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The getting ready to learn program

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Title:
The getting ready to learn program an impact report
Physical Description:
Book
Language:
English
Creator:
Avila, Rosa M
Publisher:
University of South Florida
Place of Publication:
Tampa, Fla
Publication Date:

Subjects

Subjects / Keywords:
Early development
Native American
Early intervention
Infant
Children
Dissertations, Academic -- Community & Family Health -- Masters -- USF   ( lcsh )
Genre:
non-fiction   ( marcgt )

Notes

Summary:
ABSTRACT: The Getting Ready to Learn (GRTL) program is an early intervention program designed to improve the developmental skills and learning capacity of Native American children in the Northwest Arctic region of Alaska. Early intervention programs have been found to decrease high school dropout rates and increase employment rates, which contribute to better health outcomes in young adulthood. The Northwest Arctic is a remote area that lacks many resources. As such, the people of this region experience various health disparities. The GRTL program was implemented in 7 of the 11 villages in the Northwest Arctic Borough of Alaska (NWABA). The purpose of this thesis was to evaluate the impact the GRTL program may have had on the development skills (communication, gross motor, fine motor, problem solving, social-personal skills) of participating children and reading behaviors of participating caregivers. Two survey instruments were used to evaluate the GRTL program.Specifically, the Ages and Stages Questionnaire (ASQ) measured developmental skills of participating infants and children, and the Parent Questionnaire (PQ) measured caregiver's satisfaction with the program and reading behaviors of caregivers with their child. Interviews with program employees were also conducted to further interpret the results from the surveys. Program employees reported there was significant community support for the GRTL program, and parents were pleased with the program. Parents especially liked having a place that allowed them to focus on their child and believed the atmosphere provided positive socialization opportunities. Key informants also reported barriers to participation, which included harsh weather conditions that limited program participation. The ASQ indicated an increase in the means of development skills on the post-test; although most were not significantly different.The PQ showed a significant increase in reading behaviors from participating caregivers. Overall, the qualitative results suggest the GRTL program had a positive impact on its participating children and caregivers.
Thesis:
Thesis (M.S.P.H.)--University of South Florida, 2008.
Bibliography:
Includes bibliographical references.
System Details:
Mode of access: World Wide Web.
System Details:
System requirements: World Wide Web browser and PDF reader.
Statement of Responsibility:
by Rosa M. Avila.
General Note:
Title from PDF of title page.
General Note:
Document formatted into pages; contains 71 pages.

Record Information

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University of South Florida Library
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University of South Florida
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
aleph - 002018849
oclc - 426959830
usfldc doi - E14-SFE0002405
usfldc handle - e14.2405
System ID:
SFS0026723:00001


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ABSTRACT: The Getting Ready to Learn (GRTL) program is an early intervention program designed to improve the developmental skills and learning capacity of Native American children in the Northwest Arctic region of Alaska. Early intervention programs have been found to decrease high school dropout rates and increase employment rates, which contribute to better health outcomes in young adulthood. The Northwest Arctic is a remote area that lacks many resources. As such, the people of this region experience various health disparities. The GRTL program was implemented in 7 of the 11 villages in the Northwest Arctic Borough of Alaska (NWABA). The purpose of this thesis was to evaluate the impact the GRTL program may have had on the development skills (communication, gross motor, fine motor, problem solving, social-personal skills) of participating children and reading behaviors of participating caregivers. Two survey instruments were used to evaluate the GRTL program.Specifically, the Ages and Stages Questionnaire (ASQ) measured developmental skills of participating infants and children, and the Parent Questionnaire (PQ) measured caregiver's satisfaction with the program and reading behaviors of caregivers with their child. Interviews with program employees were also conducted to further interpret the results from the surveys. Program employees reported there was significant community support for the GRTL program, and parents were pleased with the program. Parents especially liked having a place that allowed them to focus on their child and believed the atmosphere provided positive socialization opportunities. Key informants also reported barriers to participation, which included harsh weather conditions that limited program participation. The ASQ indicated an increase in the means of development skills on the post-test; although most were not significantly different.The PQ showed a significant increase in reading behaviors from participating caregivers. Overall, the qualitative results suggest the GRTL program had a positive impact on its participating children and caregivers.
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The Getting Ready to Learn Program: An Impact Report by Rosa M. Avila A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in Public Health Department of Community and Family Health College of Public Health University of South Florida Major Professor: Julie Baldwin, Ph.D. Stanley Graven, M.D. Kofi Marfo, Ph.D. Eric Buhi, Ph.D. Date of Approval: March 25, 2008 Keywords: Early Development, Native Amer ican, Early Intervention, Infant, Children Copyright 2008, Rosa M. Avila

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i Table of Contents List of Tables ................................................................................................................ ...... ii List of Figures ............................................................................................................... ..... iii Abstract ...................................................................................................................... ........ iv I. Introduction .................................................................................................................1 II. Statement of the Problem ............................................................................................2 III. Review of Literature Concerning the Significance of Early Childhood Intervention .................................................................................................................7 IV. The Getting Ready to Learn Program .......................................................................12 V. Methods.....................................................................................................................15 Theoretical Framework ..........................................................................................15 Research Questions and Hypotheses .....................................................................17 Secondary Data ......................................................................................................22 Secondary Data: Participants .....................................................................22 Inclusion Criteria ...........................................................................22 Exclusion Criteria ..........................................................................23 Secondary Data: Measures .........................................................................23 Secondary Data: Evaluation Plan ...............................................................25 Primary Data ........................................................................................................28 Primary Data: Participants .........................................................................28 Inclusion Criteria ...........................................................................28 Exclusion Criteria ..........................................................................28 Primary Data: Measures .............................................................................29 Primary Data: Evaluation Plan...................................................................29 Primary Data: Analysis ..............................................................................29 VI. Results ....................................................................................................................... 32 Secondary Data Outcomes .....................................................................................31 Developmental Skills .............................................................................................31 Parent or Caregiver Reading ..................................................................................34

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ii Primary Data Outcomes .........................................................................................37 GRTL Staff ................................................................................................38 GRTL Program ..........................................................................................40 Program Barriers ........................................................................................41 Evaluation ..............................................................................................................42 GRTL Participant and Non-Participants ................................................................43 Community ............................................................................................................45 Developmental Skills and Reading Behaviors .......................................................46 VII. Discussion .................................................................................................................48 Data Collection Process .........................................................................................48 Interpretation of Results .........................................................................................49 Limitations .............................................................................................................50 Conclusion .............................................................................................................52 References .................................................................................................................... ......56 Appendices .................................................................................................................... .....58 Appendix A: Parent Questionnaire ........................................................................59 Appendix B: Ages & Stages Questionnaire Sample ..............................................60 Appendix C: Question Route for GRTL Program .................................................67 Appendix D: Human Subjects Protections Consent Form .....................................68

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iii List of Tables Table 1 Operationalization of Variables .......................................................................18 Table 2 Independent & Dependent Variables ...............................................................25 Table 3 Age and Participation Level of Children by Village: Ages & Stages Questionnaire Pre-Test & Post-Test ................................................................32 Table 4 Developmental Skill Scores of Children: Ages & Stages Questionnaire Pre-Test & Post-Test (N = 36) .........................................................................32 Table 5 Score Differences in Developmental Skills: Ages & Stages Questionnaire Pre-Test & Post-Test (N = 36)..................................................33 Table 6 Age and Participation Level of Children by Village: Parent Questionnaire Pre-Test & Post-Test ................................................................35 Table 7 Reading Behavior Scores of Ca regivers: Parent Questionnaire Pre-Test & Post-Test (N = 36) .......................................................................................35 Table 8 Score Differences in Time s Read to Child per Week: Parent Questionnaire Pre-Test & Post-Test (N=36)....................................................36

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iv List of Figures Figure 1 Theoretical Framework ....................................................................................16 Figure 2 Goals and Objectives .......................................................................................21

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v The Getting Ready to Learn Program: An Impact Report Rosa M. Avila ABSTRACT The Getting Ready to Learn (GRTL) progr am is an early intervention program designed to improve the developmental skills and learning capacity of Native American children in the Northwest Arct ic region of Alaska. Early intervention programs have been found to decrease high school dropout ra tes and increase employment rates, which contribute to better health outcomes in young adulthood. The Northwest Arctic is a remote area that lacks many resources. As such, the people of this region experience various health disparities. The GRTL program was implemented in 7 of the 11 villages in the Northwest Arctic Borough of Alaska (NWA BA). The purpose of this thesis was to evaluate the impact the GRTL program ma y have had on the development skills (communication, gross motor, fine motor, pr oblem solving, social-personal skills) of participating children and read ing behaviors of participati ng caregivers. Two survey instruments were used to evaluate the GRTL program. Specifically, the Ages and Stages Questionnaire (ASQ) measured developmental sk ills of participating infants and children, and the Parent Questionnaire (PQ) measured caregiver’s satisfaction with the program and reading behaviors of caregiv ers with their child. Interviews with program employees were also conducted to further interpret the results from the surveys. Program employees reported there was significant community support for the GRTL program, and parents

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vi were pleased with the program. Parents especi ally liked having a place that allowed them to focus on their child and believed the atmosphere provided positive socialization opportunities. Key informants also reported ba rriers to participat ion, which included harsh weather conditions that limited program participation. The ASQ indicated an increase in the means of development skil ls on the post-test; a lthough most were not significantly different. The PQ showed a sign ificant increase in reading behaviors from participating caregivers. Overall, the quali tative results suggest the GRTL program had a positive impact on its participating children and caregivers.

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1 I. Introduction This study, entitled The Getting Ready to Learn Program: An Impact Report was an assessment of an early intervention program in the Northwest Arctic region of Alaska. The purpose of the Getting Ready to Lear n (GRTL) program was to improve the developmental skills and learning capacity of Native American children in an effort to ensure they entered kindergarten with the skills necessary for success. The GRTL program was unique since it was tailored specifically to the Native American community. In order to be sensi tive to cultural values and to implement a successful program in Native American comm unities, program planners should have an understanding of Native American beliefs and traditions since the cultural and family environment of Native Americans may be very different from that of non-Native Americans (Teufel-Shone N. I., Staten, L. K., Irwin, S., Rawiel, U., Bravo, A. B., & Waykayuta, S., 2005). The purpose of this thesis project was to eval uate the impact of the GRTL on children’s developmental skills and to determine if and how the program influenced parents’ behaviors. The GR TL program may not only prepare children for kindergarten, but it may also have long-term positive effects for a community experiencing many health and economic dispari ties. This evaluation has the potential to provide the preliminary data needed to impr ove the existing program and possibly aid in the expansion of the program in to other Alaskan villages.

