noticed their child's interest in books:and(c) had children's books in:heir home.
It seems that Dialogic Reading showed parents how to optimize resources and in-
terests that were already present and to do so in a way that was pleasurable for
them and their child.
This observation may be especially reie%,ant for families who lack a surplus of
time. In this study,the mothers who reported owning more children's books were
more likely to be high school graduates and more often supported their families
through wages rather than government assistance. Surprisingly, these same in-
dexes of relative socioeconomic advantage were related to less frequent par-
ent—child reading at baseline. It seems plausible that the better educated mothers
•
• •
SUPPORT FOR PRESCHOOL READINESS 311
valued children's books and reading but, because they tended to work outside the
home, had less time to read with their children. As national efforts to move fami-
lies from welfare to work gain momentum. it is paramount that we endorse readi-
ness activities that are both potent and realistic of parents' time.
In conclusion, the benefits of this shared reading intervention appear to derive
from its ability to help parents of very young children experience books as"objects
of reciprocal interaction which result in pleasure"(Pawl. 1987). For many parents.
especially parents who lack time or have difficulty reading, this intervention
helped the unfamiliar become familiar. It helped parents provide a new and safe
context for their toddlers' independence and learning and engendered shared pride
in these very accomplishments. As one NL mother beamed. "You know, I think
my boy's gonna be a reader!"
ACKNOWLEDGMENTS
This research was conducted while the author was a research member with the Cen-
ter on Families,Communities,Schools,and Children's Learning at Johns Hopkins
University.
Major support for this study was provided by the Office of Educational Research
and Improvement(OERI),C.S.Department of Education(R-1 17—Q00031),and by
• ZERO TO THREE: National Center for Infants,Toddlers,and Families.
The author gratefully acknowledges the family center staff and parents of"FC"
and"NL"who participated in this research.
The opinions expressed are of the author and do not necessarily represent OERI
positions or policies.
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search Quarterly. /3, 263-290.
McLoyd.V.C.(1990).The impact of economic hardship on Black families and children:Psychological
distress.parenting,and socioemotional development. Child Development.61.311-346.
Morisset,C.E.(1996)."Mommy,I wanna read to you now"-Strengthening child language skills by lis-
tening.In K.E.Barnard(Chair), What do we know about enhancing parent.'child communication
• and interaction with infants and toddlers?Symposium conducted at Head Start's Third Research
Conference,Washington.DC.
Mortsset,C.E.,&Lines,P.(1994).Helping Your Baby Learn to Talk.U.S.Department of Education,
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`eedlman.R.,Fried,L.E.,Morely,D.S.,Taylor.S.,&Zuckerman.B.(1991).Clinic-based inter-
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Pawl.J.H.(1987).Address to the American Library Association.San Francisco.
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•
314 HL'EBNER
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=99
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•
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1
1
•
r
Board of Health
New Business
Agenda Item # V. , 5
Topics for Local Board of Health
• Workshop
Survey Results
June 21 , 2001
•
Possible Topics for Local Boards of Health
•
Workshop in Autumn 2001 (WSALPHO)
TOPIC High Medium Low _
Powers/responsibilities of Local Board of Health 59 47 11
Health Care Access/Health Care Costs 46 52 12
Illegal Drug Labs and Public Health 52 38 13
Youth Violence Prevention 43 53 15
Public Drinking Water Systems 53 43 16
Onsite Sewage Systems 51 49 16
Solid Waste and Public Health 37 55 16
Child Health/Early Intervention 55 46 16
Emerging Disease with Public Health Impact 52, 47 17
Local Health Jurisdiction Fees and Other Revenues 35 55 20
Using Information for Decision-Making 30 59 22
Sexually Transmitted Disease/HIV/AIDS 32 60 22
Antibiotic-Resistant Bacteria 39 52 22
Child Care and Public Health 43 43 22
Powers/responsibilities of Local Health Officer 32 59 23
Tuberculosis/Communicable Disease Control 36 53 23
• Tobacco and Minors 39i 50 23
Nurse Home Visiting with High-Risk Families 33 53 25
Pandemic Influenza 44 47 26
Bioterrorism 39 49 26
Food Safety/Food Handlers 33 51 27
Immunizations 31 54 29
Tobacco Prevention and Control 40 42 29
State Board of Health Role 20 56 30
State Department of Health Role 23 59 31
Family Planning 34 46 32
Dental/Oral Health 22 52 36
Jail Health Care 14 59 37
Recreational Water Safety and Health 14 56 44
Clean Indoor Air Act/Indoor Air Pollution 15 52 46
Shellfish Safety 20 47 51
Other— Please Describe (See Attached Sheet)
Respondents—members of local boards of health
Total number of surveys received — 119
III
Local Boards of Health Workshop
Added Comments:
• • Providing health care access will be paramount. If the awardsro is any
l�'�
indication of the direction this state is going - we are definitely in trouble.
• Board of Health workshops need to be combined with other AWC functions. There are
already too many meetings we all attend.
• Please - coordinate with annual summer meeting of WSAC or in between AWC &
WSAC legislative meetings.
• Added to Jail Health Care - Cost of jail health & how to pay.
• Youth violence prevention, tobacco prevention and control, tobacco & minors are all
areas that currently are being addressed by community & school organizations (non-
profits). Any actions from the C/D Health District should be in support of these
existing organizations.
• The need to understand the values and culture of the community and make allowances.
• Needle Exchange Programs
M • Community Mental Health - monitoring outcomes, problems.
• Health Promotion Programs.
• Large need in L-C for senior health issues and for cont'd review of the seniors that are
• not covered by other programs.
• Public Health issues in local nursing homes.
• Liability of Board members.
• Mini review of parliamentary procedures.
• Working with local hospital - common goals.
• Domestic Violence Prevention.
• Alternative Technology for sewer & water.
Q2
• Non-iodizing radiation from wireless antennas!
