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Home My WebLink About06 June JEFFERSON COUNTY BOARD OF HEALTH MINUTES Thursday, June 21, 2001 Board Members: Dan Titterness, Member - County Commissioner District # 1 Glen Huntingford, Member - Coun!y CommiJJioner DiJtrid #2 Richard Wqjt, Member - (òun!y Commissioner Distnd #3 GeoJf,!y Masci, Member - Port TownJend City Coun"ï ]zïl Buhler, Chairman - Hospital CommisJioner District #2 Sheila Westerman, Vice Chairman - Citizen at Lu;ge (City) Roberta Frissell - Citizen at Large (County) StatfMembers: Jean Baldwin, Nursing Sen;iccs Director Lar!:)I Fqy, Environmental Health Diret/or Thomas Locke, MD, Health Officer Chairman Buhler called the meeting to order at 2:30 p.m. All Board and Staff members were present. Commissioner Titterness asked that an item titled Clearinghouse for Medicaid Billing be added under New Business. Member Masci moved to approve the agenda as revised. Commissioner Wojt seconded the motion, which carried by a unanimous vote. APPROVAL OF MINUTES A correction was made to the last sentence on Page 3. The word "made" should be added so that the sentence reads "Member Frissell said while this may satisfy the situation when the property is sold, what is the mechanism when payments have not been made establishing a fund for system repairs?" Commissioner Huntingford moved to approve the minutes of May 17,2001 as corrected. Member Masci seconded the motion, which carried by a unanimous vote. OLD BUSINESS .Jefferson Health Access Summit 2001: Dr. Tom Locke noted that the meeting summary for this well- attended event was provided in the agenda packet. He believes the next step will include the original workgroup polling participants to plan a follow-up summit, which would focus on specific proposals, associated costs, legal authorities, and other issues. In other words, moving from issues to solutions. Member Masci noted that a common thread among the Summit workgroup was the idea of a community clinic. He proposed that since this subject keeps surfacing, the Board of Health may want to make a statement of support or a directive to look into it. Vice-Chairman Westerman said while the subject of common elements from the summit workgroups could be a Board agenda topic, it may be premature to make a statement of support. HEALTH BOARD MINUTES - June 21, 2001 Page: 2 Dr. Locke said in planning the next summit, the work group will be looking at common issues among the Summit workgroups and the possibilities for bringing in more money or spending less money on administrative overhead. Commissioner Huntingford asked whether there may be a tie-in between the Hospital's search for additional revenues and the goals of the Access Committee? Chairman Buhler said that aside from looking at increasing revenue, the Hospital believes it will be important to reevaluate the many programs offered by both Jefferson General and the Department of Health to determine who can do the work most efficiently. Some trends in reimbursement may favor one entity over the other. Dr. Locke said the workgroup would be reporting back to the Board of Health in July. Le!!islative UDdate: The legislature produced a status quo budget of $22.8 billion in the two key public health areas of concern which were the 1-695 backfill money (which replaced 90% of $27 million in local health funding and added a modest fiscal growth factor for the next two years) and local capacity development funding (which was to be a down payment on the public health improvement plan). The Child Death Review received a modest appropriation of $1 million, which will help defray some local expenses in reviewing unexpected deaths. It appears there is also some funding for investigating and cleaning up clandestine methamphetamine labs. During discussion about what was not funded, County Administrator Charles Saddler commented that this budget included $600 million which came out of a one-time pension trust fund. It is projected that some agencies will run out of money before the end of the biennium. Community Indicators Workshop: Jean Baldwin reviewed the list of attendees of workgroup meetings . whose task it is to review data and how it is used, as well as identifying problems and priority areas. Topics of concern are senior issues, violence among kids, school enrollment, substance abuse, and affordable housing. The group decided that a review of health issues must include quality of life issues. She reported the County applied for a Motor Vehicle Accident grant to investigate the high incidence of motor vehicle injuries in Jefferson County. The County website incorporates data as it becomes available and includes regional data. As the BRFSS data is available, the committee will release this information to the community. Dr. Chris Hale expects to have her analysis of BRFSS complete by spring 2002. She will attend next month's Board of Health meeting. Member Masci mentioned that while the City and County agreed to co-fund BRFSS for two years, he believes a commitment to sustain this funding over a longer term will be needed as a way to support the strategic planning processes of each government. HEALTH BOARD MINUTES - June 21,2001 Page: 3 Take Chare:e Proe:ram Implementation: Jean Baldwin described this program as a family planning waiver that allows DSHS Medical Assistance Administration to make available family planning services for clients not currently enrolled in DSHS, but who qualify based on their income. The intent of the program is to decrease unintended pregnancies and lower the number of births. She noted that JCHHS is increasing its family planning services to both Port Hadlock and Quilcene. A June 18 memo explains that 550 out of 936 JCHHS clients could qualify for Take Charge. Although there are billing issues to work through, this program provides an unexpected source of funding. Jean Baldwin reported that she recently received a contract from DSHS for an outreach program in Port Hadlock and South County. Because these contracts are only available to nurses, there is an opening for a three-days a-week, 4-hours-a-day nurse to perform this outreach and education. Additional handouts were a Provider Newsletter and a June 15 letter from Ms. Baldwin in support of Jefferson General's hospice work. Maternal Child Healtb - Hear & Say: Readine: with Toddlers Proe:ram: Jean Baldwin explained that this universal prevention program encourages parents to work on reading to promote toddler language development. The philosophy is based on the knowledge that kids who cannot read well end up performing poorly in school and that a lack of success in school can lead to other issues. The study has proven that if a parent works with the toddler, the child's reading skill will improve. This research project is funded by private donations and will be available to all two year olds, using several different methods. The client base will be chosen from volunteers using birth certificate records and the WIC program. A part of this project will be training three or four local individuals to TUn the program so that it will be sustainable. Aside from providing office space, there is no cost to the JCHHS for this study. In response to questions about how success will be measured, Jean Baldwin said some of the data will be available in six months. Regarding funding an ongoing program, she said the amount of funding needed will depend on the best method. This program may be able to be integrated into another program. She noted that the schools and the libraries are both involved in the planning group to get the program going. Chairman Buhler suggested this item be placed on the agenda in seven months for an update. Topics for Local Board of Health Workshop - Survey Results: Based on a survey of interests for a potential leadership development workshop, Dr. Locke reviewed the prioritized list of topics included in the agenda packet. This list will be used to plan for the workshop, which has been scheduled for all day October 25 and a half-day on October 26 at Sea Tac. He reviewed the workshop format of presentations followed by small group discussions and urged Board members to put the workshop on their calendars. Member Frissell suggested a format allowing several different presentations to occur simultaneously so Board members may choose which to attend. HEALTH BOARD MINUTES - June 21, 2001 Page: 4 .Jefferson Health and Human Services Director Recruitment: County Administrator Charles Saddler briefed the Board on the internal assessment of JCHHS needs and issues. Based on this feedback, the BOCC approved the appropriation of funding for the position of Health and Human Services Director. Staff has begun creating a recruitment brochure and gathering information on important traits or management skills. They expect to fill this new position by the fall 2001. In response to a question about this position's impact on the Board, Dr. Lockc responded that when the expanded Board was created, the Director of HHS became the Administrative Officer of the Board. In Washington State, the role of Administrative Officer and Executive Secretary default to the Health Officer. Thc new director would become the Administrative Officer to the Board. This new position will not only allow the department managers to focus on the issues at hand, but assist the Board and managers' efforts on medium and long-range planning. Clearinszhouse for Medicaid Billinsz: Commissioner Titterness asked to discuss the potential efficiency of a centralized Medicaid billing n~twork. County Administrator said this issue arose from a problem identified by Jefferson Mental Health and the Department of Mental Health, where significant staff resources were necessary to do Medicaid billing. The question is whether there can be economies of scale. Jean Baldwin said that Washington is one of the hardest states in the country in which to accomplish DSHS billings, with a major problem being reimbursement rejections. Member Masci talked about medical software, which he and other practitioncrs use. He believes a good way to choose a product is to get a consultant to come in and evaluate the range of software, vendors, and support. Maybe several agencies having difficulties with billing could participate in such an evaluation. Jean Baldwin said what makes the billing complicated is that public agencies are asked not only how much the service costs, but to specify the deliverablcs and the types of services. There was consensus that a centralized Medicaid billing network is not a topic on which the Board wants to proceed. AGENDA CALENDAR / ADJOURN Charles Saddler said the Board would receive cmail asking them to identify the five most pressing issues concerning public health so as to assist the BOCC and elected officials in Jefferson County in a strategic planning process. HEALTH BOARD MINUTES - June 21, 2001 Page: 5 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) Meeting adjourned at 4:33 p.m. The next meeting will be held on Thursday, July 19,2001 at 2:30 p.m. JEFFERSON COUNTY BOARD OF HEALTH (ì I¡ A J!:J---- J~hler, Chairman ~U-\}Jtl-¡~'~WJ-~ Sheila Westerman, Vice-Chairman ,,w'- ,.,_',"'~ --- ~ Erin Lundgren BOCC Office PO Box 1220 Port Townsend W A 98368 --.... .-.'- Jefferson County Board of Health fRi~(Ç~U~~r-> JUN 1 5 ¡J2 2001 JEFFE BOARD OFHJgMN CUUNTY MISSIONERS 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 2. Community Indicators Workgroup 3. Take Charge Program Implementation 4. Maternal Child Health - Hear & Say: Reading With Toddlers Program 5. Topics for Local Board of Health Workshop-- Survey Results 6. Jefferson Health and Human Services Director Recruitment Tom (15 min) Jean (15 min) Julia (10 min) Jean (15 min) Tom (15 min) Charles (15 min) 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 , ! JEFFERSON COUNTY' BOARD OF HEALTH MINUTES /:)þ .A Thursday, May 17, 2001 If'''''¡:r ORÞ>.f't BlJard .\I'moer.e: Oat: Ti:remw. i\-Immer - CONnn COJJlJJ1ÙJiotler Distr:d #. 1 Glen I-{¡mttngTfJr;;, iHember - Cr)Un!.~' CommlJJwner DtJ/r:ä -¡:;;.: NClJara IF?;:, i\ÜmlJer - COUll!) Commismner DISTI1t:;::3 Geo¡ïr~1 AI(,/.ì;~. i'vIemher " Por: Town.œnd CD' Counti! lit! Bunier. Chairman - Ho.spÙai CommÙsione¡- DÚtn,: #: S hÚ,'a ¡r"estermar.. Y"ice C9airman - CitiZen at LIrge (0::1') Roberta FrisseJ/ - CÙi::::..en at urge (County) S¡a':'-.\lem¡}er.r: Teal: BaÚiwin. .\'/lmt(~ Serl'ices Dim10r ~r:: F~ì. EnlJlronmentai HtaÙt, Dire?'/or '""':'jQlJJaS 1....o"R.e. _HD. Heaitl7 0lfiær RECEIVED JUN 0 5 20tH . Jefferson County .j-_...... 1)¡1I"1I_.~Yicæ 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 continues 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 IVIINUTES 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 FrisselJ seconded the motion, which carried by a unanimous vote. PUBLIC COIVIlVIENTS - None OLD BUSINESS On-site Sewage: As directed by the Board at the last meeting, Larry Fay reported that Staff amended Section 8.15.1-+0(12), changing "may" to "shall." Even though the meeting about the expedited rule process was published in the newspaper, no public comments were rec~ived. -!' HEALTH BOARD MINCTES - May 1';'. 200J Page: :. 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 pan of the support this legislation enjoys is not only for the rarc occurrence oÍ a catastrophic bio-terrorist event. but also for its use against the far more frequent risk of imported infectious disease. The L.S. is not prcpared 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 ami-influenza vaccination to those most at risk. Communitv On-site Sewaee Svstem Financial Assurance A2reement 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 oÌ 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 penn it 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 MINCTES - Ma~ J ~. 2001 I Page: 5 Le2islative IJpdate: Dr. Locke reponed 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 fina! 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 S 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 40C::[ 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 ro 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. 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 lÌst 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 - Mav 17.2001 Page: -; 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 COUNn' BOARD OF HEALTH Jill Buhler. Chairman Geoffrey Masci. Member Sheila Wesrerman, Vice·Chairman Richard Wojr. Member Glen Huntingford, Member Roberta F risseIl, Member Dan Titterness. Member .. Board of Health Old Business Agenda Item # IV., 1 Jefferson Health Access Summit 2001 Meeting Summar¥ June 21, 2001 Jefferson Health Access Summit 2001 May 22,2001 Summary Prepared by: Kris Locke 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. 2 T¡í~ FiIí8lîr:(1í(1 (;~IGf8 2000-200[) 1" Hospital Rates 1" Physician Fees ,.-.. Shedding Losing Lines l' Rates to Business ,... More Consolidation ~ Governm ent Pay Dropping Coverage 1" Drug Costs ,.. ....... 1" Wages l' Uninsured ,..,.. ,.. ....... .... Hospital Margins .J.. MD Income 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. 3 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 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. 4 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 Xz 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. A Summit discussion included the following comments and questions. 5 The rising costs of prescription drugs are a complicated problem. Because many of the 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. Why hasn't government jumped on the economic development bandwagon in 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, Area Agency on Aging Director, Port Townsend Paper Mill, Insurance Broker, Physician 6 Chief of Staff, United Good Neighbors, Jefferson County Administrator, Washington 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. 7 · 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 financiallimítations 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 8 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 SOH has been working on what essential health servÎces 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. 9 · 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 Qui/cene. 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. 10 Discussion Group 2 facilitated by Lorna Stone. Is 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'KlaJlam 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? 11 · 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 12 · 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 10M 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 Îs 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? 13 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. - Le 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. 14 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. 15 Jefferson Health Access Summit 2001 Participants Ann A vary 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 F rissel 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 J onientz 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 SXlallam 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 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 1 Minor 2 Moderate distress 3 Serious 4 Critical distress 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 1 Slightly Generally agree 2 3 Strongly Completely agree 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. 20 Board of Health New Business Agenda Item # V., 2 Community Indicators Workgroue June 21, 2001 -ì Memorandum Date: April 5, 2001 To: Charles Saddler, GeoffMasci, Bill Woolf, Roberta Frissell, Katherine Baril, Dan Wollam, Chris Hale, Jue1ie 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 oflife and some of the data indicators of Jefferson County with Dr. Chris Hale on Friday, April 20th 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 infoID1ation we need to gather before we begin to look at the contextual valley quality oflife 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 Ap(~ zo )-';)0 - ~l'j 0 · Build a D/\.T.\ l":-.crs Croup · Welcome to Visioning .8: Planning · Introduction to Jl'1fcrS0I1 County Data Anah'::::is PaSl & fU!lIrl' · CenslIs Data"... Tho.: Sequel · Data.8: Trends Cm CÎari!~ Communit; Proti!es. \fceds & Stn.::ngths · Is this tho.: right dirl'c1iol1'.> · Timl' Framc rÒr .\SSl'SSillC¡¡¡ in Strategic Pbnning Jean BaIJ\\in Geofr \ilasci Charks Saddkr Katheri 11l' Bari! Chris Hale Chris Hale .Jean !3aJd\\in Kmh....rinl· Bari! Cieotl \Iasci Charles Saddler April 20, 2001 Health Indicators Steering Committee Meeting Attendees: Chris Hale, Charles Saddler, Tim Caldwell, Roberta Frissell, GeoffMasci, Syd Lipton, Mary Ann Seward, John Elrock, Bill Woolfe, Katherine Baril, Jean Baldwin r;enjf Mn<:Ò Design data collection systems Get a handle on future trends Health, law & justice, human services, traffic flow impacts rJwrlp<; Snddlrr Knowledge based decisions Jefferson County commitment to more infonnation 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 Plarming process K athprinp. Rnril 1. Community Deliberative dialogue to view data that is Credible Consistent Comparable Comprehensi ve 2. Rural Sociology provides some barriers to engage discussions 3. Public decision-making process Chri<: 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 infonnation then in the context of our experience TRIANGULA IION Gather every piece of infoffilation 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 200 I. 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 infonnation 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 expenences 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 ~~ ~'f: 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 Ii .. .. 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 coroners 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. Proiect Goals . Create a database from coroners 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 W A 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 Char~ Program Implementation June 21, 2001 " What is the TAKE CHARGE Waiver? 'f Medical Assistance Administration Family Planning Waiver Information Fact Sheet, May 2001 · 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 anew S-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 plarming 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. T AK.E 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. · Plarming 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 ,'" .. Apnl 1. 2001 TAKE CHARGE Federal Poverty Level (FPL) Chart for Income and Family Size ~--~,. Number of People in Family 200% FPL Income (includes parents and Limits i i children) I >----____."J -.- j 1 Up to $1,432 ! -. 2 $1,935 I f----"-..- --- 3 $2,439 . -- -..- --- ..-- ._,. -----~ . ... ~ ,. . i 4 $2,942 I 5 $3,445 I , - I 6 $3,949 i I 7 $4,452 -.. I 8 $4,955 t I 9 $5,459 ..... "~.,----- 10 $5,962 I Add $504 for each More , , additional family member - .,-- ,~ Î H~~I¡h News Release For Immediate Release: June 11,2001 (01-49-kml-2) Contacts: John Whitbeck, Center for Health Statistics Phyllis Reed, Center for Health Statistics Linda Jacobsen. Family Planning Program Kate Lynch, Communications Office (360) 236-4321 (360) 236-4207 (360) 236·3469 (360) 236-4078 Teen pregnancy and abortion rates down, 1999 statistics show Washington rate lower than U.S. OL YMPIA - 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. Ofroughly 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/OOfacts/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 confinns 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- _ ~........ :r 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://wW\V ,doh, wa. gOV /EHSPHL/CHS/ defaulthtm. 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/defaulthtm#Abortion ### fl' '~, ~"" Board of Health New Business Agenda Item # V., 4 Maternal Child Health Hear & Sa'l Reading with Toddlers Program June 21, 2001 í- t rOOd -0 ~cr~~ "0 "M cu 0 5. ~ ~ ~ ~ ~ .... f1) ., 101I :t: æ.. "'!j "'< o c: ., n 2: ël:ó I;;J c:: ~. ~ -0 g:. < m 2: "ê m.... a.~" "'< lit ~ 0 t: g I:!. C ~ ~ ¡¡ å Zo ~ .- ;I c: OQ (þ " 11\ ., .... õ' =s -0 :r ~ 101'I tzI III . . J: ~ m .." C Z ."m cu :J ., t'\ ,.. 0 -c:: -., !:!, ~ ~ " "0 C.J ., I'D :::I tir ;J':I~;cg'1 .., ~ ~ ~ n :.,..~~~ -AI :J- o ~ ~OQ ri ...... 5' '< ~ " S- 110 ;;;. ~ 11);:;> ;:r cu :5. ".., 9- ~ Q. _ :J ~..... , ¡;: õ .g 8 ~. S l"\ (1)..þ,. 0.."0 o ~ ";J 5. ~ ~ B. :::I ;¡t;;"" VI n ; :~ õ ~ ¡;¡ 3 - I'\) cu I'D O~ c.. 3 : 3' AI _ OQ :::I -. ;::\ a.. :::Ia. 0.. 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Seme STC~ ~el(nQ ecny, :::na ctrBrs G:.:: ret Most leTe Tctlt:ars ere busy 'scrr,¡nQ etrar TlIr'ÇS, ::::uT TO be sura, ask a dCCTer, ,"\ursa, or omer professlorCI c:ccut It :f ',Iour ceeV' :$~ot tollt:¡r~g :ike ather :::0::185. ThiS cncrt l"1elps yeu dec¡Oa wneo to ask. Age Whet to iook for in 0 growing, healthy baby Tolk with 0 protessioncl- : 3 monrhs SecV' ¡¡siers TO 'lCLòr vorce, 48 or sl">e coos Gnd :;;urgles end v if your 3-mcnTh-old dees not ! Tries to mek:e The seme 5cuncs 'fOU mcke. listen to your voice. 8 months BCDy ~ieys with scur.ds. Same of mese seunc like words. v jf your 8.month-old is not such cs'bcccr' or "::cda." Bcby smiles en l'"1ecr.ng a happy making different sounds. VOice. or:d ciies or lookS unnappy on liecnng an angry vOice. 10 months BODy ~ncersronas simple worcs. She STOÇS to iOOk: at you if v if your 10-month-old does ¡ ':lCU sçy'No-no." if someone cskS 'Where's Mommy?" Baby not look wnen peoPle telk Nlil :oak for 'iCU. Bct:y will pçlnt. ory, or co amer things to to him or her. l 'teil" VOL. 70 pic:': ner -,p, or oring a toy, 12 months ¡ Fir:;i 'NcrCS! Boby scys 1 or 2 words end '..Inderstcnds 25 v jf your l-year-old S not I worcs or more. 3cov w¡lI;ive you a toy if YOU ask for it. pointing at favorite toys or : ~ven without words. Baby con ask you for scmetning-by tt\ings he or sne wents. i ¡ pOinting. ,ecching fcr it, or Icoking at it end bebbling. 18 months ;\"'cst c¡.ilcren ccn 5C:y ~cm( 'feu' cr,c::r leasT 30 other v if your 18-month-old cannot worcs, crd ccn foilew simple::irecnons ¡¡ke 'jump!· say mere then 5 wares. I 20 months lour c,,:Je ocn OUT 2 wares 7cgemer in ~ ~enrence, suen v if your 2O-month-old cannot I as "ccr go.' or "went Juice.' He ccn fOllow directions when follow simple commands, I '(ou SOY mir:gs like ·c!cse me coor.' :"'9 can copy you sueh as 'come to Decdy." I .liner. 'IOU say severel worcs tegemer. , ì 24+ months l \lour cnild ades erCings ¡O 'Nards. suen cs "running," or v if your 2-year-old connot ';:Icvec. . or ~oys." She likes neefing c SImple children's say 50 words or does not story, She underSTends 3 wores ocout ;:;1009, SUC!'1 os 'in.' use 2 worcs together. 'on" or "at.· ßABì' C.iJR'i\~ CALlëD Me r"MÂ~MA"! ',.IE REC.OGNI1.S-s. ME ~~ ¡"¡IS MOT~~R ! when to start birth 3 months I 6 months I I I 9 months ! í ; i I 12 months I I I I 15 months I ¡ I I I 16 months ¡ I i I 2 years I I I -~ IUt=U~ IU n~µ TOUr \.....nuu L.t=Ufll au I UIK. .. Do the first activities as long os your child enjoys them. Add new activities as he or she grows older. Help your baby løam how nIce voices cen be. v' Sing ~:) lOlJr bcDy. \lw con do !1l1$ even I:,)elora your boO'( :s 0Cm1 You bODy will héor yOU. v' T elk Te '!C\.;r DeCY iak ~o oTt1en 'MIen Booy IS near, 8cby won t undemcnel me wores. but WiI Yke 'JCl.Jr 'JC4ca ~d YOU 7!'oIIe, Booy W1II enjoy heonr-.g one! seetnC omer peoDe. too. v'~cn ter qulet;!me, 9coy needs T\rT'Ie TO OCbb4e one! plcv OUIEJfty wI1tIOut iV'r::J rodlo or omer noises. Help your baby see now people telk to eacn other. v' "del vo..:.r oc!:v acse $0 !J19 ex "'a 'NIIJ look," Y(X;l ayes. Tol<. to Beey ana smile. v' 'M'Ien vour OOOv cot:oIes. mnOfe me so~cs. v' :1 3cOY tnas to mD:e !tie sema souna 'lOW aa. scY !tie WOld COCIn. Hele your baby understand words (even It he or she cen't say them yet). ý Ploy çcmes ilks ?ee«-o-Boo ex POf-o-Ccke. HeIc 8cby move /'lis IlOndS to mctch the game. v' 'M1Qn 'lOW gIVe &:0'( 0 Toy, soy somettllng ot;)Olft It. :ike "FeeIl"IOw fvzrf Tec:IdV Beer is." v' Let YCIJ :JOCy see ni1'UeIf iI1 0 mllTef ena ask. ....,,0· s tnct?" :1 r'\e aoes'l't answer. soy his nome. v' Ask '/c,-,r ::xJOY auest1C(1S. Jke "'Miera's DoggJe?" it he dOesn·t Cl"lSWer. show him where. Heip your baby "telk" by pointing and using his or her hands. ý Shew 3ccy how to wave "bye-oye: Teil OCCy "Show me yC:AJf nose.' T1"1en pont to yOl.S nose. SIle wi~ !.CCn com to ner nose. 00 !tIis 'Nith toes. flnQers. ~ eyes. knees. CJlcI so on. v' ;"iCe ::: ~CYNnlle 3coy <S..