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2 II. Statement of the Problem Although the American Indian/Alaska Native (AI/AN) population comprises a diverse group of over 550 tribal areas with different demographic characteristics and health issues (Roubideaux, 2002), a historical le gacy of outside forces have threatened the social, economic, and physical wellbei ng of Native peoples in North America (Cameron, 1999). Loss of land, loss of language genocide, and forced alienation from cultural traditions have all been a part of that history. For some tr ibes, this history has contributed to signifi cant community and family disinteg ration, as well as to greater distress and negative health outcomes. The polit ical struggle for health care services and resources also sets the stage for many hea lth disparities and risky health behaviors observed in today’s youth a nd adults in the Native American population (Cameron, 1999). This thesis study was particularly concerne d with health disparities in maternal care and child health, as this has a great impact on the development of young children. Specifically, when one looks at live birth rates in Native American women ages 18 to 44, the highest birth rates are among women betw een the ages of 20 to 24 (108.8 per 1000) (U.S. Department of Health and Human Se rvices & Health Resources and Services Administration, 2005). Lack of prenatal care for pregnant wo men in this population is an important concern (U.S. Department of Hea lth and Human Services & Health Resources and Services Administration, 2005) Of Native American moth ers, 7.6% receive late or

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3 no prenatal care as compared to 3.5% of the total population (U.S. Department of Health and Human Services & Health Resources a nd Services Administration, 2005). In 2002, the infant mortality rate for the American Indian/ Alaskan Native population was 8.6 per 1000 compared to the national infant mortal ity rate of 7 per 1000 (USA.gov, 2007). For the age group with the highest birth rates (women ages 20 to 24 years), the infant mortality rate rose to 9.4 per 1000 compar ed to 7.8 per 1000 in the total population (USA.gov, 2007). Many of the infant mortality cases were the result of preterm births. Prenatal services would have helped identify and manage high risk pregnancies, which, in turn, could prevent further progression of disa bilities, illnesses, and unnecessary death. In addition, Native American women ages 15 to 44 are more likely to participate in binge drinking (35.1%) and more likely to smoke (52%) than any other ethnic group in the United States (U.S. Department of Health and Human Services & Health Resources and Services Administration, 2005). With these statistics in mind, it is critical to provide services to children who may be more at ri sk for developmental delays due exposure to harmful substances in utereo and due to a lack of prenatal services of mothers while pregnant. Despite the existence of high risk conditions in some Native American communities, families are known to be “supportoriented,” reflecting the importance that the culture places on family (Teu fel-Shone et al., 2005). Teufel-Shone and colleagues noted: Among American Indians, family connectedness, cohesion, and support have been attributed to playing an important role in the physical and cultural survival of the people and, more specifically, in having a significantly positive influence on academic persistence, substance abuse

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4 prevention, suicide prevention, safe se xual practices in youth and physical and emotional wellbeing. (pg.416) In the Native American culture, children cont inue to learn about their extended family and clan of their paternal and maternal lin eage (Teufel-Shone et al ., 2005). Traditional wisdom passed on to each generation also pr omotes healthy lifesty les through stories of cultural foods and activities (Hindelang, 2006). Positive family environments may have a stronger influence on the health and wellbei ng of Native Americans when compared to non-Natives because of Natives’ tendency to seek advice and support from family members before seeking health services or he alth information (Teufel-Shone et al., 2005). Thus, the importance of family environment a nd family involvement must be considered when it comes to influencing the health be haviors and positive health outcomes of women and children (Hindelang, 2006; Te ufel-Shone et al., 2005). With an understanding of the culture, communities can successfully implement family-oriented interventions that reinforce exis ting strengths (Hindelang, 2006). Both the risk factors and the cultural strengths noted above demonstrate the significance of introducing ear ly intervention programs for Native children. Early intervention refers to services that target populations at risk for developmental delays or disabilities in its youth (Kotch, 2005). The ch ildren experiencing these disparities may be at a large disadvantage in their capacity to learn and their ability to form healthy relationships, which may later translate into negative social and health consequences (Kotch, 2005). Early intervention program s have been implemented with some documented success (Palfrey et al., 2005). However, one unique program currently in practice in the Northwest Arctic of Alaska ha s not yet been evaluated. This thesis aimed

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5 to evaluate the Getting Ready to Learn (GR TL) program in the Northwest Arctic of Alaska, which is primarily inhabited by Inuit Eskimo. About 85.8% of the population in the Nort h West Arctic is Alaskan Native ("Profile and General Data Characterist ics", 2000), with a total population of 7,208 people ("Profile and General Data Characterist ics", 2000). The Northwes t Arctic is also a rural area that is very isolated, only acce ssible by plane or boat. Women in rural areas are more likely to report they are in poor health compared to women that live within or around urban areas (U.S. Department of Health and Human Services & Health Resources and Services Administration, 2005) Women in rural location s may be in poorer health status as a result of fewer hea lth care providers and the lack of health resources in their area (U.S. Department of Health and Human Services & Health Resources and Services Administration, 2005). Residents of rural ar eas also often experience more economic challenges, are older, and are less educated th an those of urban areas (U.S. Department of Health and Human Services & Health Res ources and Services Ad ministration, 2005). The Northwest Arctic faces challenges si milar to those stated above. In the Northwest region of Alaska, there were 1,243 people below the poverty level in 2000. Among families with a female as the primary householder, 31.1% were below the poverty level ("Profile and General Data Ch aracteristics", 2000). In August 2006, the unemployment rate in the No rthwest Arctic Borough was 11.0%, which is much greater than the statewide average of 5.5% ("A ugust 2006 Unemployment Rate", 2006). Fiftythree thousand Alaska Native and American Indian grandparents are raising their grandchildren ("Profile and Ge neral Data Characteristics" 2000). Due to their poorer health status, economic challenges, and lack of health services, Alaskan Native women

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6 may not be in optimal health and thus may ha ve more difficulties in carrying out healthy pregnancies. These health disparities, th reats to economic security, and challenges in obtaining resources have translated into the educatio nal disparities the y outh of the Northwest Arctic experience. Ninety-five percent of students enrolled in the Northwest Arctic Borough school district are Alaskan Native (" Local School Directory: Northwest Arctic Borough School District", 2006) In 2003, only 200 of the 2,165 students enrolled in the Northwest Arctic schools tested as “proficien t” in the areas of reading, writing and math ( Northwest Arctic Borough School District Records 2003). The dropout rates of students in the 7th through 12th grade have decreased from 9.6% in 2000-2001 to 7.2% in 20052006 in the Northwest Arctic, bu t continue to be higher than the statewide dropout rate, of 4.9% in 2005-2006 ("District Dropout Rate s", 2005). Besides higher school drop out rates, other health issues among youth include greater depression, hi gher suicide rates, increased anxiety, earlier initiation of and mo re frequent substance use, and generally lower health status (Camer on, 1999). American Indian/ Alaska Native adolescents experience the highest suicide rates. Risk f actors for suicide in the American Indian /Alaska Native youth include: “strained interper sonal relationships, family instability, depression, low self-esteem, and alcohol use or substance a buse (Gary, Baker, & Grandbois, 2005).” Having supportive tribal leaders, a positive school experience, and a caring family relationship can help prevent su icide incidents (Gary, Baker, & Grandbois, 2005). For these reasons, early intervention programs, such as the Getting Ready to Learn Program, are critical for addressing the needs of the Native American children on multiple levels.

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7 III. Review of Literature Concerning the Significance of Early Childhood Intervention. In the 1960s, researchers began explor ing the importance of developing attachments between the ch ild and caregiver (Kotch, 2005). In 1964, the Economic Opportunity Act (Public Law 85-568) was pa ssed as part of President Lyndon Johnson’s war on poverty. As part of the Economic O pportunity Act, education legislation was passed, including Project Head Start. Proj ect Head Start was a program created by a panel of child development experts, in an effort to improve developmental growth in disadvantaged pre-school ch ildren through parental invol vement and by addressing educational, social, and hea lth needs (Summers & Innocen ti, 1991). In 1975, the US mandated the provision of free education to ha ndicapped children ag es 3 to 21 with the Education of All Handicapped Child Act (P ublic Law 94-142) (Summers & Innocenti, 1991). Access to early interven tion programs for children ages birth to five with special needs was finally mandated by the Education of the Handicapped Act Amendments of 1986 (Public Law 99-457). The 1986 Law has been considered “the most significant event impacting on early intervention” (Sum mers & Innocenti, 1991). The most recent mandate influencing early intervention pr ograms, such as the GRTL program, was the 1997 Individuals with Disabilities Educati on Act (IDEA), Public Law 105-17, which provides assistance to states that provide free early intervention services to children with disabilities or “at-risk children” and thei r families ("Individuals with Disabilities

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8 Education Act", 1997). At-risk children are defined as infa nts or children under the age of three that may be at risk of developmenta l delays if early intervention is not provided ("Individuals with Disabili ties Education Act," 1997). Early intervention is described as “the provision of services to young children between birth and school age with or at ri sk for developmental disabilities and their families” (Kotch, 2005). It has also been trad itionally defined as “external manipulations of environmental events in the form of enrichment, education, and physical or psychotherapeutic input, with the objectiv e of maximizing the infant’s potential” (Barrera, 1991). The term that best describes the use of early intervention in the GRTL program is, “the combination of enrichment education, and psychosocial support within the ecological context of the community and the family” with the objective to “maximize the development of both infants and parent s” (Barrera, 1991). The focus of this definition is not solely on the infant, but ra ther includes a more holistic approach where both the infants’ and caregivers’ development is addressed in the context of the family and the community. Research on child developm ent has demonstrated the family unit and the social environment have a great impact on the developmental process of children and infants, and can buffer some of the effects of genetics and exposure to harmful substances in pregnancies. Children’s biological and social environmen ts are highly intertwined with regard to developing both learning capacity and beha vior patterns. “Neu rological differences only render a child more vulnerable to nega tive environmental circumstances” (KarrMorse & Wiley, 1997). The biological and social factors interact with each other to mold the interests and behaviors of children. They can serve as either a protective quality

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9 when social and biological factors are nur tured properly or can serve as a high risk characteristic in children’s lives when so cial factors aggravate or enhance biological predispositions to negative interests or behaviors (Karr-Morse & Wiley, 1997). Biological factors such as he redity and environmental expos ures during pregnancy, such as substance abuse/use and physical trauma can negatively affect the developmental process of a child (Karr-Morse & Wiley, 1997). Besides biological factors, social factors such as family dynamics and social envir onment can have a great effect on a child’s development and behavior, and must be cons idered when determining risk factors for developmental delay. “Precursors of devel opmental delay have been identified more accurately by including the impact of multiple family risk factors, such as stressful life events, mother’s education level, mother’s ment al health status, and father’s presence in the home” (Kotch, 2005). Therefore, risk for developmental delay must be addressed by taking an ecological look at the child’s life. Some of the negative consequences of biological effects and predispositions can be al tered by modifying the so cial environment. Reducing family risk factors and nurturing a ch ild can directly affect brain chemistry and brain tissue development in a positive way (KarrMorse & Wiley, 1997). Understanding how family relationships a nd environmental context contribute to the development of a child is important when trying to understand th at child’s likelihood to succeed in school (Kotch, 2005). When an infant’s early experiences are unstable and attachments to a caregiver are compromised, the child will not be able to form healthy relationships with peers and adults pushing them into “constant vigilance” and this compromises learning in school (Karr-Morse & Wiley, 1997). Even if children have high intelligence, some emotional security, which develops through their relationship with

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10 their caregiver, is needed for children to focus on abstract concepts (Karr-Morse & Wiley, 1997). Children are more at risk of developmenta l delays if their ca regiver shows signs of depression and substance abuse regard less of socio-economic background (Kotch, 2005). Early intervention programs that are culturally sensitive can help reduce some risk factors of developmental delays, such as familial instability, by promoting child and caregiver attachment and family involveme nt. Early intervention programs can also provide care and developmental screenings at a critical age of neur o-development, which can prevent developmental delays. With the implementation of early intervention programs, socio-economically disadvantaged children with developmental disabilities who live in a disruptive environment are give n a chance for greater opportunities in life by minimizing some of the risk fact ors in their surroundings (Kotch, 2005). Early learning intervention programs have shown positive effects on children who participated in pre-school in tervention programs. Children in preschool programs tend to be more ready to learn for kindergarten than children who do not attend (Magnuson & Waldfogel, 2005). Early childhood programs with a health component can also decrease racial disparities in school r eadiness by addressing health issues that can negatively affect the development and behavior of children (Currie, 2005). Intervention programs that include a parenting component that promote nurturance, teaching, discipline, and language use can improve parenting and the children’s readiness for school (Brooks-G unn & Markman, 2005). A 15-year longitudinal study conduct by Reynolds and associates of an early intervention pr ogram demonstrated positive improvements in children. Children who participated in the program for one to

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11 two years were more likely to complete sc hool (49.7 % vs. 38.5%), less likely to dropout of high-school (46.7% vs. 55.0%), and less likely to be arrest ed as a juvenile (16.9% vs. 25.1%) than children who did not participate (Reynolds, Temple, Robertson, & Mann, 2001). Early intervention programs can improve children’s development and learning capacity, and as a result, help children to atta in better health outcomes in the future. For instance, the Brooklyn Education Project, a 25year study, found that children enrolled in an early intervention program from 1973-1978 de monstrated better hea lth behaviors, less depression, and higher education le vels as young adults than t hose who participated in the control group (Palfrey et al., 2005). Since pa rticipating children we re more likely to finish high school and pursue higher educati on, the participating st udents had a greater opportunity to attain a job w ith health care benefits and practice healthier behaviors (Palfrey et al., 2005). An early intervention program is a prev entive tool that can have long term positive effects in the lives of children that come from otherwise disadvantaged backgrounds. To summarize the principle, “children reflect what they have absorbed biologically and socially” (Karr-Morse & Wiley, 1997). Reducing harmful exposures and providing a nurturing social environm ent early in life can potentially reduce developmental delays, influence the child’s behavior in a healt hy way, and provide the child with a better chance for success in school and in his or her future.