•
Jean Baldwin
Srom: Ward Hinds [whinds@shd.snohomish.wa.gov]
ent: Wednesday, June 13, 2001 12:14 PM
To: WSALPHO@listserv.wa.gov
Subject: LBOH Workshop
111,
Unknown Document
A group of WSALPHO members and Vicki Kirkpatrick met with several county
commissioners in Yakima this morning to discuss the LBOH workshop for
this year. We will fill you in on the details of content and format
later, but wanted to get the following dates and location to you as soon
as possible, so you can let your Board of Health members and Board
Advisory Committee members know.
The LBOH Workshop will be held on Thursday, October 25th (all day) and
Friday, October 26th (half-day) at SeaTac (exact location to be
determined) . These were the dates the County Commissioners picked.
Please inform your Board/Advisory Committee members as soon as possible,
so they can put these dates on their calendars.
The survey data you helped to collect was very useful in determining the
content. We got about a 90% return rate! The results of the survey are
attached. Thanks for your help.
Ward
. Ward Hinds, MD, MPH
Health Officer
Snohomish Health District
3020 Rucker Ave.
Everett, WA 98201
425-339-5210
FAX 425-339-5216
whinds@shd.snohomish.wa.gov
•
1.
•
Board of Health
Media
• Report
• June 21, 2001
•
Jefferson County Health and Human Services
MAY — JUNE 2001
NEWS ARTICLES
These issues and more are brought to you every month as a collection of news stories regarding
Jefferson County Health and Human Services and its program for the public:
1. "Jefferson forms new office" — Peninsula Daily News, May 8, 2001
2. "41 establishments honored for `safe' food standards" — P.T. LEADER, May 16. 2001
3. "Hamburger bacteria feared" —Peninsula Daily News, May 22, 2001 and "Peninsula: No
health woes expected from E. Coli"—PDN. May 23, 2001.
4. "South county counseling clinic to open: Agencies unite in Quilcene" —Peninsula Daily
News. May 17. 2001
5. "We're growing older" (2 pages)— Peninsula Daily News, May 24, 2001
6. "Unwed pairs on the rise in Jefferson" (2 pages)—Peninsula Daily News, May 25, 2001
7. "Subsidized clients' health care axed" —Peninsula Daily News, May 27, 2001
8. "Survey seeks health data for Jefferson"—Peninsula Daily News, May 29, 2001
9. "No pill for health care ills"— P.T. LEADER. May 30, 2001
10. "Parents lax about drugs, Jefferson teens say" —Peninsula Daily News, June 1, 2001
11. "Local mental health services could end" - P.T. LEADER, June 6. 2001
12. "Jefferson kid, family center project begins" — Peninsula Daily News, June 8, 2001
13. "Mental health agreement due" — P.T. LEADER, June 13, 2001
•
0
.Jefferson new office
funding County Administrator Christensen estimated he
Panel allocates staff,
Charles Saddler asked the spends most of his time deal-
for natural resources work commissioners to anticipate a ing with natural resources
$40,000 ongoing annual cost issues. He anticipated spend-
BY PHILIP L. WATNESS Jefferson County commission- for the new department. He ing even more time as more
PENINSULA DAILY News ers voted unanimously Mon- promised the unit would be issues present themselves
day to establish a Natural funded primarily through through state and federal pro-
PORT TOWNSEND — Resources unit. state and federal grants. grams.
Salmon and other natural "We don't want this to be a In addition,county commis-
resources will finally have a 'Enough need' chase after grants, though," sioners approved a Conserva-
designated point-person in Jef- Saddler said. "We need to tion Futures Tax last year
ferson County. The department would con build enough capacity to with the moneyto be used to
Dave Christensen, water sist of one half-time and two
resource specialist for the full-time employees to handle address the current require- purchase land or easements
county Health Department, education and outreach, do ments." for open space.
has been handling natural watershed/salmon
atershge/salmon recovery Clear mission Saddler said the planning
resources issues for more than planning, provide assistance to for that will require one full-
a year, but the ever-increasing other departments, coordinate Commissioner Glen Hunt- time person alone during the
responsibilities have detracted land conservation efforts and ingford, R-Chimacum, the first year.
macum, said
from his job to handle water write grants to fund projects. new unit should have a clear The specifics aren't avail-
issues alone.Additionally, Pub- "There's enough need for able on how the new depart-
mission Works and Community this out there now," Chris mission and defined responsi- P
Development employees find tensen said. "A few years ago, bilities so it won't continually ment will be formed or when it
themselves dealing more and we identified the need for five grow in response to requests will be up and running.
more with endangered species additional people just to deal by the state and federal gov-
and environmental issues. with Endangered Species Act ernments or by special inter-
To remedy the situation, issues." est groups.
S
r
--pbk•
• 41 establishments honored
c �
for sae food standards
2000 Outstanding Achievement Harbor,Jerry Anderson;and Silverwater One-year honorees are Salal Cafe,
Awards have been presented to food ser- Cafe,Alison Hero and David Hero. Pat Fitzgerald; Queets Clearwater
vice establishments and their proprietors Honored for three years are School, Gloria Fairchild; On Common
who have demonstrated highest stan- Bloomer's Landing, Jim and Pamela Grounds,Doug Roth and Marga Smith;
dards for safe food handling.This year, Morgan; Brinnon Seniors, Lynne Fay; Plaza Soda Fountain, Donna Hogland;
41 businesses and organizations have Hard Rain Cafe, Michael Rasmussen; Mountain View Cafeteria, John Koch;
earned this award,given by the Jefferson Lanza's, Steve Kraght and Lori Lanza; Manresa Castle, Walter Santschi;
County Health and Human Services Portside Deli,Lynda and Brian Douglas; Ferino's Pizzeria, Scott Browning;
Environmental Health Division. Tri-Area Senior Nutrition, Tom Daly; Fountain Cafe, Kristen Nelson; Grant
Receiving the honor for their sixth and QFC Port Hadlock Deli,Ron Reed. Street School, John Koch; Head Start
year are Port Townsend Senior Nutrition Two-year recipients are QFC Port Program, Mechel le Petersen;
Program,Craig Yandell;and Valley Tav- Townsend Deli, Jeannette Baker; Ajax Harbormaster Restaurant, Pam
ern, Chuck and Karen Russell. Cafe,Thomas Weiner;Heron Beach Inn, Hubbard; Chimacum High School Caf-
Honored for five years are Java Port, George Eubanks; Khu Larb Thai Res- eteria,Linda Boyd; Blue Heron Middle
Linda Kennedy; Jefferson County Jail, taurant, Paul Itti; Maxwell's, Chris School Cafeteria,John Koch;BPO Elks,
Eleanor Such; and Lonny's Restaurant, Sudlow; McKenzie's Deli, Michael Randy Unbedacht; and Brinnon School
Lonny Ritter. East;Niblick's,Pam Elkins; Pizza Fac- Cafeteria, Hope Nordland.