-aTc."'\/ng. Helo BcCy flnd it. Shore,.,er deftght at 1'rdng It. V 'N'r,en 3coy ;:õC1I"'tõ ~ Cf ;rve5/OU scmemlr.g. tOlk aboUt ~ cOjed INIth her. Help your child to say the words ~he or he knows. v' 'Olk COOUT :i1e !tIirçs you use. ¡¡ke '=-:..'0.' ';uics.· 'doll." GIve '104.:1 ct'Jld 11mø to nome them. iii' ,~k your <:rlla Gt;esI1cr\$ abOut:t1e DlÇlJr9S in~. Give 'leu d'1l1d time to nome tnIngs in !he piC'lUe. v' ~T\i!e or o~cc '(CUf :"!CI'\CS 'Nf'\en yO,Jr o.'llld ncmes me Itl1l"\Q 1'hc't he sees. Say sorne1hinQ otx:ut It. Help your child talk with you. v' :clk coout wnct 'lCtJ/ cr-Jd wcnn mcsr to telk cbout. Give hllT1 !1me to tea you 01 about It. V As\( CCOl.t 7t";lrçs 'lCU co SCc."'\ doy- "'/~Ic:n sNrT 'Ntl you OICX ~ooaýi'" "Do you want milk or Juice?" v' '^~en '101.1' d'lIC Sl::y$;usr , woed.lke 'tell." rececT it 'M1h a :!me eXITo-"n-ars Bcbv's t;)ctl." v=>taTer,o 'lOW ç:!"1/eI's fcvortte call or toy arJmol COf1 toile. Hove convenat1~ wtIh 1he toy. Hele your cnlld put words together and 1eom how to follow simple directions. v' .~ 'ICA.ir o....,tld tc reIC '/01.1. Fa excmcle. osk her to p.¡t !"Iei' C\.P on the teCle. v' 'ecCt"\ your cNoSlmDe sonçs Ot'd rlJrsery rnvmes. Read!o vr:;1J eNcl. v' :'~coucge 'leur Of'Ic TO telk to :'!1enc1S end femilY. A 0"I1e! ~ ted mem aocut 0 new toy. 101 exOl'1'lOlØ. V :.9t '/01.;( cr-Jld '::1Cy te!eCt">One.· Hove 0 preteno telepnOne convør1OtlCn. Help your child put more woros together. Teach your chíld things that are important to know. v' ~ seen your ct'Jic TO soy rus 01 net :'Irst ono lost name. v'.:..sk ODOI.it 1t\e nl,;r.'Cer. >lZe.=nd slicoe 01 tt',¡r.;s '.IOI.X chtld st1CW$ YC\J. if It's worms. you eoud soy. "'Nt-.ct fGr '.v1çr;;ty \IoQmS1 How r'!1cny are ttlere? ,. 'Mlere ere Tt1ey goInQ~ 'Nett. wctd'I. ond listen to 'ria Cr's.vel. ~ on answer II ~: "\ see five. . . . Are may gOing !'o ~ pone 0I1he stOte?- v' ~.s¡¡ lC1.Jr cnlld to tell you it1e story ~ gees W\1t'I a fevente t:>ock. Ý :heck YCAJ( lOCo! boy 101 proçrcms for TodOJers. .Ask at '-fO'...Z health c.ln1C fOf other guIdeS. v Don·t forget wnct wor1!8d eortIer. For exempje. you diUd st1II needS quiet 1rne. 'INs IS not just fef naps. 7L:m Off the '1\.' dr\d rado and let YCL6 child 9f'.oY owiet Dloy. sIngng. ana tc1Idng. For oeMr ode,s ::>n now 10 ~elo your caÞy deYelOØ. UIc at 'fOIJI1oc.a1 n..M dine !or ¡:",n"enOU~'$ Den,.., Oewicømam.l ~ (1987). FOf II\CIM icS... 01\ \I'IC19S cI1llQAn m.gnl ¡¡q 10 dO. ",me :0 C';Mumer m/orm.non c"uJgg. F>u~. CO ðl009 and u" tor a::::>cy 01 the tre. Con&umlf Inlønn#On CafaIc9. ~e"",s.saon 10 r8Qn:>duce :n'$ 9ulOe tor educallOTlal ~1tIO&M anc frM dlSlrOUIIOn 1$ 9ranted and ~ged. This guide was developed by C"Ueen Ë. Manu.! 01 hi UtW8I$11'( 0/ WasnlnqlCln and ?1tnci¡ l;l1es 01 !TIe U.S. Dtøal1ment 0/ ËOucauQn. Mattnill "'.s ~Ud on ZEAD TD Jt.IREElNilhonal Canter lor Cli/1Q1lntanl "'rogt;.ms (1992); Fenson et al.(1991): 111,I'nd SallIS (1989): &yley (19691:.nd oØIe1 sources CITed iI1 h,¡ 1/\ Cotleen E, Monsse!. -unQuage a"o E",oltol\lll Mtl-.Þ... on the Ao.Id to Re,C_: 1m. ~ no. 18. Center on Fa",»,es. Communm's. ScnoeIS. ancl CI'IIlcIr.rs L"mlng. The canoon .. ~ WIllI ~IUIOII of Ray B<lbngsley. The Oeoa"",ent of cducatJOn extendS III apc:nc,¡lllOn 10 Ray Bihingeley for \I'Ie o-nerous gill of hIs WOlle. 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Q....c:: =~;~:: Ü c Q,I ~ ~ . . . , Promoting Toddlers' Language Development Through Community-Based Intervention COLLEE\i E. HLEB'\ER CniVfrSlt\' or ~\/Lislllllgr()1I This study è\'aiuated an ~¡J;lpIJlion of a de\<:ll)rmen,;}lh based. I)-week parent--...:hild rèJding: program (",JialoglC r<:;lJin{' I JèIT1unstLlkd ;_U I;}Cliiuk -.ocahuiJf\ ~l!1d 'yntactic sktib uf todJkrs, including thusè at nsk ;or lang:ud:,':c [:1ro!'knb. In ,hiS <lud\'. dialogic reading w:lS moditic:J for brudd disscmination through Ù1ur hr:lnches of :1 em' library s\!stèm. Children \ librariJns t;}ught p;Hel1ts t hè rC;lding: tèchIlllues in two: -hour sessions. The ~tud\! design was an dticdC\ trial with two ,hirds ~)¡ !;¡miÌiö ranJomlv ::ls,igned to the dialogic rè~Hjjng condilluIl II! == ,""I ~\[lJ \mc thIrd l,) a compar:suIl ':lmJition. The comparislm condition was comprised of e:-;isting: !ibDr\ sènices lor :;arènts and childrèn (n == -+1 ì. A.nalysis of baseline' ro posHest change sho\\e'J ~l ,i"niticant inrer\<:'ntl0n-group dfect on parent-child rèJding ,:tyle 3nd chiidrèn's-.::-;prcssl\e languagt.'_ In ;¡ddition. at a _'-month follow-up assessment. pare'nts :.n the Jiaiogic re'dding :;:ruup rèporteJ less parenting strèS~. ~pecitìcally "trèsS resultlIlg from charact.:ristics ,Jt :hèir ..:hild. Studies uf social intèfaction lxt\Veèn parents and young children ha':e id¡;ntified many \vays in which everyday conv.:rsation supports the child\; task of language learning. Amung the most common èxampìèS are parents' use I,)f expansions. repeti- tions. extensions. responses. and quötions that fol!c)\v the child's intèfest (Barnes, Gutfreund. Satterly. & W·ells. 19x3: .\fcDonald & Pien. 191:\2: .\ksseL 19-8: Morisset Barnard. & Booth. 1995: .\Iurph:i. ¡CrK: ~inio & Bruner. 19;1:\: :'-iinio. 1980: Snow. Barnes. Chandkr. Goodman. & Hemphill. llJ9 ì: Snuw. Per]mann. & :'-iathan. 1987: \Vells. 191:\5). In addition to encuuraging develupment implicitly. parents also en- courage language explicitly by reaching social routines \vith prompts such as "say thank you. '" providing ohject labels. asking the child to name objects. and correcting errors in word meaning or linguistic form (Gkason. Per!mann. & Greif. 1984: Messer. 1978: :'vloerk. 197-1-: .\Iurphy. 1975: :'-iinio & B rund. 19ï5: 0iinio. 1980; Sokolov-. 1993). Direct all corresponde'ncl.' to: Colle'eT1 E, Huebner, \L1krnal and Cllild Hèalth Progr;lm. Box 35ì230. Department of Health Savices. School ()f Public Health and Community 'vkdicine_ L'niversity of Washington. Sc::attle. Wr\ l)k19S. '::-colk<;.'nh(gu.wJshing:ton,èdu::-> Journal of Applied Developmental Psychology 2/(5): 513~53.:' ClJp:right ,~, 2U()() Els.;\içr Scic:nce Inc. rSSN: () IlJ3-.39ì3 AIl ri gh ts I Jf reproduction ic ~ll1\' form reserved. 513 514 HUEBNER . Shared picture book reading appears to he an è\:ce!lent activity for drawing forward the types of verbal exchanges that support young children's language development. Descriptive studies of hook reading \vith toddlers and preschool children show that many parents naturally intersperse reading with conversation ahout thc pictures that accompany the story. In doing so. parents capitalize on opportunities to kach new vocabulary and sentence-level skills through the use of tutorial questions (i.e.. what-. when~. whcre-. and \vhy-type questions). directive pointing. \)bject !abeling. fine-tuning utterances to the dlild's level of understanding, and corr¿ctive. informative feedback ( Beals. De Temple. & Dickinson. ! 994: Deme- [ras. Post. & SnU\v. ll)~h: \Ioèfk 197-L 1976: .'\ielson. Il)7.3: New'Pon. Gleitman. & Gkitman. ¡ c)77). Intc:restingly. studies of social class differences in mother-child cunversation hnd that working-class mothers are more apt to use a language- facilitating speech styJe during shared reading than in other interactive settings (Dunn. \Vooding. & Herman. IYT7: Hl)ff-Ginsberg. 199 I : Snow. Arlmann-Rupp. Hassing. Jobse. Joosten. & \/orster. I Y76). 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 \vay for mothers \vho might not have the capacity l)r inclination. . ." (\Iocrk. 198.5. p. 5(3). Studiès of shared reading over time have identitìcd progressi\è changes in the demands made on children from ages 1 to -+ years (è,g,. DeLoach. cited in Brown. Bransford. Ferrara. & Campione. 19N3: vVheeler. 1983}. Labeling routines directed by relati\ely concrete questions (e.g.. "'vVhat"'i tha!''''') :.lrè more characteristic with children at the younger ages. \vhereas at the older ages. mothers tend to ask more open~ènJed questions that go beyond the immediate scope of the book (e.g.. "Do you think George will get in troubk'''''). Evidence from cross-sectional research with 4- and 5-vear olds. with J.nd \\ithout communication delays. indicates that . . progressi\-e changes in shared reading interactions are the result \)f adults' adjust- ments to children's burgeoning language skil1s. rather than differences in children's age (Pellegrini. Brody. & Sigel. 1985ì. 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 rJ.thcr than passive. and if the nature of the interaction supports the child to clchieve just beyond her current level of mastery. Experimental support for these assertions is just beginning to accumulate (i.t.. Scarborough & Dobrich. 1994: Bus. van IJzendoorn. & Pel1egrini. 19Y5). Causal links between aspects of shared picture book reading and 2-yeJ.r-old children's oral language development were demonstrated hrst by Whitehurst and his colleagues in a study of a shared reading program called dia/ur;ic reading (Whitehurst et al.. 1l)88). Dialogic reading integrates and amplifies the language-facilitating behaviors described above. The program is based on three general principks: (a) the use of evocati\e 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 & vVhitehurst. 1994). Instruction in dialogic reading consists of as few as t\vo brid 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 \vith normal development and developmental disabilities (Dale. ~otari. Craine-Thoreson. & Cole. 199.3: Lonigan & vVhitchurst. I 99t'S: Whitehurst d al.. !9)s8: Valdez-Menchaca & \\¡hitehurst. 1992). The most consistent positive tìndings arc from implementations that include home reading. with or without a concomitant school or daycare dialogic reading component (Lonigan & \Vhitehurst. 1998: Whitehurst et a!.. l(94). Perhaps as Bronfenbrenncr speculated. engaging the mother-child dyad as an interactive system generates a momentum that becomes independent of the formal intervention (Bronfenbrenner. 19¡'..\" as reported in Lev- enstein. Levenstein. Shiminski. & Stolzberg. I(98). The goals of the prcsent study wcre to adapt dialogic reading for broad-based implementation through neighborhood public libraries and to evaluate the effect of these moditìcations 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 \vithin 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. \vould have an added benetìcial effect on self-reported parenting stress during this period of childhood characterized by rapid developmenta! change. often accompanied by heightened resistance and negativity (Kopp, 19(J2). and more commonly known as the ··terrible t\\ 0 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. :\'IETHOD 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 arc: on average well educated. More than 86()i:, of adults more than 25 years of age have completed high school. and 38% have a "'¡'-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. 19(2). 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 ( l"'¡'%) and to African American mothers (13%: vVashington State Department of Health. ! (191). The program described in this study took place at four different branches of the Seattle Public Librarv. T\vo of the four libraries were locakd 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- end. predominately white. middle-income neighborhoods with a median yearly 516 HUEBNER income in the range of $15,()()() tu $30.()()O dollars (Seattle Office for Long-Range Planning, 19ym. Recruitmen r. 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 U\vaves" at each of the four librarv locations. Recruitment into the four successive waves was continuous throughout the study. Announcements wcrl:' posrçJ in neighborhood businesses and brief articles describing the program Wè[e placl:d in local newspapers. Informational lÌias that included a tdephone ~lnd address contact form and a hrid de\-elopmentJI screening questionnaire were a\aiJabJe ~lt participating libraries and in ()[her nearby locations including chí1dren'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 tlier and returning it to the project of rice. Alternatively, some inkrestèd parents were referred to the project by community agencies and then project staff initiated contact by phone. Critèria for inclusion in the study were: (a) signed informed consent. (b) parent's self-report of adequate reading skill. connrmed later by observation of their ability to complete written questionnaires. (c) a child 2-J. to 35 months of age at the pre- h:st date who scored at or above age le\'eJ 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 dc.'termined by tdephone intervie\\. Interested families who did not mc.'et the critaia received a children's book as a token of appreciation and. if indicated. \Vere referred for appropriate services such as deve!opmental testing or alkrnative library programs for youngc.'r. or older. children. One hundred -eighty-four families \vere recruited and interviewed: of these. 89°ò (164) met the eligibility criteria. The reasons for exclusion '.vere: children were too young or too old. \verc bilingual. were language delayed (and attending spc.'ech thèrapy). or lived outside the study area. ~o family was excluded because of parent"s 10\\ reading skill. Run-in. Families who met the eligibility criteria were contacted in the month bdore the t1rst parent group session to arrange a meeting at the library for child language pretesting and baseline data collection. Because in this -;tudy instruction in dialogic reading \vas modit1ed for community-based implementation. it \vas essen- ti::ll to determine \vhether these changes dilutèd the effect of the training to change parents' re::lding style. Thus the l-month span between child pretesting and group assignment \vas used as a run-in period during \vhich parents who did not read very often could be excluded from randomization into one of [he study groups. That is, to continue eligibility. parents ",vere 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 \vere dropped bdore 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 l. Sample Size by AssèSSrn~n[ and Study Period .';,.,.e(!f!ed & Eliglh/e F()/lt¡¡V-Up .-\ssesslf!/:'nr' [>n!lesled & Rilt/dol!l i,~ ,'d PO\ï-rCSft'li Familv Rackground S\Jciodèmogr:lphics and F:.lmilv C()mp'Jsiuun Parènting Stress [ndèx (PSI) and Life Stress Scale Child ChaLlctef1stics D~\èlopmçntai Status (R-PDO) .--\.gc:. Sex. Binh Ordèr. Hc:alth Status. Child Care Child's Language: .--\bilitv PC:~lbody Picture Wurk Vocabularv Töt ( PP\iT) Earl\' Ono:- \VorJ Picturè Vocahularv T èSt ( EO\VPVT\ Illinois Tèst ut Psvcholinguistics .--\.bilitíès. Verhal Expression SublCst (ITP.--\. VE.) .--\.udiotapes ()( Lll1guagè During Reading with Parent Child's Exposure l() Rèading Frequency and Enjoymènt IoS 12_~ -1-9 ih5 129 12f1 L !: 50 L I-=:5 l ' - -1-9 , - -I-K ,- -I-S L29 113 50 Vliles: Da,hes indicat<: the data were not collected during this period. Thc ,Iud: :!1\nhed four jifferent .ibr:¡ry locations Jnd four succösive waves of famili<:s at e:ach site. \Vithin èach cohort. on:tÖ¡I[1!!: occurrc;d before randomization I up to Ó weeks bdore the: tirst parent group session). :lnd posHesting '.JCeurred within Ó weeks aiter the :n[ervention. Of 1 S..¡ ;'ilmjUes scrct:l1t:u, il toted or IÖ"¡ met ciigibi1it\" <:ntçr::l ¡'or the: ,ruJy. ()r the:se. 13 ¡ completed thlè pre¡óting. ilppomtment and [29 \\ij¡h pretest Jata wefe ranGomizeJ. Of :hese. pust'lest JaD \\ere collected ror 11-, Fulluw-up data wen: collected tor,:::n of,.,: eligibk ,',¡miiies. , For famiiic, in the :ìrst two Wa\"èS of the stud\". Collow-up dat:! \v<:re coile:.::cd ~¡pproximate;\ .~ months after ¡ he: posHest ilppO\l1!ment. . ."\udiutapes ,J{ parcont...-dliJd reading in the home we:re: c\)llected Jllrin~ :he :ntenention I)el\\<::cn :he pre- and ;JOSHest ;'eriods: data 'sere a\ailabk ¡"ur ! 1- r,¡mili<:s cl[ter :he nrst parc:n¡ tr~llnin~;<:ssllJn ilnd llJ.3 r'amilies ~Ükr the: <econd tuining session. Of the remaining 1-1.1 families. 131 completed pre-test appointmçnts. During the pre-test appointmen t. parents (usually the mother) and children \vere audiotaped reading a book of their choice. A.fter the reading. children completed a language ;;lssessment while parents filled out a sociodemographic survey and a stress inventory (see Table I 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 One wçek bd'orc their first parent-group sösion. parents wÇre tekphonçd and informcd of the uak and timc of thç meeting. An additional t\NO families were lost hetwecn pre-testing anu this tekphonç call hec1Use they m()\'ed out of the area. Randomi::;atiofl. {\t the time of the phone call to schedule the first parent meeting:. fami1iö \\t:?rc assigned to either the dialogic reading: or comparison group. .-\!Iocltiotl to the t\\O stuU\ conditions \Vas ranuom and Jètermined h\ an individual . - \\h\) had nt) knowkJge uf the haseline or pretest data. T\vo thirds of the families (1/ = ,sK) were :lssigned t\) the dialogic reauing: group and one third (11 = -+1) was assigned tu the comparison group. Content of (he Intervention. The intervention was based on the dialogic read- ing program as described by Whitehurst and his colleagues (Whitehurst d a!.. 1988)_ Training in the uialogic reading method consists of two I-hour parent-training sessions (sèSsion I and sösion .:) that occurred .3 weeks apart. Typically. instruction in Jialogic reading is conducreu by U nivc?rsity-based research staff on a one-to-one basis. In the pn~sent study. children's librarians were taught to conduct parent training at the library sÎkS. anJ training procedures \vere moditled to accommodate small groups of h tl) I': parents at a time. The contçnt uf the training foJ\owed the recommenùations of Arnold and \Vhitehurst ( 19L)-+). Parents \vere asked to diminish reading: behaviors that minimized the chiJcrs verbal participation in favor t)f evo<:ative techniquö that facilitate the chilù's active participation in r..:l!ing: the story, Adult reading behaviors to diminish included: reading (without the child's participation) and asking the chi1d pointing qUèStions. yes/no quötions. and criticism. Specific dialogic reading behaviors taught during session 1 included the use of "What?"" questions. questions about function and attributö. praise. and repetition. In session 2. parents \vere shcwm how to use verbal expansions of chi1d utterances and open-ended questions to he1p children huild more sophisticated senknce-!evel skills. During each session. videotape illus- tration \vas useù to provide real-life examp!ès of the new reading techniques. fol- iLw,ed by interacti\-e stop-action segments that asked. --\Vhat could this parent have done differently':" or "\Vhat else could this mother have done?" The videotape was complemented by one-to-one practice that included role-play and corrective feeuback. At the end of each session. parents receiv'ed a single-page revie\v of the dialogic techniques and were asked to use the new \vay of reading with their children daily, 3 to It) minutes per day. during the fol1owing .3 weeks. The experienœ of parents in the comparison condition was -¡imilar to those in the dialogic-reading group except they did not receive any instruction to change their reading style, Instead. the curriculum dre\\' from the ìibrary's regular services for parents and young children. Several activities were combined to form two I-hour sessions that took place. like the dialogic reading training sessions. in weeks 1 and -J. of each "vave 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 \vere identical except that for parents in the ùialogic-reading group. parent sessions focused on PROMOTING TODDLERS' LANGUAGE 519 [earning. the dialogic-styli: of reading. Parents in both groups participatèd in two gmup sösions approximately] -hour in length. conduckd hy the resicknt children's librarians and held at the librarv. Each session was offered on at least t\VO occasions tl) acc()mm()d~l!e parents' various \\l)rk ami care~iving. respl)(1sibilitics: the sessions \\ere 'ichedukd t() ()Ccur approximakly :, weeks apart. Jluniroring Program Integrity and Strenglh. To munitor the integrity anù 'itrength l)f the program. as moditieJ in this 'itudy. parent-child reading \vas cl)ded frum audiorapèS at four successive:: points in time: baseline:: (taped ~n the library). during the intervention period afkr parent tr~lining 'iösion I Jnd ~Ifkr session .2 (taped in the [wme). and at fulll)w-up töting (taped in the library). The: purpose l)f the coding was to de:termine the extent to \vhich parents cIctually use:J the: targeted techniques. either spontaneously or as a result of training. and \vhdher parents' dialogic reaJing behavior had the: intènded dfe:ct to incre:ase: tht: child"s verbal involvement in shared reading. To facilitate audioraping ~lt home:. small battery- operate:d tape recorders were provided to parents ,1£ the group meetings. Parents in both the dialogic and comparison groups \vere Jsked t() read daily with their children and to audiotape at kast one rèadin~ session per day. Families \vere contactt:d weekly to answer questions. to problem sohe. and to rc..::mind them to continue:: re~ldin\:!. Measures Parent questionnaire data and assessments of childrcn's ¡an~ua~e ability \vere collected during four periods: screenin~ (by tckphone I. baseline: and prt-töt (up to 6 weeks bèfon~ the intervention). post-test I \vithin h \Ve:::Ks after the intervention period), and follow-up (3 months aftèr the post-töt appointment). Because of budgd and time constraints. only families enroikd in the rìrst t\VO \\aVÖ of interven- tion we:rt includtd in the follo\',,-up testing. An OVdvic\\ of measures by time and typè of aSSèSsmenr is provided in Table 1 each is discussed in turn below. A.dult's Reading A.hility. Parent's skill level \vas assessed during the tele- phone-screening: inte:rview by asking them about their reading habits. particularly their ability to read the newspaper. Experts in adult literacy estimate that a fifth- grade reading le\'è! is required to read the nc\vspaper and that asking ~ldults general q uötions about their functional reading ski!!s gi\'c:s a better indication of reading difticulty than brief screening tests (R. AlJen. personal cornmuniGHiL)n. t Y91). Par- ents' self-assessment was contìrmeJ latèf by observing the èase '.vith which they compkted written questionnaires in person. at baseline. Developmenca/ SlalUS. The Revise:d Dèfl\er Prescreening Developmental Questionnaire (F rankenburg. 1 Yts6) is a parent-report quötionnaire that provides information about four domains of deve]opment: personal-social. rìoe motor. lan- guage. and gross motor. Children are considered to be dç\eloping normally if thty pass all items that correspond to their chronulogical age. In the prèSènt study. age~ appropriate: items from the Rèvised Dènver Prescreening Developmental Question- naire were included in the information flie:rs used to announce the re<.lding program. Parents reported their responses during the telephone-screening interview. The 520 HUEBNER Röised Dènver Pröcn~ening. Devèlopmental Questionnaire was used to screen out children with obvious de\elopmental delays. Childrèn 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 providèr for further c\'alllation. Sociodem og rap h ics. Inf\.)f¡nation about child health status. family composi- tion. and social status \Vas ascertained at baseline and follow-up by parent question- naire. Questil)!1S incillded the child''j age anù 'je,'c birth status (recollection of gesta- tional age). and \vhdher the child had noticeable spet:ch or language problems. Questions about family composition included: the number of adults in the home and tht:ir rt:lation to the studv child: the number of children in the home and their ages and relation to tht: study child: and parity of the study child. Additional questions were asked about èthnicity' and what languages other than English were spoken in the home. Children's Reading Exposure. Chilùren's exposure to books in the home was based on a survey Jevelopt:d for \\¡'hitehurst"s original study of dialogic reading (\Vhitehurst et al.. L (88). The questions include who reads to the child. how fre- quent!y. and wht:ther the child enjoys being read to. Parenfing Stress. Self-reported parenting: stress \vas assessed with the Parent- ing Stress Index (PS I: Abidin. 1(90). The PSI consists of items that tap parent, situation. and child characteristics. RèSponses reRect the degree to \vhich 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) assessö: depression. attachment. restrictions of role. sense of competence. social isolation. relationship with spouse. and parent health. The child domain (.17 items) assessèS: adaptability. acceptability. demandingness. mood. distractibility or hyperactivity. and reinforces parent. The PSI contains an optional 19-item !ifè 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 folkw,'~up. Percentile scores are used to interpret an individual's PSI scores. The percentile scores are derived from a norming sample of over 26()() mothers with children ages I 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, 19YO). 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 (t.g.. Caughy. Grason. Guyer. Hughar. Jones, & Strobino. 1996: wlathematica Policy Rt:search & Administration on Children Yauth and Families. 1997). PROMOTING TODDLERS' LA.NGUAGE 521 Standardi;.ed Tests of Child Language. Standardized ass<:SSI11ents of child language ability wert iden tical tD those used in \Vhitehurst"s previous studies (see \Vhitehurst d aL. IlJSS: Valùe¿-\!