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12 IV. The Getting Ready to Learn Program The Mikiruurat Ilisaqtuat: Getting Ready to Learn (GRTL) Program is an early learning and development program for expecting mothers, infants, and children up to the age of five years. The GRTL program was de veloped to increase th e learning capacity of Native children by encouraging parent and community partic ipation in the learning and developmental process. GRTL is a program th at was initiated by the Northwest Arctic Borough of Alaska School District (NWABA). The program was implemented for the firs t time in August 2004 in three villages: Kivalina, Selawik, and Noorvik. By Augus t 2006, the program had expanded into four more villages: Ambler, Kobuk, Noatak & Shugna k. Each village has one village liaison, with the exception of one village, which has two liaisons. The village liaisons are responsible for organizing the program activ ities, teaching, and administering yearly questionnaires. There are two major components to th e GRTL program: play groups and home visits. The village liaisons organize and im plement the play groups and home visits in their respective villages. A play group consists of th e village liaison and a group of caregivers with their ch ildren (ages birth to 5 years). At each play group, the village liaison has the opportunity to teach caregive rs about ways to stimulate learning and development in their children. Play groups give children the opportuni ty to build social skills by playing with other children in thei r age group. The home vi sits are scheduled by

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13 the village liaison with partic ipating caregivers and their child ren. Home visits give the village liaison a chance to go into the home and utilize the tools available in the home environment to teach caregivers how to stimul ate their children. Th e liaison also has an opportunity to build a relationship with the ca regiver and answer any questions that they may have about their child. The village liaison also implements a developmental screening process, and refers children to special needs programs if they require additional care and attention. The village liaison reports monthly to the coordinator of the program in Kotzebue, Alaska, and receives training three times a year. Training includes the Early Childhood Conference in Anchorage, Alaska, a three da y staff in-service that focuses on program development, child development and the use of assessment tools, and a video conference on learning and early brain development. The GRTL program has been evaluated yearly to assess its strengths and weaknesses and to determine where program improvements can be made. Leaders and staff members of the GRTL program have c onducted two previous evaluations, but have not been able to accurately assess the imp act of the program. Inability to assess the impact was due to not implementing one of the surveys in the first year, administering the surveys only once a year, and inconsistencies in the timing of the administration of each questionnaire between the villages. Prior to this year, the program also did not have any children who had graduated from GRTL into the school setting and so the team was unable to conduct a thorough eval uation of the program’s im pact on the developmental skills of the children.

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14 In August 2005, the first evaluation wa s conducted by analyzing the Parent Questionnaire (PQ) administer ed in May 2005. The PQ was used to obtain feedback on the caregivers’ satisfaction with the program and to assess the reading beha viors of the population. In the past evaluation (as shown in the Appendix), the majority of the parents indicated they were satisfie d with the program. Unfortunately, no baseline data were collected to ascertain if any improvements in the caregivers’ reading with their children could be attributed to par ticipation in the program. For the second year of the program, the PQ was implemented in both September 2005 and May 2006, although the program lacked the time and resources to analyze any changes in reading behaviors. The coordinator of the program decided also to implement the Ages and Stages Questionnaire (ASQ) to help identify the developmental status of each child, although the times each village implemented the ASQ varied. For instance, two of the villages implemented the ASQ in September 2005 and May 2006, but the other two villages only used the que stionnaire in May 2006. Due to differences in how and when the instrument was administered, the evaluation was only able to determine differences in a small number of children. After the evaluation process in August 2006, the staff of the GRTL program clearly defined when each instrument would be used so the impact of the program could be more accurately determined.

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15 V. Methods This thesis study assessed the impact that the GRTL program had on the participating children and parents. The focus of the project included: 1) an examination of the developmental progress of the partic ipating children, and 2) information on how participation in the GRTL program affected fr equency of the caregiver s’ reading to their children. The study was a mixed-methods ev aluation, which included secondary data analysis and collection of primary qualitativ e data used to interpret results of the quantitative analysis. Theoretical Framework There are various factors that influence children’s development from infancy to the time they enter kindergarten. The framework outlined in Figure 1 came from the concepts upon which the GRTL program was ba sed. The model used for the theoretical framework of this study was not tested. Rather, it was used to obtain a basic understanding of how the partic ipation in the GRTL program could impact the children’s developmental skills and caregiver’s reading behaviors, which were the primary focus of the study. The model posited the primary factor aff ecting the development of children is the participation of caregivers and children in the program. When children and caregivers participate in the GRTL program, the children are involved in activit ies that stimulate learning and skill building. Thus, the GRTL program had expected the developmental

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16 Family Participation Level of Developmental Skills Level of Readiness for School Caregiver’s Reading Habits skills of participating childr en to progress optimally and to prepare the children for kindergarten. Caregiver participation in the GRTL program may also affect the behavior of the caregiver, such as reading to his or her chil d. The participating car egivers learn about the importance of regularly readi ng to their children, the importa nce of play, and stimulating skills. If the participating car egiver begins to adopt some of the behaviors taught in the play groups or home visits, the children are mo re likely to build the skills and learning capacity needed to ensure the child’s readiness for school. Figure 1 Theoretical Framework.

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17 Both caregiver reading behaviors and the level of child developmental skills were mediating variables in the framework, but were treated as primary outcome variables in this evaluation study. Caregiver reading behaviors may influence developmental skills, where more reading to children may increase some developmental skill categories, including communication skills and problem solving skills. As depicted in Figure 1, the model suggests that level of developmental sk ills determines whether the child is ready for school or lacks the skills and learni ng capacity needed to be successful in kindergarten. The ultimate goal of GRTL is to prepare all children for kindergarten, but due to limitations in sample size, this st udy does not focus on the level of readiness for school. Research Questions and Hypotheses The primary research question for this pr oject was: To what extent did the GRTL program impact developmental skills of childre n in the Northwest Arctic of Alaska? The secondary research question was: To what ex tent did the GRTL program impact parental involvement in the child’s development? Th e primary outcomes measured were the level of developmental skill categor ies (see Table 1) per child and the caregiver’s frequency reading to child per week. There were two hypot heses being tested: 1) participation in the GRTL program helped participating children improve developmental skill levels; 2) participation in the GRTL program helped pare nts increase reading skills. To further interpret the results, the st udy looked into the community and parents’ involvement and acceptance of the GRTL program, and how the program was implemented to address the

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18 Table 1 Operationalization of Variables Construct Category Question Response Development Skill Communication Does your child name at least three items from a common category? For example, If you say to your child, “tell me some things that you can eat,” does your child answer with something like, “Cookies, eggs, and cereal”? Or if you say, “Tell me the names of some animals,” does your child answer with something like, “Cow, dog, and elephant”? 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Communication a) Does your child answer the following questions: “What do you do when you are hungry?” (Acceptable answers include: “Get food,” “Eat,” “Ask for something to eat,” and “Have a snack.” Please write your response: b) “What do you do when y ou are tired?” (Acceptable answers include: “Take a nap,” “Rest,” “Go to sleep,” “Go to bed,” “lie down,” and “Sit down.”) Please write your response: (Mark “sometimes” if your child answers only one question.) 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Communication Does your child tell you at least two things about common objects? For example, if you say to your child, “Tell me about your ball,” does he say something like, “It’s round. I throw it, it’s big”? 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Communication Does your child use endings of words, such as “s,” “ed,” and “ing”? For example, does your child say things like, “I see two cat s ,” “I am play ing ,” or “I kick ed the ball”? 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Communication Without giving help by pointing or repeating, does your child follow three directions that are unrelated to one another? For example, you may ask your child to “Clap your hands, walk to the door, and sit down.” 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Communication Does your ch ild use all the words in a sentence (for example, “a,” “the,” “arm,” “is,” and “are”) to make complete sentences, such as “I am going to the park” or “is there a toy to play with?” or “are you coming too?” 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Gross Motor Does your child catch a large ball with both hands? You should stand about 5 feet away and give your child two or three tries. 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Gross Motor Does your child climb the rungs of a ladder of a playground slide and slide down without help? 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Gross Motor While st anding, does your child throw a ball overhand in the direction of a person standing at least 6 feet away? To throw overhand, your child must raise her arm to shoulder height and throw the ball forward. (dropping the ball, letting the ball go, or throwing the ball underhand should be scored as “not yet”) 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Gross Motor Does your ch ild hop up and down on either the right or left foot at least one time without losing his balance or falling? 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Gross Motor Does your ch ild jump forward a distance of 20 inches from a standing position, star ting with her feet together? 10 – Yes 5 – Sometimes 0 – Not yet

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19 Table 1 (Continued) Construct Category Question Response Development Skill Gross Motor Without holding onto anything, does your child stand on one foot for at least five seconds without losing his balance and putting his foot do wn? You may give your child two or three tries before you mark the question. 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Fine Motor Does your child put together a six-piece interlocking puzzle? (If one is not available, take a full-page picture from a magazine or catalog and cut it into six pieces. Does your child put it b ack together correctly? 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Fine Motor Using child-saf e scissors, does your child cut a paper in half on a more or less straight line, making the blades go up and down? (Carefully watch your child’s use of scissors for safety reasons.) 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Fine Motor Using the shapes below to look at, does your child copy at least three shapes onto a large piece of paper using a pencil or crayon, without tracing? Your child’s drawings should look similar to the desi gn of the shapes below, but they may be different in size. 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Fine Motor Does your child unbutton one or more buttons? Your child may use his own clothing or a doll’s clothing. 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Fine Motor Do es your child draw pictures of people that have at least three of the following features: head, eyes, nose, mouth, neck, hair, trunk, arms, hands, legs, or feet? 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Fine Motor Do es your child color mostly w ithin the lines in a coloring book? Your child should not go more than inch outside the lines on most of the picture. 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Problem Solving When you sa y, “say five eight three,” does your child repeat just these three numb ers in the correct order? Do not repeat these numbers. If necessary, try another series of numbers and say “Say six nine two.” Your child must repeat just one series of three numbers to answer “yes” to this question. 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Problem Solving When asked, “Which circle is the smallest?” does your child point to the smallest circle? Ask this question without providing help by pointing, gesturing, or looking at the smallest circle. 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Problem Solving Without givi ng help by pointing, does your child follow three different directions using the words “under,” “between,” and “middle”? For example, ask your child to put a book “ under the couch.” Then ask her to put the ball “ between the chairs” and the shoe “in the middle of he table.” 10 – Yes 5 – Sometimes 0 – Not yet