Receiving the award for four years in tory,Francis and Balorie Danielek;The These food service establishments
row are Whistling Oyster, Sandra Van Village Baker,Andre Le Rest; and Up- have demonstrated their efforts to pre-
. Wagenen&William Bailey;Fat Smitty's, town Pub and Grill, Laura Millett and vent illness caused by foodborne
Carl Schmidt; Seabeck Pizza of Pleasant Katy Snell. See AWARDS, Page C 14
"8 o Q o a g '8 3 B O <. o P x c o w o x D w y
O D „000 9 5•Q, cf = w a' 'ry, OOa �, ry ° ': ( O = C
a.
" .1• C9 n O O O O O O ] n. C r) piuO 5- (7 rn y O
`..7' Q. C Q• C0Q 0D � �'+ y C O Q. 9 CD C(.15 ^ (D
° $
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co � ° - y
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•
r. LEA oet2.
5-/b -0I
Beef: Food scar .._--_-_,, Je
co r>'rL-ED rapt Al "We sell to excellent restau- ; „ /�
Consumers may wish to rants that hive a great track ,'t," :.� r 4/'
ask restaurants or places'" Chiassor,said. = inA
• where they consume ground The contaminated beef ''t C
cams from one of three dis- 1Lli-
a
] n
beef i. the product or meal contains the recalled product " Portia d — Western Box In • ��,
Portland, On., Plymouth n
Potentially deadly bacteria Po
F. 3
ultrySeattle or Sound z1:1 O
E. coli is a
Meats in Mountlake Terrace, �-
potentially he said. •
I ' Cr
deadly bacteria that can cause "They are just box storage
bloody diarrhea and dehydra- companies," he said. "They s C
tion, Billy said. The very don't touch the meat." Z
young,elderly and people with The contamination most Ir e
n
compromised immune systems likelyIR
are the most susceptible to the ° at a slaughter •oma -
food•borne illness. house, he said `q cro,
As long as restaurants E. coli is commonly intro- ••
cooked the meat in accordance duced to beef when meat
with county Department of come,atte contact with fecal
Environmental Health regula. matter. �' .
Lions, diners should have "We're il buyingL. the same �.,"
nothing to worry about,Chios- product and its gettingp'
sT,
eon. tion'"
through on the first inspec- ' 'ifS
Ae of Monday, no cases he said "It's get Cr
associated with the possible E. through at the pro
r if ril. tu
coli contamination had been plants.'
reported. According to Chiasson, the p
The hamburger in question USDA found the possible E. .,
was ground Leat Wednesday, coli contamination in a one- ' d
Chiasson said. It was tested bypound sample taken from 6. . 4 6 °0
cultu.re Department 8,000 pounds of beef ground O
the A
food safety and inspectionbythe Port Angeles company q 1 4 M
s�
division Friday. last week
lrut.al test results showed I've owned the business 23
ei
possible E. coli contamination Y and this is the first time �I
Friday, but USDA officials we've had a warning,"he said. v a N i 1. . , ' g.
weren't ready to say a health "But cooking solves this probto
-
hazard ersted. Chiaaaon said Lem." O
his company notified restau• !t*13 _
• rants that might have received Operating1." ii mil
the pail since 1934 Q
potentially contaminated A
meat that day. Chiaason said his company ,;t 41451: 0 CD
By Monday, USDA off riAls hu been in business in PortAll
decided the health rink was Angeles eine 1934, but he's el
el
"high," but did not order a owned it for 23 yUears' N
recall. So Chiasson said hie The meat company, located ' 0
company voluntarily recalled at 906 S.Valley St., employee. 8 $? 1 3 •.
the meat, which was packed in eight people and is the only 1 r. q r� 0
•
bags
10 pound CAGae and and USDA approved plant on the
distributed to some of its 120 North Olympic Peninsula, heL6b4i ;
customers on the North said.
Olympic Peninsula "We're veryPO
Restaurants with any facility," he said.proud of our
potentially contaminated People with questions can . .
ground beef began returning it call Eve ip-een Meats at 360- ' s` i •!i [0 O i
Monday, he said. �s
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Edition May 17, 2001
• Center
Southcounty
CONTINUED
FROM Al
The Domestic Violence pro-
gram previously offered ser-
counseling
n g vices in Quilcene, but lost its
office space, Smith-Moore
said. The lack of office space
has also kept other service
providers away.
clinic "There is kt a lot ofisoffice
to
open
since, and lack of money is a
hindrance," she said.
Year-old idea
never had this many services in this The idea for the center was
Agencies unite location." broached at a meeting of the
clinic's citizens advisory board
Jefferson General Hospital,
in Quilcene; which runs the clinic, is providing nearly a year ago.
the space without cost under a Members of the board
approached officials from Jef-
huge bonus 7 renewable one-year lease, Smith
Moore said. The hospital leases its ferson General Hospital, who
space at a "low cost" from building to provide the space.