ènchaca 8:: \Vhitèhurst. Il)92L They an:: the Pea- body Picture Vocahulary T cst. the Expressive One \hmJ Picture Vocabulary Test. and the verbal èxpression sllbtcst of the lllinois Test uf Psycholinguistic Abilities. Language tèSting \vas conducted ~lt the library by cvalllaturs trained for this project: \vhere possihle. a Jifferent version uf the tcst \vas llsed at pretcst than at post-test and follow-up. Descriptiuns \A the mc~lSurcs are pro\ ideLi ix/ow. TIlt-; PeaboJv Picrurc \/oclhuLlf\ Tcst-RèvJSèd í PPVT-R: Dunn & Dunn. - - Il)~ 1) is a -;wndanJized. I11ultipk-choice töt lJf receptive \l)Cabulary. Testing encom- passes both recognition and visual comprehension skills: the child lS asked to look at a plate of four picturcs and point tl) the object named by the examiner. The PP\;T has two forms. Land \L with ¡ 75 plates in each furm. The t\vn forms are highly correlated (Pearson r codtìcients range from .(15 to .~N: Braken. Prasse. & \1cCallum. 19;-S..+). In the current study. Form L \vas used ~lt pretesting. and form \1 was used at posHest :1Od again. ~ months lalèr. at the t'l)llt.n\-up testing. The Expressive One- \Vord Picture Vocabulary Test í EO\\' PVT: Gardner. 19ì9: EO\VP\'T-R: Gardner. 19(0) is :1 test l)f èxpressi\e vocahulary that asks the child to name pictures Df cummon obje;;cts. T >:st item~ tal! into t'ullr cakgoriö: gent;?ral cDncepts. groupings. abstract concepts. ~lOd descripti\c CC!1CCpb. Concurrent corre- lations with scores or rcœptive language. as IT1èasured by the Peabody· \/ocabulary Test. ranQ:e from .ó- to .;ð. with a median of .-[) I Gardner. IYïl)). The two forms used in this stud\' are the l)l<.kr ]lF9 versilJn and thè rè'.-ised ì S1L)() version. The two forms are highly correlatèd: coeftìcients range frum .:-(J. to .9."' and the J.\erage correlation across cdl age groups is .S~ (Gardner. ì l)l)U). T1è EO WPVT \vas adminis- tered at baseline. the revised version \vas used at posHest and fo¡]cw-up. The third standarJized test used in this study was t.;e vcoal expressive subtest of the Illinois Test uf Psycholinguistic Abiìities ! ITP.-.\.: Kirk. \kCarthy. & Kirk. 19fJS), This suosCJÌc: ass¿sses children's ability to put ideas into words by asking them to describe simple objects. For instanc-:. the child is handed a button and Jsked. --Tell me;; all about this." ff the description is incompkte. the examiner encourages the child with prompts such as --"Vhat do we call ir.)" or "'yVhat can you do with i['7" Scoring focuses on the number of discrete concepts expressed by the child (e.g.. label and classitication. shape. function. COll)f). BeGlllSe there is only one version of the ITPA.. it was not administen:J :H oaseline to avoid pOkntial item familiarity. It \\~lS administered ~1t post-test and r()ll()\v~up. RESLLTS Sociodemographics family sociol.kmographics Gnu characteristics of thè study children arc pre- sented in Tables :2 and 3. Similar to the city as a \vhok. most mothers (ð 1 ~/o) were white. The largest minority group to participate in the -;tudy was of African Ameri- can mothers (12(~~). the next largest \vas Asian (Y~{»). Mothers' average age was 3et years. ""[ost (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 \lothèr's-\,cè (yrs) \lud1èr'~ EJucation (yrs) \(oth~r"~ R"ICè or Ethnicitv Whitç African-\mèrican Asian Otha and \lixèJ Living with Spouse l)r Partnèr (yes) $othèr W,)rks Outside Home (yes) Source: of Family Income (governmènt COli/hilled Grollp l)i - I }.I)). \\ ISO) IIr % 3..1..IJS (:'i.2S) t.:'.h.:' (2.09) -':1 ')~ 12 .)~) ... 01 _~ 0 '''I """t n :is (~'0 -1-9°;' assistance: I !()";' )it). Chitdrçn in Home )io. AJults 10 Home PSI Parentmg Stress Total" PSI Parcr1t Domain PSI ChliJ Oomain PSI Life St:-.:ss Scale l.--I-1l.05) 2.uS (0.6S) 21:'.:)9 (37.03) 117.L)~ (22.16) 9-.u3 \ 17.2Y) h.:'" (6.02) Dialllgic Reading 10 = 88), \I ISO) or % 3-1-.-+ 1 (-t.b({) i57""' (2.m) "', .)/ ~..,~ n 1 1 ";' .....Of ~"'t 0 iw --+ " 92°;' --1-7°{" S"I l. ,() l.76 (1.U2) 2.lO (().68) 213.5.5 (33.91) 1 1 7.l)- \20.3Y) 96.-+S (16.26) 6.19 (:'.95) Cumparison (n = .J/), \\ (SO) or % 33.337 (6AO) 15.39 (2.15) Sl ()~ 12 "{) ")Of _ ° SOh 7W){" 54";' 1- 0; J" 1.71 (1.12) 2.02 \ 0.69) 221.0:' (-+3.19) 1 [lJ.S9 (25.83) L01.l6 (19.20) 6."'Y (6.25) \'0 {t's: T çS¡S :',)r JiÌferences betwc:en groups were 10l ,t.ltisticallv signiticlrlt èX.:èpt for ,hè propurtion $[ mothers li\'ingxlth \ersus without a spouse or pannçr I 'c '-" :'.D4. P < .(5). 'v = ! 2lJ tor the combined g.roup on all \ar¡abies èXcept the PSI. n = l::. for hOLlsèholds to include extended familv and unrelated adults: 1(Y~tQ 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 vounger siblings. Onlv 6 households (.5 0/0) 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 < .(1). Proportionally more of the south-end mothers were minority women (39°'0 \5. 5°{-¡ in the north end). more wçre single parents (26% vs. -t-% in the north end). and proportionally more of the south-end families received public assistance ( ì(') 0/ ,'C 10f) _ ,'0 VJ. ---t,o. Parenting Stress and Life Stress at Baseline At intake to the study. the average PSI total score was 216 points: 12 (YcJ 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 Charactèristics Dr tl1è Randomized Sample: ( ',llI/hlll,'<I ( ;rlll/f)· \[ ISDI IIr .,;, f){¡¡/ogit Reading. $ / SD ¡ ¡)/' ':\¡ f"ll....... ~ $ /14 ()~) -() ";, C, III/parlson. \1 15D) Of "It, 2:-;.93 (3.59) :;h% tí3 0~ CÎH()!l()I()!,'i..:al-\sc I n1U~) Sc'\ (mal..:) Birth ()rJèf I tir:.;th'rn i PrCtll~llur-: Birth I \c, ¡ I-k';t/th l)r \p<:c:ch Pruhkm I \ c~ I E,lr Inl<:L·ti()n ,)r P~lill I V~) In 1"r..:~d1(),)II'r Da\'Clfè (\,~~\ . . R-:~ld r() -1- ,)r \Iof': Timö per Wc:c:k (YL'~ I Fnl()Y~ R..:aJin~ VCf\ \Iu..:h ,)f "L()\èS [t" St~lIlJJ.fJiz<:J LlIlguag.: T <:sts PP'vT StanJarJ Scnr..: EO\VP\T StanJard Scor<: 2~.'" 1 (.~..;:) hi ";, 2(;.h 1 (:;,21) "";'(),') .:;()¡ . " , 0/ .' 0 .....1)' " ....Ot " -:01 o ~h~\l ~Mo~) ,\S');, ljO ";, ~l) ()'o h_~ (\) '11)";, '1h "" l) I ''';, l)::'.":, 4....1)/ _} 0 y~I)1 _ 0 l():;,~l.) (lh,-11 lllì.-...!. 12:'11~ \ iiJi1-1-2 ll-;,-~5) 11·L~9 \2.../.-1--1-) UJ:.55 (15.10) L02.':ì"7 (2.../..94) ,\,.v \',~ ¡:9 fur Ih",:.)lllbineJ "r')llC "n,lll ,,'clOcklllograohic JI1,1 :lealth \'Jri;¡¡'lö. For rh.: ,tanJardized töts. rl = ; > :ur ,11," PP\T ,ln0 .'! ~ '> f,\r ¡h-: f.( )\VP\T: ,::rc:e~;~iidr-:o Je:.:!in<:J ¡'orh [ö¡S: UTle Jeclined <)oly the E()\\P\'T \\¡thln :no: ,¡¡di",:I:': ~;;':Iùin" o;,,-,up, ,ample ,IZ-: :>r L'hiiJ \:lrd'k~ ,ang<:0 [r,'Hn '-'-I. ',() ,"11: ,ampk ,ize !-:.If1:;~'d ::rnrTl .~I-": :u JI in ~r.1.,:' ~i_ìn1t='~lr1~('n :1f(\Up. 1-";~l,.' ~·ur ,-~:~'t';::"~n(..:-.; '-"'è(\\'~;;:n ,;rlìups b~l~-':.J ~)fl ra~ç!inç' ~hild :.:h"L1L·~èriqiL·' "erè ¡WI '.¡afi"i,::¡i!\ ,ignlrk:lI~r ",\cept 'l'r '!1è '·:,,'1 (,r' Jiffer<:nœs in EOWP\T : '" .'.,J.'., P"': .US'I. The sum of all six child subscales form an overall child domain score: it exceeded the recommendtd high-stress cutoff for 12°'0 of sample. Parent domain scores \vere elevated for -uo of tht sample. The.: twO parent ':iubscales most frequtnt!y elevakd were related to poor health (parents' health. 21 (~';)) and a stressful reJationship \vith the.:ir spouse or partner (relationship with spouse subscak. 13°~)). In addition to overall and domain scores. the PSI contains a subscale that renects defensive responding: this subsca1e \vas elevated for 11 % uf the respondents. At baseline. tht: aVèfage scort on the PSI Life StrèSs Scale \vas approximately 6...). points: total scores ranged from 0 to 27 points. Only 7% of families earned -.;cores above the recommt:nded cutoff for high life stress (see Abidin, 1990). Child Characteristics and Language Ability at Baseline The average: age of the study children at pretesting \Vas 2t-S months: the age range spanned tht inclusion criteria. from 2..). through 35 months. Sixty-one percent wert: boys. and ó8'\) were tìrstborn. Only ..).0i:, ,)t the ;;ample was reportedly born.... or more week;; e.:arly. \-lothers reported health or speech problems for ì% of the study children: 6ho~) had been medically treated for ear infections or ear pain. Fifty- nine percent of the children atknded preschool or daycare programs outside their own homö. \-[ost parents (8 ¡ UfO) reported reading \vith 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 \vas. however. considerable variabilitv 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). .+3 scored below 100. Of these, 22 children (1 ìt~,o of the total sample) could be considered "at risk"" for language problems because or below-,werag:e tèst performance and one or more of the following concomitant psychosocial risk factors: maternal education less than 12 years: mother ..,ing]e: family poverty: PS I parent. child. or life strçss score above cutoff: or high defensive responding. Intervention Group Difl'erences at Baseline Random assignment resu!tèJ 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 \vith a spouse or partner (92?S vs. 78%. P < .OS\. One test for differences in baseline child language scores reached statistical significance. The difference. in EO\VPVT was approximately 11 points. equivalent to nearly one half of one standard deviation (t = 2'-+2. p < .(5) 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 ~). Analysis of Parent-Child Reading Over Time Coding JIethod. 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 to lO-second intervals 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 1 ì audiotapes that included multiple examples of read- ing behaviors that parents in the dialogic group were asked to increase (t.g.. "What?" questions. questions about function or attributes. repetition. labeling. imitative directives. praise, open-ended questions. and expansions) and to decrease (e.g.. reading \-vithout 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. betweçn 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 ~ OJ ... ~ ::r -, .:::! .., '.(;: x: ~ 'Ë -: ;:; .OJ ~ ,...., ~ 4" ~ 4" ~ --- ~ ;; --- ;:: :/; r- -C - ... -. ;:; ~ :¿ 1"1 x: -C Z '" .~ ;;;: 1"1 ~ - -- =' ..¿ r- eI" .- 1 '" ;- ~ ''-. .. -::: - ".i ;- ~ - ... :o.ú ~ ~ '- '- ;J) OJ '-- , :-- = --r '.J OJ r- 4" Of r-, .;: '~ ,... ....,. ;;" '.. . :- r< ~ ~. '~J '.J .. .- :.r: ,~ ;ç ::::: '" -- --'= ...::: '" - j .,. Of ? ~ ..! -- ;;: :¿ ~ -- '" --- ¡-.: -: ~ ~ ,,-, 1C .,. C". ~J ?J ;:; - ::J -' " :j '.J - -' ...::: - ~ ;:! r-.. r- ." - -- "I '.(;: ''-. '.. OJ -- ',- ,.... ;:;: r- - .~ .....: ''-. C", ::: -. - -:::. " ::: :.r: '.J ~ '- ... -. £ ~ ~ --. - ::- '- :: ¿ r-: -- ;ç -: ~ -- :..-: ? r-.. d :: < .... 'r. - :.r " ~ I ~ :.; .~ ~ .r '" ".i .- :;..- .- -. ~ '--' - ~ .. .~ :; 'r. "3 r-.. r- .~ - '"" .- ;:; ;c ::.: ,,-. .. -. ~ '- "I -: ..: ? '" ? ~ :c ,,-. -= - Z c.::.. ....:: :.r: " - OJ ~ -' :¿ cr. Á X ir, '3 " -- "'- X -. -: - ~ .~ -t '--' :; :-- --r - :; ,,-. ~. '--' ::- ,..., " -:: ~ ;! '.J 0-. >- - - - ;f. '-' ;f. .~ ;- :: " --:: ~ r", ~ ;c r- --r Z ::; 1"1 ;r. ;! - .- .~ :::: .... X t- z :.r: 1- 'J -. - 2 :> ;5 ;:-¡ .. ::- - 2:. r- ? -:: .,. ~. "I .~.J - '" '-' f'. ¡ 'r. .- - ~ z -- " j :; ~ '" :; OJ ~ -::. ..... - ~. -:: -- -- "'; ? ;:; "'3 --.; r- ? '- .- i- ?: '.r =' ,..,.. ,~ r. " :~ ~ r--: r-- r-: OJ - ....:: :.r: ~ ;; ~ ::- ÎL ~ ¿ i7:", ~ ,,-. ~ oL '-;;j ,,-. -= -- _. .- ..: 'd .:;:: '" ~I ;=::'1 ,,-. - OJ ;; .~ .. .::; " :.; :{' - - " ^J -J - OJ ." J" '" ~ .::::: -J 'J ." .- .~ ;;;: '-' ~ .:: ;; ::: ~ ;:; ~ ~ ;;;: ., '- ~ '- :¿ OJ ~ 1C :; ':¡:j -:; -:; ~ .- .. 1 " .'-J 'J .:::: -' '.J 5 " :::: 'r. -' -' 5 ~ ::- -g .~ 'J '::: -~ ~ 3: Ir;; ~j .. ~ >- -= .. ¿ ~ :::; .:::! 'J -' ~ ::: OJ ~ 2 .... "" '-' 2:. " . - '-' ~ 526 HUEBNER from the computation because: they rarely occurred. lntraclass correlations for child behaviors were .h I for vocalizations. .9S for one:-worJ utkrances. anJ .97 for multiworJ phrasö. Because \ocalizations were not a targetçd child be:havior. yet one:-worJ and multi\vorJ utterances wae. this level of agreement was judged to he adequate. Training to this level of proficiency took approximately 90 hours. lnter-rate:r reliability was computed for 2()<J'Ó ur the tapes chosen at random over the: coding period. The average: intraclass correlation for parents' reading behaviors was .42: the range \vas .7k to I.()O. Cnef!ìcients for the three child behaviors were .9S or above. Three coders unaWJre of JIl otha assessments transcribed the child's spoken language from the same: set of Judiotapes used for behavior coding. The written transcripts were used to compute a free-speech measure of children's syntactic maturity. mean length of utterance (NILU). The measure used in analyses reponed hae. MLU -5. was base:d on \vords (Ndson. 1(77) rather than morphe:me:s. and on the: longest the utte:rances rather than the e:ntirç speech sample. because in this study. the amount and clarity of child speech varied greatly. i\[eJ.n length of utterance-5 was computed based on the chikrs longest tìve utterances from tran- scripts of the in-library reading sessions and from the tìrst 5 minutö of the home reading sessions. Training to compute .\lLU -5 took place on a subset of 30 practice; tapes. Pron- ciency \vas demonstrated on ~1 set of 10 rapes. Inter-rater agreement. indicated by Pearson correlation with an "e:xperr" (the study investigator) \vas .98 for coder A and .9ì for coder B. Training to this level of proficiency took approximately -1-0 hours. Inter-rater reliability between coders A and B was computed for 10°'0 of the tapes chosen at random Juring the coding period: the correlation was .90. Changes in Parent-Child Reading Over Time; Table -1- summarizes the con- tent of parent-child reading over time by intervention group. At basdine. parents were remarkably similar in their lack of dialogic reading behaviors. At baseline. the sum of dialogic reading behaviors over the )-minute period was 20 for parents in the dialogic group and 2-1- for parents in the comparison group. Th-: groups were also similar in the frequency of behaviors the dialogic-reading group would be instructed to diminish. On average. the:se 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 s to rv. After the parent sessions. the reading behavior of parents and children in the dialogic-reading condition changed dramatically. AudiotJ.pes of home reading in the weeks after each of the two training sessions showed thar 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 -1-). Likc\vise. 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 Tahle 5. \kans uf Child Lang:uage Test Scort:s at PosHest anJ r\\iCOV.-\ by IntdVl'ntiun Group Diu/c1!;it r~('Ildill!; ('r '1/1/Jilrisl)1I !.dll1;II(U.!.tJ [¡',II \1 ISO! 11 \1 ISDI n ,\'v('O~,',\ r PP\'T ¡ 1:1 It) I 1'::; .~-;.~ "¡ -l) \ t ¡¡ 1 I 1.::'..1 )"~) .;h flUl.::'.) = h7 .--I-t EO\\P\T , ,~ __~h : ~ 0.==) -" ! 1--1-,IL~ ( 1-,'¡;--\) ,~h Fi 1.1 II) ,- hI) , , lTP\ \ E. --I-II.-,~ ,'--..')1)) -:-, -'--I-'--I-J I h.! 1) '.h F( l.t 11 ) = (\.-1-h ()(L; \, 'f~'\.: ~I)r:) ..1f -..:'~lí...:h .:tuJy ~n 'Lit"'! \"~l~ ~l)";l ~·r(')nl ~unL1C[ \"'t.:t\\'I;:'èn ~"'ri..:' .lnJ pust-i.~S{Jn~, Analyses of children's language during reading also revealed group differences. Compared with the: comparison group. Juring book reading the dialogic-reading group children use:d almost twice as many multi word utterances. more one-word utterances. and had longer \;[L U -5s. Pearson correlations wae computed to assess the strength of concurrent rela- tions bet\veen parent's behavior and child language during sharc:d reading. The association between dialogic reading behaviors and the fre:quency of multiword and one-word utterances \vas hi£hlv si£nitìcant afkr tralI1in!:l sessions 1 and 2 (r rJn!:led ~. ~ ....... ...... "- from .5':- to .64. p .<: .00 I). Ukewisc correlations bet\vècn the sum l)f nondialogic beh,wiors and child language were consistently strong and negative (r ranged from - ._~l) to - .66. p <: .0(1). Intervention Group Differences at Post-Test Having established that training in dialogic reJding achie\ed the goal of chang- ing the interactive behavior of both parents and children. the next step was to examine group diff..:rences in postintervention scores on the child language tests: the PPVT. the EO\VPVT. and verbal expression as measured by the ITP A. Post- testing took place at the !ibrary \vithin I) \veeks after the end of the 6-\\eek interven- tion period. AnalysèS of differences between the dialogic-reading and comparison groups at post-tèSt 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 & Commjngs. 1988). Although possibly attenuating the magnitude of the intervention effect. the advantage of this analytic approach is that it increases the generalizabilìty of these tindings to other community-based implementations of the dialogic reading program. Post-test datJ were available for Y3 °'0 of the dialogic reading g.roup and 93 % of the comparison families. Because of the imbalance in language scores benveen groups at pretesting. differences in post-test scores were determined by analysis of variance: pretest scores \vere used as covariatèS to correct for initial differences. The results are presented in Tabk 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 EOWPYT scores). the average post- 528 HUEBNER tèst IT? A verbal expressive subtest score was 4 t points for the dialogic~reading group and ]4 points for the comparison group (F( 1.111) :::: 9.-+6. p < .n t). The difference. equivalt:nt to more than one half of one standard dèviation. is considered a medium dfect size (Cohen. I 9ìì). 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 tì.rst two waves of rhe inkrvenrion were con- tacted approximately 3 months after their post~tesr appoinrmenr 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 shmved no intervention- group effect on the follow-up PP\;T or EOWPVT-R scores. In addition, at follow- up. the difference between groups on the fTPA verbal expressive subtest had diminished and was no longer statistically significant. Between post-test and fol1ow- up. the mean score of both intervention groups increased. The adjusted mean for the dialogic reading group was -\.1.03 points. a negligible incre:lse over the adjusted post-test mean of -\.0.73. The adjusted mean for the comparison group was 38.78 points. 4 points higher than rhe 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 follmv-up. comparison group ¡,;hildren had begun to catch up. Perhaps carch-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 posr-testing and before rhe follow-up. As soon as the formal intervention period ended. librarians and parents relaxed their aIlegiance to group secrecy and information about the two conditions was shared casually. \io data \vere available on the frequency of this practice. although the extent to \vhich dialogic-group parents continued using dia~ logic reading and to \vhich comparison group parents adopted the dialogic style on their own was assessed with families \vho participated in the follow~up testing. Analyses of audiotapes of parenr-child reading recorded in the library at the follow- up test appointment showed persistent group differences in parents' reading style. yet 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 2ì (5D = 18. P < .05: data nor 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. 19q 1, for a discussion of these treatment PROMOTING TODDLERS' LANGUAGE 529 Table 6. \;1eans of Parenting Stress Scores at 3-Month Follow-Lp and A~COV'-\ by Intervention Group ¡'elrel/fin,>; Sfr<,\.\ [)[U!O'>;[(' R"tldil/'>; ('{ '/ll{Jlln.\1 'II (lIdt'X I /'."¡ i \1 ISO I 11 \\ ,SDI 11 .I\COI.I P T,)ul Sc()r~ 21Ih.I)I) (_,2",S I ,-+ 22(I.Sh ¡.f7..'::: ) 1-+ rl 1.-1.." ) = .+..+;-; ,¡)..¡. P:lrcnt O\)ll1dlIl Ill.r (21)i::: ) .-::...¡ ¡ IhSh (25,'7(1) 1-1 /'1 I..~.';; \ = ' " , L~ ChilJ OOll1dltl l)-I.53 11 (1,("''\) ,-+ II )..I.,I)() 125,1 )lJi 1-1 F(U:'I = :' . <''it} 1)2 \"II'S ()nl\ r~\[nilit.:, who WlOre Jl11on~ tilt.: :ir'l .¡nJ \lO(()nJ Wil'lO' () p:lrtiClpate In :Ik :ntèf\~ntion \\ierc lO¡'':lrk ,1Jr tht.: IlJllow'Cl¡J JS't.:',nh:nt: PSI :oilow-up ,bta ..'t.:rt.: ,ì"\ILìbie (\Jr -+:-- )[ (il~s~ ": "i¡~¡rlè rarnil¡t:" 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 \vith baseline PSI as a covariate revealed signitìcant 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 shmved a similar pattern. The proportion of high child domain scores in the t\\'o 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 tìv'e-fold differcnœ between the two groups' child domain scores (p < .05. Fisher's exact töt), T\venty-nine percent of comparison-group families and 6°~) of the dialogic-re<lding group families scored above the cutoff for high stress, for the follo\v-up subsample as a \vhole. the three most frequently elevated child subscales were related to negative mood. difficulty adjusting to changes. and the parent's vie\v of the child as rewarding. Only 4% of parent domain scores \vere above the recommended cutoff for high stress: the most frequently elevated parent subsca]e reAeered feelings of emotjoni.ll closeness to the child (i. eO. parental attachment). Effect of Recruiting ~[eth()d on Sample Composition Despite widespread recruiting and the participation of four different neighbor- hood libraries. relative Iv few families uf lower socioeconumic status volunteered for this study. Lack of variation \vithin the sample precluded the opportunity to examine potential socioeconomic status differences in baseline home reading prac- tices or in the effects of dialogic training un parents' reading style. Interestingly. post- hoc analyses revealed that family sociodemographics were related w the success of various recruiting methods. \Vhen the recruiting methods were categorized by source. a different pattern emerged tor 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 cons¡,;quencc of participating in other library activities. That is. for thöe parents, establishing a relationship with project personnel preceded their involvement. In con trast. approximately half of the north-end parents came to the: program having hearJ ahout it second-hand through a friend. a 11ier in a store. collee house. or communitv center. DISCLSSIO;,\ This study tested the usefulness l)f a simpk anJ dlective shareJ reading mdhod that helps facilitate young children's language development. Dialogic reading. as moditieJ here. led to favorable changes in parent-child reading style. in children's language use during reading. and as measured by J. 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. Audiotapt::s 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 atter only one ì -hour training session. Audiotapes of home read- ing shmved 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. \Vithin the dialogic-reading group. changes in parent's manner of reading were associated \vith 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 or its effects on vocabulary knmvledge 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 sho\ved significant inten'ention-group differences on one test. the ITP A verbal expressive subtest. In light of the initial skill level of the children in this study. this hnding is not entirely unexpected. Recall that at baseline. all children were talkative. intelligib!e. and capable or combining words: on average. their maximum sentence length during reading was between 3 and --J. words (Table -+). 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' LA.NGUAGE 531 pwg:raf11 effects to he lTlore apparent in tests nf single-word vocahulary. In fact. previous studièS of dialogic reading with less highly functioning children reported "ignihcant inrcrvention-group gains as mC~lsurèd hy the EOWPVT anu PPVT. but not the ITPA \/erhal expressivc subkst (Lonigan. \ l)l),;: \VhikhursL Arnold. Epstein. Ang.ell. Smith. & Fischel. 1l)9,;). It is perhaps -.;urprising that within this study ()f re!atively advantaged families. there were children \vho could be c()f1sidered at risk fl)r future language. and possibly schl)ol. difticulties. Although a single töt ()f testing. series can not be considered diag.nostic. a nuntrivial suhsc:t uf study children did earn lmver than a\erage test scores. At baseline. .;..¡."() scored kss than 100 on the PP\T a recèpti\'e vncabulary test. including 1 ()<Jj) \vho scored -J. or morc months helow age leveL Of those who scored below lO(). more than half (or 1 ¡OiO of the.' tOLlI sample) could be considered at risk for language delay by virtue of haying PP\'T scorèS below averClge (/l1d one ur more family risk factors such as lo\v matèrnal education or high family stress (Le.'venstein et a1.. I L)9S). The fact that so mar1\ children \vere identitìed as earlv . - ~lS age 2. even \vithin this !o\v-risk. sample. underscores the value of this inexpensive parent-toddler reading program as a uni\~rsal pre\el1tive intèf\ention activity. \VidèSpre~ld community-based programs such ,1") this, ,jöigned r'ur :. oung children in a stage l)f rapid maturation. can sene thr~e related ~oals; to promoti:" thè language dev~lopment or all children. to identit\ those ,1[ ~-;s\..: lor lan~ua!:!e pmblems. and - -- -- - to refer those in need tu ameliorative sef\ices è~H[\ and during a de\elopmental period that is particularly amènabk to intef\èntil_ic, An unusual hypothesis explored in this study \\~l::' that an lnrèfClCri\e. lang:uage- focused intef\ention \\¡ouJd havè an additional pCh¡ri\e-: efkcI on sç¡f-reporkd par- enting: stress. It is well iècognized that thmughout ¡he-: lifespan. but ;Jarticularly in early childhood. physicaL ment::lI. and emotional -.::apacities are functionaìly inte- gratd.1 such that maturation in one domain can ;lç :.bsociatèd wi th aJ\'ances in another (Zeanah. Boris. 8:. larrieu. \l)l)"7). C,_ìn\è:·se\:,. delays ,m8 Jir'fìcultièS can also afkct multiple areas uf development. Speedìcaìly. Jmong preschool and school- age children. language and beh,l\ior problems ,1r-: highly currelCltèJ I Benasich. Curtiss. & T alb!. \993: Cl)hen. Oavine, HorodeLky. Lipsett & Issacson, 1993: Pun'is & Tannock. 