OBJECTIVE: This article describes the impact of a bilingual literacy intervention conducted with nearly 118 000 children in Special Supplemental Nutrition Program for Women, Infants and Children (WIC) sites in Los Angeles County, California.
METHODS: All WIC participants at 6 WIC sites in Los Angeles County participated in the literacy intervention. Three cohorts of participants were selected to participate in the evaluation of the intervention. A control group of 200 families received no intervention, 103 families received 2 years of intervention, and 102 families received 4 years of intervention. Participants were predominantly Hispanic (92%), 3- to 4-year-old children and their parents. All families had low income levels, and more than one-half were Spanish-speaking. School readiness assessments were conducted with the children; parent literacy resources and activities at home were observed. Structural equation modeling was used to allow for simultaneous testing of relationships between variables.
RESULTS: The Spanish-speaking subset showed a strong intervention effect. Among Spanish speakers, the 4-year intervention group (P < .001) and the 2-year intervention group (P < .05) had significantly higher school readiness scores, compared with the control group. The structural equation model revealed that exposure to the intervention significantly enhanced literacy resources and activities at home, which in turn led to greater school readiness.
CONCLUSION: WIC-based literacy intervention significantly increased low-income, Spanish-speaking children's school readiness.
- early literacy
- Special Supplemental Nutrition Program for Women
- Infants and Children
WHAT'S KNOWN ON THIS SUBJECT:
Large social class differences exist in children's exposure to experiences that support the development of literacy skills. Pediatric clinic-based literacy promotion programs have demonstrated effects in promoting reading activities at home and accelerating children's language acquisition.
WHAT THIS STUDY ADDS:
This study describes the impact of a Special Supplemental Nutrition Program for Women, Infants and Children–based intervention on the school readiness of low-income children. The study examines the impact of the intervention on English- and Spanish-speaking children's readiness for school.
Nearly one-half of all children <5 years of age in the United States live at ≤185% of the federal poverty level and are served by the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). Core WIC services include checks or Electronic Benefits Transfer cards for the purchase of specific nutritious foods, nutrition and breastfeeding education, and referrals to health care services for low-income women and children with, or at risk of developing, nutrition-related health problems. WIC programs throughout the nation work closely with pediatric providers, sharing a common goal of optimizing the health and development of young children. Countless pilot projects have been tested to enhance the ability of both WIC sites and pediatric offices to go beyond core health messages and to provide children's books and educational materials designed to enhance young children's literacy development and school readiness. Pediatric clinic-based literacy promotion programs, most notably Reach Out and Read (ROR), have demonstrated effects in promoting reading activities at home and accelerating children's language acquisition.1,–,9 The goal of this article is to describe the impact of the Little by Little (LBL) program, a WIC-based intervention modeled after ROR, on the school readiness of low-income, preschool-aged children in Los Angeles County, California.
Extensive studies have documented large social class differences in children's exposure to experiences that support the development of emergent literacy skills.10,–,12 Disparities between Hispanic and non-Hispanic white children in reading abilities also have been widely documented.8,13,14 The majority of WIC participants in Los Angeles County are low-income Hispanic women and children, nearly 60% of whom speak primarily Spanish in the home. The LBL intervention was designed to enhance early literacy in the homes of young children through the provision of developmentally targeted children's books and developmental handouts to parents, in English or Spanish. The current study examined parents' behavior and children's readiness for school, hypothesizing that LBL services would contribute to a richer home literacy environment (including resources and activities) and lead to enhanced school readiness skills for children.
Funded by First 5 LA, LBL services began in May 2003 at 6 WIC centers in Los Angeles County, California. Nearly 118 000 individuals have been touched by the LBL intervention. Each LBL contact consists of 3 components. The first component is brief individual counseling regarding child development by WIC staff members, tailored to the ages of the children. A centralized LBL database was developed for the project, through which interactive counseling scripts are provided for staff members. The counseling scripts differ according to child age, with the common theme of reading to children daily and interacting with them verbally whenever possible. Parents are encouraged to talk to their pediatric provider about any concerns regarding their child's development. The second component is receipt of a brief handout, targeted to the child's age, that includes information about developmental milestones and appropriate ways to interact with the child to encourage optimal development. The handouts are written at the fourth-grade level and include activities that do not require the purchase of additional toys or materials. The third component is receipt of a children's book or developmentally appropriate toy (eg, black, white, and red chart for newborn infants or building blocks for 2.5-year-old children). Of the 22 items given to families from the prenatal period to age 5, 16 are books.