BY Sr EL.uoowner and Quilcene resident Wally The center is not expected
'ru TT
PENINSULA DAILY NEWS Pedersen, Smith-Moore said. to significantly increase the
budget of the county agencies
QUILCENE — Social services Six agencies offer services and nonprofit organizations
0 from juvenile probation to drug and operating there, Smith-Moore
alcohol counseling will be closer to Counselors from six agencies — said.
the doorstep of south county resi- county Department of Health and "This is mostly money they
dents when a new center opens next Human Services, county Juvenile had budgeted in to provide
Tuesday. Services department, Community services," she said. "There is
The South County Social Services Recovery Center, WSU Cooperative the cost of transportation. But
Extension Office will open the three- Extension and the nonprofit Jeffer- it's servicing people that are
room complex in the same building son County Mental Health Services already part of their client
as the South County Medical Clinic, and Domestic Violence and Sexual base."
294843 U.S. Highway 101. Assault Program — have agreed to
The new office will provide office provide services at the center one or
space where counselors from six two days a week.
agencies can meet with clients, mak- The grand opening of the center
ing access to social services easier. is from 6 p.m. to 8 p.m. May 22.
"For residents in this area, it's a Agency workers will hand out
huge bonus," said Shirley Smith- brochures and explain the services
Moore, the chairwoman of the cen- they provide.
ter's board of directors. "We've TURN TO CENTER/A2
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in
Jefferson
Census figures In Port Hadlock-Irondale, the
percentage of families slipped from
70,2 percent to 67.9 percent during
show families the last decade.
Countywide, the decline was
slightly decline more gradual, with a three percent
drop in the number of families as a
percentage of all households.
BY STUART ELLIOTr The nuclear family breakup is
PENINSULA DAILY NEWS also evident in decline in the num-
An increasing number of North ber of families headed by married
Olympic Peninsula residents are sin- couples.
gle parents, living in nontraditional In Jefferson County, the number
of married-couple families slid from
households, U.S. Census figures
released this week show. 57.4 percent in 1990 to 53.6 percent
in 2000.
show the station-wagon driving, 2.2- Port Hadlock-Irondale followed
child nuclear family on a slight the trend as well.
decline over the past 10 years in Jef- In 1990, 57 percent of all house-
ferson County, particularly in Port holds were led by married couples.
Townsend. By last year, that number had
The trend is similar in Clallam dropped more than 5 percent to 51.6
County. percent.
Port Townsend has seen the num- In Clallam County, the number of
ber of families drop more than 7 per- families has slipped from 69.6 per-
cent in the past 10 years, from 63.9 cent in 1990 to 66.5 percent of all
percent of all households to 56.2 per- households.
cent. TURN TO CENSUS/A2
Percentage of households comprising
married couples
0 10 20 30 40 50 60 70
Forks 49.4%
........................................... •� 64.0%
Neah Bay .. ' 36.2%
'•''� 42.7%
�+ 2S `O Port Angeles 44.0%
5151.Pb
Port Hadlock/Irondale 51.s%
57.0%
Port Townsend ..................................•.j 42.3%
50.7%
Sequim 4°1%
• 42.4%
Clallam County .111111.11111111111111111111111.111:•:•] 53.9%
58.4%
Jefferson County . 53.s7.as% •
%
■ 2000 Census D 1990 Census
3
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•
A6 SUNDAY, MAY 27, 2001
u s� ize clients '
•
healthcare axed
Care facility ing operating our residential treatment plan and/or suffi-
houses for chronirAlly mentally cient information to 'justify
blames lack ill people in our community," diagnosis or treatment.
he said. The Peninsula Regional
Support Network has also
of funding 'Service . . , will continue' informed the nonprofit organi-
Jefferson Mental Health zation it needs 'to change the
BY Pin L. WATNESS Services Director Laurie way it does business to conform
Strong said the organization to the network's contract.
PENINSULA DAILY NEWS will continue to operate despite "We need to make sure they
PORT TOWNSEND — the contract situation. - provide services that are ade-
Dwindling federal and state "The bottom line is service quate;" Edgerton said. "It's
dollars and increasing adminis- in Jefferson County will con- been an issue for awhile.
• trative requirements have con- tinue," Strong said.
q There's been compliance and
vinced the Jefferson .Mental . Strong said she's heard var-
iousqualityissues for at least a
Health Services board it can no rumors that the facility year. Once we find a new
longer afford to provide mental had closed its doors or lost its provider,I think we'll have bet-
health services for govern- state license, neither of which ter services
ment subsidized clients. is true.
The Mental Health Services
But Henry said other men
But the issue may also be Office of the Washingtontal health providers have also
that the nonprofit organization State
Department of Social and decided to reject the contract.
hasn't lived up to its contract. Health Services, however, did "The RSN doesn't presently
The board recently conduct an on-site review of have a contract acceptable to
informed Anders Edgerton, Jefferson Mental Health from any of the three regional
Peninsula Regional Support May 15 to May 18. providers," he said.
Network (RSN) administrator, State Mental Health Ser-
that Jefferson Mental Health vices Director Richard Onizuka New provider sought
won't sign a new contract. said his office found 19 issues it
That could mean a loss of 80 wants to resolve before a ached- Edgerton said he will fmd
percent to 90 percent of its tiled June visit, another service provider,but in
business, board Vice-President The state wants Strong and the meantime, he's willing to
Chuck Henry said. her staff to develop policies for extend the current contract
"If we don't have the RSN handling medications, provid- with Jefferson Mental Health
contract for public mental ing around-the-clock crisis ser- for another three months.
health services, we would be vices and conducting at-home Henry said the board for
forced to consider what visits. Jefferson Mental Health Ser-
remaining mental health ser- The visit also revealed that vices will discuss the situation
vices we could provide, includ- not all client records included a in depth at its June 4 meeting.
•
PENINSULA DAILY NEWS -O/ �I
•
Survey seeks
health data
for Jefferson
Study'S ai•m • Jefferson County have funded
y the study.
to improve care, "We're also looking at sub-
tle things like people's use of
government says preventive services," Hale
said. "For instance, do people
BY PHILIP L WATNEss know their blood pressure and
PENINSULA DAILY NEWS when.was the last time it was
checked? It will begin to give
City and county officials us clues to areas we need to be
hope a telephone survey will strengthening."
give them a look at health-
related issues in Jefferson Access measured
County.