1907: Srevenson & Richman. : 'r~!. Thus it-;eemed likdv that the dialogic reading could beneÍÌt parents ~ll1d childrèn neg:otiating the ··terrible t\\o's" because it off¡:rs parents a way t(~ kt their child practice: Jutonomy and indepçndence within a developmèntally appropr¡ak and \\iddy \alued context: "hared book readin~. The data supported this prop(~"i tion, Analyses l.if tollü\v-up scures on the PSI shu\ved a hve-fold difference between the study g:roups after controlling: for baseline scores. Parents in the '..:omp,nisun group \\en: mO'3t likely to report ekvakd strèSs hecause of acceptability uf the chile! and ..:hi!d's negative mood. Both sources of strös threakn parents' a\'~libt:,ility to a child who is perceived as denlanding and unrewarding, Because brief community-bas.:d prog:rams such as dialogic rcadin~ are intc:ndèd for all families. ~lnd thachy dl) not srj~matize selected groups. they' could be a way to hdp parents smooth out difhculties thelt are common in the preschool years. while offering a fìrst step tn mure intensi,-e services for families experiencing: more persistent problems. A limitation of th~ program. ~lS carried out here. was that it \',,-as 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- Iowa-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 interestèd in providing parenting-support ser- viCès to Imver-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 \vho were not eligible. or did not volunteer. for the present program, including parents with low literacy skills. those who read infrequently. and those who tind 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 Imv-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. mav gain even more from one-to-one interaction with other ....... '--.. '-- caregivers. such as child care \vorkers. 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 \Vas a post- doctoral fellow at the University of Washington and \vas supported by grants from the John D. and Catherine T. .\facArthur 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. REFERE~CES Abidin. R. R. ( [ljY(J). Pilrmring srress index (3rd ed.). Charlottesville: Pediatric Psychology Press. Arnold. D. S.. & Whitehurst. G. J. (L l)9..¡). Accekrating language development through picture book reading: A summary of dialogic reading and its dfc:cts. In D. K. Dickinson (Ed.). Bridges to fÚerlli.:v: Children, {(ullities. and schools (pp. [03-[28). Oxford. UK: Blackwell. PROMOTING TODDLERS' LANGUAGE 533 Barm;~, S.. Guttreund. \1.. Satterly. D.. & Wèlls. Cl. ( IlJX3). Charactèristics of adult spt:ech which predict chi¡Jren\ language development. Jilllm,,1 /)( Child Llflguuge. II). 65-X4. Beals. D, E.. DcT<:rnpk. J. \-1.. 8.: Dickinson. D. K. (llJY"'). Talking and lisrcning that support early litcrJcy devcluprnent uf chiluren from low-income familiès. [n D. K. Dickinson (Ed.). Bridges II> !ilt'file\' Children. t(unifin elllll \,¡'hol>ls (Pp. 19----41)). Oxford. LK: Blackwell. Benasich. .--\. A., Curtiss. S. 8.: T~tllal. P. ([993). Language, learning. and heh;}vioral disturbances in childhood: .\ longitudinal perspectiv<:. Journill oflhl! AmaiCiln Au[(le1l7v I>(Child ilnd Adolescent Ps\chiuln', .;::. ~K5-';;l).... Braken. B.-\.. Pr;}ssc. D. P.. 8.: \1cCallum. R. S. (It.JX4), Pcabodv Picture Vucabularv Töt-Revised: An :lpprcllsal :1I1d re\'1ew. Sâ/,)ol P\Tcholo~\' RI!\'{¡:w. /.;. ...9-rÚ Brmyn. :\.,... Bransford. 1.. Ferrar.:!. R.. & C:1mplOne. J.( I LJX3). Learning. remembering. and undèrstanding. [n J Flavell 8.: E. \\arkrnan (Eds.). Hundhook ¡)f ¡:hild psnj¡¡)il>~v: Cognitive ,In·t'/opmt'f1l (pp. 7"7-¡llhj :\èW York: Wiley. Bus. :-\. G.. van IJzèndoorn. \1. H.. 8.: Pelkgrini. .-\. D. II YY:5). Joint buok rl:ading makes for success in learning to read: A meta-analysIs \)11 imergen<:rational transmission of ¡itêracy. 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J. 119-;,';). Thè inrcgrati()n of rnoth<:'rs' referential spèech with joint play. Child Devtdopmmt. ·N.7,';1-7,';7. \--[()èfk. E. L. ( 191-\:'1. Picture-book readin~ by mothers ~md young chilJrè!1 clnJ its impact upon language d<::vdopment. Jour/wl o( Pmgtncl/lcS. (I. :5-F-5hh. \[oèfk. E. L. (1976). P:-ocçsscs uf language teaching dnd tr;:¡ining: in the interactions of motha-child dyads. Child Dn¿fopme//f. ·1-7. 10h..+--107S. \.[uerk. E. (1974). Changes in verbal child-mother inkr;:¡ctions with increasing: language skills of the chi1J. Journal 0 ( Psychlllinguisfic Research. 3. 11) 1-[[ h. \-[orissd. C. E.. Barnard. K. E.. Grçènberg. .\L T.. Booth. C. L. & Spieker. S. J. I I 9l)()). Environmçntal influences on t:'ad", language devçlopmçnt: The contçxt of social risk. Development ilnd Psvchopa- fholo'{\'. .:. 12-;-:..1.9. \[nrisst:'t. C. E.. Barnard. K. E.. & Booth. C. L. ( 1995/. Toddler's language development: Sex differences within social risk. Developmentul Psychology. 31. S:51-:-\6:'. \-Iurphy. C. \-1. (197¡"\L Pointing: in thç context of sharçd activitv. Child Develllplllenr. ./.9. 371-3KO. "elson. K. (1\r:'7L Facilitating children's syntax acquisition. Deve!oplllelHul Psnhologr. 13. LOI-107. "\çlson. K. (197:;). Structure and stwteg:", in !earning to talk. .Hollu!{mphs ot' [he SociefY tf)/' Rt'search ill Child Dne!opmou. 38( 1-2. Serial "io. 1.+9). "\e\\port. E. L. Gkitman. H.. 8.: Gkitman. L. R. (1977). \-Iother. I'd rather do it mysçlf: Some çffects and non-drt:'cts ~1r' matèrnal speech style. [n C. E. Snow & C. .--\. Ferguson (Eds.). Talking to ~hildre/1: LIIIi;lIlI:;,' il1plllllntl ¡/cquisirio/l (pp. L09-1.+9). CambriJgè: Cambridge Cniversity Press. "\inio. .--\. (I 9NO). Picturo:-book reading: in mother-infant dyads bdonging to two subgroups in Israel. Child DeveloplIl<!/I!. 51. 5S7-590. :'\iinio. A.. & Bruner. J. 11 '-f-;'S). The achie\'c::ments and antecedents of bbeling. Journal 1)(Child Language. 5. 1-\5. Pellegrini. A D.. Brod\. G. H.. & Sigel. 1. E. ( 1 %5). Parents' book-reading habits with their children. Journal o( Etluc,llio!/al Psn-!lOlogr. 77. 332-34(). Punis. K. L.. & T annock. R. ( 1 l)97). Lmguagt:' abilities in childrt.'n with attention deticit hyperactivity disorder. reading Jisabilities. :Jnd normal con troIs. Juurnul ,) l Ahllormul P\\chulog)!. 25. I 33-....... Ram.:\'. C. T.. & Campbell. F. A (191'\.+). Pre\entive èducation for high-risk children: Cognitive conse- yutnces uf the Clrolina .--\becedarian Prujçcr. Alllerican Journal ()('v/emul Dt'jiciel1cv. 88.515-523. Ramey. C. T. & R;:¡n1e\. S. L. (1998). Prevçntion of intellectual disabilities: Early interventions to improve cognitive development. Preve/1five .Hr!ilici/lr!. 27. 22+--2~2. Scarborough. H. S.. & Dobrich. W. (199.+). On thè eft1c3cy of reading to preschoolers. Developmental Ret'im. I./.. 2-+5-~02. Seattle Office for Long-Range Planning. (1990). Comprdlensivt' plan frilfnelvork policil!s: Population and hUmall needs. Seattle. W.--\: Author. PROMOTING TODDLERS' LANGUAGE 535 Snow. C. Ed .\rlmann-Rupp. .\.. Hassing. Y.. Jobse. L Joosten, .I.. & V,)rst~r. J. (I i.)76). :'vluth~rs' spe~ch in three sm.-ial dass<.'s. JOIln/ulof Plvcho!i/lgllisric Reseurch. 5. [-20. Snow, C. E.. Barnes. W. S., Chandkr. L Goudman. L F., 8: H<.'mphill. L. ( ['N[). L'nfÚltille¡[ expeua£Îof!s: !!"Il/t: iI!ld school iJlI/II<!llces Of! !¡¡emcv. Cambridge. :'vIA: Harvard Lni\'ersity Press. Sn()w. C E.. Perlmann, R.. & 'iathan, D. I [9N7), Why routines are: difkrent: Toward a multi-tactors model ()f the relation between input and language acquisition. In K. E. \idsun & :-\. vanKleek I EJs.). Children '\, 11lIrglltl~e (Vol. h. pp. ó:'-97). Hillsdale. 'iJ: Erlbaum. S()k,t)lo\, J. L. (199.~ L A local contingency ~1I1alysis of the tine-tuning hypothesis. Developmental Ps\'chol- u!:y. ~(). [00('\-1023 Stevcns'JI1. L & Richman. \i 1197:-;). Behavior. language ~l!1d Jen:lopmcnt in thn,:e-year-old children. Joun/a! ot' .~lIfislll (/1Ii1 C!rildflOod Sc·fu::ophrl'niu. .'I. ::lI9-3 L~. V~dJez.\knchaca.:'v1. c.. & Whitehurst. G. J. (19l¡2). Accelerating language J<.'\'èlopment through picture book reading: .--\ systematic extension t,) daY-";J.re. Devdopmenral Ps\chology. ~8, I IOh---1 11'+. \-Vashingwn St;lte Department of Health. I I i.)l¡ I). \liral srarislics. /CN(): AJI/lual slImmar.\' reporl. Olympia, \V.-\: Author. \Ve:bster-Stratton. C. i, 1 i.)l) I). Stratègies fur helping families with conduct disordere:d children. Journal Ii I Child p\'\'c-!w/¡),;V ulld Ps\'ch iarn' und Allied Disciplines. 3.:2. to..¡. 7 ~ lOó2. Wells. C. G. (lllS:5). Ltlllguilge devt'!liplllel1f Ihmuf£h rhl! preschool It'urs (pp, _~9:5--H6). Cambridge: Camhridge Lni\ersit\ Press. Wheekr. :'vI. P. ( 1 9S3 ì. Cuntöt-relateù l~e changes in mothçrs' speech: Juint bouk-reading. Joun/al of Child LUllfjutl,<t'. I(). ::.:'9-'::ó_~. \Vhikhurst. G. L-\rnuld. D. S.. Epskin. J. 'i.. Angdl.-\. L Smith. \1.. ,,\: Fischel. .J. E. (;LJi.)3). A pi..;turç buok rçadin~ intCfwntiun ¡¡¡ Jaycare and 11om<.' tor children trom lo\\-incume families. In G. J, \Vhitèhurst (Ch~tir). hHeTt'emiuils in shared (t'ilding r;)r childrenci'JlII [u,,-incon?¿ -;¡milies. Symposium conducted ~lt the biennial meetin~ of the: S,)Cièl\ tor Rcscarch in Child Dc\'eiopment. \icw Orkans. L.--\, :'vlarch Lyl¡3. Whitehurst, G, L Epstein, .I. :\.. Angell. A C. Payne. .-\. C. Crone. D. .--\.. & Fische!. J. E. : 199"¡'). Outcomes of an emcrgc:ntlitêrJ.cy ìI1tÇf\ention in Head StJn. Joumul OT Educuriot/al PSH'hology. Sf¡. 5"¡'2~5:5:5. \Vhikhurst. G. L Falco. F. L Lanigan. C. L Fischd. .I. E., DeBaryshc. B. D.. Valdez-:'vknchaca. \1. C. & Caultì.eld. \1. 119KH). .--\..;celerating language: Jcvelupment through picture: book rçading. D-lc'cÙ)f!fI1t'lITai PI'\'clzo/¡¡<.;v. ~-f. :552~5:51.), Zcanah. C. T.. Boris. :\. \V.. '-\: Larrieu, J. .--\. (1997). Infant dçwlopment anJ Jevelopmental risk: A fe'.lew of the past tU ye:ars. .!Olln1,/Ì ¡)lllze AmericulI . \ Cllltetl!\' (II Child ,inti .--1.,lo¡nCt!1lI PndrÙury. .~n. Ih:'-[-:--;. ~~~~~~~~~..~~.......~~~~.!~.:~..:...~..~....!.!..~~~.~~..!~~~.t~~1Iilf1f.:......fr:'f"f"~~""!'''''r., l'11~ìì'1'11'1111"'" 1 r11n"'-::·~i"~"f'"T T""I r'f11'J~"I"''T'''T1'''r'T ~ ~ '1T1~-q"lr~'" JOLR.'>¡Al OF EDCCA nON FOR STlTDENTS PLACED AT RlSK.. .'1 }). :91-31.. Copyngh( ç :000, Lal!lTence Erlbaum .\SSOCI3tCS. (nç Community-Based Support for Preschool Readiness Among Children in Poverty Colleen E, Huebner Department 0/ Health Ser·ilces School a/Public Health and Community' .\.1edicme Cniversiry 0/ Washingron This study tested the feasibility ofan intervention designed to increase the &equency and quality of shared reading 3l11ong low~income parents and their young, 2- and 3-year~old children. The program was based on an lllteracÜve reading method known to facIlitate children's receptive and expressive language skills. Study panicipants were 61 children and their parents; they resided ill 1 of2 socioeconomIcally disadvan- taged communities. Prior to the intervention. few parents reported !Tequent home reading, and most children's language skills were at or below that oîothers' their age. After the intervention. the !Tequency of home reading more than doubled.. and signifi- cantly more parents reported their children enjoyed shared reading. Tbis study dem- onstrates that relatively simple. inexpensive. ~o=unity-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 thelf middle-class peers. Despite the national goal that "by the year 2000 all children in America will start school ready to learn" (Goals 1000: Educate American Act. 1994ì, an alarming number of the nation's children are not prepared for academic lessons when they enter fonnal 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-ciay de- mands of family life. In the past 25 years the proportion of children who live in pov- erty has risen steadily. TIlls is especially true for very young children; currently nearly one child in four under 6 years of age lives in poverty (Lamìson- White, ,. Requests for reprints should be sent to Colleen E. Huebner, ~atema¡ and Ch.lld Health Program, Box 357230. Department of Health Services, School of Public Health and CommunHY Med.ic1l1e. Universtly ofWasrungton. Seattle, WA 98185. E-maJl: colleenh@u,washmgton.edu ,1':'1111:1 I,:' , ','Iii' 'iil!;lllllill ii/IIi liilllll 'I"illl If: Ii: lillli 292 HeEBNER I yC¡-'¡. \Vhen parents an: not abk to meet basic economic m:eds. It IS especially dif- ticuit for them to provide ,;ocially and emotlonaJ1y for theIr young children (Barnard. \-!orisset, & Spieker. 1993. Conger et aL. 1992: \-!cLoyd. 1990: Ramey & Ramey, 1990; Schor. 1995) Tne cumulatIve effect of unremitting economic dis- tress IS retlected in a less stimulating, less responSIve and more punitive parenting styk that is more common among ¡ower-income parents and parents who are young, kss educated. and rJ.Islng their chlldren alone (Conger, :vtcCart'y', Yang, Lihey. & Kropp. 1984; Culp. Culp. Osofsky. & Osotsky, 199 L Dodge, Pettit. & Bates, 1994; Hash 1[11 a & Amato. 1994; Haskins. 1986; Kelley. Power. & Winbush, ¡ 992; \kLoyd. 1990). Given the hardshlp of poveIl! and the accompanying social and persona] stress. perhaps it IS not surprising chat children \vhose famllies are poor are kss likely to be ready t'or kindergarten. more likely to fall behind in grade school. and more likely to Jrop out of high school (Duncan, Brooks-Gunn. & KJebanov, 1994: Hare & CasteneJl, 1985; Krein & Belkr. ¡ 988, Schweinhart. 1994; Zill. Collins, \Vest. Hausken, 1995) :-\ second impediment to parents' ability to prepare theIr chIldren tar school re- iates to recent changes 1D the labor market that requIre more time in the workforce tOr nearly all parents to adequately support thtlr t"aIT1Ilies and maintain their em~ ployment One result has been a new "po verry of tlme" (Fuchs, 1988). Working parents. but especial1y working-poor parents who cannot afford to purchase mate- nal resources and help with ~asic household chores. are short On time for their iamilies (Smith, 1989). Lack ofnme can limit parents' abllity co provide tar the in- 5trumentaJ, emotional. and educational needs or' theIr children. .--\ recent national poll of over 1.000 parents of infants and toddlers found that nearly half ¡he parents surveyed end most days havIng spent less time than they wanted to with their chil- dren (ZERO TO THREE. 199~) The social and economic conditions that have created a ,teady IOcrease in the number of families who :lIe struggling, including an Jdditional 1-+ million new \vorklng·poor families between: 989 and ¡ 996. ,how no signs of reversal (AMie E. Casey Foundation. 1998) Thus. although social and health ser.'lce profession- als advocate for the ¡;}Olicy' changes necessary for long~terrn Improvement, we must acknowJedge that the problems of too little time t'or parenting and too little money ['or adequate child Care are datiy re3.1nies for mtilions of .-\rnerican families. As In- terventionists, and In program planning, the education and 5etVlce communities must be ready to r1lnction withm the constraints of limited time and limited money. In short, We must work "smaner" on behalf of families and young chlldren (Barnard. 1995). Tl) do so requm:s that we articulate the models and assumptions that support our InterventIOn dforts and evaluate our programs and practices with scientific rigor Tl) do less Insults the hard-earned time and trust oftamilies we in- tend to help l\1orisset. 1996). No sIngle Intervention will ameliorate the disadvantages faced by young chil- dren from poor families. Individual families' needs and resources must be con- I --l ~. ".". ..,... "",.. ""....',.,..... .,.........., ...............",.1111...11.1111··.....,.".11'f!'I'T'I"I"T'!'rfT'f'"''f'f'!"''f"'I''1111....'..'''''..,.··''"...,.1......................,.. ,.... SlPPORT fUR PRESCHOUL READINESS 293 sldercd when ..ktermlr,mg the llmmg, lnt<:nSlr., an<.Ì Juratll)t1 \)f supportive Sef\iœS, \Vith regard to educa¡¡,onal :ntef\'ention programs. some children. for Instance those of mothers with limlte<.Ì Intellec:uaì abIlities. respond favorably to intensive. contlnUl)US educatlonai Intef\'entlons :hat begin In Infancy (Ramey, Bryant. Campbell. Sparling, & \Vaslk, 19Rx: Ramey & R:tmev, 1990). Other children can benetit from relamely jess :ntenslve center-o<.lsed programs. in- cJud1l1g Head Stan: IB:trnet1, i 995: Schwemhart : 9941. Home,based fam¡¡y sup- port programs c;:m <.I]so have posItive effects \)n opportUnities tor children's learnmg ;:md on the quality of parent---child Inter:tction (Booth, Barnard, \1itch- ell. & Spieker, ¡ 9R'7: Seltz. 1990: Y oshibwa, 1'195 )--\s these illustrations show. formal preventive Intervention programs \'ary in focu$, :nten:my, and du- ration of services. NeIghborhood and community net\vorks can shape the Jives of children and fimilies 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 instiru- tions, such as churches, public tr:msportatiol1, schools, and health and child wel- fare CY oung & \1arx, 1992). :--.iaMal support nerv.orks, such J.S ~xtended family, religious groups, merchants, or social dubs, benetit chlldren indirectly by provid- ing parents with instrumental and emotional su!='port i. 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 (Cochr;:m & Brassard, 19ì9: CotterelL 1986). Experts in early child development emphasize home reading J.S one way parents can support their children' $ learning and readiness t'or school (Boyer, I 99l). The relations between home reading and later school achievement are multiple and complex (Snow, Bames, Chandler, Goodman, & HemphilL ¡ 991), At the youn- gest ages, there IS general agreement that parent-child reading can add substan- tively to children's vocabulary and <:mergent literacy skills I Bus, van IJzendoorn. & Pellegrini, 1995: Lanigan, 1994ì, Differences in:he frequency of shared reading are apparent as early as the child's tlrst] years <J(Iife;:md are ;;trangly associated with parents' education and income (Y oung, Davis, Schoen, & Parker. 1998). So- cioeconomic differences in home literacy activitIes persist ~hroughout the pre- school years, For example. the 1996 National Household Education Survey identitìed a strong linear relationship between parem education and home reading with preschool-age children, Among parents with less than a high school educa-etion, only 59% reported reading three or more times per week with their ]. to 5-year-old children; the percentage was no,o among those with a hIgh school di- ploma or GED, 8ì% among those with some college, 91 °'0 among ¡hose with a col- lege degree, and 96°/0 among parents with a graduate or professIOnal degree (Wirt et a!., 1998), 11'1/1 iI III 294 l-fL'EBNER This study tested the feasibility of a community-based intervention de- signed to increase the frequency and quality ()f home reading among lower-in- come. less well-educated parents and their young, 2- and 3-year-old children. The program was based on an interactive "dialogic" reading method known to facilitate the expressive language skiJls of children from lower- and middle-in- come homes; and children with nonnal development and developmental dis- abilities !Dale. Craine- Thoreson. ~otari, & Cole, 1996: Lonigan & Whitehurst, 1998; Whitehurst et aI., 1988), Dialogic Reading differs trom typical reading in that it emphasizes active involvement of the child in telling, and retelling, the story. fnstruction in Dialogic Reading consists of as few as two brief ses- sions. The techniques, which include asking questions, expanding the child's responses, and giving praise, are straightforward and easy to demonstrate, fn a randomized controlled study of Dialogic Reading in Seattle, Washington, anal- 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 children's Jibranan. 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- titions, and gave more praise. In rum, children in the Dialogic Reading group used more one-word and multiword utterances during reading and showed more sophisticated language skills on a standardized test or word use (Huebner, in press). The results of the Seattle study are particularly impressive because most par- ents began the program with a strong tradition of famIly reading, and the major- ity of the children were developing apace. That the intervention could enhance the language abilities of these children testitìes to the potency of the reading techniques. However, this unintended design "strength" limits the generalizability of the Seattle tìndings- to less socioeconomically advantaged groups. In the Seattle study, only 100/0 of the participating mothers were receiv- ing government assistance or had nor gone beyond 12 years of formal schooling. Analysis of recruitment by recruiting method yielded an important lesson, In Se- attle, lower income, !ess well-educated mothers were more likely to enro]] in the study if they had an opportUnity to discuss the value of the home reading with program staff and witness other parents' enthusiasm. fn contrast, middle-In- come, hIgher educated mothers were willing and eager to "sign up" and did so without the additional personal contact. Sociodemographic factors and self-identitìed parenting stress were associated with parents' panicipation dur- ing the intervention, too, Parents with fewer social and tìnancial resources were less likely to adopt regular reading :tS a family routine. Perhaps for some, spo- radic reading ret1ected their own discomfort with reading or the relative unim- portance of literacy compared to more pressing family and neighborhood problems (Gadsden, 1995). . ,~ tef' :me -. ..:, If: ',1,;', m2 5tg s¿ ~ 'T" 20 -:0 ., i1J ;1; ~:1 .., :)\.. . ~ :J¿ Y· ; , 0' .. .. n y., ,~ IJII ,..,r.'.,.""..", qPPUR T FOR PRFsnw()1. RE\[)I'\ESS 295 1 hc purTwsc ,¡fthc pre:scnt stu,h WJS to karn \\hcthcr thc Dui')~IC Rc:aJing In- :e:0 c'ntll1n cuulJ be JJ3pteJ t,) L'ommurWJçS Ch3L:¡..;tc:nzed hy <.\ldc:spre:iJ PO\crty .mJ ,c:iJ\!\ o:!\ 1,)\\ le:\e:i, .,t ,¡Juit c'dUCltllHl, T:,c [JrlmJr- ýuestll1ns \\crc: CJn tho: In(e:r\cnuvn 11.: :-n<JJltleJ tn (It ',\ ¡thin e::\:st:ng ,\st<.:ms ,¡f(ummu- :lltY-O:isc:J famil\ suppor: .;er-'I<:O:S,' Dl)ÇS the: ,ntenentll)r1 (hJn~ç ,he homo: ilteLlC\ J<:tl\¡[;Ö ,)t' families In ,<1Ul)eCnnuml<:JI [\ c1lSaJ\ J:ltageJ <:ummunltlO:S lr1 way s ~hJt Jrt;' pkasur- Jr¡Je .wd JÖliaoie ,<1 p:iro:nts JnJ ¡ho:¡r yuung "pro:" rJr<:s<::-:(),)i~hiìdrt;'n' If ,uccessfui. the: resuits ,)1 ,hIs stuJ\ \vili halO: slgmll<:aIlt implll.'ations tÓr more \\iJt.:spre:ad uSt: <)fth.:: Inkr.c:nuun, In partICUlar, the: tìnJlngs (an l.'onrnÌJute mfor- m:itlun to the national s<:huol rèadlnt;'ss goal. Ideas for E \en S tart programs. and de- signs for uther twn-generJl1unai tJmtly literan pn,grams METHOD Setting TV\l> communttles I FC JnG :'-:L I repn:s<:nteJ ::¡y lucal ('am1ly reSOurce centers go\'eming councils chl!,;e :0 participate Ir1 this srudy The f(;:source centers were clJntacted and oltaed rJrt~l.'¡pJtl()n hecause ut' :hc:¡r recent pa,;t ;n\oi\ement with J ccmr.1unity case srudy l)f ch¡Jd and fJm¡]y ser\'ice systems conducted by the national organization. ZERO TO THREE (View & .-\mos, 1(94) The opporru- ,my to work cooperJtl\dy w¡¡h ZERO TO THREE. a weil-respected par- ent--professional ad\ OCJcy and education group. :illowed the current project to build on establIshed reiatiunsh¡ps wnhlr1 the commUl11tles and gJtn a neh under- standing uf lucai ser\lces. ,;er\'I<:e delivery systems, and the expenencc: uf fami- lies with y'oung childrc:-,. f:C, FC IS a ruml ~0unty In :h<: '.vc:stçrn L'nllc:d Stat<:s, T~e ~ounty encom- P:.b:iCS clppro.\imJte::. : ,5Uu 'yLh\fc: miks and h"J" pupulali,'n ,H':iDl)ut 32.000 peo- ple. :ncluding I. -'01 chIldren under 5 years of age ( 199()) .-\eeordlng to LS, census Gata. In 1990 the po\ert\ and unemployment rates were highc:r lr1 FC than for the stat<.: as a whole (http: ww\\'census,govl, Atthe outset of the presc:nt study in 1994. many FC families were ro:cC:I\1ng A.id for Famij¡çs with Dependent Children, :VIost fam1Ìies who receivc:d government aid wen: :le\c:r-mamea r11othc:rs or ['amilIes supponed tempor~rily because UI' po::rwds of unempluyment :Vledl um-slZI.:d bUSI- nt:ssc:s were scarce, and It W:l,; dlt'tì(uit 10 tìnd :1Jl)b thJt paid more than mtnlmum wage, Residents l)fFC \\ere predomlnatdy \\hlte. [1Un-Lallnl! In ethnlc:ty I, View & A,mlK 19(4) : i :1' ¡I, i I I ,II ., ! ~ 1 296 HLEB:\ER NL \ L :s J ..:ommun¡ry that encompasses ,\VO census tracts of In urban Mid- western cIty. It was the <linth poorest of that Clry'S 7ï wmmunities. Former major employers have left the area. and the rate of violent crime \vas hIgh. :nore than double that of the city l5 J whole, In ¡ 995. at the time or the present study. many of ]\¡1.,'s streets were lined with boarded-up and burned-out shops and housing, Census data from 1990 reported employment at about 25~'iJ; among those who were working, many were underemploved. in lov"'-wagcJobs The ethnic make-up or'the community was predomInately i 96')" i .-\rncan ..\mencan (as reported In View &-\mos. 1994). Recruitment Recrui tment to th.:: study \vas org:rnized by the participating famIÌy centers and took the [orm ofintorrna¡¡onaJ posters. :mnouncements in the local newspaper. and word of mouth, The program '.vas open to all parents of 2- and 3-yeah)id children. Thus, '.lilthin each site. the intervention was universal in scope. This decision was based on each communlty's insIstence that the program be promoted l5 a special opportu- niry for ail famdic:s 3.nd not stigmatized as a remedial program tor tamllleS and chil- dren "at risk,"' Extra drort was made to include parents \vho. Jecausc: of limited economIc and .::ducJtional resources. might be kss likely to read with their children on a regular basIS. as well as children observed to be slow in language acquisition. In additlOn. a ,"o:w t'amtlles with ..:hildren outside the pre ¡erred age range were in- cluded at the request Or;.1arents and family .:enter starTwho relt they would benetìt from the reading progrJ.m, Content of the Intervention The goal of ¡he intcr.e:1tlon "vas to encourage trequ.::nt parent--(::",tld reJding and teach parents J '.val" to !'Jlde ..:hddren· 5 verbal parti..::pation dunng book reading through the !.Jse :)f specal": con\ersatlonal Jevlces. such as :'requem..iwl. ;vhere, and \\hv questions. I) pen-ended questions. COITect1\e feedback. and praise, The in- terventIOn. based on :h.:: Dialogic Reading program for toddkrs de.. eloped by \Vhi!èhurst et elL IIlJ8~ )...:onslsts üftwü ¡ -hour parenHraimng sessions that occur approximately 3 \ve:::ks apart, The training includes videotaped dlustratlOn. model- ing. role play. and wITecti ve teedback. [n this study. paraproresslünals were taught to conduct the parent-training sessIOns by the study investigator. \\,:ho received her training from the developers of the Dialogic Reading program, Community adaptations of the intervention. [n the ongmal '0ihitehurst et .11 (¡ 988) study. parent training sessions 'Nere conducted one-to-one, In this study. ~ ~,. , . . r r ~ ¡ . . , t . T ' ,'tf",'!I' I I ~ ! ! r I , , 1 , , T I I . I I oj of I , t .,. I . , I 1 . .. . T . r , . . .. 