The intervention begins with women in the third trimester of pregnancy and continues up to the child's fifth birthday, when the child no longer qualifies for WIC services. Families receive LBL services for each of their children at every LBL WIC visit and receive an average of 4 books or developmentally appropriate toys per child per year. The LBL intervention is designed to be culturally and linguistically sensitive; the 6 LBL WIC centers are staffed by English- and Spanish-speaking staff members, counseling is conducted in the participant's language of choice, and all handouts and books are available in English or Spanish. The primary goal of WIC staff members' interactions with parents is to guide the parents in using the handouts and toys to play and to read with their children.
Study Design and Subjects
Three random samples of families were recruited to participate in an evaluation of the impact of the LBL program on parent behavior and children's school readiness. All research participants in all groups completed consent forms and research protocols approved by the Independent Review Consulting institutional review board. The research protocol included a single 2-hour visit to families' homes and involved assessments of the child, caregiver, and home environment.
The control group (N = 200) was recruited first. Families with children 39 to 51 months of age were recruited from the LBL WIC intervention sites immediately before initiation of LBL services (May 2003). All target children in the control group had been receiving WIC services since the mother was pregnant but received no LBL services because the program had not yet begun. The control group was selected in this way to ensure that families came from the same neighborhoods, were counseled by many of the same WIC staff members, and received the same core WIC benefits and WIC “dose” as families in the intervention groups. Four months before the start of the intervention, a sample of all families with children in the target age range was downloaded from the WIC participant database. Families were reached by telephone to schedule a home visit. For completion of 200 visits, 234 families were contacted. Twenty-two families declined and 12 families scheduled visits but were never able to complete the visit.
Two intervention groups were recruited from the LBL WIC sites. A 2-year intervention group (N = 103) was composed of families with children 39 to 51 months of age who had participated in the LBL program for 2 years (assessments were completed in the summer of 2005). Target children began receiving LBL services at 15 to 27 months of age, when the program started. For recruitment of the total sample of 103, a sample of all families that had children in the target age range and that had received 2 full years of LBL services was downloaded from the LBL database. The first 140 families were contacted by telephone to schedule a home visit; 103 chose to participate. Twenty were not reachable by telephone and 17 declined a home visit.
A 4-year intervention group (N = 102) was assessed in the summer of 2007 and was composed of families with children 39 to 51 months of age who had participated in the LBL program since the mother began receiving LBL services in her third trimester of pregnancy. The first 400 pregnant women who enrolled in LBL were recruited into this sample at the program's inception in May 2003 (14 declined to participate). These families were monitored annually throughout the study period, and 188 were still receiving WIC and LBL services at the same WIC site when the target child was 39 to 51 months of age. Participation for the full 4 years, as documented in the LBL database, was required for inclusion in the sample. Home assessments were completed for 102 of these families.
A trained assessment team of 6 WIC paraprofessionals conducted home visits with participants' families and assessed children's school readiness and home literacy environments. The assessment team staff completed the Bracken Basic Concept Scale Revised15 with the child to assess school readiness and the Home Observation for Measurement of the Environment (HOME) scale16 with the mother to assess characteristics of the home environment. All of the materials were available in English or Spanish, and the preferred language was chosen by the child and the mother at each visit. For all assessments, measurements of reliability between observers were conducted at the beginning of each visit period and then monthly throughout the periods of data collection, such that 8% of all assessments were coded by 2 observers.
The Bracken Basic Concept Scale Revised15 assesses children's knowledge in 6 domains (colors, letters, numbers, sizes, comparisons, and shapes), yielding a composite school readiness score. The assessment is identical in English and Spanish. Raw scores were used for analysis, because the standardization samples did not match the low-income population in Los Angeles County. The intraclass correlation between observers for the Bracken scale was 0.99.
Home Literacy Environment
The HOME scale16 was used to investigate the home literacy environment. Three of the original 8 subscales of the HOME scale were used, that is, learning materials, language stimulation, and academic stimulation. The learning materials subscale score was used alone to measure the richness of literacy resources at home. A composite language stimulation and academic stimulation score was created to measure the level of literacy activities at home. Literacy resources and activities scores were then used to create a latent variable of home literacy environment. The intraclass correlations between observers for the 3 HOME subscales ranged from 0.82 (academic stimulation subscale) to 0.96 (language stimulation subscale).