The survey, already under The survey will gauge
way, will continue through access to health care, includ-
December. ing dentistry and medical ser-
Jefferson County Health vices.
Department officials and Dr. Surveyors will ask whether
Christine Hale,an epidemiolo- the person being questioned
gist with the University of has insurance and whether
Washington,developed the 20- access to care has been a prob-
minute detailed questionnaire. lem during the preceding year.
Officials hope to get "The survey is part of an
responses from 600 families overall plan to get a compre-
• about their health, habits, hensive look at our commu-
insurance coverage and other nity," said Jean Baldwin,
issues. Health Department commu-
Some of the questions could nity health director. "The
be disturbing,such as whether BRFFS (behavioral risk sur-
a family member has experi- veillance survey) is one piece
enced domestic violence or of information. We'll also look
alcohol abuse. at prenatal risks, the census
"The domestic violence data and regional data."
questions have been really Baldwin said the data col-
interesting because a lot of lected through the phone sur-
people don't want to answer veys will be analyzed by a data
them," Hale said. "And that steering committee compris-
tells you something right ing elected officials, govern-
there." ment administrators, health
and hospital board members,
Behavioral questions
representatives of social ser-
Other risky behavior, such vice agencies and law and jus-
as tobacco and alcohol use, tice professionals.
also reveal much about the
general health of a community, Findings to be released
she said. Hale said their findings will
"Alcohol and substance be released to the public in
abuse keeps resonating in the several phases next spring.
community as an issue,as well "We anticipate releasing
as tobacco use," she said. our findings every two to three
"Tobacco is a huge health weeks,"Hale said."We'll prob-
issue. ably do the health access infor- •
We're also asking about mation first. Then,we'll
pro b-
firearms and firearms stor- ably look at the use of preven-
e. tive services. Tobacco,
The information will be firearms and alcohol will be
used not only by the county looked at as a group."
Health Department to design The findings will also be
programs and set policies, but compared with those of a
• also by law enforcement, the study done in Kitsap County
judicial system, county com- in 1999, the Washington state
missioners and others. health surveys and a study
"We will be using these data currently being considered in
to draw budgets," Hale said. Clallam County.
"Where your tax dollars go Officials hope those corn-
will be determined, in part,by parisons give policymakers
the responses to this question- useful information to consider
naire." when funding different gov-
Both Port Townsend and ernment functions.
L.--
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\62)
Local mental health services could end
By Janet Huck "What's going to happen to me?"he asked his sis- services for Medicaid clients, the chronically men
Leader Staff Writer ter,Darlene Coker,who plans to work for the agency tally ill who are indigent or people in crisis. It was
until June 16, when she is resigning to take another business decision for the agency,said board membe
•
When one Jefferson Mental Health Services client job."He asked me if he was going to have to live in Chuck Henry,because the state funding didn't cove:
heard the agency may be closing it doors,he became his car." the state's increasing demands for services.
quite agitated.He lives in JMHS-subsidized housing. Last month,Quentin Goodrich,JMHS board presi- The PRSN might not have renewed the contract
He receives subsidized medications.The agency staff dent, notified its funding and oversight agency, the that expired June 30 anyway. Its advisory committee
helps him manage his money and even gives him one Peninsula Regional Support Network(PRSN),that it recommended the PRSN not renew the contract,saic
square meal a day. would not renew its contract to provide mental health See MENTAL,Page A 9
ental; Requirements not met
Continued from Page A 1 "We can't guarantee we could mental health centers. to go back in 30 days,"explained
Molly Gordon, advisory corn- provide the services outlined in • The PRSN conducted four Onizuka.
mittee chairwoman. But there the contract,so it would be irre- onsite inspections since the middle If the deficiencies were not
are 250 clients who could be sponsible to sign," said board of 2000 that found the agency had corrected,Onizuka could ask the
affected. member Vic Dirksen, Jefferson been out of compliance with its agency to address another series
"What is going to happen to the General Hospital administrator. state contract and the Washington of corrective actions or the
clients who are corning to the cri- But the board is working on Administrative Code. agency could lose its license.
sis center?"Laurie Strong,JMHS an alternative proposal that it "They have had several op-
director, asked the JMHS board plans to submit to the PRSN next portunities to meet the require- Pleas for help
d the PRSN at a meeting June week. merit of the law, but they have Strong believed JMHSIn"What do we say to the person "We will have something in consistently failed to do it,"said wouldn't lose its license.She said
who comes for an appointment? place on July 1," promised Maggie Metcalfe,local president her agency has corrected innu-
What are the options?" Edgerton. of the National Alliance for the merable deficiencies over the last
The JMHS board decided to Mentally Ill and a member of the year."We have provided retrain-
Not enthusiastic withdraw from the PRSN con- PRSN advisory group."And the ing for the staff,changed forms,
There aren't many workable tract simply for business reasons. requirements of the Washington formats and ways of doing op-
options.The PRSN is legally re- According to Goodrich,the state Administrative Code area far cry erations to comply with the re-
sponsible for providing those ser- funding is based on a statistical from what should be done for the quests from the PRSN"
vices to government-subsidized assumption that 10 percent of the clients." explained Strong.
clients,but it doesn't appearP g."We thats."have done
the county's Medicaid clients are In the last PRSN review con- hundreds of this and Chats."
g
regional network has a plan in mentally�ll.�.'We have propor-.. ductedinApril,the independent But she said her-staff was ex-
place':for thecliepts"on';July, 1.'„ tionally more mentally ip1 who., monitoring te'ani suggested the hausted.'"'It'Speak's"well`of the
Anders Edgerton,PRSN admin-' are indigent, so the 10 percent Jefferson County agency rely less staff that they have not quit en
istrator,tried to convince mental funding doesn't cover them all," on a therapy-based structure masse during the past year,when
health centers in neighboring said Goodrich. "We don't want similar to a private clinic model they have been asked to continue
counties to open a Jefferson to go bankrupt." and implement an outreach and their work and to reinvent them-
County satellite, but one center He noted even large agencies medical model used by most selves on a quarterly basis,"said
turned him down and two were were struggling to provide ser- mental health agencies. They Strong.