1 .,. "'I , '"'I.. '" "'I .. ... 1 1 1 .. .. " " .. . . .. 1 ,.,......,., . . . , T . . . . ! . , ... .. '"', ,.... .... ~. t........,. .."',"'......."1". SLPPORT FOR PRbCt-j()()L R[,\OI"\ESS 297 ,he :',ìm1J( WJS mt'dltied ,t) Jcct)mm,)dat\: mJivldu<lls J~ \\e:l J~ -;m..lil );,'TUUPS ùfpar- ~Ilt~ \\'hen ,:!r')\lp~ md, th.-:\ \le\\eJ (he vIJel)t::lp\: .lfIJ then hwke mttì paIrs for the ,)nt.:-'u-nn.-: ¡ralnlO!f.\ll ;Mrent-(rJlr1lng -;ð~¡,.1[1S o<::,:!an with ,1 J¡s,:ussl\'n about the '.:'¡!Uè ,1!'b'ìIJk'.lfId readmg r"tJr \uung ch1Ìdrell' \ de\e!,'pme:H ;,mJ enJèJ wlth:.¡ ques- :1,)[1 .lfIJ anSI, <:r o.-:nl,d: J-;UmITMry uf g(Jais '-or thar ¡:>ha;;e ,ìf :he Int<::r-entlon: re- ~T1Im.!er sh\:\:ts for par\:nts' use at home: rè:.lding logs to keep :racK ùf the¡r home read- !ng sessIOns: :lnd <l m:.lgnet to dl~play the re:.lJing logs m :.¡ prommerH pbce, such as :he:r rd'ngerJtors. \Iost pare:1ts ~pent 3 weà.s workmg w1th çJch set 'Jf reading tech- mques for:.¡ :ma!lnt\:f\entlon p<::n,Jd uf b \veeks Occa;;lOn:.l!!y, when !'JJT1¡)y obliga- tIons contl¡c[\:d ,Jr parents reuuestc:O that their child gO on, tr.ç Im:rements 'xere short- ened to :-w~á Inter-a Is. In both FC.lfId:\L. par<.:nts r\:l:el\ed threl:: chiidren's books 0ver th~ cours\: of the study ,jne hook at eal:Ì1 \)f the two parent-tr:.linmg sessIOns and J third book <It the posttest daw colb:tion \lsit. In addition, parents who completed both tralrung sesSIOns rel:~I\~d J "'certiticate of excellence." Oth~r program adaptations were tailored with respel:t to the ~treng1hs and limi- tations of the indi\idual sites .~s mention<::d_ paraproksslünals empioyed by the participating family centers were responsibie for recruitm\:nt ::Ind parent training \,,¡thin ~ach .:ornmu!1lty. In Fe. a rural. sparsely popubt\:d ::Ire a with no public transportation. the maJonry of the 25 parent partll:ipants rel:\:lved at Ìlome instruc- ¡ion m DIalogic Reading Four of seven E\en Start famdies leam~d :h~ reading techmques;iS part of theIr center-based Even Start literacy classes. .-\1I instruction :n DialogIc ReadlI1g was pro\'ided by one :r::.lineJ ':t)mmunir¡ r~sldent. Parent tr3mmg, in home or Jt ¡he center. W:.lS offered four succesSIve times over a 1 U-month period. [n contrast. in densely populated \iL. all 33 par\:nts began the intervention \\1Ihin the same month. To acwmpiish this, parents met :n small groups on several dirTerent days 3.t the fam1ly n:sourl:e center. Child care was pro\'lded on site. The parent-trairung sessions were conducted by paIrs ofpar::lprofessionaìs \\no worked for the family center reguiarly as paid home \,(Sltors. ,-\ total of rllne staff members rec~ived traming m Di:.llogic Reading \iL study tamilies were drawn primarily from :he staffs eXIsting C;iSe loads. Baseline ::Ind posnest data wer~ collected as part of theIr regularly schedukd home visits Remuneration. Each communlr: rel:el\ed 53,Oau to compensate for the ex- penditures oÌtime and resources requIred by [he research activities The governing councils, with the family center staffs input. chose how to ,;pend the money. The '\L center chose to purchase cellular telephones and air time for their home-visiting teams' use. As described previously, :\L was J very ;J0\J[, otten \Iolent. inner-city area. The telephones were::l welcomt: safety me;iSure. In ~L. the rem:.lln1I1g funds were spent on a Diaioglc Reading "'graduation" celebrat:on for study ;Jarents. chil~ dren, ¡heir other Ìamdy membt:rs, and the re::lding program surf 298 HCEB:SER In FC, ;,¡pproxlm;¡tdy half the ri.mds were used to establish parent--child book nooks. one;,¡t the Lunily ..:enter ;,¡nd another in the children', se!.;tlOn c)t'the county libr;,¡ry One third of the money was used to hire a part-time Dialogic Rtading in. ,tructor who also :;trved as the prOJe!.;t coordinator. This person. a community resi· <lent and mother of two preschool boys. took responsibility for :lll :1spects of the Intervention. induding recruiting, parent trainmg. :.md <lata collection. The re- maining funds went toward additional staff training and supplies necessary to con· tmue the reading program beyond the study period. Data Collection and Instruments Dat3 collection was orgamzed in two ¡¡me penods: pretest I c)r baseline) and posttest. To facilitate parent ;,¡nd starT cooperatIOn with the study protocol and mini- mize respondent ÌJurden. primary data coilection \vas kept to a mmimum. Where possible, and with parents' consent. routIne mrOl1T1atlon. such as manta] status and family size, was obtained from exIsting family center tìles. [nform3tion about chil- <lren's literacy activities and language skills was obtamed at baseiint: and posnest from intervie\vs 'Nith parents or self-administered wntten questionnaires. Parent satisfaction was ascertained in the posttest mterview through a series of open-ended questions, Each ¡;¡pe of <lata wiil be discussed in turn. Sociodemographlcs. Information lbout :he 'nother':; 1ge. education. marital status, me orne. and household composition was abstra¡,;ted from tàmily -.:r:nter records at baseline. The :"ather' sage :1nd education ',\'ere recorded only if :he father was living in the child's home, :\dditlOnallnformatlon was collected about family dhnicity and '.vhat languages. other than English, were spoken in the home. Children's interest in literacy Chlldren' s :nterest m booKs ;,u¡d reading '.vas assessed from pre I baseline) and po:;ttest parer:t interviews, Parents were asked aÌJout the chli<l's exposure to reading. mc;uding :he age;¡t whi¡,;h the parent began reading with his or her chIld. who reads to the child. how frequently. ,md whether the ¡,;hild enjoys being read :0 (Whitehurst et aL i 988) One item, Things Yuur ClJ/ld Likes iO Do, ';.¡as added ':>ased on the work of\íeedlman, Fried. \-lorely, Tay- lor. & Zuckerm;,u¡ 11991). This was :1n ()pen-ended question that :1sked parents to OlliTIe thei r chli dren' s three fa\'ori te acti vi tles, [n this study, parents' responses were ,cored .\'es or 110 based on 'shether reading was among the three Items named. Finally, to retk¡,;t the community-based context of this study. parents were asked about VIS¡ts to their public library and to ..:hildren·s story times, -- ....., S¡;PPORT FOR PRESCHOOL READI:-'CESS 299 r"f.,..,.n"''''''I'T''I''I'I''/'''1'''7'1'1'1'1'''''''''''''''T'',..,.,..,....,.-r ;1,' I \ \ - \ .- \ ':':""'1 \ .- \ -...r ....- :0 ::;e ;;:d. ~~ Assessments of children's language abilities. Two m~thods that are rel- .ltIvely brid' and str.J.lghtfo!viard w~re used tu collect pre· ;md posttest inlormation about expressive languJg~ sk1l! The tirst ,)Ccurr~d as part of the baseline :nterview: Parents were asked t,) recal] the three longest sent~nces. or phrases, they had heard thelrch..iid say phrase length IS considered a proxy r'or grammatIcal skill because. in the ~arlv stages of multiword spet:ch. increasmg kngtÌ1 is one Sign of increasing syn- taCtic mattinry (Fenson et a1. 1993). The :.¡,,~rage length ofth~ chIld's longest three phrases was computed based on tht: numbt:r c)¡" srammat1caJ un¡¡S (morpht:mt:s) and 'oased on words. Relatively few children had mort: :T1orphemes than words To mini- mize errors because c)f parent rt:call. the average length of uner;mce was based on words rather than morph~mes (e.g. grarrunatic::ll markers ot plural and past tense). After th~ mterview, parents were asked to compkte the \-lacArthur Short Form VocabuJar:-i Checklist: Level U (CDLSF II: Devdopmental Psychology Lab, 1993) as the second method of measunng ~xpressive language skilL The CDIJSF Ills a parenHeport inventory of words t;--plcally saId by children in the age range of 16 through 30 months. Parents were asked to indicate which of the ì 00 words they have heard their child say and whether or not their child has begun to combine words (eg.. '"more juice"). The C01SF II toddler version is available in tWO paral- lel fonns (Form A and Form B). The inventory .:an he completed in less than 10 min by most literate parents or, as an altemati\'e. :t can be read aloud. In the present srudy. parent preference determined the method ()f administration. Parents who were obviously capable readers and grew impanent with the interview ¡'ormat. that IS. by reading ahead over the interviewer's shoulder. could complete the form on their own. The CD1SF is intended to identify children' s expressive language skills and be sensitive to changes caused by maturation or :ntervention. In addition, by desig- nating the 50th percentile as the average number of words typical of children at monthly age increments, CDl/SF norms can 'Je used to estimate age equivalents for developmentally delayed children \vhose .:hronological ages are beyond the specitied age ranges (Fenson. Pethick. & Cox. ! 994). It was for these rea- sons-brevity, availability of pre- and posttest forms.:illd the potential to interpret the vocabulary skU! of delayed chtldren-that the CDV SF was chosen for this study. Parent satisfaction. As part of posttest daw collection. parents were asked about their and their children' s experiences in the intervention. Th~ questions were open-ended and asked. "what did you <::specially 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 fu- ture. As Defore. parents could respond to the questions in an mterview or as a writ- ten questionnaire, ;':', 'iii, I I': ',I :1 ,I iii, 300 HCEB~1'R RESULTS Program Participants Study particIpants ¡ncluded a total of 61 children and their families: 26 children trom 25 different ràmilies in FC, and 35 -::hildren from 33 different families in Nl. Sociodemographics of study participants Me provided in Table I, Recruiting meth- ,)ds were successful in attracting a wide range of parents, including teens and par- ents who had not completed hIgh school. IDd families living in poverty, Compara- t!\'e! y. the t'amd ies to \iL expenenced a relati vel y greater degree of socioeconomic hardshIp: 52% were teens at the binh of their tirst baby. 53% had :1ot '~ompleted hIgh school. S8% were single parents. and 94% lived below the annual I ; 995) Fed- eral Poverty Level. :\11 particIpating \iL mothers were African American. In FC. '38°/0 of study mothers were \Vhite, non· Hispanic, and 12% were bIlingual Span- ish-speaking mothers who completed the program III English. In Fe. 20°'0 were teen parents. 32% had not graduated high school. 20% were single parents. and 400/0 lived below the Federal Poverty Level. Table ¡ also provides information about the children participants. As intended, the majority were between 2 and 3 years of J.ge ill Fe. only 39°'0 ,)f the sample were boys: the ratio of boys to girls ·...as about even tn \iL sample 15 ¡ % boys I, Roughly one thIrd of children in each sampie were tìrstbom. Children's Reading Exposure and Language Skills at Baseline Exposure and interest In literacy. .-\t the baseline inte¡yie'.I. most parents described books and reJ.dmg as present to the:r homes I see Table 2). [n both FC J.nd \-L. well over hal f saId they began reading to theIr child before the children were 12 months or age I 63°'[) and 59°'0, av'erage age S. - months and 99 months. respec- ti\dYI Chddren's books were currently anibble in all but one home. \-Iost tami- hes had at least tì ve children' s books Relative to '.;L familÙ:s, proponionately more of the FC famIlies had many. ! ¡ ,x more. chIldren' s books Withm each of the tv.·o communiti<:s. a greater number nt' children's books was associated with moth- ers who were married. high school graduates. and with families supported by wages rather than government assistance. .-\.t baseline. virtually all parents had observed their young children looking at books. and t\l,O thirds or mOre said their child "liked" or "loved" reading. Despite positive descriptIOns of their home environment and of ¡heir child's past experience with books, few parents reported many current literacy J.ctivities. Only 8% of FC children and 28°/0 of \iL children had been read to frequently, tive Or more times. in the prior week. Only one third of the children had ever been to the --~ . ~ - - . - ~ - - - - - -- ~ ~.. "'/"'/ . , ~ " .. . . " ...... ............... "''T'T".,........ "'''1.."...,..,,,"'1.... "..'" SL'PPORT FOR PRESCHOOL READ[j'.'ESS 301 TABLE 1 Descnptive Statistics 0/ Study Participants by Site FC SlIe .\'L SlIc 5D o. 0 . I <, ,.. :- ~, 100 0 0 ~8 "9 94 i5 " , i) 30 14 6 51 :9 \1"theT, age (years) T ecn jt tirst bll1.h \hJthcT, education I years I ,",ot a hIgh ,chool graduate \Iother', race or ethnlcl¡Y B lack. not H ISpa!1lç H Ispal11C White. not HispanIc \1amal ,tatus (single) F=¡(v Income ReceIving government aSSlstaJ1çe Below federal povertY level Huusehold sIze 13dults IDd ch¡Jdrenl Child', 3ge (months) <2 years .:: y tars ; ye3l'S .. year'> Chlld's sex (male) BIrth order I fim born) ~f SD 233 -1" l ::.) , , -1 < 1.6 " 0 ~f 25.b :0 11 -1 " I) 12 38 20 20 -1() -1 , 31.6 62 35 0 39 35 .vale, FC group included 26 cruldren from 25 'amilles; ~ group Included 35 children from 33 iamilies. 30 1 , ' public library, and just one fourth had attended an out-of-home literacy event (e.g.. a storytime 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 I year of age), were better educated, had fewer children iiving at home. and were more likely to be participating in the intervention with their tirstbom child. There were no signiticant relations between family back- ground characteristics and initiation of reading among the :-IT- families. Like FC families, approximately 60% reported reading with their children since infancy. 302 cHEB:-.:ER r ABLE 2 Child'S Reading Exposure and Language Skills at Intake by Site FCS;'" \L Silt' If SD " " !(I.1!1ge ,If .I'D " Rar1,?e Chi iJ'; Home Rêaûlng E,xpen~nê~s :J:Ho::nt he~¿.1n í~Jd:n? ~o -:hild 'me,nIhs I ?)rtr"!t Î~3d ~t) ~nlid :as( \\c.;~k '! ,;¡ 6,) 11-24 \ - ¡ ~ < - ~, < 4~ r :-~S I P;ucnl '~Jû :0 .;r.dd 5- nm.:s last "",à "(anv I 11--, childr",n'; hu"b In ;"üme lS S5 -F I.':llid ioob.1t h""ks "n his or ~èt lJ" ,Hi ,1\\n C"u:d "!ikcs" ,)r ""lo\ ~S" n:JJiog R~Jdin~ IS jmong rop :hree :·.:)\'()ntc.: )(;UV1t\çS C":-:lìu ~;lS ç'. ~r b~::n :0 public ::brJry -\~cr\l.:kd ;:br3.~, ,\r S!OrY(lrnè !~S( ".l..eek E.\'.I!r;::S'I\'~ L:.mgUJ~è; )k1l1 CDLSF, ." ,'L~blliary :\)ul :~ ,:n IX :¡bu\"~ 1\ g. :"or i:;e \ ul.:,jDuJJ.r~; :OfJ) ;j ~ :D J months 6~ " ,- I- . ) :3S .;~ -. ,~ i_' IIi '. >;e~¡J\\" j\ ¢tJ.~ç \. ,""':..iQu.IJry :ot;1lls -.1. :Tlonlhs to -~ "e;l,~\""" )'. :::-:-1;.:c ,r:¡nlne-; "\.¡~·rU$:n -..:on'!;erSJ{lon '·JM:en l",)mh\n~s .1..\,)rüS "-;\ìffièUml:s" ·"~dí :;~t" '':I.)mD:n¡r.~ .\ol)rJs -\", e::).~~ :c=ngth \_\( :ungest lhn~e ;:hra$è's !~ ",...ords -() ].J 1--6 u l,S , -.< '.",,, CD! "iF ~ C.)mmUnl~aIl<.Jn D",',doprnent Inven[()ry Short Furm Lev'cI II. 'I;I(¡Stle> reIkç( (hc r!',a\llnUrn sJrr.ple <liC, [he FC >Jmpk rJngcc from 211. for (he CDL SF \",)c3bularyl to 2b. 'L rJnged tTc>m 2:3 1 "'r ,hc COt SF \ I.'dbular;.) to 3U In hoth cDmmunitit:s, then: was a ne~ati\'e Jssociattún Jmong reading exposure, mantal status. and Income such that manied mothers were less likely to have read rrequently (tì\è lJr more times) in tht: past wet:k with th~lr children. This tinding is somewhat surpnsing and most likely Illustrates the lack of time among the mar- ned. workmg poor. In both community samples. most of the m::mied mothers "t''''·''f''l'·.."'I'''I'."....,''!'.,,.,,''I,,.,''!',,...''1'1'·Pl11'1''.,'''''f''t'.,.,.,.T''r''f'f''''''f''f'f'f''l''t't,, 1111111111 q"''''''''"11l''''''''~''f'f'''''''f~'If'''I'"'r'''~'n'l' 1 l' ~"!", , '1 ,,"!,""'!' 1 ",,,.""~. 'TPPOR. r FOR i'RESCH()OL READ[~ESS 303 worked 'Jutslde the hlJmc: all were supported iìv wages rather than ,=,o\emment x;- 'Ist;in<.:c. and theIr family income wa.:; abm e the Federal P(J\erty L,:'.cl. ::Je :3 Expressive language ski/I. The average age of chiìdren ¡n the FC and NL samples at baselzne dltTered IWlust !J weeks. with \iL chiìdren beIng somewhat ()Ider. or the comhlned group. lJnly 25 children '),'ere ()f chronuioglcal ages appro- pria[e for the COt SF II inventory and its vocabulary percentile s<.:onng (16-30 months), Because a] scores could be interpreted in terms of language age equiva- lents. the CDl/SF II scores wil! be discussed In these terms instead of percentile ranks, RelatIvely few children participants earned CDLSF [I vocabulary scores com- parable to children in the sample provided by Fenson ( J 9(6). a sample uf markedly higher SOCIOeconomIc status Among the FC sample. only 3 children scored at or 3.bove age level; 4 scored I to 3 months below age level, and the remainmg 14 chil- dren (67%) scored 4 or more months below age level. [n \'L 3 of 23 children scored at or above age level: 3 scored ì to 3 months below age level. and 17 (ì4%) scored 4 or more months below age ieve! (see Table 2), The m;LXlmum number of months below age level was greaterthan 12 months and was true of~ children: 3 in FC and 4 in :-.IL An alternative way to interpret the CDI/SF 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 'Nords total or no combinatorial speech (Morisset & Lines. 1994: Thai & Bates. 1989). [n this study. 4ì children were 24 months or older at the time of the ba5eline COL SF \'ine of them were combining words only "sometimes:' and one, "not at alL" Eleven of the 4 7 chil- dren had vocabulary scores jess than 50. They ranged in age from 25 months (a child with a score of3 words) to 39 months (a child 'Nith a score uf 36 words). The numbers of children \',ho 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-momh threshold; their ages ranged from 27 to 35 months Certainly. some children used words that do not appear on the COl;SF list: however. the overall impressIOn of the vocabulary data suggests a sample at considerable risk for language 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 phrx;es l~fLC-3) was 33 words (SD -= I I: range 1--6). Among :--.iL children, the average was 4.8 tSD '" 1.6; range 1-8), Few children's scores increa5ed when \1LL-3 was computed based on morphemes, and uf those that did increx;e, the gain was less than one pOInt. ~1LC-3 comparison data, based on norms established for the long full-length CDI (Fenson et aL. 1991). indicate that the average :VfLC-3 score of 304 fflEB:-;ER ;.;!-;1idro:n Jgo:s 26 months Jnd jbove lS :It least I'Ll). This ;.;omparison supports the c.:onduslUn that the: c.:omblnatonal skills of most c.:hIldren In this study w<::re Jlso be- [0\,,,' those: '-1f the:ir middk-c!ass peers. To summanzo: the baselino: data, the study participants induded many low-in- c.:ome: parents with relativdy low kvels of education;:¡,l :.malnment. :\t baseline. most parents reported the presence of children' s books In the home, but infrequent parent·--<;hIld reading. \Vhen asked about their c.:hildren· s expressIve :anguage, most descnbed skills that suggest the children' s deveiopment was slower than oth- as their age. Changes in Reading Exposure and Language Skill ."..fter the InterventIon penod. parents completed CDLSF [I. Form B. .lI1d were Jsked a subset ofthe same questions about books and reading that they :mswered at baseline. Quantitative analysis of their responses focused on those vanables most ¡ ikely to retlect changes over rime In parents' atTitudes and behaviors: parents' per- ception of the child's enjoyment of reading, freljuency of in-home shared reading, :md frequency of out- of-home literacy activities. VMiabies were excluded t'rom the analyses 11' virtually all participants showed the beha\ lor at baseline I eg.. child looks at books on his or her own) or ¡t"improvement ;,;ould retlect nothing ;nore than ;Jassive participation. For example. the numher of children' s books in the ~ome was ~xpected to mcrease over the course of the study because each r'amily recel\"ed three ~hildren' s books as a ;.;onsequence ,)1' participation. Because the data from FC and \iL were reasonably '1milar ::It haseline and posttO:St. the ,it<::5 were ;.;ombmed for éhe purpose or' statistic:d analysIs. Doing so Increased the total sample size and thus the statistical power of Jetectlng pre- to posttest di fferenœs The results l)f the statistical analyses for the c.:ombined group are presented in Table J Parents' responses to the posttest quo:st¡Onnalre .ndicated t\\iO Important changes: after the Intervention ;nore chlldren en.l(.)yed reading and \\ ere read to more often. ......fter the ¡nterventlon. slgnitlcantly more parents In FC and m :\L mcluded reading ilmong their chddren' s tlJp three favontl: actinties. For êhe combined group. the percentage of parents who listed reading as a t'avortte :1<.::tl\lt} :ncreased from 1.+°/0 a¡ baseline to 39°'0 at posrtest, ;(( L .\"= 51) = 6'?6.p <OllTable 3). [n addition. the number of ;,;hildren ·.vho were read to frequently more than doubled. The proportion read to frequently. detìned as rive or more times in the previous week. mcreased from 16°0 at baseline to 47°0 at posttest. ;('( 1. .V = .+3) = 3.47. P < . U l (Table 4). In contrast to substantial chan'.!es In in-home experiences. there was linle change in the t'requency of l)ut-of-hom-e literacy actIVities (e.g.. \ Isits to the library ¡)r family center story times [data not tabled]). ..,"'....,..,..,.f"...,.....","'"......"".,,,"',..,..,...,.,"',,,.,.,,,....,.,.,..,.,,,,.,,.......,....,.,"".,,..,..."f'l'..,."""...,.,...,"'...."" "T,..,..,.l'l''Tl''T'T'T,"T..,~.,.'''''",...,.~.,''I'..... ......"''''.. ..."'''''''''............,.......,,''!''t"'''"'''I'''''f''t'.,...,........,~..,~''t1f,.-T'' : - ;:- . " - - ';; . ~ - - - - 1 e- - ..." " .C; ::;; 'J g ;... "" ~ .,. :< ~ ;': ~ ,<:; ... '" .J .¿ - us ~ ~ ,... ~ ~ ';; .c ;; ~ c ~ ;; " .., Q :> ,-, ::< .;; " '" ... " ë ~ ~ '" ... ~ ~ .J '" .2 z ::< Ë '" ~ ¿ ;: e- ¿ ,~ ~ .C; e- x " '" 01 '-' ." ,-, x ... e- .,. ~ c :.... "-- - ~ " ;:¡ ':; - Z .2 ~ :( '.J 0:0 Õ :õ e- LL.. = N ¿£ ," Ô' ..,.. c .C; :: t:.. e- ... ~ ~ .J ~ ::;; U) <I:> - .3 01 ;::; " .., m - ;:¡ ::< cry :::> - "- ~ 01 ., "'~ "" '" ,-, ;¡; lJ.J C ~ ~ N '" -r, .., ..." - ::< ~ m - 1: £D ....J :: :p ;; ;¡ « "C .;; '~ " :!> ~ "'" f- c:: -.: <0 ~ ;¡ '" <I:> ~ .C; M '" "" ~ ;:¡ .., ~ '3 :: 0' '" N .C; .,. ~ " --:; ... "' '- -;; ,j " 0 .š '" " c. g ~ ~ x '" uJ ...:;: '" g> r- .,. J .., ~ .- ,0 ::;; '" ;;: r- -. -::; .<:: '6 0' '" '- .1 1 ;¡ ~ '" .2 - :~ Q) j i! a:: ~ " U i - .~ ~ ~ "- N r- x ,-" ~ ;¡ ~ 1: :t 0 r- ~ = ~ r- 0: t u OJ ê. '" s - ;:¡ :: ~ - ~ " U " '.J <I:> ~ ." ~ <: 2' ;0 ~ " 1 " " 0 Õi .~ "" '- t ~ " '- ~ ¡::;: 'j .I:. ~ "'" :: ~ '" u " -; " :!> ;:- " - ~ N - ~ ~ "5 ~ " g "2 .J :: 3 s . '" ~ ~ " ~ ,; 0; ~ OJ ~ " õ . ~ " " '", 1: ....¡ ~ ~ - - ; '0 := '" ~ " '" ~ '3 <: '" " , ..':! " ~ '" , t :¡; ~ ~ " ;:.. ? ..." > ~ E ~ -" '¡:: '" ~ c: " '" ." ~ :~ " " .., " ~ r ." ~ ~ 1 'j ;!. .; ~ ~ ~ ~ " - :;; - '-' ¿ '- ."'- ] x "J '" Ç. .... - ;:¡ - -¡¿ '.J '. " " " " 'J: .J , " ::.. " -5 " 3: '" -t ;¡ Q '"' :.: ',-, ;,,; -~ ;: 305 I' ¡:,: " ,I' ,. 306 HLEB~ER TABLE ~ Parent Feedback at Posttest by Site FC Site I ~.'61 '.'L Sue r%) \\. "hat dId vou ~sp<:claily I,k~ ur rind usdul~ The <:,\{ì.I Ume r \p<::nl with my ,hdd HdD<::d mv ,;h'¡d', ¡"3m¡¡¡g: ",~'. m<:morv¡ Hdped my ch'¡d ê31k :)r1<:n. mor~ cleMly ,or bçrr~r [nr1u"nç~d ulh"r '-3mdy m"mb"rs' r~3dlng to ;;hild Gl f¡ or' ,hildœn'; :-.ooks W;'31 Jld vou nol Ilk~ Jr ·.vould i,k" '0 change' r ...::ould h3\.'¢ wsçd more ;;nl Idren ,;; bl)oks it ''''35 Jlt'fiç~11 '0 ,;h3ng~ my ,jld r~aJing ,'I.,.k '-.\"dl ::ou ..;ominue to ¡~;lJ thiS W3Y ,1 Yes. YèS' :lI1d Yes. ,j~rìnllely -, 54 61 13 -t 21 ~R So )6 23 .¡ '( II -t IU() 100 "'Ole, Summary.)f pa.r~ms· mSWèCS ,0 '-'pen-ended yuesuuns :ife ',;rouped by theme. Data rerlect feedback :Tom :5 FC pa.rems md 23 '<1. parents, [n this study it '.Iias nor possible to assess change In vocabulary as measured by :he CDL SF [I because many children grew !:1eyond the age range and language age ~quivaiencic::s providc::d by thc:: comparison data. Recall that at baseline most chil- dren 'Nere aìready beyond the age level of the tc;:st. In addition to having even fewer c:hi:dren within the age range or'the norms at posnest. it IS not possible to Interpret -:hange >cores based on age equIvalency because age equI valency scores do not cant-arm to J known mathematical distnbution. C;-¡angcs lwer tIme in children's sentence-level skills were noted by parents in thar, at posttest. siighrly more children were reportedly combining words "often." Improvement was most evident in the length of çhildren' s spoken phrases, The av- erage length of the longest three sentenc<::s and phrases Increased from baseline to posrtesr. pamcubrly for children in :he -:\L sample /recai! Table 3). Stability and Change in Home Reading Experiences .-\dditional anaiyses w¡;re conducted to understand more about the effect of the in- tc::rv,-,ntion (In home reading, Families were grouped by whether children's home reading expenences Improved, remained unchanged, or apparently worsened over the :,ltervention period. This approach, to ,-,xarnine potentia! unintended negative -:onsequenœs directly, IS otten overlooked in intervention research. In the current study. the analysIs reveakd lirtie of ,enous concern. .-\ total of eight children's scores on one, and only one, of the three reading outcome variables d<::clined from baseline to posttc::st. 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- 't,. '"'f 'I '!,. "I "I "I "I "I "I ~"'f" '!"'"""f "I.."....".. 1 'II" "I" ~,,~ 11"". .."'" "'..........,."'"... " .,." ..."''''....''1'.,1........ "'" "''''''''''''''''''''''''''''''''r1''''''~'''''''''''''''''''' '" ",'4''' "'... "'.........".., "'.. "I "I "I......".,..,......,...,"'''...,.''f''''I',..,..,.'''..,.....,....''f'''t'T't...,...,..,....