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20 Table 1 (Continued) Construct Category Question Response Development Skill Problem Solving When shown an object and asked, “what color is this?” does your child name five different colors like red, blue, yellow, orange, black, white, or pink? Answer “yes” only if your child answers the question correctly using five colors. 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Problem Solving Does your ch ild dress up and “play-act,” pretending to be someone or something else? For example, your child may dress up in different clothes and pretend to be a mommy, daddy, brother or sister, or an imaginary animal or figure. 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Problem Solving If you place five objects in front of your child, can he count them saying, “one, two, three, four, five,” in order? Ask this question without providing help by pointing, gesturing, or naming. 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Personal – Social Does your child serve herself, taking food from one container to another using utensils? For example, can your child use a large spoon to scoop applesauce from a jar into a bowl? 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Personal – Social Does your child tell you at least four of the following? a. First name d. Last name b. Age e. Boy or girl c. City she lives in f. Telephone number Please circle the items your child knows. 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Personal – Social Does your ch ild wash his hands and face using soap and dry off with a towel without help? 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Personal – Social Does your child tell you the names of two or more playmates, not including brothers and sisters? Ask this question without providing help by suggesting na mes of playmates or friends. 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Personal – Soci al Does your child brush her teeth by putting toothpaste on the toothbrush and brushing all her teeth without help? You may still need to check and rebrush your child’s teeth. 10 – Yes 5 – Sometimes 0 – Not yet Development Skill Personal – Social Does your child dress or undress himself without help (except for snaps, buttons, and zippers)? 10 – Yes 5 – Sometimes 0 – Not yet Parent Behavior Reading Habits How many times in a week do you read to your child? 0 – None 1 – 1 to 2 xs per week 2 – 3 to 5 xs per week 3 – More than 5 xs per week Parent Behavior Level of Partic ipationHow involved are parents in the GRTL program? Coded as parent participation Community Impact Community Awareness How do people know about the program? In your opinion, how aware is the community of the GRTL program? Coded as community awareness Community Impact Community Acceptance How do people in your community perceive the GRTL program? Coded as community acceptance

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21 Table 1 (Continued) Construct Construct Construct Construct Community Impact Community Involvement How involved is the community in the GRTL program? Coded as community involvement Subject Information Home Environment Can you describe what it is like to conduct a home visit? Who participates in the home visits? What kind of difficulties do you face when planning and conducting home visits? Coded as home environment Dose of Intervention Child Participation Includes play group and home visits A continuous variable in the analysis process Program Sensitivity Cultural Competencies How does the GRTL program cater to the Native American culture? Coded as cultural competencies Program Sensitivity Recruitment ProcessHow do you get parents a nd their children to participate in the play groups or home visits? Coded as recruitment Program Sensitivity Referral Process When you notice that a child has developmental problems, what do you do? Coded as referral process Program Sensitivity Scheduling/ PlanningWhat determines how you schedule play groups and home visits? What kind of events affect the way you plan GRTL activities? Coded as planning (1) Evaluation of increases in the learning capacity of infants and children up to the age of four participating in the GRTL program. To compare the Ages and Stages Questionnai re (ASQ) post-test results given in May 2007 with the ASQ pre-test results obtained in September 2006. To compare results from the five categories in the ASQ with level of participation in the GRTL program. (2) Evaluation of parent involvement wi th their child in GRTL participants. To compare the May 2007 Parent Questionnaire (PQ) post-test results with the September 2006 pre-test result s for improved reading habits. To compare results from PQ question on reading habits with level of participation in the GRTL program Figure 2. Goals and Objectives

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22 needs of each participating village. Th e evaluation project focused on the following goals (Figure 2): 1) increases in the learning capacity of infants and children up to the age of four participating in the GRTL program, a nd 2) parent involvement with his or her child and increases in reading habits. Secondary Data The thesis study focused on secondary an alysis of data collected from GRTL program. There were two questionnaires whic h were administered in the beginning of the program year as pre-tests in September 2006 and at the end of the program year as post-tests administered in April 2007. Secondary Data: Participants The participants of the GRTL program included caregivers and children in the Northwest Arctic Borough where the vast major ity of the population consists of Alaska Inuit Eskimo. The student investigator conduc ted secondary analysis of data collected from the GRTL program particip ants who fit within the following inclusion or exclusion criteria: Inclusion Criteria Any participant who follows the elig ibility criteria of the GRTL program, which includes infants and children up to five years of age, plus their caregivers. Children and caregivers who live in a village which offers the GRTL program. Any participant who has completed both a pre-test and post-test of the ASQ and/or PQ.

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23 Exclusion Criteria. Any person or child who does not meet GRTL eligibility requirements, and/or does not live in a village which offers the GRTL program. Any participant who did not complete a post-test for ASQ and/or PQ The final number of participants fo r the 2006-2007 GRTL program year was 294 children out of 403 children in the villages. In the 2005-2006 program year, there were approximately 170 infants and children participants in the GRTL program. For this reason, approximately 170 pre and post test su rveys were expected to be completed for the ASQ and PQ. Secondary Data: Measures The GRTL program has used two instrume nts to determine the developmental status of the child and parent s’ reading behaviors. The tw o instruments used were the Ages and Stages Questionnaires (ASQ), and the Parent Questionnaire (PQ). The evaluation used the data collected from thes e two instruments for secondary analysis. One item was used in the parent questionnaire to determine changes in reading behaviors from September 2006 to April 2007 results. The ASQ (Appendix 2) was developed to measure the developmental skills of infants at 4 to 60 months of age (Technical Report on ASQ, 2006). The questionnaire tests the following skills: communication, fine motor, gross motor, problem solving, and personal-social skills (Technical Report on ASQ, 2006). The ASQ was intended to be easily used by parents. The questions were based on skills that could be easily identified by pa rents and skills that were commonly seen in home settings ("Technical Report on ASQ", 2006). The questionnaire has a readability

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24 level of the fourth to sixth grade, and incl udes illustrations to cl early demonstrate the skills being tested ("Techni cal Report on ASQ", 2006). Th e ability for the test to accurately assess normal child development wa s high (specificity of 86% overall), and the ability for the test to accurately id entify delayed development was adequate (sensitivity of 72% overall) ("Technical Report on ASQ", 2006). A Cronbach’s alpha test was conducted by the student investigator and by developers of the ASQ to assure that each subset of questi ons reliably measured each corresponding development skill by having values greater than 0.70 ("Technical Report on ASQ", 2006). Parents completed the ASQ with the assistance of the village liaison. The PQ (Appendix 1) was designed by the GRTL Program to test the caregiver’s satisfaction with the program and to assess the reading habits of caregivers. The PQ was completed by the primary caregivers who par ticipated in the GRTL program with their children. The questions related to reading included: the first time the parent read to the child, number of times read to child per w eek, and number of children’s books owned. To determine changes in reading behaviors of caregivers, this study primarily used one item: the number of times read to child per week. The project had two independe nt variables of interest: 1) Child’s participation level in the GRTL program and 2) initial as sessment, which included pretest results of parent reading habits and deve lopmental skills (Table 2). The child’s participation level in the GRTL program was assessed by using the number of days the ch ild participated in the program from the beginning of the progr am year to the date the post-test was administered.

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25 Table 2 Independent & Dependent Variables Variables Categories Source Independent Variables Initial parental reading habit Times read to child per week Parent Questionnaire Initial developmental skills Communication Skills ,Fine Motor Skills, Gross Motor Skills, Problem Solving Skills, Personal-Social Skills Ages & Stages Questionnaire Child & Caregiver Participation Number of times that child and caregiver participated in play group or home visit. GRTL Program Play group and Home Visit Records Dependent Variables Parent reading habit post intervention Times read to child per week Parent Questionnaire Level of developmental skills post intervention Communication Skills, Fine Motor Skills, Gross Motor Skills, Problem Solving Skills, Personal-Social Skills Ages & Stages Questionnaire The following dependent variables were m easured: 1) level of developmental skills, which included five developmental sk ills, which are communication, fine motor, gross motor, problem solving, and personal-so cial skills; and 2) parent behavior, as measured by parent reading habits (Table 1) The Independent and Dependent Variables were operationalized as shown in the Construct Table (Table 1). The ASQ questions were all designed to fit different age groups from 4 to 60 months of age. Secondary Data: Evaluation Plan To evaluate the impact the GRTL progr am had on developmental skills of children in the Northwest Arctic of Alaska the student investig ator analyzed data obtained from the ASQ and PQ to examine whether participation in the GRTL program changed parental reading behaviors and developmental skills of their children. To assess whether participation in the GRTL program helped participating children improve

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26 developmental skill levels, the student inve stigator compared the Ages and Stages Questionnaire (ASQ) post-test re sults taken at the end of th e program year with the ASQ pre-test results obtained at the beginning of the program year and tested for an association between the five categories in the ASQ compar ed with child’s participation level. To assess whether caregiver partic ipation in the GRTL program helped caregivers increase reading skills, the May 2007 Parent Questionna ire (PQ) post-test results were compared with the September 2006 pre-test results for improved reading habits The association between the PQ question on reading habits with child’s participation level was also tested (Figure 2). Both instruments were administered by th e village liaisons at different times throughout the year. The ASQ and PQ were both administered in the beginning of the program year (September 2006) as a pre-test, and then again at the end of the program year (April 2007) as a post-test. Each de velopmental skill was measured by the ASQ, and parental reading was measured by the PQ The ASQ pre and post-test scores from the GRTL infant/child participants were compared to determine changes in level of developmental skills. The PQ pre and pos t-test scores from GRTL parents were compared to determine changes in level of parental reading behaviors. Thus, the ASQ was used to determine any improvement in skills of participating children, and the PQ was used to determine whether participat ing caregivers improved the amount of times they read to their child. Each child served as its own cont rol by using a pre and post test study design.

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27 The variables being measured by the PQ and ASQ have already been determined by those who developed each instrument. The op erationalization of each variable can be seen in Table 1. Secondary Data: Analysis For the quantitative portion of the stu dy, secondary analysis was completed on two instruments to determine the developmen tal status of the ch ild and caregiver’s reading behaviors. The ASQ was deve loped to measure the following skills: communication, fine motor, gross motor, pr oblem solving, and personal-social skills ("Technical Report on ASQ," 2006). To measur e the reliability of each instrument, a Cronbach’s alpha test was conducted for each ty pe of developmental skill. This helped determine whether each item consistently meas ured the category of interest in each instrument. The PQ was designed by the GRTL Program to test parent satisfaction and the reading habits of participants such as: first time read to child, number of times read to child per week, and number of children’s books th ey own. Analyses of all survey results (ASQ and PQ) were done through the SAS pr ogram by the student investigator. The SAS program was used to conduct univariate and bivariate analysis of the quantitative data. The univariate analysis included: frequency and proporti on distributions, and measures of central tendency (m eans, medians, and modes). In addition to the univariate analyses, bi variate analysis was also conducted to determine the association between variables. The pre-test and post-test data were first compared using a paired indepe ndent t-test to determine wh ether there was a change in responses of scores. The preand post-test data were then stratified by participation level.