extremely reluctant. vices on the state funding for- were also concerned with the Even exhausted, staff mem-
"We are not enthusiastic about mula.The King County agency lack of a seven-day-a-week,24- bers are still concerned about
taking it over,"said Helen Dawley, recently closed it doors, said hour-a-day crisis program. their clients, who are getting
vice president of Clallam County's Goodrich. Asa result of the critical PRSN more nervous with all the uncer-
Peninsula Mental Health Center. reports,Richard Onizuka,chief of tainty.The crisis calls have gone
"Our board recommended ex- Failed effort mental health services with the up significantly, said mental
treme caution." This crisis between the PRSN state mental health division of the health specialist Bernard
Consequently,Edgerton came • and the JMHS has been building Department of Social and Health Donanberg.
to the JMHS board on Monday to for nearly a year. The JMHS, Services, found 19 deficiencies At the meeting, he pleaded,
ask board members to accept a which has been audited five times which needed to be corrected be- "There's got to be a way to solve
three-month extension on the con- in the last year,felt it couldn't help fore the middle of June. ' this and continue treatment for
tract. The JMHS board said it clients and keep up with the PRSN "We were concerned enough the clients."
ouldn't accept the extension since demands for more documentation
any of the staff,who have been and paperwork.The PRSN didn't
working on the assumption they understand why the JMHS
would be out of ajob June 30,have couldn't follow the same rules and
resigned or are looking for work. regulations as the region's other fi
. , • )
Q____ _..)
•
Center
CONTINUED FROM Al
Laurie Strong, director of
Jefferson Mental Health Ser-
vices, supported the concept
-- —, Edition June 8-9, 2001 and representatives from law
enforcement, alcohol/drug
counseling, juvenile justice,
state child protection services
e e rso nk. dy
and county administration
joined the effort.
Range said special education
students will no longer have to
■ travel long distances to receive
a mcentercombined
education and coun-
seling
services.
"It will benefit the schools
because it will provide an
■ appropriate therapeutic envi-
rOsad. ent"So fori stes st nts,"dent she
Cbeginssaid. "Sometimes students run
herd over the classroom, but
with the low teacher-student
ratio and the mental health
Building to be day treatment for disturbedyouth support, that will strengthen
y
and offer parenting classes. the child's skills so they can
,
The $465,000 center will be opera- return to school.'
base for many tional by the end of the year. Comfortable reunification
Most of the funding came from
service agencies Washington state,which awarded Jef-
Bill NeSmith, supervisor for
ferson County a$450,000 Community the Port Townsend Child and
Development Block Grant a year ago Family Services office of the
BY PHILIP L. WATNESS February. The building will be located Department of Social and
PENINSULA DAILY NEWS next door to the existing center at 884 Health Services, said families
W Park St.
PORT TOWNSEND — Thugs- will be able to be reunited more
The center will bring to fruition an comfortably because of the cen-
clay's literal groundbreaking for the idea hatched five years ago by Pat ter's family visitation room.
Child and Family Resource Center Range, director of Learning Support "With the family visitation
can also be considered a symbolic Services for the Port Townsend room in a neutral location,
groundbreaking for Jefferson County. School District,and Kris Lenke,direc clients will be a lot more com-
The center will provide services tor of Special Services for the Chi-
Portable visiting kids who've
and facilities for many different orga- macum School District. been in foster care," NeSmith
nizations. They dreamed about a center that said.
From law enforcement to educa- could serve the special education He said the center's Foren
tion, the resource center will fill the needs of students in their districts sic interview Room will also
need for a safe, neutral environment while addressing the pressing needs provide a better venue for
to interview children about traumatic of other organizations. interviewing children who may
experiences, reunite families, provide have suffered abuse.
TURN TO CENTER/A2 "Law enforcement, child
services and schools can do one
interview, so we can limit the
number of times a child will he
interviewed," he said.
David Goldsmith, deputy
county administrator, said the
collaborative approach to offer-
• ing services is what convinced
the state Office of Community
• Development to fund the pro-
ject.
. F
•
Mental
agreement due
Jefferson Mental Health Ser- and the PRSN."
vices (JMHS) was planning on For nearly a year,the two en-
closing its doors June 30,but now tities have had disagreements
negotiations are underway to -about how the mental- health
• keep its services operating for its ,agency sl ojld ope«te.fiQodrich
indigent and chronically ill cli- explained that his small-town
ems. agency, which has been audited
Last Friday, the executive five times in the last year,didn't
board of the Peninsula Regional have enough money to run all the
Support Network(PRSN),which programs and meet all the re-
funds the Jefferson County quirements required of larger
agency,conducted an emergency agencies. Anders Edgerton,
meeting to discuss possible so- PRSN administrator,said that he
lutions. As a result, the PRSN was only asking the agency to
offered to extend the agency's follow the same basic rules and
current contract with some modi- regulations as the region's other
fications for 60 days. That time mental health centers.
• frame would allow the two agen- The Washington State licens-
-cies to develop a long-term con- ing agency is slated to do a sec-
tract with JMHS as the sole and review of JMHS this week.
provider for the publicly-funded Goodrich said JMHS Director
programs. Laurie Strong told him she is
: "It will buy them time to ne- confident the agency will pass.
gotiate a longer-term contract so Additionally, JMHS is hold-
-the provider can stay in business ing a community forum June 20
and continue to serve the clients," at 6:30 p.m.at the Port Townsend
said David Goldsmith, a Jeffer- Community Center to elicit com-
son County deputy administrator. ments from residents about what
The PRSN executive board they want from their local men-
•consists of the county commis- tal health agency.
:sioners for Kitsap, Clallam and
-Jefferson counties.
Quentin Goodrich, the chair-
• man of JMHS services, was
pleased with the emergency
meeting's outcome.