~ SLPPORT FOR ?Rl'SCHOOL Rf,-\Dr:-;ESS 307 wise g;.lined ur maintained thclr enjl)yment 01 reading; th;\t IS. although reading was 'Jmttted from the lIst of three t'a\onte actl\îtles. parents reported theIr ..:hildren did ~nJOv reading In three of the four cases. reading as a favonte actIvIty was sup- planted by outdonr activities "basketbalL" "bIke nding:' or "go outside," The de- motIOn of reading as a favorite pastime IS probablv best explaIned by concomitant Improvement In the weather, In two other cases. reading frequency diminished :'rom more-than-tìve to less-than-tive times per week, It IS not obvious why this was so. Indicators of these chddren' 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. Interestinglv, 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 posnest, 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 tinal segment of the posttest interview asked parents genera! questions about the program-things they liked dI1d things they would like to c:hange. After the 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 infonnation 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, :he 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 "[1 especially liked] holding my baby while reading to him." The second most fTequent 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 bnngs the book for me to read every day" Some comments referred to children's leamIng new vo- cabulary and language skills. such as "[It was useful because] he pronounces words bener," "The way I read to him-it caused him to talk more," and "It helped my daughter learn more words" Other comments were specitìc to the Dialogic 308 '{U:8~;ER K.:;:¡ding :eci1nlljues.)uch J.S "The progr:lm taught me 'hat It'S ,¡by [Jot to tinish :eadwg the book because ¡his gl \ies ¡he .;hIiJ J. chance :0 :lsk ljuest!ons." .--\n unIntended, but wdcome, benttit of the Il1terventJOn WJS its Jpparem etfect )n ()¡her ;àmily members, Sc:veral parents offered <.:omments such as "Thls enCOur- Jged my [older) )-ve:lf-,)!d to re;:¡d to her Sister "\I1th mv JSSlStilI1ce," "[t got my ~usband ¡m'olved as welL" and "It encour;:¡ged more re;:¡ding Jnd more t;:¡lking." Su)) othç¡s appreciated the children's books ¡hev received. r'or eXJ.mpie. "U liked] my daughter getting the book. She !Ikes to re3d" ?:trents '.\Iere ;:¡Iso :lsked :lhout :lspects of ¡he progmm they did :Jot like or '''ouid like :0 ch;:¡nge. The mos! <.:ommon reedback In thIS c;:¡tegory was that they "could have '.lsed more boob" .--\ iew :lI,;() admnted chat :he new conversational ~e;:¡dlng sr;,ie 'x;:¡s unfamiÌIar and sometimes cunt11cted with their old reading ,r:,je Three parents commented that it '.V;}S "diff¡cuJt ro change myoid reading ,,:-Ie." The most common reas,)n ·.vas, '"f'm used to aslung '-III th.: questions and cluing all the reading.' Through discussIOns with parems ;:¡bout their ;;hild' s language Jnd home activi- ~¡es, the InterventIOn ~reated 3n awareness :lboLlt early language devejopment Jnd :lbout roddlers' inkrest in books and reading. ft 31so ~lSked parents to <.:hange exist- Ing habits. Specrrìc;:¡lly, parents '.ven;: asked to look;:¡t bouks rrequently I Jaily) with their toddlers. ~o read in J new ',va)', ¡Òi/ow their ~h¡jd's Interest In the story, and ;:¡r;:¡lse theIr talk 3bout the ;"ook. Change. even pOSltl\ e change. .;:m b.: stressful. .".[,)og ¡his ¡Ine, one parent lamented "th;:¡t"s;:¡lI she :my daughter] 'Named:o do'" .-\i1oth.:r moth.:r's comment. ,,[ wish th.: program \voujd COnt1nLle," is an important rer:1ìnder :hat '.vhen successful. applied ,esearch .;reates changes for ch:ldren and famliles that extend '.v<:I1 b¡;:yond the limIted penocl of Jata collec!lon. DISCUSSION Benefits of the lnter¡ention fhe ~esults ,jf this sn.Jdy demonstrate that Dlalug:<.: Re:lding ;;an change th.: home lar.""'"Jgc .lr.d [itcJ<.:Y actl\ Itl':S ,)( tJ.mlj¡es '.vlth :<oung ~i1¡¡dren. Induding those at gr'::ltest risk ofs..::hool fallure. Whethenhese changes [] :J.m:ly practices ....'l! be re- lated to eventual schuol 3chlevemem, particularly !n ¡itency knowledge 3-nd read- ing. is ÌJeyond the scope of this study. Several other deSirable uUtComes, conceiv- abiy ¡t)stered ÌJy shared reading :1I1d more appropnate to the ;:¡ge range ofch:ldren in this study, were: Iden!lfied. Specltically, the mtervention :ncre;:¡sed the trequency of home reading :lnd parents' perception of theIr toddlers' èn)oyment of shared read- ing. \!orcove:-, the sr;,'le qf DIalogic Re:ading brought the question-and-answer lan- guage llf r"l)rTI1al .'Choolmg iota the en:ryday experience l't" ëhe home. ....... , ",,,,,,',, ',n',' .. ~ "... .... ... 'I ,. " ""1" .. 'I " "., 'I 'I 'I"...,.., "''' "''' 'I"" 'I "",. "I "I'" .. .. . ~ . ., . T ~ .. "' .. .. .. .. , .. .. ., T., "1 ,. "'f " .. " .. "t "I "1 "I .,. "I" "I .. ... .... ...... "I'" "I 't"..,..,."I" "I 'I "I .. ' , ! ~ ~ 1 , ~ ! 1 1 'Ii ~ 1 1 1 I , IT" 1 T , , 1 1 , .. ! , , I , , , . 1 I , I 1 I .. ., 1 .. .. .. 'I ., "I .. "I .. 'I "I .. 'I ... "I .. .. \1'PP(jR C' !'()R PRbl.'I()t;l. Rf.-\DI'\ESS 309 F,)r :he subset \)f !·J.m illes ('or whl)m 80th pre· ;.Inti p,¡,;ttt,¡ "':J.tJ."v at 1v~llbbk. the CJrnportlon ud'e ..:!1dtiren w':u Weft reJ.d:u r:\e ,'f :nore 'Imes In :he preVIOUS week :nCr<.:;.Iseti JrJ.m;.ltleJ.ily. trum .~u 0 I basdlnc:) to '¡I)"o. In '''L. :he oroponlOn doubled. 'rum :'.ö')·" to ::> ~"" Thus. Jt1er :ht Intentntlon. m;.lny chI/tire:'! were re;.¡J :0 more of- ten. ;.Inri as uHen. ;.¡s mure ';l)ClOtcIJnomlcJ.lly advantaged preschookrs whose par- ents reponedly re;.¡d to ¡hem -15 to ilLS times per weà iScJ.rborough & Dobrich. ¡ 'i<j.¡ ) PJ.rents also reponed changes In the I r ehIldren . s readrng p le;,¡sure. ThIs is not to ,;.¡y J.ì1 <.:h1ldn:n enJoyed re;HÚng: some dId nor. At baselrnt. ; I "0 were reported to ; Ih reJ.ding --a II rtle-- ·-the lowest Intensity response for ¡hat Item. In ;.¡norher study ,)f preschoolers. Wells 119~SI Jlso tound ¡hat Jbout 11 "0 or the children enjoyed reading "nor at a]l" \Jr "not much." .-\Ithough the <:ffect of the Inter.:ention \In increas- ing children 's enjoyment of~eading \lias n\Jt unl\ersaL It was dr;rn¡atlC .-\ rter the in- tervention. only mo children (3110) enjoyed reading only --a :ink-- It seems likdy that DialogIc Re;.¡ding gains Its potency from ¡he fJet that shared hook reading. and especially this interactive style otreading. IS developmentally s;.¡iient for young preschoolers ;.¡nd for parents clt' young presehuolers (\tlorisset. 1996) Llio lines ofre:.¡soning .suggest ¡his IS su. First. shared bock reading offers parents Jnd theIr mobile. InCTeasrngly independent young chiidren ;.I ne\\i way to strengthen emotional tIes. Evidence of the neh J.tlecrive dimenSIOns of shared oook reading have oeen identitìed by Bus Jnd van JJzendoom (! 9S8. 1995), who ')Dsef\led that the Interactions of securely ;.¡ttachcd dyads tend to be more sensitive to the child's needs J.nd less r1egati\e. controlling. and rnatter1!l1ie :han :hose of in- secure dyads. Second. simultaneous with the opportunity tOr emotional closeness. book read- ing Drovides a comext for the young preschool chlid and parent co negotiate the .::hIid's budding independence Jnd Jrgem rleed to "do it myseif-- This IS particu- larly true of Dialogic Rtading interactions because the techniques spec:tÌca!1y in- struct parents to let the .::hild Set the pace. take the :ead In teiling the Story. and in rummg the pages. \-vÌ1ether Dialogic Readrng would be J.n effective :herapeutic in- ¡er. emion for cont1icted or avoidant mother· toddler pairs is ;.¡n ¡ntngul11g question fÒr future research. It is temptIng ro discount the tìnding that all parents l!1 thIs studv said they would continue Dialogic ReadIng on their own T \J the extent ,hat they do con- tinue. i¡ is likely that these reasons-the opportunity for emot:onal .::Ioseness. the encouragement of developmental advances. J.nd the :'act thaI even parents with low re;.¡dmg skills feel comfortablt with the conversatlonaì methods of DIalogIc Reading---.wiil he Involved A habit \)f pleasurahle talk aÌJout hooks ;,¡nd cver;:da\ events could ~o a long way toward diminIShIng the str.kmg dis- parities obser.ed between middle· and lower-income toddlers' e:<penence with language. vocabulary growth. and preparatIon t'or school entry (Hart & Risley. 1995). 310 ;llE3\,:~ Cautions and L:mltatlons S<.:'.~;al pUknt:..JI :irTIltJtll)n" ,nuuid tJe: :1uteJ :;¡ -:onsld~;;;¡g the: resews ,)t'this ,t',:,:\" first. 'Jc:c..Ju~<.: :h<.: :Jr0:'f,Jrn 'X..JS '. '1[Untar:, JnJ;]u <.:,'rnp;.¡n:i,)!1 -:ondition 'XJ~ :;¡<.::uJeJ. It IS pos)lhi~ :hJt pJr<:nt:i JttrJct<.:J tu tht: :ntC:i\t:ntiun '.'ert thost ,)Jrent,; :Y1(\rt ;: ktl y :0 cJrry ,Jut pru gum :<.:'-1 Ul rèmtnt~, \1.. thuut random stlec- t")[1 lnù :..¡se l)¡' .I <':ümp;.¡n,;un -:unùitlo;]. '.1r ;tp~at~ù ubs~rvatlons uf par- o:nt-ch1iù :<::Jding, w~ ha\~ no WJY ,)fknowlng: ftht str<:::1gth oftht intervention '.\;.¡s l)\crt~t:mated ~)~CJus¿: l)f Pl)S,lbk :'J\urJbk prelnt.:r,~ntion characteris- tld ,)t" the pa[<~rns. .\irhough :h~ Jcslgn C:Oè:S :¡mlt the: ;e:ne:ralilJorllty of the ,\LId\ t:nJIngs. soc1lJdemographlc~ ,)r' :ht ::¡;'¡f!lclpaung 'amili<::s Jo:scnbed a grùup slightly .ess J.(Ì\;.¡ntago:d thI.1n :h<:: <.:.\mmunlty as J. ·"'~ok;:¡nd .l group for ',' r, UIT. ) n.HeJ :<':JJi ng "., .b nut ..J ,'rc:q u<:::-: t ,1<'::: '. : t:- Fur thc:sc: ;t:J,;U ns, tne rì mii ngs Jrç :e!<::'.ant tu '_Hhc:[ tamliles w:tn1f1 :he,;<:: .lnd_,tn<::r <::~!,;.\;¡Y Jiverse high-risk ::ommunltiö. _\ sè:cond caution pdUln,; to th~ mag!lltudeJt' the inte:-. ention effects. It was !lut :>osslbie to Know; t parens' responsc:ssere :~onest re:1ectlons or' their home rtaulng practices or: t thty were blasC:Q to meet :ne expectations ot' the program srJIT. Two ;:¡rguments against this posslbiliry are ,ge:mane, F:rst. there was consid- e:-.lojç ,;¡nabdiry in parents' respon~è:~ :0 :he ¡J0sttest questIons about rtading fre- quency lnd enioym<::;¡t. Second. :n r:ìosr casts ;)art:1ts had ',ung-standing, trusted :-elJ.tion~hlps with the paraproresslL'O;.¡isshu Ueil'.e:-c:d tn<:: :ntervention Jnd col- !.:<.:teJ the satlstactlOn Jata~reÌJt10nShlpS .n -shlÒ ;JJrdHS :'dt comroruble dis- c~bslng -:hoices :lnd :¡k e\penenco:~ :bt 'sere much more ;Jt.::-son~1l than the cunttnt ,Jt thb slmpk r1l)mt readin:; ..JCll' 1(\ rhe thm.! caution concerns tne DiJIL'g:<.: :m:thL'd .tscl t, in :hlS study: t was not posslbi<:: to ~eparatt the btnâit ut gi tt :)('<)1(5 ..Jnd e¡¡cour:.lge:-n<::;¡t trom :ht :;,tTeets :.miqu<:: co the Dlah)gie m<:thod .-\ntcdotai c:'.:der1c<:: sugg<::StS :htrt '<(.IS ;,)methi;¡g Sp<::CIJ! about DIalogIc Reading: many par¿:ras :iaiJ they "'<::r:;, :eiie:vtd oy not hav- Ing to ..:io "Jll the rtading," Jnd [he'. <::n:l):dv¿w.:nmg JI1J htlDmg rh¿:jr ::hi¡d's ~r,)w¡ng languagt t'ac:liti<::s. R::c;.¡il. tou. :r.at Jt J~bc:line. t'e',,, ;Jarer.b 1)1 rtported i'rt:~uem rtaJing, despite saYing [he" h:.:ci re.lc wIth theIr :::::J:n tht past; Ib) had nut:ceu :helr ::l1lu"s ¡nterest:n DUuks: ar.è ':: 11JJ:hildre:;', ",'l1ob:n their homt, it 'èérT1S th;.¡t D1Jloglc R.:aJir.g shuw::lÌ ~ar<::¡¡:,; hL'·.' :0 c1Dt:;-:-,.:¿,; r<::-:ourc<::s .lnci ¡n- kr:;,s¡s :hat ·xo::-<:: jireJcy Dresent Jnu :0 -~,) )l) :<1 J. "';:¡y 'oat '-'JS DìeJs;,¡rablt for 'h<:::r1 Jnd :helr -:hIlJ This .,bs.:r.Jt:un mJY he c:spec:Jil\ ro::o:'. ant :"or :-;.¡m¡[l<::s ,'no lack J. ,urpius or' tim<::. In ¡hb stuJy, the mothas who reporto:J uW;-:lOg more <.:hIldro:n·s :)Ooks were rT1l'rt ltii:dy to ;:,t hIgh school graduates anu :ThHe olien supported their families [¡-'úl-,ugh wagt:s :Jthe:- than govemmè:nt .lSSlstanc::. Surpr.singlv, these same in- Jc:XèS ,)f relau'.<:: ,0c;oeconomlC .l(hJntJg~ ·.'ere relat<::d to i.:n freýuent par~ ent~hIlJ reading J.t bastlint It s<::tms pi::1usible :!lJt the Jet:er <::duCJt¿:d ml)thers .~"":,...,....~, ~ 1 ~ t1 l' ~ ~. ~,., ~ 111 ~ ~ ~ 11 . T l' 111' 1 tIT T 11'" 1 r", 1" I t 1111., , I 11 '"11""1..1......,....1"'''''''''1''1.''1''1"..", """"'.."111..""1''''1''''''''.'''".".,.,''1''1"''1'..,,,....,......,11 ~.., '"..111....1....~....1'T"I.....".,,,"I"I',,"I'......."I',,"I'''I.......''I...,''I'''I'''I'.''I' St'?P(1H r fUR PRFSC!i1 J()l RE,\J)I~ESS 311 " J.¡ll~d~htlJren·, h()uks Jnd ~eadlng hut. he:caus~ they te:nd~ò :() work l)utSlòe the: ::¡)rne. hud kss time: w r~ad with ¡helr .;h1idren. A.s nat¡<Jt1al <:ffÒrts to mov~ taml- :1es r'rom wc:! lar~ to \vork gain momentum. it is paramount that w~ endorse readi- n~ss actl\itl~s that;ue both potent and reaji,ti.:: 'Jlparents' tim~. [n conclusIOn. th~ benefits ot' thls shared reading lnterv~ntton appear to deriv~ :rdn its ubdity to hc:!p parents \)Ive:ry young c:hllJren expenenœ books as "obJects ,H'rec¡procallnte::ra.:tlon whlc:h r~sult In Dkasure" t.pJ.wl. 1 y~Ç). For many parents. esp<::.:ially parents "vho lack time:: or ha\<:: Jifflc:uity ~eadIng. thIs intervention :l~lpe:J the unr'amlliar become famdiar. [t hdpe:d parents provide J. n<::w 3.I\d safe context lor their toddlers' independence and leamlI1g J.nd engendered ,hared pride lr'. these very accomplishments. As one: \:L mothe~ beamed. "You know. I think my boy's gonna he J. reader'" ACKNOWLEDGMENTS ThIS research was conduct~d whik the author was J research memb~r with the C~n~ :er on Families. Communities. Schools. and Children's Learning at Johns Hopkins Lniversity \-laJor support for this study was provIded by the Oftìce of Educational Research :md Improvement (OERJ). CS. DepamnenrofEduca¡jon (R- i ¡ 7-Q0003 ¡), and by ZERO TO THREE: )iational Center for Infants. Toddlers. and Families, The author gratefully acknowledges the family center staff and parents of"FC" wd "NL" who participated in this research, The optnions expressed are l)fthe author and do not n~cessarily represent OERl positions or policIes. REFERENCES ~.rJ\1~ E. C:l5~Y F"undauùn. I ¡99S). 1998 X/DS COC.\T :;ùli.l Book Baltimure:-\uthor. !3;m¡ard. K. E. (1995). ~CAST '-eedmg:lI1d :eaching ,cales: \1eaQlog:lI1d uulization. SCiST .Va/zona! St'l-\S, J l. ¡ -]. S !3amara. K. E.. ....Ioriss~t. C. E.. &.: Splek.::r. S.; 199;\. PreventI\e InterventIons: Enhancing parent-infant ,dataJnshlPs. In C Zenah ¡Ed.). Handhook ')(,nfanl menlù¡ neù!lh (PP. :;~6--IOII. ~ew York: Guilford. 8amen. W S. 1,1995). Loog-[erm effects e,f earl\" .;hl1Jhooo programs "0 cogmuve ~od school out- wmes. Tht? .C'uture rfChl/dren. 5. 25·-50 30oth. C L Barnard. K. E.. \In.;hell. S K.. & Spieker. 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C:HiJ JÇ\ doprn¡;nt J.nd p~rsúna¡ ::'UppUIl r1er'w",ürk.s. Chtfd De- '.<.:'~f)pr~H:!1t. 5(), !JO ¡ --'"1 ¡ >S. ·,-'uip. fl.. E. (:lip.."> \1. Usots~'.. j D. US0r'sk:-,. H. J , i 4'1 II ..\<1olesc~nt In<1 ()ld~, ml)[hers' Interac- :Ion )~¡¡ems ',òlth ~helf >lx-mlJnth-,)ld 'nfants, joumui ,;("iJoiesc¿nc¿, ,.... i95-200. D~l<, ? S.. Cr~lTI- Thoreson, C . :-.Iolan. S"", & CUlé. K. 11496) P:uent-chdd ':Jook r~admg ", an mler. ',enUon t~c~nlýue :or young~hddren ',>;Ith lill1gu"g~ J~b:..,. TopIcs in [..:.r:'·" L'illiJhooJ Spec,,;" EJ". ~atzon, !~. 21]-:35. Delgado. ~,,1. l ~ ()92). 7tH! Pu¿r:o Ric:.1n commun10' .Jnd f1ururiJl )'upporr systems /mp¡¡~'ationSJor the cd. .'C::::un w' ,'h¡/èen Repol1 \;0. : I»). Baltlmo'e: Johns Hopk:n:; L'nl\ erSlty. Centef on F:unilies, C!mmt¡nltl~s. Schools JIld C~'¡dren·.< Learning. De, ei()om~ntai p,vcnollJgy LD. 1 19931. \,fuçirtiwr Short Form ¡'oçc;o"'c;r, Checklist; :'¿,d ¡/I Forms ·1 ~r.d 3, S:ln ~)Iego. e,,,>, San DIego Scat.: Ln"CfS¡{v. D"d~~. f..:. .\" Petm. (j S...s: 3_)[~s, 1. E. (19'1..\\. SoclJiiz"tlün medl~tors ,)('"~e ,~l"tlùn ~clween SOCIO' ~.;(~nom¡c q.;)(Us md chiiJ .:nnduct problems. CñÚd D¿....¿lopment. )5 S..¡9---i1t15. :)unC1rl. ~J,. arr.)()~:j-Gunn, j.. ~ ~¡eban()v,? i ! (qJ \, Economll.: J¡,:pn'.-::H:Or1 ";'Iid ~ar:y ;;~lÌdhood d~vd- \')pm~n~, Chlili Dt!\'I!Ù)pmt!,~!. "55. 296--313. Dunst. C. Triv~~~, C.. .& D~J.i..-\. 19381. ~nuD¡lnX ,-lnJ t!m.~u~\~r;n',.! .'~ml,'lt!.s C.1moridge. \L-\: Broüi<.ÜnÈ. :-::nscn. ...... I :1..}1..J6:. .~.IJ.c.lr:hur ';(¡ort F:U7n V')~'4i:}/.J.Ù..1r:; Ci1t!c,:;Ùst ~;,;".t.:: ,'/ :i1:p~niÜnt:;.'d.~reiimi!1ar¡,' 7(!T7!j San Ðlqi). CA: ,)m D/q() St;¡te L'rll\'~'Slty, remDn, L. Dale. f> Ranlck.; S, fhal. 0.. BatC>, E" Hemung.;? ?e!r.lá, S. &: Rdl'.. 1. S 11991 \. :-~ci-;tIlcJ.¡ t!Ùnl.J.u¡.,.'or :nt; I"f~c.1r~hur C·ummumcutn't! Dt!veiopmeu ,:'i\.'t!rHunes, SJ.n DlçgO. C.\: SJ.n JI~~I.) State L.'n¡l.¢rSj~. "ên:;i)n_ é.., JaÍ<;, p, KanlcK.: S. 'h~l. 0 8'1tes. E. ;iammg, J P ?"::1¡';~. S.. & "'el1:,. 1. S.11QI)). L.fu:;-ir!h:.J.r C.Jrn.,"/.Jn:cJu'.¿ .Je'!.è!opmt.'!1t ,I/\t!f1tnf'.t!':; ~. .,·¡-:r ·~,"!J.JLir! .1.'1d ,·t:'cnnlc..l '1'1 (Jrwu.is, Sa.n D!e;n. C.\: ')¡n;wi:;1r F.;::n~L"'n. :....., f\:-thlL:i(. S,. X (1../\.; L. 1 QQ41. :-he ,HaC,1rrhur C.)mmut!lC.../f:'.r:; :Jtf\'e/opml!!rH /,.,....·¿rttorrrtS, Sh,'/': .:",)f"F'!7 ~·¿rSilN1S S.in :)~e";~), C.\: )J.I\ DIego Stare C'nl\"er')\ty ~Ui..:t.s. ". R; ¡ y';¡S I ;romç'n \' c!~J.t!S;t()r¿conomIC ¿q14~hry C.lmbndge. \L-\.. HJ!"\ lIC L~m\"ers¡ry Press. C.Hi.sl.iè:î. '.,. L. I ! 995). ~:rer:1c:; lnLi ;Joverty: ¡nlcrgen~¡;:llHm;11 !~SUCS ';"'I:11m :\(n(;;1ll :\m~n¡,;a.n (ami· :Ie>. In H. :õ. Fltlger3id. 8 \1. L~ster. .\: 9. l.t¡ckerm:ln I Ed5, ¡. Ch",irèn ,J(povl?r,'1" Research, ;'¿~.:h .1nJ poue' ..rs//<,s. "ew York: Garland. G"als =1.'00 Educ'1[e""m~"';3 .\';1. P1w L. -';0 \1)3-=2-. IOS S[.]t. 125 I ; C¡Q,¡ \. HMC. 3. ;{.. $: (Jstct.cil. L. .\ ' : C¡HS I. \;" pbcc to run, nO place ~o hldc: C..'mpar~nv~ '[.]II,tIC' and fu· tUfe ;J""pccts ()(- 31~CK ~lJ'; In \\ B Spencer. (i K. Brookins, & '.V R. ..>,llen I EJs.I, B¿ginnlng5' ~ "I "1'"'I"'i 1,., "I't"l ~ ~""I"" 1 't l" """1"......"" 'oj "'... ......Ij....,.I'1f'll''''''''~,.IIt....'''...,,''.,.''I''''''''''I'......''I'''!'''I'''.''TT~',.T'T'.,...,.'T'.,..,.,.'!',.T.""""1'1". '"''''.,...,.... "'. "! """'/ 't "" .,.'t't 'I''I"'I"'''''''''''"'''''''f''''''''''''..f f'l""'...'I''I',...,.'''I'.......,...,.'fT........ S\PPOR r FOR PR.LSCHUOL R£AD!:--':ESS 313 Th,> We':,-" -1nJ -'1/,,,":1\,, ,¡"ânt'm,,"1 ,)1 HI..J('~ ,';,¡iJr,'n 'PI' : ~~-':'I)()\. Hillsd.1le, ~J: Lawrence Eclbaum .\';S0êlaf~S. In.; H:.lI""{. ß . .s.: R !$k..... T R.. I ¡ qy~ '). .\,ft!i.lrHn~t:Ú ,.Ùrf~'Tf~ni.·i~s ;n :n.!, (,TI:'r"'''Li:..n· ,~xt)l:!nt!ncI:..'S I)' .ì'(ntn~ ...fmcrtCUTl ~·nziJrl.>n 3a¡nmt,"'Ire P H Brnokçs ~-L]sk:ns. R. I ; ~~t'!, Si}~:a.¡ .u,d CU!{t¡.).j n~k r'J.t..:wr:; \r'1 j'"1S.~ ,'I.:)Sè~~nh~nt :lnd menl.J.l retardation. In 0 F :lIun & J \f.;i(¡J'\n~:.' Elis :, H:.p(:n ;nteiiec:uul unuf)l·,·,,';''¡iOC;ui Jo!\'o!wpmo!nt Orlando. FL: Aca- ,.km,c. :-b,;h,ma, P y , & ....mato. P it ( : <)441, I'ovem', ;oel.11 sup[}<)rl. anJ par~ntal behavlur (¡uid D<"'elup- ml'nt, -;5, .~94-41)3 Hu~bn~r. C E I:n :Jr~sSl. PromotJng to<ldkrs lan~uag~ de';ei"pment: A randomlz",d conITolled IT1al of J communl~·based Inter'e:ntlo", )OUm<.l1 ,)(~ppl,o!d DevâopmeMial P>.v,hol0'5} :1. Kdley, \1. L. Power. T. G, $. Winbush. D. D i 1992). D"'termmant5 ofdJSClpJm3Ij' practices in low-in' come: Black mnthe" Child Devdopmo!Mi,'jJ. ~-1-~~2. Krein. 5 F. & Belin, .\. H.II nS) Educ"tlúnai J[t;),mmcm úfchlldren trom stngle·parent families: Oif- !àences ~y e'posures. g~naer. rJC~ DèmOr;raphv :5. 22: -234 L;lIT1ISOn- \V)1It~. L. ( 19·:¡-). fover.., ,n !hè i;mlèd SIa/es ! 996 Il;S Bureau nfthe Cc:nsus. Current Pop, ulatlons Reports. S~ries P60· i 98', \VashlI1gton. DC L'S Government Pnntlng OUlce. l.,)nlgan. C. 1. 11994). ReadJn~ to preschooler; e'posed: Is che emperor really naked') DevelopmeMial R¿v,,,,, 1 { 3 03 ··3 23. L,omgan. C. J. & W)ufdmr>t. G. J. i ¡q<Jg). Rdaf1v~ dticJc\ l)fparent Jl1d teacher lI1volvemem in a shared r~adLDg program for pr~schl,ol ~bIidren from !OW-I[K.)me background¡;. Ea.rl\' Childhood Re· ."Ì¿Qn..'n Qtl.u.r,:erl\·, / 3, ':63-~90. \1cL0yd. \; C. ¡ 19<J0) The Impact of economl'; hardstup on Black :-amIÌi~s and c!uldren: Psycbological disITéSS. parentIng, and s<XlOemOlHJIlal devdopm"'nt. C{¡lid D",vâopmeMi. 61. 311-346. .\10nsset. C. F. /1996). "\fommy. ¡ \Vanna read to you l)OW"- Strengthenmg child language skiHs by lis. tenmg. In K. E. Barnard rChair), Whal do we know a.bo~I en;,anclng parenrich¡fd comfflumcarion ~nd 'ntera'lion WII;, 'nJanlS and loddlt'rs' S:-mpOSlum conduçled at Head Start's ThU'd Research Conference. Wash¡ngtor¡, DC. \10nsset, C. E.. & Lines, P (¡ <J\l4\. l-hlplng ;'our BaÒv ["<.1m 10 i:Úk. L.S Oepartment of Education, Offic~ ot' Educauonal R~search ;u¡d ¡mpro'~me!1t, L~3IT1tng L¡nk. "e~dlmJn. R. Fnêd, L. E.. ~1orely. o. S. Taylor. S.. & Zuckerman, B. I ; 991), Cir¡ic-based inter- ventIOn :0 pr0Q10f~ ;,fera.;y: .\ ;:>iI<Jf ,rudy ~m':nc.m »urn"i 'Jr'D'seaòo!s of ChlldhooJ 145. ~81-884 Pa'),·1. J H, I 1 ,}g-). ....daress \0 lh~ ....rn~ncan Library ,".SSOC.aIIOn. San FrancISco, R.am~y. C f, Bryant. 0 .\f. Campbed. F...... Sparling, 1. L & \\/asik. 3. ,,( In8) Early mter;entJor¡ for hIgh-risk chlidren: The CarolU1a ear!\' cnter:entJon pro~. In R, H, Pnc~, E. 1.. Cohen. R. P. Lonor¡. & ~I. R;urlOs-\1cK.J\' 1 Ells.). " 4 '''./!ICTS o(pn"·"n{:ùn~ ça..¡eOook ¡'or praclllioner5 Ipp, 32--43), \Vashwgton, DC: A.mel"1c;:¡n Psy'ehologlcal ..\.<SOc:alJOn. Ramey, CL & Ramey, S L. I i 991)) ¡ntens"e eouça!1onaJ ¡nterwnt:or¡ for duidren ot'poverty ¡melli. gena 1.1, ¡-9. Scarborough. H, S" & Dobnch, WI: 9941, On :h~ dficacy "f readIng to prcscboolers, D<!\'elopmemal R<!\"Ii?\<.. U 24~-302. Schwemhan, L. 1. I: 9941, LJSnng ben~tìts of ~res~hool programs. Ene ùlgesl. EDO-PS-94-2. Scbor. E. L. 11995). Oe';eiopIng communailt\" F .lU1i1y·ê"nt~red programs to improve children' s bealth and well-beIng. Builenn of:he \'¿-." York .-ica.dem.\· o/'.JeJlune. ":. 413--442. SeltZ, \' (1 (¡90\, Interv~ntlon programs t'or :m¡xJVenshed children: .... ,;omp¡¡r¡so" ,)t' educanonal Jl1d family suppOrt models. ,~nnuis o( Child Dt!\";npmem, - -3- i 03. Smith, K. P /.19891 C1uldr~n <ill1ong the poor Do!mor;rapin, :6. 235-248 Snow, C E.. B<Ul1cs, W S , Chandler, J. Goodman. 1. F.. & Hemphill. L. 1)991). l'n.r~¡jilled expeç/a- nollS. Home and school ¡n,lwnces on liferac,. Boston, :-viA: Harvard Umversl~' Press. 314 Ht'E8:--;E~ :-~:.1L 0 .. ..t 8Jtes. E ; : \,1'-<41, L.lngL.:j,~e- J.no ':Jmmur.lc;1w..Hl In ;:;lr!¡ .:nl¡JhC>tH.1. Pt..'u'lu[r!C .111IlQis, 2qQ.. :j)~ 'C",\., \ .-\.. &. .\mo~... K. J I ~ ,'QJ) L;\.'!r.~ .J.nJ ,"('",.,ur.'{ '~t' ::oi!J.nnr..lt¡~'r't)n)t.."l/\) ,i :.:;Jse \:-'.J.Jy ')(cor.r:rw_ '!¡t1-l....(1.,~·~¡j \'f:'>""\/L"r:S .'rlfe:r,:r,.JIU'.'t¡. :h¡: Pi0ml)!!rì~ :)lJCcr::ss:n Zt·ro ~o Thre~ -;e-r..¡ç;,:s ?roJt:(;t.lERO i() THREE ~·;'HIOn.lJ C~ru:;; ~'or C':JnlL:;)] !n(;.lnt ?~tJ~r;)ms.. .-\.rhngruo.. \"A. \\·~il~. Ci. I : \)~ S I. L...ll1çJt1~/:' .j~"\·t'!r'Jprrtt!!I[ . "1 .'he ;7r':'SL)W(J¡ ,'r(ln" \;t.:'.\o Y ()r~, CJmbnJge L nl\'~rslr:' Pr~s$ "'>hltt'hur~L G. J, F~k,). F L. L,Jnlg:m. C J ,F'\chçì.J E, De83f'\,hç. 8 D. \·Jdçl·.\kn(;h~(;J.:V1. C.. & CJuirídJ, \1. , I 'i~" 1.\cc,k~Jun~ IJng'JJgç ~~'."I"pmç~t :hrough pl<:nHç ~ook ·~~Jtn;;. 0""21. )pmt::r.li.4.' ,:.\....tnoiu'<..·., ~~..: 5~'=:-559. '.\C':, J. Sn$kc. T . S:liJie. L ClOY. S ? . !'L¡ç. Y . Ste~n"t1,] . GrJna.".. '" Pene, \1 ¡ i 9C¡~ \. The ;on- .¡:[lUr. I)t e:.1~ic:;r:I)f1 On-:;:¡c;. :\\'1\!ahk: ~Hlp. ~¡;;:5,;;:,d.~o\ ;:mbs~~ ~~)nJit:nn':Ì~ ir.dçx.h~rni \" '...;h!~J.'.\j, H :()t.~ì, ~..,tt):;-:~;";'"r. -...:~·~'¢,,':s ,.\r'~Jrl.'. "':,1J¡JhùPL1 ;:"'I\gr:l.Ir..-; \In ...¡,\c;:..¡II)!J¡-¡,;..:'mè'S Jnu Jc:::n- JUC;}C',' :,r'he F:'ifli"~ ')! C·',;:liJr,~>,'1. :. S: - -5. Y - :..;.;-¡.;; K, r DJ'. l.s. :-\.,. j(;hd~!1. I,,-~ . ~ PJ.r~¢!'. S ...,......., I LI...tç'n¡n~'~"" O,Hcr.t~ \ ~\iltll)n:.L )1.1I\. ~:. $t :'J.r- ~·nrs ~.\':rh >·1..1ung ..:h¡/Jn.:n, ir',:,'Aj'''<:.·'.~'' ,,r.:J=',-l!u.:nc .~nd.,~ào/¿5i..';:.ln! ,1.(1.;·J¡:...,':ne, /.'"_-. 25~ -..262. Y 'cng. K. T, ~ \br<.;:: ! 'i'i::. ;(7:111 ,Wes .'wr"JI:? 7!è;¡nr;)r 'n',;nl.; ,111" :"""Iers :1:e .;r)l¡:nb"i¡uns .I(:he ::)1/;'.:i. :he ,'an-u/y ..J.IlJ :t!t' ~-')l71nlU.n:.~ :RÇ'::~H\11 \."1), ~' 9altur.un.~· .:dfU1S Hopk¡n:-; L·n¡verslC:-'. :: ~nt~r ,.In F :lmtll~'5. C0mmL;.n:t¡c:s. S(::ll)l..)ij lnJ C::¡dJre:1·"¡ L~.1r!1Ir.g. ZERO Tn THREE. , I (¡,)~ .".pni . ~i, ?Jre~lS ,,( 'nr"es lnJ :oJdler, :'JC" ":n(orm~th)11 dç¡k¡(' ;,n :1eJ¡{~y ~hlid jc\'d()pm~I1:: \,H100:.l¡ poi! :-r'.'e':lb .~$,} ~r)(1\),. :èd?~ J.DUUí ':r'nlHlún.:lL .::)oc¡a] JnJ ¡ntdr .ec:u~1 Je\çIODmè'H ZO:;:(I) l') THREE ;{~:r:neJ .\pnl", ,'i'N :'rom '.Vor:c: \Vi,jç Web ~t:p: ··I,.:~,i,.\V ..:erOtD{i1í~~.'_)g ;;f:\',1[¢, pr_')"¡: -9- hr:nì ? :1. .'''; C,)!Lrh..\!.. \'\"è5~. ,: . J.: :-b:J$;";ç~. E, (J 'l+4~ .-\ppr\):)o.;t1:r:~ i\.lnú~fS:..lr::;:n:.\ iClll~..1l pr~s;;hcl."\i- ::n in ~,hç L;;.ne-o StJ.~Ç) :~'¡)1m,? C:r:¡jn.:·~I. -,:' -::~_~\ ~ '~ Board of Health New Business Agenda Item # V., 5 TopicS for Local Board of Health Workshoe. Survey Results June 21, 2001 A .- Possible Topics for Local Boards of Health Workshop in Autumn 2001 (WSALPHO) TOPIC Powers/responsibilities of Local Board of Health Health Care Access/Health Care Costs Illegal Drug Labs and Public Health Youth Violence Prevention Public Drinking Water Systems Onsite Sewage Systems Solid Waste and Public Health Child Health/Early Intervention Emerging Disease with Public Health Impact Local Health Jurisdiction Fees and other Revenues Using Information for Decision-Making Sexually Transmitted Disease/HIV/AIDS Antibiotic-Resistant Bacteria Child Care and Public Health Powers/responsibilities of Local Health Officer Tuberculosis/Communicable Disease Control Tobacco and Minors Nurse Home Visiting with High-Risk Families Pandemic Influenza Bioterrorism Food Safety/Food Handlers Immunizations Tobacco Prevention and Control State Board of Health Role State Department of Health Role Family Planning Dental/Oral Health Jail Health Care Recreational Water Safety and Health Clean Indoor Air Act/Indoor Air Pollution Shellfish Safety Other - Please Describe (See Attached Sheet) High 59 46 52 43 53 51 37 55 52 35 30 32 39 43 32 36 39 33 44 39 33 31 40 20 23 34 22 14 14 15 20 Respondents-members of local boards of health Total number of surveys received - 119 Medium 47 52 38 53 43 49 55 46 47 55 59 60 52 43 59 53 50 53 47 49 51 54 42 56 59 46 52 59 56 52 47 Low 11 12 13 15 16 16 16 16 17 20 22 22 22 22 23 23 23 25 26 26 27 29 29 30 31 32 36 37 44 46 51 Local Boards of Health Workshop Added Comments: . Providing health care access will be paramount. If the awards program is any 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 A WC & WSAC legislative meetings. . Added 10 Jail Health Care - Cost of jail health & how to pay. . ¥ outh violence prevenâon, tobacco prevenâon and control, tobacco & minors are all areas that currently are being addressed by community & school orvni7~tions (non- profits). Any actions from the cm 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 · Community Mental Health - monitoring outcomes, problems. · Health Promotion Programs. · Í.arge 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. <V · Non-iodizing radiation from wireless ante~ · Jean Baldwin From: Sent: To: Subject: Ward Hinds [whinds@shd.snohomish.wa.gov] Wednesday, June 13.2001 12:14 PM WSALPHO@listserv.wa.gov LBOH Workshop ~ Unknown Docu".,.",t 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 t~ey 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 M. Ward Hinds, MD, MPH Health Officer Snohornish Health District 3020 Rucker Ave. Everett, WA 98201 425-339~5210 FAX 425-339-5216 whinds@shd.snohornish.wa.gov 1 Board of Health Media Report June 21, 2001 II" Jefferson County Health and Human Services -- MA Y -.; 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: I. "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 17.200] 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 I, 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 (j) Jefferson forms new office Panel allocates staff, funding for natural resources work By PHILIP L. WATNESS PENINSULA DAlLY NEWS PORT TOWNSEND Salmon and other natural resources will finally have a designated point-person in Jef- ferson County. Dave Christensen, water resource specialist for the county Health Department, has been handling natural resources issues for more than a year, but the ever-increasing responsibilities have detracted from his job to handle water issues alone. Additionally, Pub- lic Works and Community Development employees find themselves dealing more and more with endangered species and environmental issues. To remedy the situation, f>bN '5' - 'if,.. 