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28 The pre and post test comparison through the pa ired independent t-test was conducted for all five categories in the ASQ. The pre a nd post test results for the PQ were also compared through a paired independent t-te st. Since only one test was conducted, no adjustments were necessary. Questionnaires that did not have a post-test were not analyzed. Each ASQ pre and post test had a score for each developmental skill. Since one question in the PQ was used to measure reading behaviors, if the question was not answered, both pre and post tests were re moved from analysis. To preserve the confidentiality of the participants, the names of the villages were replaced with numbers one through seven. Primary Data Primary data analysis of interviews with GRTL staff was a supplemental portion of the mixed methodology thes is study that helped inte rpret the outcomes from the secondary data analysis. Primary Data: Participants The primary investigator conducted interv iews from participants who fit the following inclusion or exclusion criteria: Inclusion Criteria. GRTL program coordinator and GRTL liaisons for one or more of the following villages: Kivalina, Noorvi k, Selawik, Ambler, Kobuk, Noatak & Shugnak. Exclusion Criteria. A GRTL employee that had not worked in the GRTL program for the entire program year from September 2006 to May 2007.

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29 The thesis study design included a purposiv e sample set of 5 interviewees. The purposive sample set included interviews with GRTL village liaisons and the GRTL coordinator. In the 2006 -2007 program year there were five GR TL staff members who were asked to participate by the primary investigator. Primary Data: Measures Each interview was conducted with a questionnaire developed by the student investigator. Each item was an open-ended quest ion that helped explain the categories of observations of play groups and home vi sits, caregiver part icipation, program implementation, and community impact. The purpose of the interviews was to help clarify and interpret results from the seconda ry analysis. The ques tionnaire was revised while the secondary data was being analyze d. Some modifications or questions were added to the question route de pending on the secondary anal ysis and emerging questions that arose from the first two interviews. Primary Data: Evaluation Plan The interviews were conducted by the st udent investigator. The study used a purposive sample design. Four of the five v illage liaisons and the program coordinator were interviewed by the student investigator to shed light on some of the results of the questionnaires, parent behaviors and utiliz ation of the program, and to determine how well the GRTL program fit the cultural environment. Primary Data: Analysis Primary data analysis was conducted for the qualitative portion of the study. The interview instrument was created by the student investigator and was used to interpret the results from the quantitative data analys is. All interviews were conducted and

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30 transcribed by the student inve stigator. Transcripts were kept on a password -protected computer. Analysis of the interviews wa s conducted through the qualitative program, Atlas-ti. The primary coding technique used for this project was to identify emerging themes throughout the coding process. The coding was guided by general categories that helped interpret the results. Categories of interest included: GRTL liaison’s /coordinator’s observations of play groups & home visits, parent involvement, community impact (awareness, accepta nce, & involvement), and program implementation (planning & cultural competenci es). The qualitative aspect of the study was used to complement the results from th e questionnaire and provided rich information that could give further insi ght into the GRTL program’s impact on the community and families involved.

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31 VI. Results For the secondary data collected in th e project, there were a total of 36 participants that completed a pre and post-te st for the ASQ, and 36 participants that completed a pre and post-test for the PQ. Of those who completed pre and post-tests, 25 had completed both the ASQ and PQ pre and post-tests. Participating children and caregivers attended the play groups or home visits from 0 to 56 times in the 2006-2007 program year. For the primary data collected, there were 5 total interviews with GRTL program staff members. Secondary Data Outcomes There were a total of 294 participants in the GRTL program from September 2006 to May 2007. A majority of the particip ants came from Village 3 (31.74%) followed by Village 1 (19.45%) and Village 2 (17.41%). The fewest number of participants came from Village 6 (2.73%) and Village 4 (4.44 %). Of the 294 participants, 158 (53.92%) participants were tested with an ASQ, PQ, or both. Two villages did not have any posttests for either the ASQ or PQ. Developmental Skills Overall, 128 participants completed an ASQ. Approximately 28% of those who completed an ASQ had completed both a pre and post-test (n=36). As shown in Table 3, the majority of the participants who comple ted an ASQ with pre and post-tests came from Village 1 (55.56%), followed by Village 2 (2 5%) and Village 3 (11.11%). The fewest

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32 number of participants who completed an ASQ were from Village 4 (5.56%) and Village 5 (2.78%). Of those who completed the ASQ pre and post test, the majority (33.3%) participated in a play group or home vi sit 6 to 10 times in the program year. Table 3 Age and Participation Level of Children by Village: Ages & Stages Questionnaire PreTest & Post-Test Age & Level of Participation n, Percent Village 1 Village 2 Village 3 Village 4 & 5 a Total (n=20) (n=4) (n=9) (n=3) (n=36) Age by months 0 to 12 4 20.00 3 75.00 1 11.11 0 0.00 8 22.22 13 to 24 1 5.00 0 0.00 3 33.33 2 66.67 6 16.67 25 to 36 7 35.00 1 25.00 5 55.56 1 33.33 14 38.89 37 to 60 8 40.00 0 0.00 0 0.00 0 0.00 8 22.22 Participation level c 0 to 5 4 20.00 0 0.00 1 11.11 3 100.00 8 22.22 6 to 10 9 45.00 2 50.00 1 11.11 0 0.00 12 33.33 11 to 15 5 25.00 0 0.00 2 22.22 0 0.00 7 19.44 16 or more 2 10.00 2 50.00 5 55.56 0 0.00 9 25.00 Total b 20 55.56 4 11.11 9 25.00 3 8.33 36 100.0 0a Due to the small sample sizes, villages 4 and 5 were combined. b Total sample size and proportion of participating children in each village. c Refers to the number of times that the child and caregiver participated in a play group or home visit. Source GRTL Program, Northwest Artic Borough of Alaska, Kotzebue, 2006-2007 Table 4 Developmental Skill Scores of Children: Ag es & Stages Questionnaire Pre-Test & PostTest (N = 36) Pre-Test & Post-Test Developmental Skills Means (SE) Mean Difference t-value p-value Pre-Test Post-Test Communication Skills 41.39 (2.21) 44.17 (1.92) 2.78 -1.16 0.25 Gross Motor Skills 46.94 (2.27) 51.67 (1.54) 5.73 0.91 0.34 Fine Motor Skills 33.19 (2.83) 36.11 (2.83) 2.92 -0.90 0.37 Problem Solving Skills a 33.61 (2.64) 40.56 (2.50) 6.95 -1.96 0.06 Personal-Social Skills 46.25 (2.04) 47.64 (2.08) 1.39 -0.72 0.48 a Estimates for ASQ pre-test and post-te st significantly differ at the 0.10 level Source GRTL Program, Northwest Artic Borough of Alaska, Kotzebue, 2006-2007

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33 Each developmental skill tested in th e ASQ (communication, gross motor, fine motor, problem solving, personal-social), had a five increment measurement scale of 0 to 60 points. As shown in Table 4, the total m eans for all the developmental skills scores were generally higher for the post-tests in comparison to the pre-test scores. Gross motor skills means increased by 10% and post-test means of problem solving skills increased by approximately 21%, but these differences were not significant at th e alpha 0.05 level. However, problem solving skills significantl y increased at an alpha 0.10 level. Table 5 Score Differences in Developmental Skills : Ages & Stages Questionnaire Pre-Test & Post-Test (N=36) Developmental Skill n, Percent No Change a Score Increased bScore Decreased c Communication Skills 8 22.22 15 41.67 13 36.11 Gross Motor Skills 11 30.56 17 47.22 8 Fine Motor Skills 1 2.78 20 55.56 15 41.67 Problem Solving Skills 2 5.56 21 58.33 13 36.11 Personal-Social Skills 9 25.00 15 41.67 12 33.33 Score differences are any changes or the lack of change between pre & post-test scores for each individual participant. a The difference between pre-test and post-test results equa l to zero indicating no change in pre-& posttest scores b The difference between pre-test and post-test results is gr eater than zero indicating an increase in post-test scores c The difference between pre-test and post-test results is less than zero indicating a decrease in post-test scores Source GRTL Program, Northwest Artic Borough of Alaska, Kotzebue, 2006-2007 Table 5 shows whether a child’s score im proved, stayed the same, or decreased from pre-test to post-test. This greatest improvement was seen in problem solving skills, where 58% of all the children had improved from pre-test to post-test scores. The largest decrease in pre-test to post-test scores wa s seen in fine motor skills, where 42% of participants had a decrease in score. Howe ver 56% of children had an increase in fine motor skill scores. Gross motor skills showed the largest number of participants maintaining the same score from pre to post te st. Each developmental skill had a higher

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34 percentage of children with improved scores co mpared to decreased scores or scores with no change. Mean differences in pre and post-test scores were also stratified by village. There were no significant differences in developmental skills between villages, but it is interesting to note Village 3 had an approxima tely 63% increase in post-test scores for fine motor skills. Mean differences in pre and post-test scores were also examined by participation. Those who participated 11 to 15 times in a play group or home visit had the highest increase in scores for communicati on skills, fine motor skills, and problem solving skills. A Pearson’s Correlation test was conducted on participation level and developmental skills, but there was no significant correlation. Parent or Caregiver Reading Overall, 102 participants completed a PQ. Approximately 35% of those who completed a PQ had completed both a pre and post-test (n=36). As shown in Table 6, most participants tested came from V illage 1 (63.89%) and the least number of participants tested were from Village 4 ( 5.56 %). Of those who completed the PQ pre and post-test, the majority (33.3%) participated in a play group or home visit 16 or more times. For those who completed a PQ, the number of times a caregiver read to their child increased from pre-test to posttest. Table 7 showed a signi ficant decrease in respondents who did not read to their child or read 1 to 2 times per w eek. There was a significant increase in caregivers who read 3 or more times a week in post-test results compared to pre-test results.

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35 Table 6 Age and Participation Level of Children by Village: Parent Questionnaire PreTest & Post-Test Age of Child & Level of Participation n, Percent village 1 village 2 village 3 village 4 village 5 Total (n=23) (n=2) (n=3) (n=2) (n=6) (n=36) Age by months 0 to 12 2 8.70 0 0.00 0 0.00 0 0.00 0 0.00 2 5.56 13 to 24 3 13.04 0 0.00 0 0.00 1 50.00 2 33.33 6 16.67 25 to 36 7 30.43 1 50.00 0 0.00 0 0.00 3 50.00 11 30.56 37 to 60 11 47.83 1 50.00 3 100.00 1 50.00 1 16.67 17 47.22 Participation 0 to 5 4 17.39 1 50.00 0 0.00 2 100.00 1 16.67 8 22.22 6 to 10 8 34.78 0 0.00 0 0.00 0 0.00 0 0.00 8 22.22 11 to 15 7 30.43 0 0.00 0 0.00 0 0.00 1 16.67 8 22.22 16 or more 4 17.39 1 50.00 3 100.00 0 0.00 4 66.67 12 33.33 Total a 23 63.89 2 5.56 3 8.33 2 5.56 6 16.67 36 100.00 a Total sample size and proportion of participating children in each village. c Refers to the number of times th at the child and caregiver participated in a play group or home visit. Source GRTL Program, Northwest Artic Borough of Alaska, Kotzebue, 2006-2007 Table 7 Reading Behavior Scores of Caregivers: Parent Questionnaire Pre-Test & Post-Test (N=36) Reading n, Percent (SE) Relative Difference Pre-Test Post-Test Pre / Post b Times read to child per week None a 5 13.89 (0.06) 2 5.56 (0.04) -60.0% 1 to 2 times a 17 47.22 (0.08) 14 38.89 (0.08) -17.6% 3 to 5 times a 10 27.78 (0.08) 12 33.33 (0.08) 20.0% more than 5 times a 4 11.11 (0.05) 8 22.22 (0.07) 100.0% a Estimates for ASQ pre-test and post-te st significantly differ at the 0.05 level b The relative difference between the pre-test resu lts and post-test results for each variable level Source GRTL Program, Northwest Artic Borough of Alaska, Kotzebue, 2006-2007 Table 8 presents any changes a particular caregiver had in his or her pre and post test reading scores. Of those who said they did not read to their child in the pre-test, 80%