A brief written questionnaire was completed by the parents while the Bracken scale was being completed with the child, to capture demographic information about the family.
Frequency counts for categorical variables and descriptive analyses for continuous variables were performed by using SPSS (SPSS, Chicago, IL). A 3 × 2 analysis of variance was used to compare group differences in school readiness on the basis of intervention (4-year intervention, 2-year intervention, or control) and home language (English or Spanish). Mother's education and employment status and child's age were included as covariates in the analyses. Testing of the goodness of fit to the data of the hypothesized relationship between the LBL intervention, the home literacy environment, and school readiness was analyzed with a structural equation model by using AMOS (SPSS, Chicago, IL), which allowed complete simultaneous tests of all relationships between variables.17
The 2-year intervention, 4-year intervention, and control groups were comparable with respect to their major sociodemographic characteristics (Table 1). All families had low incomes, with more than one-half in each group speaking Spanish at home. Slightly more families in the 4-year intervention group spoke Spanish, compared with the other 2 groups, that is, 61% (4-year intervention) versus 51% (control) and 55% (2-year intervention); however, this difference was not statistically significant (P = .21). As shown in Table 2, English-speaking and Spanish-speaking families were significantly different with respect to a number of sociodemographic characteristics. For this reason, the 2 groups were examined separately.
LBL Promotion of School Readiness
Controlling for mother's education level (P = .02), employment status (P = .53) and child's age (P < .001), both the 4-year intervention group (P = .002) and the 2-year intervention group (P = .05) scored significantly higher than the control group regarding school readiness. The difference between the 4-year and 2-year intervention groups was not significant for the full sample.
As shown in Fig 1, the effect of intervention was carried by the Spanish speakers. In contrast to the English-speaking subset, in which children did not show significant group differences, the Spanish-speaking subset showed a strong intervention effect. Among Spanish speakers, the 4-year intervention group (P < .001) and the 2-year intervention group (P < .05) had significantly higher school readiness scores, compared with the control group. Although the result was marginally significant, the 4-year intervention group scored higher than the 2-year intervention group (P = .06) (Fig 1).
Overall, the Spanish-speaking subset scored lower regarding school readiness, compared with the English-speaking subset (P = .006). This difference was most noticeable in the control group and decreased as children's exposure to LBL increased; it disappeared in the 4-year intervention group, in which the Spanish-speaking subset scored the same as the English-speaking subset.
Although the use of raw scores allows for more-accurate comparisons across language groups than does the use of standardized scores normed to groups that do not represent the study population, a brief examination of how the raw scores related to standardization samples allows tentative conclusions to be drawn regarding children's overall readiness for school. It also allows for examination of potential ceiling effects for the English speakers. The range of raw scores on the Bracken scale is 0 to 88, and school readiness scores for children 39 to 51 months of age are considered average when they fall between 12 and 48 (with a lower ceiling for younger children and a higher floor for older children within this age range). Scores below 12 are considered delayed or very delayed and scores above 48 are considered advanced or very advanced. Although some individuals from both language groups scored in the delayed or advanced range, on average all groups scored in the middle to low-average range at all time points. This suggests that school readiness abilities were generally average and no groups could be classified as having delays that would suggest an overall lack of readiness for school. In addition, English-speaking children were not performing at a ceiling level that would explain why the intervention had no effect. On average, all groups performed in the average range for school readiness, but Spanish-speaking children who received 4 years of LBL services demonstrated a nearly 37% increase in school readiness scores, compared with Spanish-speaking children who received no intervention.
Mediation Model Involving LBL Intervention, Home Literacy Environment, and School Readiness
We hypothesized that the effect of LBL on children's school readiness would be mediated through the home literacy environment. AMOS 5.0 was used to test the goodness of fit of the hypothesized model to the current data. Maximum likelihood estimation showed that the model was an adequate fit to the data. The χ2 statistic was not significant, which indicated a model with a good fit17 (N = 405; χ22 = 3.85; not significant). Model fit indices provided additional evidence of fitness (comparative fit index = 0.99; root mean square error of approximation = 0.05). Comparative fit index values of >0.95 or root mean square error of approximation values of <0.10 indicate a good fit.18 Assessment of parameter estimates revealed that the paths from the LBL intervention to the home literacy environment and from the home literacy environment to school readiness were both significant (P < .001). More exposure to the LBL intervention was associated with a richer literacy environment at home, and a richer literacy environment at home was associated with higher school readiness scores (Fig 2).