0 I Jefferson County commission- ers voted unanimously Mon- day to establish a Natural Resources unit. 'Enough need' The department would con- sist of one half-time and two full-time employees to handle education and outreach, do watershed/salmon recovery planning, provide assistance to other departments, coordinate land conservation efforts and write grants to fund projects. "There's enough need for this out there now," Chris- tensen said. "A few years ago, we identified the need for five additional people just to deal with Endangered Species Act issues. " County Administrator Charles Saddler asked the commissioners to anticipate a $40,000 ongoing annual cost for the new department. He promised the unit would be funded primarily through state and federal grants. "We don't want this to be a chase after grants, though," Saddler said. "We need to build enough capacity to address the current require-- ments." . Clear mission Commissioner Glen Hunt- ingford, R-Chimacum, said the new unit should have a clear mission and defined responsi- bilities so it won't continually grow in response to requests by the state and federal gov- ernments or by special inter- est groups. Christensen estimated he spends most of his time deal- ing with natural resources issues. He anticipated spend- ing even more time as more issues present themselves through state and federal pro- grams. In addition, county commis- sioners approved a Conservd- tion Futures Tax last year with the money to be used to purchase land or easemen tS for open space. Saddler said the planning for that will require one full· time person alone during the first year. The specifics aren't avail· able on how the new depart- ment will be formed or when It will be up and running. @ 41 establishments honored for 'safe' food standards 2000 Outstanding Achievement Awards have been presented to food ser- vice establishments and their proprietors who have demonstrated highest stan- dards for safe food handling. This year, 41 businesses and organizations have earned this award, given by the Jefferson County Health and Human Services Environmental Health Division. Receiving the honor for their sixth year are Port Townsend Senior Nutrition Program, Craig Yandell; and Valley Tav- ern, Chuck and Karen Russell. Honoredfor five years are Java Port, Linda Kennedy; Jefferson County Jail, Eleanor Such; and Lonny's Restaurant, Lonny Ritter. Receiving the award for four years in row are Whistling Oyster, Sandra Van Wagenen & William Bailey; Fat Smitty's, Carl Schmidt; Seabeck Pizza of Pleasant Harbor, Jerry Anderson; and Silverwater Cafe, Alison Hero and David Hero. Honored for three years are Bloomer's Landing, Jim and Pamela Morgan; Brinnon Seniors, Lynne Fay; Hard Rain Cafe, Michael Rasmussen; Lanza's, Steve Kraght and Lori Lanza; Portside Deli, Lynda and Brian Douglas; Tri-Area Senior Nutrition, Tom Daly; and QFC Port Hadlock Deli, Ron Reed. Two-year recipients are QFC Port Townsend Deli, Jeannette Baker; Ajax Cafe, Thomas Weiner; Heron Beach Inn, George Eubanks; KllU Larb Thai Res- taurant, Paul Itti; Maxwell's, Chris Sudlow; McKenzie's Deli, Michael East; Niblick's, Pam Elkins; Pizza Fac- tory, Francis and Balorie Danielek; The Vùlage Baker, Andre Le Rest; and Up- town Pub and Grill, Laura Millett and Katy Snell. One-year honorees are Salal Cafe, Pat Fitzgerald; Queets Clearwater School, Gloria Fairchild; On Common Grounds, Doug Roth and Marga Smith; Plaza Soda Fountain, Donna Hogland; Mountain View Cafeteria, John Koch; Manresa Castle, Walter Santschi; Ferino's Pizzeria, Scott Browning; Fountain Cafe, Kristen Nelson; Grant Street School, John Koch; Head Start Program, Mechelle Petersen; Harbormaster Restaurant, Pam Hubbard; Chimacum High School Caf- eteria, Linda Boyd; Blue Heron Middle School Cafeteria, John Koch; BPO Elks, Randy Unbedacht; and Brinnon School Cafeteria, Hope Nordland. These food service establishments have demonstrated their efforts to pre~ vent illness caused by food borne See AWARDS, Page C 14 ~ ("> .,., ("> '< e! ~ '8 0 a '8 a ::. Er Õ' 3 :J: () Õ ¡¡; 8 ;':J: ;' :J: ¡r ~ ~ S [O~ ~ ~... S' Ii 0 Ëï 0 ~ ('II c:: g ...¡ ª- :::: I:' g. ¡¡¡ 0 c :::; g æ.. ~ e~ g'<-S'~r;:~ ~g_~~('II~=_~30_~~ ~~~ ~~~< ~ _>~S>o~"'~~~~~:- 8 êf 0 g. - F ö' -2 ;;r S' ;- 0.. í" =' ~ ¡ç Õ' b Ii ¡ç g ¡:;s 0 :;:r § ~ :;sn~~3g~¡¡;KS~:;s~:~~ ...:;S~_=_~:;S_~:;S o('ll<o~('IIaaN:;S ~on~ 0-'< ('IIn:;S ~ Ë < ;:; _0' ~. E? o' o' 0'< õ.s¡ :;s ¡a. ~ ~ !r n e! 5-0 n !r:! 0 -ô ¡G ~ . <: I» _.:;s :;s :;s .... 0 ,<"'" 0 ~ 0 ~ 0 ~ _. ~ n .,.,:;s o -..... ¡¡; ~ :::s ~ ~. o:::s.... \ J ::I e¡ ¡: '< ¡::: a 0 n - ("> :l 0.. ¡;¡ s:- 0.. a. "" c::r "Q :.:r 5 r:- 0 ~ n g 1»' ('II Ei g :;s g, ~ "0 ('II ~ :; - '< _ . ('II < 0 'g c 0 ~ r::. _. .... 0 :;s 0.. .... -:J: t::': ~ '< _. 0 0 ~ õ' ¡¡¡ :;s ¡;. R' 0 ~ 'g ¡;¡ q S -< !i' ~ S' N'< r! ¡;. 8.. S' t:I :J: g ~ ~ I» ¡¡;. ~ 0 :;s S' "g -. "g .....:;¡ < "" OCI s< ~ ~ 0 :.:: c::r 0 ('II ~ :T ... ~ a.:::s :;:. ~ ~. ~ Ø> C n ¡:?.t::. 'TI[ !!. 8.. > :30 g. -d ::z. ~ ~ I» n 0 ~'oon""~~_~a~~ 0 (">. II' ~~~~~c::r ; :;:rC ~ ~ Õ',< K 8..-'0'-0 ~ 0 ¡=. ... ~ "" å- ::r'<"g ("> 3!" ~"':;:r a. .... :;s :; -. ~ V'J Q.:; o' 0.. 0.. e: ~ ('II 3 c::r .... g~]:g~g8..~~aõ:;s~c::re-~ og.~~~g~~~~ ,....0.,....001(1)1"<0 ol,,<n, ~Ota"',..,.......("þ.O f~ ~ S ~;t ~ ~ r: l£A þet'<... 5"../" -() I Beef: Food scare "W. MlJ to u.cel.l.n t ""tau. rant.a that !lav. I ¡rut track ~rd," ChW.on aa.id. Th. contamlnat.ed b.er c.a.m. (rom on. o( three dia. t.ributorl - Wett.rn Box [n Portl&nd, Or.., Plymouth Poultry II¡ 3e.&ttJ. or Sound Meat.a In MOUI1 tl&k.e Terra.C$, h. aa.id. "They U9 Ju.t box Itor&¡1l comp~let" h. uid. "They don't touch th. meat." Th. contamination malt likely oocurr.d at a alau¡ht.r hOUN, h. aa.id. E. coil ¡, con:unonly Intro- ~ lon¡ u. relt&ura.nt.a duced to b.ef wh.n meat 000 j( ad U¡ e meat u¡ accorda..nc.l comet In con tact wi lh (ec:.a.I w1th county Department o( InI.t~ EnYl.ron¡z:ent..aJ Health re¡ul.a- "W.·'re all buyin¡ the lI.lIIe (10nl. dlnul Ihoud h:"ve product ar¡d ill ptlin¡ :;un¡ t.£ worry about, Chiu- throu¡-b on t..h. flnt inapec- ~ o( Monday, no cu.. UOD.." h. aa.id. "It'l pttin¡ uaociatsd with the poaaihl. E. lhrou¡~ at the prO¢eUinr coli cont.&rnination had been plant.a. re po rt.ed. A.coordln¡- to Chlaa.o n, the The hamburi'3r in question USDA (ound th. po&albl. E. W!U ¡round wt Wedn~ coli contamina.t..ion II¡ I. one- Ch.i.auon uid.. It wu ~ by pound u.:mple tù.n (rom the Agriculture ÐepartInent', 8,000 pound. of beef ¡round (00<1 aar.ty ar¡d in.pectlon by th. Port A.l1gel. company divi.aion Friday. l.ut week.. lrlitiAl t.a.at ruult.a ,howed "I'v. owned the buainlll.l 23 poa.aible E. coli contamination yean ar¡d thU ¡, ili. nnt tim. Friday, but USDA omci.u w.'v. had . warnln¡: h. aa.id. weren't ready t.£ aay . hea.lth "But oookin¡ IOlv. thU pro!>- hAzard ezatsd. ChWAon aa.id lem." hit co m p.a.ny notliied rutau. rnnu that might !ave received OperaUng alnee 1934 th. po t4n tLaily con tam.in&ted me.a( th.&t day. Ch.i.uaon aa.id hJ.a company By Monday, USDA offic.I.W h.u bMn In bu..tnu. In Port decided U¡. health riU wu An¡el. line. 19~, but he', I "~h, - but did not order I owned it (or 23 ye.an. recall. So Chiuaon aa.id ha The me.at company, located compa.ny voluntarily recalled . I~ 306 8. Valley 8t.: employ.. the meat, which wu packed In eight people a.nd 1.1 the only 10 pound cu.e,a a.nd hap and USDA approved plant on lhe cfutribut.ed to IOme of it.a 120 North Olympic Peninsula, he C1Jltomera on the North aa.id. Olympic Pecinaul&. "We're very proud o( our Rutauranu with any (acility," he aald. po~n t¡Ally con tamlnat.ed People with quettioru can ground beef began r-eturnin¡ it calJ Ever¡reen Meau at 36Q.. Monday, h. aald. 467 -8.666. CoN'TTh'VW P'ROIoI Al "Coruumera r:n.ay wiah t.£ uIL rut..aurant¡ or pllcea whe~ they coruume ¡round b~f if the product or mea.! co n t.aiIu the recalJ eel prod uet.. . Potentially deadly bacteria E. coli i, a pot.n tially de.a.dly bacteria that CI.n C4uae bloody d.iarrh~ and dehydra- tion, Billy uid. Th, very young, ~1:l. and people wilh co m pro unm un. aytUm.a are the mOllt I\aOept.ibJ. to th. (ood· born e illn..... ;:13?Þ<8t1 83S:::;1::.: S~ ~;: o m ~ (0.... '< m@ ~ ..... ~;:1"(j=-=~§lt?:j z J -g..... (~-~.....§- < .....~o (1)= \J ~§~go "f 2.", i[~[ C/J_ ~ = Ë ~ t?:j ~ 5' ~ ~ !t = ro= [;:;':~&.<~~ .~g:.;:1~o..~ en ~ (0 o.:!!¡ . ¡:: 8 8 P: (0 s:::; 0 œ."d -ð c' IJì ~ ¡¡¡ 3 :::J ~ 0',j;:1 ;:1 ;::; ~ f-' S :;¡. Ó CD- ;¡ g.~g. ~qp m~~P if I» (") . . ,...-+ N o -;::;!::rt"j. 00 o§! CDZ S?::<""'><i'::;! §&1"-g"""E""" ';j..J å ~ ª § l ~. g: .r § d' 0.: ~ ~ 0.0 I -+. ^ ¡" '" .. '< a F ~ go ¡¡. ;+ 2' "1 a::r ' ) ~ p ~ ~ ë. § B. :; 2. ~ ~ if 3æ ........... ~ &1" 1 ? ~ [ ¡r Çn~ }<:< ~ m;:::; ~"'~2.p [ 1f[~ f.~ .::r () ëg-!!.a~W¡;. g: f§ [~ 0 fl-Ë.~c¡r ~ ~....r¿- I -. . o..~ ~ I ; '~1:"':""" ",. ~ ' " '.~'1.~'" :" ;";ç 0 ,t -f '!~'f!1:Q' ~ :z: : [iJ.Í !i [~ ~ Ilirl ] ~ cr iz¡., tT ~ S; . ~2.~ ~ ß. ao. :f.i!jrUnIt ,~ : fii ä~ j @f~a.·~ cr- , rlrähHl m J[UhifIH i . p" -. nrfíUrl D) i.!l~!i.~ i ~ i }ü:4(irir m ~ ~HIJhh 3 1~~U~V[~ Co ~1 f!ï~~tti i,S"r~r~r! g: rJ~fH'¡f~ I [{fhUH < r¡X IJf f[f " ~4;~11 U g¡ It {!Jf¡U i" i t 5flir1 l·~··h ~ ~ H ~if. wI æ r:i ~ i- f f CÞ .... c" c:r 0' /--ì (~ C!) Edition M.1Y 17. 2001 South county counseling clinic to open Agencies unite in Quilcene; 'huge bonus' BY STUART ELLIO'IT PENINSULA DAILY NEWS QUILCENE - Social services from juvenile probation to drug and alcohol counseling will be closer to the doorstep of south county resi- dents when a new center opens next Tuesday. The South County Social Services Extension Office will open the three- room complex in the same building as the South County Medical Clinic, 294843 U.S. Highway 101. The new office will provide office space where counselors from six agencies can meet with clients, mak- ing access to social services easier. "For residents in this area, it's a huge bonus, to said Shirley Smith- Moore, the chairwoman of the cen· ter's board of directors. "We've Center CONTINUED FROM Al The Domestic Violence pro- gram previously offered ser- vices in Quilcene, but lost its office space, Smith-Moore said. The lack of office space has also kept other service providers away. "There is not a lot of office space, and lack of money is a hindrance," she said. never had this many services in this location. It Jefferson General Hospital, which runs the clinic, is providing the space without cost under a renewable one-year lease, Smith- Moore said. The hospital leases its space at a "low cost" from building owner and Quilcene resident Wally Pedersen, Smith-Moore said. Six agencies offer servlces Counselors from six agencies -'- county Department of Health and Human Services, county Juvenile Services department, Community Recovery Center, WSU Cooperative Extension and the nonprofit Jeffer- son County Mental Health Services and Domestic Violence and Sexual Assault Program - have agreed to provide services at the center one or two days a week. The grand opening of the center is from 6 p.m. to 8 p.m. May 22. Agency workers will hand out brochures and explain the services they provide. TuRN TO CENTER/A2 Year-old Idea The idea for the center was broached at a meeting of the clinic's citizens advisory board nearly a year ago. Members of the board approached officials from Jef- ferson General Hospital, who agreed to provide the space. The center is not expected to significantly increase the budget of the county agencies and nonprofit organizations operating there, Smith-Moore said. "This is mostly money they had budgeted in to provide services," she said. "There is the cost of transportation. But it's servicing people that are already part of their client base." - --~-~-- ~.---~. ~ I. G) -c o 'QO c . ~ o I. 'QO G) I. --- fl'll~a~¡ m' mu~ ;;~.~ ¡II II!~ ¡m;mf;;:~·; ~¡~~~ I II I JI ~ lü! 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C ~ " .. ..\ ~/ Unwed pairs on the rise in Jefferson Census figures show families slightly decline BY STUAR'I' ELUOTr PENINSULA DAILY NEWS An increasing number of North Olympic Peninsula residents are sin- gle parents, living in nontraditional households, U.S. Census figures released this week show. Results from the 2000 census show the station-wagon driving, 2.2- child nuclear family on a slight decline over the past 10 years in Jef· ferson County, particularly in Port Townsend. . The trend is similar in Clallam County. Port Townsend has seen the num- ber of families drop more than 7 per- cent in the past 10 years, from 63.9 percent of all households to 56.2 per- cent. In Port Hadlock-Irondale, the percentage of families slipped from 70.2 percent to 67.9 percent during the last decade. Countywide, the decline was more gradual, witb a three percent drop in the number of families as a percentage of aU households. The nuclear family breakup is also evident in decline in the num· ber of families headed by married couples. In Jefferson County, the number of married"couple families slid from 57.4 percent in 1990 to 53.6 percent in 2000. . Port Hadlock-Irondale followed the trend as well. In 1990, 57 percent of all house- holds were led by married couples. By last year, tbat number had dropped more than 5 percent to 51.6 percent. In Cla1lam County, the number of families. has slipped from 69.6 per- cent in 1990 to 66.5 percent of all households. TURN TO CENsuS/A2 Percentage of households comprising married couples o 10 20 30 40 50 60 70 Forks .. t . . . . . . I I . .. . .". . .". ........... .....................««-:<0:.:-:- 4G.4% 84.0% Neah Bay.... .. . .. .. .. .. . .. .. .. . . ..-:-:-:.:. 36f2~ Port Angeles 44.0% ...................,o... ......... ..........:.:-:-:. 51.0% Port Hadlock/lrondale . ....... ... 51.6% ................ . .................................... 57.0% Port Townsend ................................ ....... '.' . .......:-:-.. 42~~% S . 40 1% eqUlm ...................... . . 4· 2 4ca1 . . .. .... .. ..... '. ..... ..... . 70 'Pt>N 5 ~ :lS" -0 I Clallam County Jefferson County 53.9% 58.4% 53.6% 57.4% . 2000 Census [] 1990 Census rfJ V U .~ o ~ :U ,.Q o . ,......... ~ ,.Q u v u ~ Q) ::> ~. c:: .~ u ~ .v ~ 8 Q.....<..........c.....>, ~"O ""'o<... <"9.~8·0.:.. o 'bD o. cO .... .:; ..c ~.o.> 'bD.8 ~ ~ ex) .o.>! "O""c 00 - ~ c !:: 0 ~ 1; 'ca ~ :9 .s.~ ~ 1! < § C'ca ~ ..; '00 § I ~ "g ~ ~ ~ § Èc3'~ ~ i &] ~.5 ~ lÈ: ê É ~ -ð~ ~ ~ .cCII C"O s:::""'.....¿c:t.>oc ~ mô c:t.>1J'£ ""0..... 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U ð<l~~11i~ ... ~ ~~; ~ -:5 ..c: ...... ~.¡:: 0"= ~ ..9 .! ·.., ~) A6 SUNDAY, MAy 27,2001 Subsidized clients' health care axed treatment plan and/or suffi- cient information t<f'justify diagnosis or treatIÍlent. The Peninsula Regional Support Network· has also 'Service. . . will continue' informed the nonprofit organi- Jefferson Mental Health zation it needs >tõ change the Services Director Laurie way it does business to conform BY P1mJp L. WATNESS Strong said the organization, to the network's contract. PENINSULA DAlLY 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- i~ Je£!erson Co~nty will con- been an issue for awhile. trative requirements have con· tmue, Stro~g BaJ~. There's been compliance and vinced the Jefferson .Mental '. Strong BAld she s heard y~- quality· issues for at least a Health Services board it can no lOllS rumo~ that the facil~ty year, Once we find' a new longer afford to provide 'mental had cl~sed lts d~rs or lost .11;8 provider, I think we'll have bet- health services for govern- ~tate.license, nelther of which ter services." ment-subsi~ed clients. 18 t.fh~. Mental Health Services But Henry ~d other men- But the lSsue may also be Offi f th W. hingto State tal health proVlders have also that ~h~ nonprofit ,organization De~~~en~ ; Soci~ and decided to reject th~ contract. hasn t lived up to lts contract. Health Services, however, did "The RSN d~ t presently . The board recently conduct an on-site review of have a, contract acceptable to mfo~med. And~rs Edgerton, Jefferson Mental'Health from any of the, three regional Pemnsula ReglOnal, ~upport May 15 to May 18.' providers," he said. Network (RSN) administrator, State Mental Health Ser- . I 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 sched, Edgerton said he will fmd percent to 90 percent of its uled June visit. another service provider, but in business, board .Vice-President The state wants Strong and the meantime, he's willing to Chuck Henry BaJd. 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 8er- 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. Care facility blames lack of funding ing operating our residential houses for chronically mentally ill people in our community," he said. PEmNsut..A DAILY NEWS 5- ).-1-0/ (f) Survey seeks health data for Jefferson Study's aim is to improve care, government says By PHILIP 1.. WATNESS PENINSULA DAILY NEWS City and county officials hope a telephone survey will give them a look at health- related issues in Jefferson County. The gurvey, already under way, will continue through December. Jefferson County Health Department officials and Dr. Christine Hale, an epIdemiolo- gist with the University of Washington, developed the 20- minute detailed questionnaire. Officials hope to get responses from 600 families about their health, habita, insurance coverage and other Î&!ues. Some of the questions could be disturbing, such as whether a family member has experi- enced domestic violence or alcohol abuse. ~The domestic violence questions have been really interesting because a lot of peop]e don't want to answer them," Hale said. "And that tells you something right there. " Behavioral questions Other risky behavior, such as tobacco and alcohol use, also reveal much about the general health of a community, she said. "Alcohol and substance abuse keeps resonating in the community as an Î&!ue, as well as tobacco use," she said. "Tobacco is a huge health issue. "We're also asking about firearms and firearms stor- age." The information will be used not only by the county Health Department to design programs and set policies, b4t also by law enforcement, - the judicial system, county com- missioners and others. "We will be using these data to draw budgets," Hale said. "Where your tax dollars go will be determined, in part, by the reaponses to this question- naire. " Bath Port Townsend and Jefferson County have funded the study. "We're also looking at sub- tle things like people's use of preventive services," Hale said. "For instance, do people know their blood pressure and when. was the last time it was checked? It· will begin to give us clues to areas we need to be strengthening. ., Access measured The survey will gauge access to health care, includ- ing dentistry and medicalser- vices. Surveyors will ask whether the person being questioned has insurance and whether access to care has been a prob· lem during the preceding year. ~The survey is part of an ovarall plan to get a compre- hensive look at our commu- nity, .. said Jean Baldwin, Health Department commu- nity haalth director. "The BRFFS (behavioral rililk iur- veillance survey) ii one piece of information. We'll also look at prenatal riaks, the census data and regional data." Baldwin said the data col- lected through the phone sur- veys will be analyzed by a data steering committee compris- ing elected officials, govern- ment administrators, health and hospital board members, raprasentatives of social ser· vice agencies and law and jus- tice professionals. Findings to be released Hale said their findings will ba releWled to the public in several phases next spring. MWe anticipate releasing our findings every two to three weeks," Hale said. "We'll prob- ably do the health access infor- mation first. Then, we'll prob- ably look at the use of preven- tive services. Tobacco, firearms and alcohol will be looked at WI a group." The findings will alBa be compared with. those of a study done in Kitsap County in 1999, the Washington state health surveys and a study currently baing considered in Clallam County. 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Q) .s ~ -=; 11 ~ c: ~'i Q) Q ¡....c Q _s... ~ Q) CQ) ~.... cc·:æ.s "tI ~.s~"'~~~~i~~~~gå~~ ... ~ ~ lIS.,.,;: .s::s . a;"Q) ...c = .sz ~{j.a 1:d¡~13 it ~ ~,g 8 0J Local mental health services could end By Janet Huck Leader Staff Writer When one Jefferson Mental Health Services clienl heard the agency may be closing it doors, he became quite agitated. He lives in 1MHS-subsidized housing. He receives subsidized medications. The agency staff helps him manage his money and even gives him one square meal a day. "What's going 10 happen 10 me?" he asked his sis- ter, Darlene Coker, who plans to work for the agency until June 16, when she is resigning to take another job. "fie asked me if he was going to have 10 live in his car:' Last month, Quentin Goodrich, JMHS board presi- denl, notified its funding and oversighl agency, the Peninsu.la Regional Su.ppot1 Network (PRSN), that it would nOI renew its contract 10 provide mental heallh services for Medicaid clients, the Chronically mer laHy ill who are indigenl or people in crisis. It was business decision for the agency, said board mem~ Chuck Henry, because the state funding didn'l Cove the state's increasing demands for services. The PRSN mighl not have renewed the con!r<K thaI expired June 30 anyway. Its advisory commille recommended the PRSN not renew the conU1lCt, sa!, See MENTAL, Page A_ Mental: Requirements not met Continued from Page A 1 Molly Gordon, advisory com- mittee chairwoman. Bul Ihere are 250 clients who could be affected, "What is going to happen to the clients who ace coming to the cri- sis center?" Laurie Strong, JMHS direclor, asked the JMHS board and the PRSN at a meeting June 4. "Whal do we say to the person who comes for an appointmenl? What are the options?" Not enthusiastic There aren't many workable options. The PRSN is legally re- sponsible for providing those ser- vices to government-subsidized clients, but it docsn't appear the reg~onal netWorle has .~ plan, in lâci:"'for:'thé"cli" ""on"]ul"l" ~d~~s"Edg~¡:¡O~:~SN' ~in':I' istrator, tried to convince mental health centers in neighboring counties to open a Jefferson County salellite, but one center turned him down and two were extremely reluctant. "We ace not enthusiastic about taking it over," said Helen Dawley, vice presidenl ofOallam County's Peninsu.ia Mental Health Center. "Our board recommended ex. treme caution." Consequently, Edgerton came to the JMHS board on Monday to ask board members 10 accept a wee-month extension on the con· tract. The JMHS board said il couldn't accept the extension since many of the staff, who have been working on the assumption they would be out of ajob June 3D, have resigned or are looking for work. "We can't guarantee We could provide the services outlined in the contract, so it would be irre- sponsible to sign," said board member Vie Dirben, Jefferson General Hospital administrator, But the board is working on an alternative proposal that it plans to submit to the PRSN nexl week. "We will have something in place on July I," promised Edgerton. The 1MHS board decided to withdraw from the PRSN con- tract simply for business reasons. According to Goodrich, the state funding is based on a statistical assumption that 10 percent of the county's Medicaid clients are mentall)l..iU.'::'We have P¡oPQ'-~ tionally more mentally 41 wno, are indigent, so the 10 pe~c~t funding doesn't COver them all," said Goodrich. "We don'l want to go bankrupt." He noted even large agencies were struggling to provide ser- vices on the state funding for- mula. The King County agency recently closed il doors, said Goodrich. Failed effort This crisis belween the PRSN and the JMHS has been building for nearly a year. The JMHS, which has been audited five times in the last year, fell it couldn 'I help clients and keep up with the PRSN demand!