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36 showed improvements in reading habits by re porting that they did read to their child during the week in the post-tes t. Most participants who re ported reading to their child 1 to 2 times a week (53%) generally did not ch ange in the number of times they read to their child from pre-test to pos t-test. Participants who read more than 5 times a week in the pre-test showed a decrease in the amount of times they r ead to their child in the posttest. Half of those who reported reading 3 to 5 times a week in the pre-test stayed the same and the other half increased reading in th e post-test results to more than five times a week. Table 8 Score Differences in Times Read to Child Per Week: Parent Questionnaire PreTest & Post-Test (N=36) Reading n, Percent No Change a Score Increased b Score Decreased c SE None 1 20.00 4 80.00 0 0.00 (0.20) 1 to 2 times 9 52.94 7 41.18 3 5.88 (0.15) 3 to 5 times 5 50.00 5 50.00 0 0.00 (0.17) More than 5 times d 0 0.00 0 0.00 4 100.00 (0.25) a The difference between pre-test and post-test results indicate no change in times read to child per week b The difference between pre-test and post-test results indicate an increase in times read to child per week c The difference between pre-test and post-test results indicate a decrease in times read to child per week d Participants that answered "m ore than 5" in pre-test did not decrease to "None" in post-test. Source GRTL Program, Northwest Artic Borough of Alaska, Kotzebue, 2006-2007 When determining whether level of pa rticipation had any change on reading behaviors, there were no si gnificant correlations between level of participation and reading. However, among caregivers who pa rticipated 10 or less times in the GRTL program, there was a 50% increase of those who reported reading more than five times

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37 per week in the post-test. Among caregivers w ho participated more than 10 times in the GRTL program there was a 400% increase of thos e who reported reading more than five times per week in the post-tes t compared to the pre-test. The overall pre and post test results for each reading behavior option (number of times read to child per week ), were statistically differe nt between pre and post test outcomes. When stratified by village, Village 1 (n=23) had the largest differences in scores. Village 1 had an approximate 50% decr ease in respondents who said they did not read to their child, a 25% decr ease in those who read 1 to 2 times, a 29% increase in participants that read 3 to 5 times, and a 50% increase in participants that read 5 or more times to their children. All three questions on reading from the PQ were tested with a Pearson Correlation test, and the results demonstrated significan t association between times read per week and first time read to child (p <0.0001) ,a nd times read per week and number of books owned (p= 0.0059). Number of times read per week had a str ong correlation with number of books owned (0.432), a nd a very strong correlation w ith first time ever read to child (0.997). A Kruskul-Wallis Test was condu cted to see if reading levels differed by developmental scores on 25 participants w ho completed both the ASQ pre and post tests and PQ pre and post tests. The results were not significantly diffe rent at the 0.05 alpha level, but there was an increase of problem solving skills with increased reading at the 0.10 alpha level ( x = 6.34, p = 0.10). Primary Data Outcomes Interviews were conducted by the student investigator with five GRTL staff. Interviews lasted from 40 minutes to 1 hour. The following section presents the

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38 responses made by the GRTL staff, which was organized in the following categories and order: GRTL Staff, GRTL Progr am, Evaluation, GRTL Participants & Non-Participants, Community, Developmental Skills and Read ing Behaviors. Th e first category, GRTL Staff, describes how long the GRTL staff lived in the village they served, how involved they were in the village and community, and ho w they viewed their role in the program. The GRTL Program section presents the sta ff’s responses on how they implemented the program. The implementation of the evalua tion of the program, wh ich includes the ASQ and PQ, are discussed in the Evaluation sect ion, and the GRTL staff’s observations of the participants and non-particip ants are discussed in th e GRTL Participants & NonParticipants section. Details of the community’s involvement and attitudes or perceptions of the program are presented in the Community section, and the GRTL staff’s observations of developmental skills and parent reading behaviors are described in the last section. GRTL Staff Five GRTL staff interviewed for the qualita tive portion of the study. All of the GRTL program staff had lived in the community in which they worked for at least four years. Two of the liaisons interviewed had lived in their respective villages for their entire lives. The remaining three GRTL sta ff members lived in their communities from 4 to 7 years. All of the liaisons were active members in their village and participated in various volunteer activities in the church, school and comm unity. They all expressed love for their villages and felt very settled in their communities. One of the liaisons that ha d not spent her lifetime in the village recalled having a difficult time getting used to the village lifes tyle prior to working as a village liaison.

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39 After a couple years, she began work ing in the GRTL program and recalled implementation of the program was problematic Parents were quiet and would not talk during in-person meetings, and parents w ould hang up the phone when called to be invited to play groups or to sc hedule home visits. After thr ee years, her expe rience in the program was much easier. The respondent explained the experience became easier as trust was built and strengthen ed through her commitment to the community and to the program. It took one year to gain the trus t of the GRTL participat ing caregivers. Trust was a topic another village lia ison mentioned as something th at had to be built in the community. The community needed to know not just those who ran the program can be trusted, but that they could tr ust the organization itself. One liaison gave an example stating, I just hadn’t built a trust and it takes them a while. You know, this village has had so many teachers come and go, you know. Just when they get the kids and the parents used to st aff members then they’re gone. It takes about one full program year to gain the community’s trust, and to do this the liaison must be persistent in contacting and inviting people to the play groups. The GRTL staff viewed their role as promoters of the importance of early childhood development and getting children ready for school. One of the things they said was the most important contribution the GRTL program provided was socialization. They also viewed themselves as a res ource for parents. One liaison stated, We think the first step to getting them into our kindergarten program is to have them know that we’re there to he lp whenever they need any advice.

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40 If we didn’t have it, we’d do researc h, whatever the parents really wanted, we researched. GRTL Program The village liaisons implemented pl ay groups depending on the caregivers and community’s preferences. Some caregivers split the play groups into infants and toddlers, and others had play groups with al l children ages 0 to 5. Many of the liaisons would not split the play groups by age group becau se parents preferred it to be all ages birth to 5. Community organi zations influenced when play groups were implemented, as they requested they be provided at certain times of the day. Many of the liaisons did not have a set lesson plan prior to implementing their play group. One indicated ther e was no tool in which she could devise specific lesson plans. Topics taught included promoting r eading, socialization, hand-eye coordination and motor skills of children. One of the difficulties when implementing the play groups was the liaisons did not know how many ch ildren were going to attend or what age groups they would be (infants or toddlers). One noted she just had a variety of things ready for when the children came to play groups. The play groups were a way for the pare nts and caregivers to get together in a positive fashion. Many times people came together because someone was ill or to help a family that had a loved one pass away. Th e play groups were a place where caregivers could socialize in a positive way with other parents and with their child. Many noted the play groups also provided a place where th ey could focus on their child. One person explained that with the demands of taking care of elderly, household, and other siblings, the child does not get the needed attenti on to develop certain skills properly.

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41 Program Barriers Many village events affect the program Specifically, liaisons schedule play groups around sporting events, fundraisers and ot her village activ ities. Important events such as a death in the village can also fo rce the program to cancel planned play groups. Teen suicides are a big concern for the villages as some villages experience one or more deaths by suicide each winter. When a death occurs, the whole village participates in raising money for the family to cover expenses for the funeral. These types of events lead to cancellation of the GRTL program for the week since no one will be available for the classes. Another reason classes are ofte n cancelled is due to bad weather. During snow storms, parents tend to keep their young children inside to avoid sickness. The program was also highly dependent upon the village liaison. If the liaison must leave the village for personal or family emergencies, the program cannot be implemented in that village. Finally, sickness can lead to low nu mbers of participants coming to play groups. When a virus breaks out in the school, it spr eads to the whole vill age leaving children, parents, and other family members in need of care at home. Space was another issue with conducting pl ay groups. Some noted that for the first time they had their own space this year in which they could have play groups, but sometimes the facilities/space was not adequate if there was a big showing of parents and their children. Having enough space was not ju st a problem in the school district but village-wide as well. Housing was a difficulty for all of the villages. The village populations were growing, but housing development was not gr owing as fast. Many of the liaisons reported some houses have up to four generatio ns of family members living in one small

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42 house, which does not allow very much room or privacy for a home visit. For this reason, most of the participants preferred play groups rather than home visits. The oneon-one time that could be provided by a liais on in a home visit was seen as potentially beneficial to the family, but difficult to accomplish. As stated by one liaison, We have a real high demand for hous ing, but yet nothing has been done in the last five or eight years. So th ere’s multiple families in one household. Like, for me, for instance, we have thr ee generations or four generations in a bedroom. Knowing that it happens like in any other home there is multiple families. Sometimes it’s hard to conduct a home visit within that home, but when we do that it s hows the other pare nts that their involvement is very impo rtant and very crucial. Even with the housing issue, however, th ere was another reason why participants disliked home visits, which was having an unfamiliar person in the home. Liaisons stated that participants may have felt like they were being watched and critiqued and did not want to face criticism. They also did not want to let a nyone into their home with whom they had not built a trusting relati onship. It often takes a year or longer to build trust with the community members and participants of the program, making it difficult for those who have not yet established those rela tionships to schedule home visits. Evaluation All but one of the liaisons was very fam iliar with the evaluation process. For the one liaison not familiar with the process, evaluation of the program was conducted by another liaison in the village. Among the three that actively conducted the evaluation portion of the program, two stat ed they administered the qu estionnaires at the beginning

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43 and end of the program year, but one said th ere was not enough time to fully administer questionnaires in the later half of the year. This liaison ha d to end the program early due to personal reasons. The liaisons were familiar with the process of referring families with children that may have developmental delays to the early learning and family program. They also provided information to educate parents on developmental delays, or researched additional information if requested by the parents. The liaisons also stated it was difficu lt to administer the questionnaires. One reason was the parents would request to comple te it later, but then would not show up in the following play group or would forget a bout it. The participants would also be actively involved in the fall and not during the spring, which made it difficult to get enough post-tests. The questionnaires were c onsidered part of the “paperwork,” which by some liaisons, was noted as a challenge They expressed there was too much paperwork, and stated it as something that could change in the program. The evaluation process was described every year at the beginning of the program year, and the importance of it was discussed at these mee tings, as well. However, the coordinator stated the liaisons may not fully unders tand the importance of timely and thorough evaluation of the program because they were not involved in the process of evaluation beyond administering th e questionnaires. GRTL Participants and Non-Participants Caregivers who participated in the program were mostly women, which consisted of mothers, grandmothers, sisters, and female babysitters. Fathers and uncles participated as well, but not as many. However, two liais ons did report there we re increasingly more men (fathers & uncles) coming to the play groups They stated the low number of father

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44 participants may have been due to the fact that participants consist predominantly of women, which made the men uncomfortable. All of the participants were strong advocates for the program. All liaisons said the parents would express how much th ey enjoyed and loved the program, but participation was consistently a challenge in a ll of the villages. Fall was widely noted as the most popular time of the year when everyone was “gung-ho” for the program. Although after the fall, participation was scatte red in the winter and spring for a variety of reasons. During the winter months, many families traditionally do not take their young children outside in rough weat her. Weather was usually th e main reason why people did not participate in the program during the wint er. Sickness was also cited as a reason for low program participation. One liaison stated that many of the caregivers believed the weather was the cause of sickness and not th at it was a communicable disease such as a virus that had spread throughout the school. Besides not be ing able to leave the house due to children becoming sick, many househol ds also cared for elderly who also had health issues that demanded much of the ca regivers’ time. In the spring, more people started attending program activities, but tended to spend more of their time doing seasonal activities such as berry picking, hunting, and just spendi ng time in the longawaited sunny outdoors. There were some people in the community with other reason s not to attend. A liaison noted there may be a dispute between caregivers, and they both would not attend to prevent running into each ot her. Another liaison stated alcohol was a problem in the community, and some parents did not particip ate because they were more preoccupied with their drinking than thei r children. The villages ar e dry, meaning alcohol was not