To further investigate the mediating role of the home literacy environment, we also tested the model with an additional direct path from the LBL intervention to school readiness. Theoretically, this evaluates whether part of the effect of the LBL intervention on school readiness is direct and not mediated through the impact on the home literacy environment. This additional path was not significant; therefore, the impact of LBL seems to be on the home literacy environment, which then affects children's school readiness. English-speaking families generally had higher home literacy scores than did Spanish-speaking families (Table 3), which suggests that the primary impact of LBL was on the home literacy practices of Spanish-speaking families.
To our knowledge, this is the first controlled study of a WIC-based literacy promotion program that examined school readiness as the outcome of intervention. Results showed strong support for the effectiveness of early literacy intervention for Spanish-speaking families. Whereas children from Spanish-speaking families scored much lower than their peers from English-speaking families in the control group, this gap was significantly reduced in the intervention groups. In fact, in the 4-year intervention group, the gap disappeared and children from Spanish- and English-speaking families scored the same with respect to school readiness. The gap in home literacy practices between English- and Spanish-speaking families also disappeared in the 4-year intervention group, which suggests that the greatest impact of LBL was on Spanish-speaking families that enrolled in the program prenatally.
Our study shows that the effect of the intervention on school readiness can be explained by improved literacy resources and activities in the homes of Spanish-speaking families. Findings suggest that provision of LBL services to Spanish-speaking parents increased their awareness of the importance of early literacy activities and encouraged them to provide a more literacy-rich environment at home. Parents' stimulation of literacy in children's early lives contributed to the children knowing more numbers, letters, colors, and shapes at age 4. This result concurs with previous speculation that early-childhood literacy intervention affects parenting and home literacy practices, thereby preparing children to be more ready for school.3 The stability of home literacy scores across intervention groups for the English-speaking groups suggests that those parents were already engaging in language and academic stimulation and therefore the LBL intervention had less impact on those families. It seems that the English-speaking control families were already engaged in higher levels of language and academic stimulation without intervention (Table 3), which could explain the lack of intervention effect for English-speaking families.
Bracken scale scores demonstrated that children from low-income families had average school readiness scores and, despite the LBL intervention, still had significant room for improvement. The LBL intervention seemed to support Spanish-speaking children to achieve similar performance, compared with their English-speaking counterparts, but children in both groups were performing in the middle to low-average range. This suggests that, although interventions such as LBL and ROR are successful in affecting the home literacy activities and school readiness of low-income children, broader efforts to combat the effects of poverty on school achievement are needed. LBL doses of 4 contacts per year made a difference for Spanish-speaking children, but daily immersion and exposure to literacy-rich environments are likely to have greater effects on readiness for school. Programs such as ROR and LBL play an important role, and it is imperative that the evidence from these programs becomes part of the national dialogue regarding early-childhood education policies. The cost savings for children entering school ready to learn far outpace the costs of remedial education for children who begin school without the skills necessary to learn,19,20 and early investments linked to programs such as WIC and pediatric practices may be a practical strategy for significantly improving the school readiness of low-income children.
The LBL program costs approximately $40 per child per year, to provide 4 LBL contacts. The primary costs include the books and handouts provided to WIC families and the brief individual counseling linked to the receipt of these materials. It may not be the books or handouts alone but the combination of the materials and one-on-one interactions with a trusted provider that affects families.1 The developmental handouts were written at the fourth-grade level and were targeted toward helping parents encourage literacy in the home. These handouts were written for the LBL program but are useful for all families and can be accessed and shared through the Internet at no cost (LBL handouts can be downloaded in English and Spanish from www.phfewic.org). They can be used in the pediatric clinic setting and may enhance the literacy promotion activities that clinicians provide. Overall, the materials may be most effective when paired with brief individual counseling.
Although the LBL outcomes show that the program has significant effects on Spanish-speaking children and families, there are study limitations to address. First, the use of historical control subjects (ie, the control group was recruited before the intervention was implemented) raises the possibility of secular changes that could at least partially account for the observed findings. We monitored this closely at the LBL sites and at 5 WIC sites not participating in the LBL program by asking WIC staff members every 6 months (1) how much they talked to families about early literacy and (2) whether participants reported new early literacy resources in their communities. As expected, WIC staff members at LBL sites reported that they talked to families about early literacy significantly more over the course of the study, but they did not report new early literacy resources in the communities. WIC staff members from the non-LBL sites reported no change in either measure. This led us to conclude that significant secular changes during the course of the study did not seem evident.