"It sounds like we are begin-
ning to get somewhere instead of
the stalemate we have been in for
the last couple of months," he
said. "They are recommending
we use some kind of mediation
so we would able to resolve the
disagreements between JMHS
•
-( L
l3 --cl
,rosslule I()pies for a Local Boal us 01 llealtilt VV or ksliop in 1'all, 2001
•
// ,r^'
•seindicate your level of interest in each of the topics listed below. This will aid _"\a <k,r
ally in planning for a workshop. Also provide the following information: ��o"
Number of Years you have served on a local board of Health: X:
Your capacity on your local Board of Health (check one):
6_ County Commissioner
_ County Council member
— City Council member
_ Non-elected member
Makeup of your local health jurisdiction(check one):
County Department
,_ City-County Health Department
_ Single County Health District
Multi-County Health District
Your Level of Interest:
Topic High Medium Low
•wers/responsjbilities of the Board of Health
owers/responsibilities of the Health Officer 2
X
Local Health Jurisdiction Fees and other Revenues
State Board of Health Role /'
State Department of Health Role
Tuberculosis/Conununicable Disease Control
Sexually Transmitted Disease/HIV/AIDS
Immunizations —childhood and adult
Recreational Water Safety and Health x
Onsite Sewage Systems x
Public Drinking Water Systems x
Solid Waste and Public Health
Tobacco and Minors
Tobacco Prevention and Control
Clean Indoor Air Act/Indoor Air Pollution
Food Safety/Food Handlers
Shellfish Safety
•
'gal Drug Labs and Public Health
• ntibiotic-resistance Bacteria4.
Bioterrorism
Pandemic Influenza111111111111
IIIIIIIIIIIIIIIIIMIIerging Diseases with Public Health Impact _ IIIIII
,Id Health/Early Intervention
Family Planning
Nurse Houle Visiting with high-risk families
=11n .....11111M11111
Youth Violence Prevention
IIIIIIIIINMIIIMIIIIII
Child Care and Public Health
minnIIIIIIIIIIIIMIIIIimmllMMIII
Dental/oral health
IIIIIIIIM.....1;imnllIllIllimmllMIIII
Health Care Access/Health Care Costs
NMIUsing information to understand public health issues
TOTALS 1.11111111111111111111. ,
IIIIIIIIIIIIMIIIIIIIIIIIII
Thank you. The results of this survey will be compiled
and made available to all local Board of Health members
within the next several weeks. p
,i u5iure i upas tut a Lul,at Dual LISill lieallll yr ut 1011011tilt 1'an, LUU1
•
se indicate your level of interest in each of the topics listed below. This will aid
atly in planning for a workshop. Also provide the following information:
Number of Years you have served on a local board of Health: J)
Your capacity on your local Board of Health (check one):
County Commissioner
_ County Council member
City Council member
_ Non-elected member
Makeup of your local health jurisdiction (check one):
/ County Department
_ City-County Health Department
_ Single County Health District
MUM-County Health District
Your Level of Interest:
Topic High Medium Low
ewers/responsibilities of the Board of Health
Powers/responsibilities of the Health Officer
Local Health Jurisdiction Fees and other Revenues
State Board of Health Role
State Department of Health Role
Tuberculosis/Communicable Disease Control
Sexually Transmitted Disease/HIV/AIDS
Immunizations —childhood and adult
Recreational Water Safety and Health
Onsite Sewage Systems
Public Drinking Water Systems
Solid Waste and Public Health
Tobacco and Minors
Tobacco Prevention and Control
Clean Indoor Air Act/Indoor Air Pollution •
Food Safety/Food Handlers
Shellfish Safety
''gal Drug Labs and Public Health
- tibiotic-resistance Bacteria
Bioterrorism
Pandemic Influenza
SEmerging Diseases with Public Health Impact
rid /Early Intervention
Family Planning
Nurse home Visiting with high-risk families
Youth Violence Prevention11111111111111
11111111111111111111111
Child Care and Public Health
Dental/oral health
Health Care Access/Health Care Costs
Using information to understand public health issues
Lov
/ 44.'01;t-ti L < NJ
TOTALS an f
Thank you. The results of this survey will be compiled and made available to all local Board of Health members
within the next several weeks.
,rossiluie iupics lur a Local Boards ul lleallll VV orksliop iii l�'all, LUU1
ase indicate your level of interest in each of the topics listed below. This will aid
eatly in planning for a workshop. Also provide the following information:
Number of Years you have served on a local board of Health:
Your capacity on your local Board of Health (check one):
_ County Commissioner
County Council member
City Council member
Non-elected member
Makeup of your local health jurisdiction (check one):
County Department
City-County Health Department
Single County Health District
Multi-County Health District
Your Level of Interest:
Topic High j Medium Low
`were/responsibilities of the Board of Health
Powers/responsibilities of the Health Officer
Local Health Jurisdiction Fees and other Revenues
State Board of Health Role
State Department of Health Role
Tuberculosis/Communicable Disease Control
Sexually Transmitted Disease/HIV/AIDS x
Immunizations —childhood and adult
Recreational Water Safety and Health
Onsite Sewage Systems
Public Drinking Water Systems •
Solid Waste and Public Health
Tobacco and Minors
Tobacco Prevention and Control
Clean Indoor Air Act/Indoor Air Pollution
Food Safety/Food Handlers
Shellfish Safety
gal Drug Labs and Public Health
Antibiotic-resistance Bacteria
Bioterrorism •
Pandemic Influenza -
iF erging Diseases with Public Health Impact ��
ld Health/EarlyIntervention on
Family Planning
Nurse Home Visiting with high-risk families X
111111111111
Youth Violence Prevention
Child Care and Public Health
Dental/oral health
Health Care Access/Health Care Costs
1111011111111.0
Using information to understand public health issues
TOTALS 11111111111.11111111111.11
Thank you. The results of this survey will be compiled and made available to all local Board of Health members
within the next several weeks.