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45 permitted to be sold or consumed in the village by law. At one point, there were a lot of problems in one village with alcohol, whic h corresponded with a couple of murders and a few suicides locally. Due to this, the liais on did not make any home visits for several months until the village was “cleaned up.” Some non-participants also expressed to the liaisons their reluctance to join GRTL since so many programs have high turnov er rates. The participants valued longevity of a program which demonstrated a program was committed to the village; in the past, many programs like Head Start have quickly come and gone leaving the village without a resource they both needed and appreciated. Community For the most part, the community was very supportive of the GRTL program, with many local organizations as strong s upporters. Liaisons noted some community members even helped by promoting the villag e and encouraging pare nts and caregivers to attend. The liaisons did feel there could be mo re community involvement with the GRTL program, particularly by having elders particip ate. Elders are vita l as they bring the language and culture to the child ren. One liaison even stated th at it was almost too late for the older children (teens and tweens), who had lost respect for their elders. The main barrier elders face is their declining healt h, and many are not strong enough to make it to the play groups. Some liaisons did indicate they could have done more to invite elders to the play groups. The GRTL program was reported as a res ource that was specifically focused on infants and children in the community. Many liaisons listed popular activities in the

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46 communities, which included sporting events, bingo, traditional gatherings of the women, and traditional gatherings of the elderly a nd teenagers, but there were no activities or events specifically for infants and ch ildren. GRTL provided a place where the community could focus on its infants, children, and supporting young families. Developmental Skills and Reading Behaviors Liaisons were asked about any improveme nts they had seen in the children and parents. From their responses, they did not indicate any specific skills had changed, but did say they observed the children learned a nd developed the appropr iate skills at the correct age level. They noticed the children became more social and comfortable with other children as the ye ar progressed. One liaison stated a couple of parents from the previous program year had mentioned having an easier time introduc ing their child (that participated in the program) to Kindergarten compared to their ol der siblings (who did not participate in the program). The liais ons mentioned parents also became more interested in what their children could do and what they accomplished. One liaison gave an example of this stating, We kind of modeled this one little ac tivity with a parent and her son, who she thought didn’t care for reading. I put some toys near the child and he sort of chose which ones he wanted to play with... So anyway, I sat down two to three feet away and started just readi ng a book and sounded real exciting and the book facing myself and the child was able to look up from his playing, see the book that I was r eading and numerous times he would look up and point right to what I was referring to from the reading and – the child is three years old, by the wa y – and I just kept reading throughout

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47 the book, and every time he looked up and showed any kind of interest I put the book closer to him and he ju st was following along and his mother was really surprised that he was listeni ng. And the point that I made to her later was even though you th ink that the child was not listening, per se, he is listening, whether you th ink he’s listening or not The liaisons encouraged reading as much as they could and did notic e the parents became more aware of the importance of reading to their child.

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48 VII. Discussion Data Collection Process The liaisons tried to complete an AS Q and PQ pre-test and post-test for participating caregivers and children in the fall and spring of the 2006-2007 program year. There was a lack of pre-tests for some children, but mostly there was a lack of posttests. According to the village liaisons, participation from the caregivers and children was sporadic throughout the year. Some noted there was strong partic ipation in the play groups in the fall, but when spring began, participation decreased due to seasonal activities such as hunt ing and berry picking. These activ ities were very important for families who practiced subsistence living, as those living in the villages did. For this reason, most children completed a pre-test, but due to low participation in the spring, a post-test for that child could not be completed. Even though a large number of children initially part icipated in the program, regular participation was only seen in a small number of ch ildren throughout the year. Besides the spring activities that would take up a family’s time, the winter had low participation rates due to harsh weather condi tions. As the year progressed, people also participated in community events or united to mourn a death and assist the family in need.

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49 Interpretation of Results When the mean scores of each development skill were compared at pre-test and post-test; there was an increase seen at the post -test, relative to pre-test scores. The results showed higher scores in the post-tests th an in the pre-tests for both ASQ and PQ. Paired t-tests revealed these changes were not st atistically significant at p<0.05 level, but significantly higher scores were revealed in the post-test for problem solving skills at the p<0.10 level. The main reason why a statis tically significant outcome may not have resulted in the analysis was likely due to the small sample size. Another factor that may have played a role in the outcome of the anal ysis was the lack of a comparison or control group. Without a control group, we cannot attrib ute changes seen in developmental skills to the child’s participat ion in the program or to other fact ors not measured in this study. Another important finding was the change in parent reading habits potentially due to the participation in the Getting Rea dy to Learn Program. There was a strong correlation between initial time of reading and times read per week in the PQ. With this finding it further supports the notion that havi ng parents exposed to the program early in their child’s life may increase the chances they will continue to read to their children in the future. The qualitative portion of the study assisted in discovering possible explanations for attrition in post-tests and for the outcomes of the ASQ and PQ. The small number of pre and post-test completions might be a result of participation in other activities popular within the village and during certain seasons. The small nu mber of pre and post-tests make it difficult to find significant differen ces between each developmental skill. Another reason why there may not have been any significant differenc es might be due to

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50 the inconsistencies in how play groups were implemented in each village by having different lesson plans, different ways of sche duling, separation or incl usion of certain age groups in play groups, and the lack of partic ipation in home visits in most villages. However, even though significant differences were not found in developmental skills, liaisons did report positi ve changes. Liaisons reported pa rents were more interested in what their young children could do and accomp lish; the GRTL program helped parents realize they need more one-on-one time with their children, and it made parents more aware that reading at a young age was importa nt. These findings help explain why there were significant positive changes in parents r eading to their children each week. Another positive change revealed by the liaisons was children became more comfortable being among and interacting with other children. Furt hermore, it was seen that parents who had their children in the GRTL program in prio r years had an easier time introducing their child to kindergarten than their older siblings who did not participate in the GRTL program. Limitations Although this evaluation provides useful in formation for the GRTL program staff, it was not devoid of limitations. One of the limitations acknowledged by the student investigator was the use of proposed evalua tion instruments. Other instruments to measure development of children and reading be haviors of parents could have been used, but the instruments had already been selected and utilized by the GRTL program as part of their original program design. Questionnair es used for children aged five years old tested the child’s read iness to enter school and used a different measurement scale. Where as, the questionnaires used for child ren under the age of five measured each

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51 developmental skill, therefore the pos-test questionnaires comple ted for children who turned five at the end of the year could not be compared with their pre-tests. Due to this, three ASQ pre and post tests were excluded from the final analysis. The GRTL program chose to use the ASQ in the 2006-2007 program year to stay consistent with testing techniques used in previous y ears and for future evaluation. The lack of a control group for the qua ntitative data analysis was another limitation. When the GRTL program was impl emented, there was no established control group. The analysis conducted involved a pretest and post-test comparison evaluation; whereas the most rigorous type of research design would involve a control group and randomization to the intervention or control group. Even though there was not a control group, the study did employ a qualita tive phase to help with in terpretation of the results. Determining the precise dose of each ch ild’s exposure to the program was a limitation to the study. The play group and hom e visit attendance sheets did not always correspond with dates the ASQ or PQ were implemented for some children. The number of times the child and parents participated in the program may not be completely accurate if the liaison made a mistake or forgot to record information. Another limitation encountered was the scheduling of the pre-test and post-tests. The pre-tests for the ASQ and PQ were not a ll given in the first month of the program (late August to September 2006). Some pre-test s were given when the participant entered into the program, which for some was closer to the middle of the program year. All of the post-tests were given anywhere between th e end of March to the beginning of May. Thus, the opportunity for each participant to have participated in a play group or home visit varied.

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52 Unpopularity of the home visits was also a limitation. Only one village had successfully implemented home visits in their program. Since the home visit was still an intervention the participating child and caregiv er experienced, it was included as part of the level of exposure estimated for that child. Not including home vis its in the level of exposure for the participant would further bi as the results by indi cating the child and caregiver had less exposure in the program than they actually had. There were no significant findings between those who attend ed play groups and those who had a home visits due to the fact not many people particip ated in home visits. Some villages did not implement any home visits because participants did not want to schedule them. For this reason it is unknown whether home visits coul d have impacted children’s developmental skills. The main limitation to the study was attr ition. The GRTL program had a great amount of participation in the beginning of the year, but due to weather and subsistence living activities, many participants attended play groups and other GRTL activities less frequently in the winter and spring. Conclusion The results showed a significant differen ce in reading behaviors and higher mean scores in developmental skills. Problem solv ing skills increased the most from preto post-test, although the difference was not signi ficant at 0.05 alpha level. The program also appeared to increase careg iver’s reading to their child. There are some areas that can be improved in the evaluation process. Efforts have been made to help liaisons understand th e importance of evaluation, but ensuring all liaisons are adequately prepared to conduc t evaluation would be highly recommended.

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53 Liaisons may also benefit from having a booklet with set lesson plans. This would help to ensure the GRTL liaisons taught the sa me materials in each village, and all developmental areas were being addressed in ea ch play group. Efforts should be made in the future to administer as many pre-tests as possible in the first mont hs of the program in order to increase chances of ge tting more paired pre and post te sts. Inclusion of both the Parent Questionnaire and Ages & Stages Ques tionnaire as part of the enrollment process is recommended, and modifying the Parent Questionnaire to include only questions on reading for the pre-test, which will shorten th e questionnaire significantly, may increase pre-test completion rates. Due to traditional seasonal activities a nd weather affecting pa rticipation rates, different approaches to rece iving post-tests could be c onsidered. Full communication about the importance of completing the pre and po st test with the parent may be helpful. Post-tests were also generally completed in the play groups. Incorporating scheduled appointments for parents to complete a pos t-test at a time and location that was convenient for the caregiver or parent may increase posttest completion as well. The challenges faced in evaluating the developmental skills and reading behaviors of parents or caregivers are important lessons learned whic h may help others that are planning on implementing and evaluating progra ms in isolated communities with strong traditional practices. Consideration of loca tion, the community’s history, culture and traditions are all important. Understandi ng these challenges can lead to new and innovative approaches to eval uation and research in the ta rget population. When in the beginning stages of program planning, it is recommended that the evaluation process,

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54 including the analysis of the evaluati on data, be thoroughly discussed with the participants. Although the secondary data analysis was inconclusive, the qualitative information collected in this study supports the idea that the Getting Ready to Learn Program had a positive impact on its particip ating children, caregiver s, and community. The GRTL program’s largest accomplishmen t was to change the way parents and caregivers think about readi ng and spending one-on-one time with their children. The program managed to become an acceptable, and to some, an integral part of the community. Overall, the GRTL program ha s established a str ong foundation by gaining the trust of parents and the community, a nd changing the way they think about the development of their young children. GRTL is a program with the potential to ma ke a difference in the lives of children in remote and isolated areas with limited re sources. GRTL promotes early development and building a healthy relationship between caregiver and child. Children that are nurtured with strong family ties may be able to prevent developmental delays and build healthy relationships (Karr-Morse & Wiley, 1997 ; Kotch, 2005). This has shown to help children successfully complete school, which will lead to bett er health outcomes such as less depression, better health behaviors, and bett er health care benefits later on in life (Palfrey et al., 2005). Strong family ties and positive school experien ces can also prevent suicides (Gary, Baker, & Grandbois, 2005), whic h is more prevalent in Alaska Native villages. By creating aw areness and providing resour ces through the GRTL program, caregivers of young children can greatly impact their child’s future by reading to them

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55 and being conscious of developmental needs so their child can be adequately prepared for all the learning and life challenges that lie ahead.