Blinding of assessment staff members to study hypotheses is always a concern in intervention studies, particularly those that take place over a period of years. The 6 trained observers were not fully blinded to the fact that the LBL intervention was taking place, but they were blinded to the specific aim of the home visits, that is, to assess whether families who received LBL services performed better than families who did not. With both of the aforementioned concerns, the fact that English-speaking participants did not show significant changes over the study somewhat mitigates the concerns that secular changes or lack of blinding compromised the study aims.
We did not quantify whether families had any exposure to ROR during the course of the study, but no families reported receiving any books or literacy materials from their child's pediatrician. LBL was designed as an intervention with all families in 6 large WIC sites in Los Angeles, California. Although findings were robust for Spanish-speaking subjects in California, who are primarily of Mexican and Central American descent, replications of an early literacy program in other English- and Spanish-speaking WIC populations are important.
With these limitations in mind, the LBL project demonstrates that WIC sites are potentially powerful venues for early childhood intervention. Approximately one-half of all US children receive WIC services at some point between birth and age 5.21 Similar to a pediatrician's office, a WIC site is one of the few places that young families visit regularly from birth up to entry into kindergarten, with the exception that WIC services begin prenatally. Therefore, families can benefit from school readiness interventions that begin long before school age. With appropriate funding, WIC and pediatric providers are in a unique position to encourage early literacy behaviors in the home, thereby significantly improving the school readiness of low-income children.
We acknowledge First 5 LA for funding the intervention and evaluation, the Majestic Realty Foundation for funding 1 intervention site, and the Bannerman Foundation for providing initial funds to pilot-test the intervention.
We gratefully acknowledge Denise Gee, Nelly Mallo, Nancy Wong, Ekeila Clark, Nancy Ballardo, Adelia Ramirez, Claudia Guinea, Guadalupe Mendez, Alexandra Vasquez, Veronica Flores, Roberto Roque, and Amanda Bueno for their important and unique contributions to this research.
- Accepted November 10, 2010.
- Address correspondence to Shannon E. Whaley, PhD, PHFE WIC Program, 12781 Schabarum Ave, Irwindale, CA 91706. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- WIC =
- Special Supplemental Nutrition Program for Women, Infants, and Children •
- ROR =
- Reach Out and Read •
- LBL =
- Little by Little •
- HOME =
- Home Observation for Measurement of the Environment
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MAKING CONTACT: On a recent flight from Philadelphia to Burlington, the airline attendant began her well rehearsed monologue on the importance of wearing a seatbelt, not smoking in the lavatory, and reading the safety placard in the seatback in front of us. Since I was in the back of a small commuter plane, I had a good view of all occupants of the plane. Passengers were reading, tapping out messages on their phones, or even dozing but nobody was even looking at the attendant. Not a single safety placard was open. I felt bad for her. I have been around long enough to remember when airline attendants were admired, respected, or at least their presence acknowledged. What has happened? As chronicled on CNN.com (January 24, 2011: Travel + Leisure) the role of the airline attendant has changed greatly over the years. In the earliest years of the airline industry, the attendants were cabin boys. The first female stewardesses had to be registered nurses. In the 1930s, “sky girls” were just as likely to pour drinks and pass out pillows as they were to help refuel. After World War II, airlines did not require female attendants to have nursing degrees but did require very specific (and restrictive) anthropomorphic measurements. Heels were to be worn at all times and the mandatory retirement age was 32. Gradually, the military style uniforms of the 1930s were abandoned and the hem lines rose. Flight attendants became the subject of airline advertisements. Although hard to believe, Eastern Airlines actually provided male passengers little black books to collect the telephone numbers of the stewardesses. Civil rights laws in the mid-1960s forced the airline industry to abandon its preference for hiring young women as well as its no-marriage and no-pregnancy rules and weight restrictions. Still, airline flights were considered a bit of an adventure. That spirit has mostly faded. According to the article, Americans book their seats online using search engines designed to find the cheapest seat, not the best service. We expect that an attendant will know what to do in an emergency but there are no pillows or blankets to be passed out and no conversation other than “orange juice please.” So while I still book the cheapest seat possible, when the attendant begins his or her monologue, I take out my placard, follow along, and do my best to pay attention.
Noted by WVR, MD
- Copyright © 2011 by the American Academy of Pediatrics