¡ for more documentation and paperwork. The PRSN didn't understand why Ihe JMHS cou.idn'l follow the same rules and regu.iations as the region's other mental health centers. The PRSN conducted four onsite inspections since the middle of 2000 that found the agency had been out of compliance with its state contract and the Washington Adrninislrn1ive Code. '"'They have had several op- ponunities to meet the require. ment of the law, but they have consistently failed to do it," said Maggie Metcalfe, local presidenl of the National Alliance for the MentaU y m and a member of the PRSN advisory group. "And the requirements of the Washington Administrative Code are a far cry from what should be done for the clients." In the last PRSN review con- ducted in April, the independent m6Ì1ì\~ring tearn' ~üg8è8ìed'th,i:',' J efferiori County agency' rely lC;Ss' on a therapy-based structure similar to a private clinic model and implement an outreach and medical model used by most mental health agencies. They were also concerned with the lack of a seven-day-a.week, 24- _ hour-a-day crisis program. As a result of the critical PRSN reportS, Richard Onizuka, chief of mental health services with the state mental health division of the Department of Social and Health Services, found 19 deficiencies which needed to qe Corrected be- fore the middle of June. "We were concerned enough to go back in 30 days," explained Onizuka. If the deficiencies were not corrected, Onizuka could asle the agency to address another series of corrective actions or the agency could lose its license. Pleas for help Strong believed JMHS wouldn't lose its license. She said her agency has corrected innu- merable deficiencies OVer the last year. "We have provided retrain- ing for the staff, changed forms, formats and ways of doing op- erations to comply with the re- quests from the PRSN ," explained Strong. "We have done hundreds of this and thats." But she said herstatf was ex- hausted.''''ri'speak'SwèU/Þf the staff thai Ù16'yhäV'è' n-or'quit en masse during Ù1e past year, when they have been asked to continue their work and to reinvenl them- selves on a quarterly basis," said Strong, Even exhausted, staff mem- bers are stiU concerned aboul their clients, who are getting more nervous with all the uncer- tainlY, The crisis calls have gone up significantly, said menIal health specialist Bernard Donanberg. At the meeting, he pleaded, ''There's got to be a way to solve this and continue treatment for the clients." 'p-r lfAOE~(2~ 0~0 -C)! ) ---~ ~i Center day treatment for disturbed youth and otTer parenting classes. The $465.000 center will be opera- tional by the end of the year. Most of the funding came from Washington state, which awarded Jef- - ferson County a $450.000 Community Development Block Grant a year ago February. The building will be located next door to the existing center at 884 W Park St. The center will bring to fruition an idea hatched five years ago by Pat Range. director of Learning Support Services for the Port Townsend School District. and Kris Lenke, direc- tor of Special Services for the Chi- macum School District. They dteamed about a center that could serve the special education needs of students in their districts while addressing the pressing needs of other organizations. TURN TO CENTEB/A2 CONTINUED FROM Al Laurie Strong, director of JetTerson Mental Health Ser- vices, supported the concept and representatives from law enforcement, alcohoVdrug counseling, juvenile justice, state child protection services and county administration joined the effort. Range said special education students will no longer have to travel long distances to receive combined education and coun- seling services. "It will benefit the schools because it will provide an appropriate therapeutic envi. ronment for students," she said. "Sometimes students run herd over the classroom, but with the low teacher-student ratio and the mental health support, that will strengthen the child's skills so they can return to school." , Edi~ion June 8-9, 2001 Jefferson kid, family center project begins Building to be base for many service agencies By PHILIP L. WATNESS PENINSULA DAILY NEWS PORT TOWNSEND - Thurs- day's literal groundbreaking for the Child and Family Resource Center can also be considered a symbolic groundbreaking for JetTerson County. The center will provide services and facilities for many different orga- nizations. From law enforcement to educa- tion, the resource center will fill the need for a safe, neutral environment to interview children about traumatic experiences, reunite families, provide Comfortable reunification Bill NeSmith. supervisor for the Port Townsend Child and Family Services office of the Department of Social and Health Services, said families will be able to be reunited more comfortably because of the cen. ter's family visitation room. "With the family visitation room in a neutral location, clients will be a lot more COm- . fortable visiting kids who've been in foster care," NeSmith said. He said the center's Foren- sic Interview Room will also provide a better venue for interviewing children who may have sutTered abuse. ,"Law enforcement, child services and schools can do one interview, so we can limit the number of times a child will be 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. ''',-..~ r'~''''''''''f ....,................... ......_..... ...._~........_ @ Mental health agreement due Jefferson Mental Health Ser- : vices OMHS) was planning on dosing its doors June 30, but now : negotiations are underway to : keep its services operating for its indigent and chronically ill cli- ents. Last Friday, the executive board of the Peninsula Regional Support Network (PRSN), which funds the Jefferson County agency, conducted an emergency meeting to discuss possible so- Julions. As a result, the PRSN offered to extend the agency's current contract with some modi- tïcations for 60 days. That time frame would allow the two agen- CIes to develop a long-teon con- · tract with JMHS as the sole · provider for the publicly-funded programs. "It will buy them time to ne- gotiate a longer-teon contract so · the provider can stay in business : and continue to serYe the clients," : said David Goldsmith, a Jeffer- · son County deputy administrator. The PRSN executive board · çonslsts of the county commis- : ~lOners for Kitsap, Clallam and Jefferson counties. Quentin Goodrich, the chair- man of JMHS services, was pleased with the emergency meeting's Outcome. "I t sounds like we are begin- ning to get somewhere instead of the stalemate we have been in for ¡he last couple of months," he · ,;aid. 'They are recommending · we use some kind of mediation · so we would able to resolve the · disagreements between JMHS ~ T, l t-:-;"*: D ¿~ 1<-. (o-{3-0) and the PRSN." For nearly a year, the two en- tities have had disagreements about how the mental· health .9gency $b.o).lldgpç{¡t.t<;. ~900rich explained that his small-town agency, which has been audited five times in the last year, didn't have enough money to run all the programs and meet all the re- quirements required of larger agencies. Anders Edgerton, PRSN administrator, said that he was only asking the agency to follow the same basic rules and regulations as the region's other mental health centers. The Washington State licens- ing agency is slated to do a sec- ond review of JMHS this week. Goodrich said JMHS Director Laurie Strong told him she is confident the agency will pass. Additionally, JMHS is hold~ íng a community forum June 20 at 6:30 p.m. at the Port Townsend Community Center to elicit com- ments from residents about what [hey want from their local men- tal health agency. Provider Newsletter Jefferson County 615 Sheridan Street, Phone: 360-385-9400 Health & Human Services Port Townsend, Washington 98368 Fax: 360-385-9401 Jefferson Health Access Summit 2001 Moving Towards Solutions Washington State's rural health care ac- cess crisis has come to Jefferson County with a vengeance. Few health care providers need to be convinced of its severity or its worsening impacts. The current crisis is, at its root, a breakdown in the health care fi- nancing system. In the aftermath of state and national efforts at health care system reform, political leaders have taken positions either denying or minimizing the severity of the problem and the responsibility of govern- mental agencies to address it. Rural commu- nities are responding to this leadership vacuum with innovative, community.based alliances to protect deteriorating health care delivery systems. Jefferson County has been a statewide leader in this process. A unique partnership of the County Board of Health and the Hospital District Commissioners, has spent the last year meeting as a joint board to research the issues and develop creative solutions to identified problems. A workgroup com- posed of local physicians, business lead- ers, county health officials, hospital ad- ministrators, and other community leaders was appointed by the joint board and has summarized its fmdings in a report dated April 19, 2001. On May 22,2001, an invi- tational summit will be held in Port Had- lock to take the next steps in moving from analysis to action. Health care providers wishing to learn more about this unique community-based response to the state- wide health care access crisis should con- tact Dr. Tom Locke, Jefferson County Health Officer, at 360-385-9448, or Jean Baldwin, Community Health Director, at 360-385-9408 May, 2001 Inside this issue: Pneumococcal 2 Vaccine/or Infants Tobacco Clinical 2 Intervention Tetanus Vaccine 3 Shortage Hepatitis A 3 Reminder Measles Update 3 Do You Ever Need 4 A Language Interpreter? Behavioral Risk Factor Surveillance System Jefferson County citizens are changing and there is tremendous in-migration. What are the health risks here? Do they differ from other places? Jefferson County Health & Human Services and the City of Port Townsend are paying for a 2001 Behavior Risk Surveillance System Survey (BRFSS). From May 2001 to December 2001, 600 Jefferson County households will be included in the CDC & state-wide BRFSS calls. Special national modules on tobacco use, domestic violence and health care access have been included. Additional data will be collected for Jefferson County on Environmental Health and questions about the number of people leaving the community for work. The BRFSS will provide some baseline behavioral health information to augment the census data this fall. Much has been in the news about the two Jefferson Counties ~ well-off retirees and poor families. As providers you know it is not that simple, but we are having huge demographic shifts. Using the CDC's Prenatal Risk Survey, we will be contacting all new births in Jefferson County over the next year. JCHHS has signed contracts with the Bremerton-Kitsap Health District assessment team and Dr. Chris Hale of the University of Washington School of Public Health, to analyze health indicator data in a regional approach. There are preliminary regional similarities in some health problems like senior suicide, substance abuse and tobacco rates. The data will be analyzed in montlùy meetings by the newly established Jefferson County health indicators committee. If you want more information, call Jean Baldwin at 385-9408 or write to jbaldwin@co.jefferson.wa.us. All health indicator data is available at www.cojejJerson.wa.us Page 2 Provider Newsletter -', Pneumococcal Vaccine for Infants The new pneumococcal vaccine, PCV7, is now available for use in your clinic. It is available from JCHHS through the State Supplied Vaccine program along with your other pediatric vaccines. PCV7 is included on the 2001 ACIP Recommended Childhood Immuni- zation Schedule from the CDC, thereby making it the new standard of care for the prevention of invasive pneumococcal disease. To prevent liability issues, parents should be made aware of the availability of the vaccine. Vaccine infonnation statements are available from the Washington State Dept. of Health Immuniza* tion Program. If you do not wish to administer PCV7 in your clinic, parents can be referred to the JCHHS immunization clinics. The schedule for PCV7 is similar to the schedule for Hib vaccine. Pneumococcal Conjugate vaccine is recommended for: . A11 children from 2 months of age up to the 2nd birthday. . Children from age 2 years up to the 5th birthday with the following conditions: . Sickle cell disease, other sickle cell hemoglobinopathies, congenital or acquired asplenia or spleen dysfunction · Infection with immunodeficiency virus (HIV) · Immunocompromising conditions, including: · Congenital immunodeficiencies · Renal failure and nephrotic syndrome · Immunosuppressive therapy · Chronic illness, including: · Chronic cardiac disease · Chronic pulmonary disease (excluding asthma unless child is on high dose corticosteriod therapy) · Cerebrospinal fluid leaks · Diabetes mellitus · Children from 2 years of age up to the 5th birthday who: · Are of African American, Native American or Alaskan Native descent · Attend out-of-home group child care · Children ages 2 years up to the 5th birthday upon request of parents after consultation with their health care provider The "5 A's" Brief Tobacco Clinical Interventions for Healthcare The "5 A's" . Ask, Advise, Assess, Assist and Arrange, are designed to be used with the smoker who is willing to quit 1. Ask-Systematically identify all tobacco users at every visit. Implement an office wide sys* tern that ensures that, for every patient at every clinic visit, to- bacco*use status is queried and documented. Expand the vital signs to include tobacco use or use an alternative universal identification system. 2. Advise-Strongly urge all to- bacco users to quit. In a clear, strong and personalized manner, urge every tobacco user to quit. 3. Assess-Determine willing- ness to make a quit attempt. Ask every tobacco user if he or she is willing to make a quit at- tempt at this time (e.g., within the next 30 days). 4. Assist-Aid the patient in quit- ting. Help the patient with a quit plan. Assisting patients in quit- ting smoking can be done as part of a brief treatment or as part of an intensive treatment program. Evidence from the guideline dem- onstrates that the more intense and longer lasting the interven- tion, the more likely the patient is to stay smoke-free; even an I intervention lasting fewer than 3 minutes is effective. 5. Arrange-Schedule follow-up contact, either in person or via telephone. Follow-up contact should occur soon after the quit date, preferably during the first week. Congratulate success. If tobacco use has occurred, review circumstances and elicit recommitment to total abstinence. Helping cigarette smokers to stop smoking is one of the most effective ways to prevent cancer. 24 hour Quit Line 1-888-270-STOP r Has your clinic received its free Washington State Tobacco Quitline posters, pamphlets and materials? If not, these items are available through the Jefferson County Tobacco Prevention & Control Program. Call Kellie at 385-9446 to place your order today! You can view the complete guideline at http:www.surgeongeneral.govltobaccoltobaqrg.htm#Willing " Page 3 Tetanus Vaccine Shortage The Centers for Disease Control and Prevention (CDC) reports that supplies of the tetanus/diphtheria (Td) vaccine may not be back to normal until next year, following the sudden decision by Wyeth Lederle to stop producing the vaccine, leaving Aventis Pasteur as its only developer. Diphtheria protection for adults is also affected, since the vaccine for tetanus usually contains the diphtheria vaccine as well. In accordance with previous recom- mendations, continuing to prioritize Td use will be necessary until supplies are restored. Td is available from JCHHS through the State Supplied Vaccine program for children age 7 through 18. Clinics in need of vaccine for wound care for adults should call A ventis Pasteur, telephone (800)822-2463. A ventis Pasteur is increasing the amount of Td production. However, because of the long production time required, the shortage is not expected to be resolved for 12-18 months. Prioritizing Td Usage The CDC has issued guidelines for prioritizing the use of Td vaccine. If administration of Td is delayed, clinics should implement a call-back system when vaccine is available. Recommendations for use (highest to lowest priority) ofTd are: I. Persons traveling to a country where the risk for diphtheria is high. 2. Persons requiring tetanus vaccination for prophylaxis in wound management. 3. Persons who have received <3 doses of vaccine containing Td. 4. Pregnant women and persons at occupational risk for tetanus- prone injuries who have not been vaccinated with Td within the preceding 10 years. 5. Adolescents who have not been vaccinated with a vaccine containing Td within the preceding 10 years. 6. Adults who have not been vaccinated with Td within the preceding 10 years. See www.cdc.gov/mmwr/vreview/mmwrhtm1/mm4945a3.htm for full text Hepatitis A Reminder The State Immunization Program provides hepatitis A vaccine for children ages 2 years until the 18th birthday. JCHHS offers the vaccine in our walk-in clinics, and can provide vaccine for use in provider's clinics through the State Supplied Vaccine program. The 2-dose hepatitis A vaccine is indicated for the following high-risk groups: · All foster children · Homeless children and street teens · Injecting drug users · Those who live with metham- phetamine users · Migrant Hispanic children · American Indians, Alaskan Na- tives an Pacific Islanders Measles Update · Those with clotting factor disor- ders · Those with chronic liver disease · Males who have sex with other males · Children attending therapeutic child care programs · Individuals working with non~ human primates · Those living in communities where there are high rates ofhepa- titis A · Pediatric travelers to areas where hepatitis A vaccine is indicated · Any child whose parent requests the vaccine A series of 2 doses of hepatitis A vaccine given 6 months apart provides long-term protection for children over age 2 years of age. The measles outbreak in Western Washington appears to be over. The state ended up with 15 confirmed cases-I 2 in King County, 1 in Clark County, and 2 in Island County. Hundreds of rash illnesses were investigated from January through April with many dedicated hours of work put in by state and local staff. For full text see: www.cdc.l!ov/mmwr/ore\iew/mmwrhtml/ mm4945aJ.htm Do You Ever Need a Language Interpreter? Free Interpreter Services for Medical Assistance Clients Our community experiences periodic surges in non-English speaking clients accessing health care. To provide equal access to services for all people, DSHS has contracts with several interpreter agencies to provide in.person interpretation for clinic appointments. The provider's office calls or faxes the "Appointment Scheduling and Confirmation Record" to one or all of the following interpreter agencies: AGENCY TELEPHONE# 888-202-330 I 800-893·5258 800-798-5714 888462-0500 FAX # 888-334-3881 253·272-8524 800-513-7273 877~5164347 Columbia Language Services Cross Cultural Communications Merino Language Link Universal Language Service The agency is required to respond to the request within 30 minutes. The provider may also request the agency to call and remind the client about the appointment. Phone interpretation is not paid for under this contract. Jefferson County Health & Human Services 615 Sheridan Street Port Townsend, Washington 98368 I I ¡ ¡ I ! ') ".. '~".... I I, '(11-' June 15,2001 To Whom It May Concern: Jefferson County Health & Human Services is very supportive of Jefferson General Hospital's (JGH) plan to do medicare certified home health. They have served our community with high quality home care for years. There has been a very active community supporting this bid for home health. The responsiveness of JGH to the community request is another example ofthe hospital's desire to serve our citizens and of its commitment to our community health needs. Aging health issues for Jefferson County citizens are of great concern for us. 22% of our population is over 65 years of age, so medicaid is an important insurance service. Thank you for reviewing Jefferson General Hospital's bid as a qualified committed provider with community support. Sincerely, Jean Baldwin, MSN Community Health Director HEALTH DEPARTMENT :iRO/:iR::i-ÇJ400 ENVIRONMENTAL HEALTH 360/385-9444 DEVELOPMENTAL DISABILITIES 360/385-9400 ALCOHOUDRUG ABUSE CENTER 360/385-9435 FAX 360/385-9401 ! FROM THE HOME HEALTH & HOSPICE ADVISORY BOARD [}={](Q)~~~~~ ~~\0W~ g~ SPECIAL EDITION ~~ Grace Chswes Medicare Certificøtion Committee VICtOr Dir1aJen Ex-officio member Jeffenson General Hospital Administrator Andrea Foos Kah Tai Representative Elsa Gob Executive Committee, Chair Medicare Certification, Fund Raising Jim HerTick Quality Assurance, Legislative Raison Sheila Hunt-Witte &~Committee,~~ Quality Assurance Dr. Maggie Jamison Pub6c Relations Joan Underoth Quality Assurance Karen Loving Ex-offlcio member Home Health & Hospice Office Manager Len Mandelbaum Quality Assurance Louise Marzyck executiVe Committee (Secretary) Medicare Certification, Quality Asstnnce Dana Michelson Ex-officio member Jefferson General Nursing AdminisVator Cindy Pentz Harrison Hospital Representative Peg Posey Ëx-officio member Home Health & Hospice Director a.DoIores Postma Executive Committee (Treasurer) Medicare Certification, Donations Dr. Bruce Stowe Medical Director Sam Suastegui Donations committee, Volunteer Liason Medicare Certification, Fund raising Georgia Wood Medicare Certification, Public Relations EDUCATIONAL TASK FORCE MEETING June 29, 3: 15-5:00 Port Townsend Community Center (Courtesy of P. T. Senior Association) Topic: Hospice information to alternative health care providers and consumers The newsletter will catch up with reports from task force meetings in the July issue. **** Thank you for your help with community education and your support for Medicare Certification for our Hospice program. Now your continu- ing support is needed to as- sure the Certificate of Need required for certification will be awarded to us. Please read the explanatory article and send us your thoughtful letter of support: Letters of support Addressed to: Home Health & Hospice of Jefferson General Hospital 834 Sheridan Port Townsend, WA 98368 Send to the above or Email to: bcamDbell~iah.orn NO LATER THAN TUESDAY JUNE 19TH « JefliwJ,CYVG~ H.OfþítaLwaLtaJc.e, í4 þZa.cet~f:he, he.aJ.t;h., ca.f"'eI provid.e.r.Y whc- at"eI part off:he, mcvem.et'\.t"t"& improve- eJ1.d...ofMl.i{r7ca.f"'e1 Ú\¡ A~» So said Grace Chawes, chairperson of the Medicare Certification committee, at the June 7m meeting of the commissioners, as the appli- cation for Hospice Medicare Certificate of Need (CON) was ratified. Yes! Unless.....the CON is awarded by the state to the other agency. "Assured Home Health and Hospice", with four counties in Washington, has applied for a CON in Jefferson and Clallam Countiès. Some people think it's very unlikely that the state would hand the hospice over to a for-profit agency from out of town, when a licensed hospice operated by a publilc hospital has been serving Jefferson County for eighteen years. But some people are not so sure. They say that Assured is a formidable com- petitor, with determination, deep pockets, and a certified program up and running (our hospice operates under page two Home Health guidelines). So, do we care? Everyone agrees that a certifie:d hospice is a good thing; does it really matter who runs it? The advisory board thinks it matters very much. The board is made up of commu- nity volunteers, doing their best to represent the needs· of consumers in their recom- mendations to the hospital. We share the bottom line with you service providers: WHAT IS BEST FOR THE PEOPLE RECEIVING THE SERVICES? There are many reasons, (and as providers many of you will have some of your own) why we believe that JGH is by far ahead in the answer to this question: Local control provides stability. JGH has carried the Home Health and Hospice program for ma~y years, sometimes operating at a loss, in order to meet the need for home care for disabled and terminal clients in our community. A for-profit agency will not guarantee . the future of this vital service. Control through elected officials also means the program more closely attends and responds to this community's issues and needs. It provides for a partnership with community, a voice for consumers, and neighbors helping neighbors with a sense of pride and ownership of the program. Quality care: JGH's competent and com- passionate staff is a com- munity resource of far too much value to lose. Many of you service providers who work with the program will take this idea personally, (as will hundreds of community members), with names and faces such as Joy, Ed, Marla and all the other exemplary members of the hospice team that make this program respected, even beloved in the community. Continuit-{ of care: Many hospice patients are referred from Home Health, some have been off and on the Home Health program as needed for years, and many have bonded with the staff. Not only would all the history that can't fit into a computer be lost, but they would have to make a hard choice between losing all the hospice benefits or losing their medical caregivers. Local control, quality care and continuity of care alone are urgent and compelling reasons. So even if you think it's a Isad pipe cinch that we will be awarded the CON, please join our effort to make sure and write a letter of support. We apologize for the short notice. It was just decided that the state will review our application at the same time as Assured, so it will be sent next week with your letters of support enclosed. ........................... . WORST CASE SCENARIO \Nith many "what-its" to be considered, remember that if the hospital lost the hospice program, the Home Health program would be affected. Assured is prepared to do Home Health in this area too. What if that happened, and then something else happened to make it no longer profitable to serve Jefferson County, and they left. All counties served by for-profit agendes are vulnerable to this possibility. Home Care is becoming a more and more vital part of our health care system as our county rapidly grows and ages. Let's keep ours under our wing. Questions? Here are the people you may want to call: Grace Chawes 385-0640 Medicare Certification Committee Chairperson Georgia Wood 385-6384 Medicare Certification & Public Relations Newsletter Peg Posey 385·0610 Director of Jefferson General Hospital Home Health & Hospice program Vie Dirksen 385·2200 Administrator, Jefferson General Hospital