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56 References August 2006 Unemployment Rate. (2006, October 8,2006). from http://www.labor.state.ak.us/res earch/monthlyunemprate/aug06map.pdf Barrera, M. E. (1991). The Transactional Mode l of Early Home Intervention: Application with Developmentally Delayed Children and Their Families. In K. Marfo (Ed.), Early Intervention in Transition (pp. 109-146). New York: Praeger. Brooks-Gunn, J., & Markman, L. B. (2005). The c ontribution of parenting to ethnic and racial gaps in school readiness. Future Child, 15 (1), 139-168. Cameron, L. A. (1999). Understanding alcohol a buse in American Indian/Alaskan Native youth. Pediatric Nursing, 25 (3), 297-300. Currie, J. (2005). Health disparities and gaps in school readiness. Future Child, 15 (1), 117-138. District Dropout Rates. (2005) Retrieved October 8,2006, from http://www.eed.state.ak.us /stats/DropoutRates/19912004DropoutRatesByDistrict.pdf Donders, A. R., van der Heijden, G. J., Stijnen, T., & Moons, K. G. (2006). Review: a gentle introduction to im putation of missing values. Journal of Clinical Epidemiology, 59 (10), 1087-1091. Gary, F. A., Baker, M., & Grandbois, D. M. (2005). Perspectives on suicide prevention among American Indian and Alaska nativ e children and adoles cents: a call for help. Online Journal Issues of Nursing, 10 (2), 6. Hindelang, M. (2006). Honoring our elders: hearing their stor ies, respecting their ways. Home Healthcare and Nurse, 24 (5), 294-297. Individuals with Disabiliti es Education Act Amendments of 1997, 115 Congress of the U.S.(1997). Karr-Morse, R., & Wiley, M. S. (1997). Ghosts from the Nursery: Tracing the Roots of Violence New York: The Atlantic Monthly Press.

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57 Kotch, J. B. (2005). Maternal and Child Health: Progr ams, Problems, and Policy in Public Health (Second ed.). Massachusetts: Jones and Bartlett Publishers, Inc. Local School Directory: Northw est Arctic Borough School Dist rict. (2006). Retrieved October 8,2006, from http://ak.localschooldirectory.com/distric ts.php/district_id/37/ district_state/AK/di strict_name/Northwest~Arctic~Borough Magnuson, K. A., & Waldfogel, J. (2005). Earl y childhood care and education: effects on ethnic and racial gaps in school readiness. Future Child, 15 (1), 169-196. Northwest Arctic Borough School District Records (2003).). Kotzebue: Northwest Arctic Borough School District. Palfrey, J. S., Hauser-Cram, P., Bronson, M. B., Warfield, M. E., Sirin, S., & Chan, E. (2005). The Brookline Early Education Pr oject: a 25-year follow-up study of a family-centered early health and development intervention. Pediatrics, 116 (1), 144-152. Profile and General Data Characteristics. (2000). Retrieve d October 8, 2006, from http://www.labor.state.ak.us/r esearch/cgin/sf3profiles/nwa.pdf Reynolds, A. J., Temple, J. A., Robertson, D. L., & Mann, E. A. (2001). Long-term effects of an early ch ildhood intervention on educ ational achievement and juvenile arrest: A 15-year follow-up of low-income children in public schools. Journal of the American Medical Association, 285 (18), 2339-2346. Summers, M., & Innocenti, M. S. (1991). Early Intervention in the United States. In K. Marfo (Ed.), Early Intervention in Transition (pp. 205 206). New York: Praeger. Technical Report on ASQ. (2006). Paul H. Brookes Publishing Co. Teufel-Shone, N. I., Staten, L. K., Irwin, S ., Rawiel, U., Bravo, A. B., & Waykayuta, S. (2005). Family cohesion and conflict in an American Indian community. American Journal of Health Behavior, 29 (5), 413-422. U.S. Department of Health and Human Se rvices, & Health Resources and Services Administration. (2005). Women's Health USA 2005 Rockville: U.S. Department of Health and Human Service. USA.gov. (2007). Quality Tools. Retrieved February 19, 2007, from http://www.qualitytools.ahrq.gov/

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58 Appendices

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59 Appendix A: Parent Questionnaire Date__________________S.S.#______________________ Parent’s Name______________________________________ Child’s Name _______________________________________ Birth Date______________Village______________________ Directions: Please complete the following questionnaire by circling ONE response for each item. Results will be used for research purposes and will be kept confidential. Your participation will assist us in providing better services for children in the future. Please respond truthfully to each question. There are no right or wrong answers on the survey. If you have more than one child, please fill out a separate survey for each child. 1. Were there specific things that you did in play group that you found especially useful or fun as you play and care for your child? _______________________________ ________________________________________ 2. Which activity was the most valuable? A) none B) play group C) home visit D) Both 3. Which activity was not valuable? A) none B) play group C) home visit D) other _______________ 4. How old was your child when you first began to read to him or her? A) Before birth B) Birth to 1 year C) 1 year to 3 years D) 3 years or older 5. How many times in a week do you read to your child? A) none B) 1 to 2 times per week C) 3 to 5 times per week D) more that 5 times per week 6. Approximately how many children’s books does your child have? _________________ 7. Do you plan to participate in the program next year? A) Yes B) No C) Not Sure Questionnaire page layout was modified for this document, but the text remains the same. ** Source GRTL Program, Northwest Artic Borough of Alaska, Kotzebue, 2006-2007

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60 Appendix B: Ages & Stages Questionnaire Sample

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67 Appendix C: Question Route for GRTL Program Ice Breaker/Introduction Questions 1) How long have you lived in [Village Name] and what do you like the most about [Village Name]. 2) Can you describe what positions and activities you are involved in within your community? Personal Observations of Play Groups & Home Visits 3) Can you describe your involvement in the GRTL Program? 4) Can you describe what it is like to conduct a play group? a. Who participates in the play groups? b. What kinds of difficulties do you face when planning an d conducting play groups? 5) Can you describe what it is like to conduct a home visit? a. Who participates in the home visits? b. What kinds of difficulties do you face when planning an d conducting home visit? 6) When you notice that a child has developmental problems, what do you do? Parent Involvement 7) How involved are parents in the GRTL program? a. How do you get parents and their children to pa rticipate in the play groups or home visit? b. What are some reasons why people choose to participate? c. What kinds of changes have you seen in the caregivers th at participate? 8) Can you describe the people that do not participate in the program? a. What are some reasons why peopl e choose not to participate? Community Impact 9) In your opinion, how aware is the community of the GRTL program? Can you give some examples of things people have said about the program? a. What do people in your community think of the GRTL program? 10) How involved is the community in the GRTL program? Can you give some examples of how people have been involved in the program? a. In an ideal world, how would you like the community involved? Program Implementation 11) How does the GRTL program m eet the community’s needs? 12) How does the GRTL program incorporate the community’s traditions? 13) What determines how you schedule play groups and home visits? 14) What kinds of events affect the way you plan GRTL activities? Summary Questions 15) In your opinion, what is the most important thing that the GRTL program does? 16) Overall, what do you think should change in the GRTL program? (Give a brief summary of the key points discussed…) 17) Does this sound right to you? If no, can you please clarify what was not stated correctly? 18) Is there anything else that you think I should know?

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68 Appendix D: Human Subject s Protections Consent Form Informed Consent to Participate in Research Information to Consider Before Taking Part in this Research Study Researchers at the Univer sity of South Florida (U SF) and the Northwest Artic Borough of Alaska School District study many topics. To do this, we need the help of people who agree to take part in a research study. This form tells you about this research study. We are asking you to take part in a research study that is called: The Getting Ready to Learn Program: An Impact Report The person who is in charge of this research study is Rosa M. Avila The research will be done at the University of South Florida’ s College of Public Health. Purpose of the study The purpose of this study is to get an understanding of how the GRTL program has influenced the community. You are being asked to participate because you are a valued member of the community in which the Getting Ready to Learn Program is being implemented. Study Procedures If you take part in this study, you will be asked to answer some questions. The interview should not be longer than an hour and thirty minutes. You will only be asked to participate for one interview. The interview will be done by telephone. Your interview will be audio recorded. Alternatives You have the alternative to choose not to participate in this research study. Benefits We don’t know if you will get any benefits by taking part in this study. However, possible benefits might include learning more about the effectiveness of the GRTL program in your community and across several villages in Alaska.

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69Risks or Discomfort The risk is minimal. There are no know n risks to those who take part in this study. Compensation We will not pay you for the time you volunteer while being in this study. Confidentiality We will keep your study records confidential. a. The audio recordings will be st ored for a period of two years b. They will only be used fo r the duration of the study. c. The recordings will be stored in a password protected computer. d. The recordings may be shown to University of South Florida professors who are advising the principal investigator and are a part of the primary investigator’s research committee. By law, anyone who looks at your records must keep them completely confidential. To summarize, the only people who will be allowed to see these records are: The research team, including the Pr incipal Investigator, and all other research advisors. Certain government and university people who need to know more about the study. For example, individuals who provide ov ersight of this study may need to look at your records. This is done to make sure that we are doing the study in the right way. They also need to make sure that we are protecting your rights and your safety. These include: a. The University of South Florida In stitutional Review Board (IRB) and the staff that work for the IRB. Other individuals who work for USF that provide other kinds of oversight may al so need to look at your records. We may publish what we learn from this study. If we do, we will not let anyone know your name. We wil l not publish anything else that would let people know who you are. Voluntary Participation / Withdrawal You should only take part in this study if you want to volunteer. You should not feel that there is any pressure to take part in the study, to please the principal investigator or the research staff. You are free to parti cipate in this research or withdraw at any time. Ther e will be no penalty or loss of benefits you are entitled to receive if you stop taking part in this study. Decision to participate or not to participate will not affect your job status.

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70Questions, concerns, or complaints If you have any questions, concerns or compla ints about this study or if you experience an adverse event or unanticipated problem, call Rosa Avila at 813-484-3353 or email at ravila@hsc.usf.edu If you have questions about your rights, general questions, complaints, or issues as a person taking part in this study, call the Division of Research Integrity and Compliance of the Univers ity of South Florida at (813) 974-9343. Consent to Take Part in this Research Study It is up to you to decide whether you want to take part in this study. If you want to take part, please sign the form, if the following st atements are true. I freely give my consent to take part in this study. I understand that by signing this form I am agreeing to take par t in research. I have received a copy of this form to take with me. Signature of Person Taking Part in Study Date Printed Name of Person Taking Part in Study Statement of Person Obtaining Informed Consent I have carefully explained to the person ta king part in the study what he or she can expect. I hereby certify that when this person signs this form, to the best of my knowledge, he or she understands: What the study is about. What procedures/interventions/investigational drugs or devices will be used. What the potential benefits might be. What the known risks might be. I also certify that he or she does not have any problems that could make it hard to understand what it means to take part in this research. This person speaks the language that was used to explain this research. This person reads well enough to understand this form or, if not, this person is able to hear and understand when the fo rm is read to him or her. This person does not have a medical/ psychological problem that would compromise comprehension and therefore makes it hard to understand what is being explained and can, therefore, give informed consent.

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71 This person is not taking drugs that may cloud their judgment or make it hard to understand what is being explained and can, therefore, give informed consent. Signature of Person Obtainin g Informed Consent Date Printed Name of Person Ob taining Informed Consent