,i UJJIUIC 1upICS 101 a LULU! DUa1'US 01 ilealLll IAOrKS11Up in l all, LUU1
0 ase indicate your level of interest in each of the topics listed below. This will aid
qtly in planning for a workshop. Also provide the following information:
Number of Years you have served on a local board of Health: i
Your capacity on your local Board of Health (check one):
_ County Commissioner
_ County Council member
_ City Council member
Non-elected cted member ,
,G1QOS/o/`liAG Cos/m/S5l6NEA.
Makeup of your local health jurisdiction (check one):
(County Department
_ City-County Health Department
_ Single County Health District
_ Multi-County Health District
Your Level of Interest:
Topic High Medium Low
Swers/responsibilities of the Board of Health
owers/responsibilities of the Health Officer
Local Health Jurisdiction Fees and other Revenues
State Board of Health Role /...---
State Department of Health Role
Tuberculosis/Communicable Disease Control
Sexually Transmitted Disease/HIV/AIDS
Immunizations —childhood and adult
Recreational Water Safety and Health `/
Onsite Sewage Systems
`/
Public Drinking Water Systems
Solid Waste and Public Health
Tobacco and Minors
Tobacco Prevention and Control ,
Clean Indoor Air Act/Indoor Air Pollution
Food Safety/Food Handlers
Shellfish Safety
egal Drug Labs and Public Health
• ntibiotic-resistance Bacteria
Bioterrorism
Pandemic Influenza
-------- MIN 1111111111
Emerging Diseases with Public Health Impact
iild Health/Early Intervention IIIIIIIIIIIWdllIllIllMMI
Family Planning
Nurse Hume Visiting with high-risk families — -- i
Youth Violence PreventionMEI
Child Care and Public Health IIIIMIIIIIMIIIIIIIIIII
_■
Dental/oral health .r _
IIIMIIIIIIIIIIIIIIIIIIIIII
Health Care Access/Health Care Costs Mill ■
Using information to understand public health issues
IIIIIIIIIIIIIIIIIIII
TOTALS --_.
Thank you. ■_
The results of this survey will be compiled and made available to all local Board of Health members
within the next several weeks.
,Possible Topics for a Local Boards of Health Workshop iii Fall, 2001
•
ase indicate your level of interest in each of the topics listed below. This will aid
'Featly in planning for a workshop. Also provide the following information:
Number of Years you have served on a local board of Health: 4
Your capacity on your local Board of Health (check one):
_ County Commissioner
_ County Council member 7
City Council member •
S Non-elected member
Makeup of your local health jurisdiction (check one):
_ County Department
,_ City-County Health Department
,_ Single County Health District
_ Multi-County Health District
Your Level of Interest:
Topic
owers/responsibilities of the Board of Health
High Milium Low
Powers/responsibilities of the Health Officer
Local Health Jurisdiction Fees and other Revenues (--- ,
State Board of Health Role I -
State Department of Health Role
f �'
Tuberculosis/Communicable Disease Control
Sexually Transmitted Disease/HIV/AIDS
Immunizations —childhood and adult
Recreational Water Safety and Health
Onsite Sewage Systems -----\<
Public Drinking Water Systems
Solid Waste and Public Health 7N,,_.
Tobacco and Minors
Tobacco Prevention and Control
Clean Indoor Air Act/Indoor Air Pollution
Food Safety/Food Handlers
111111111111MMA6-
!legal Drug Labs and Public Health -'��
Antibiotic-resistance Bacteria1111111111
��i
Bioterrorism 11111
Pandemic Influenza + j
IIIIIIIMIIIMIIIMIII
Emerging Diseases with Public Health Impact IM
11111111111.11111111
2hild Health/Early Intervention ..........IIIIIRIIIIIIIIIMIIIIIIIIIII
��
Family Planning
Nurse Home Visiting with high-risk milies 1111111111111.11111111111111
Youth Violence Prevention
Child Care and Public Health 1111111111111111111111
-_
Dental/oral health
Health Care Access/Health Care Costs
Using information to understand public health issues
TOTALS
Thank you. The results of this survey will be compiled and made available to all local Board of Health members
within the next several weeks.
russiule 1UpICS WI: a Local 1)Ual'uS Ul h eall,!! VvUl'KS11U[J 111 14 all, 2,UU1
ase indicate your level of interest in each of the topics listed below. This will aid
atly in planning for a workshop. Also provide the following information:
Number of Years you have served on a local board of Health: -Z
Your capacity on your local Board of Health (check one):
_ County Commissioner
County Council member
City Council member
_ Non-elected member
Makeup of your local health jurisdiction (check one):
County Department
City-County Health Department
_ Single County Health District
Multi-County Health District
Your Level of Interest:
Topic High Medium Low
wers/responsibilities of the Board of Health
owers/responsibilities of the Health Officer
40Local Health Jurisdiction Fees and other Revenues
State Board of Health Role
State Department of Health Role
. Tuberculosis/Communicable Disease Control
Sexually Transmitted Disease/HIV/AIDS
Immunizations –childhood and adult
Recreational Water Safety and Health
Onsite Sewage Systems
2 .
Public Drinking Water Systems
Solid Waste and Public Health
Tobacco and Minors
Tobacco Prevention and Control
Clean Indoor Air Act/Indoor Air Pollution
Food Safety/Food Handlers <
Shellfish Safety
egal Drug Labs and Public Health
Antibiotic-resistance Bacteria
Bioterrorism
Pandemic influenza --—
Emerging Diseases with Public Health Impact
Mild Health/Early Intervention
IIIIIIIIIIIIMIIIIII
'amity Planning
Nuise Home Visiting with high-risk tamilies -- 1
Youth VIolence Prevention111111111111M1
�.
Child Care and Public Health
Dental/oral health IIMIIIIII-_
Health Care Access/Health Care Costs
IIEIIIIINIIIIIIIII
Using information to understand public health issues
TOTALS
IIIIMIIMIIGIIII
Thank you. The results of this survey will be compiled and made available to all local Board
of Health members
within the next several weeks.
• S
•