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Evaluation of phonological awareness training on reading improvement and skills

Background and Aim: Reading is not only a fundamental skill in learning but also an important channel in dealing with the outside world. However, hearing impairment affects linguistic growth, including speaking and reading; development of understanding; and academic achievement. The purpose of this study was to investigate the effect of phonological awareness training on improving phonological reading and awareness in primary school children with hearing impairment. Methods: The present study has a quasi-experimental design. The research was conducted as pretest, intervention and posttest. A total of 20 children with moderate to severe hearing loss were enrolled in the experimental group and 20 subjects in another group as the control. Reading and dyslexia test (NEMA) was used to assess reading improvement and phonological awareness was assessed by the phonological awareness questionnaire. The data normality was checked by Kolmogorov-Smirnov test and nonparametric Wilcoxon and Mann-Whitney U test were used to evaluate non-parametric data. Results: Based on the results, after teaching the phonological awareness strategies to the experimental group, their reading and phonological awareness scores increased significantly higher than the control group (p<0.05). Also the results show higher phonological awareness scores in girls. Conclusion: The results of this study showed that improvement of phonological awareness in children with hearing loss can improve and resolve their reading performance and problems.


Introduction
Reading is one of the most important skills in modern societies. However, dyslexia accounts for approximately 5-17% of children's problems and is the most common form of learning impairment [1]. Generally, the weakness in reading skills can be seen in all academic failures [2]. Dyslexia is described as a specific learning disorder originates from a psychological neurology and is characterized by problems in the proper recognition of words, spelling, and decoding ability. These problems lead to defects in other cognitive abilities [3]. People with difficulty in reading have problems in their most academic courses. In addition, the negative impact of this disorder is not limited to educational affairs, but extends to low self-esteem, anxiety, depression and tendency to antisocial and destructive behaviors. However, when these problems are accompanied with another problem, such as hearing impairment, they will have more destructive effects [4]. It is generally believed that the difficulty in reading is related to the lower levels of neuropsychological performance and the factors of multiple impairments [1]. Recently, many studies emphasize the role of phonological awareness in reading. For example, Ramus et al. suggested that dyslexic children are defective in phonological, visual, auditory and cognitive skills, even phonological problems may be due to the more fundamental defects of the basic perception mechanisms which is responsible for processing time-sensitive information. They stated that phonological awareness skills include identification, naming, decomposition, composition, deletion, substitution, and phonological reversal [5]. Seki et al. defined phonological awareness the knowledge the sounds of the word builder, and one can divide one word into several phoneme, syllable, and intra-syllable units. Therefore, there can be at least three phonological awareness problems in dyslexic children: phonological awareness, syllabic consciousness, intra-syllable unit's consciousness [6]. In a study by Leikin and Zur Hagit, the results showed that dyslexic people have good spontaneous knowledge, but their phonological processing is delayed. They found out that phonological processing and mere awareness would play a key role in decoding words. Their dysfunctions are inadequate awareness of their defects in inferiority knowledge and phonological problems [7]. Also, studies by Di filippo et al. showed that children with difficulty in reading were less likely to be tested in a fast-titled auto test, which is one of the phonological awareness assignments [8].
In Iran, studies have also been conducted on the significant role of phonological awareness in reading skills. For example, Soleimani's research findings showed that syllabic and intracurricular skills exist both in preschool and primary school children, but, phonological awareness skills were observed only in children who received formal instruction in reading, and not in preschool children [9]. Studies have also been conducted to prove the effectiveness of phonological awareness training on improving reading skills. For example, Habibi-Kaleybar et al. showed that both phonological awareness and mental rotation would significantly improve reading performance in dyslexic children [10]. However, there is no research on the effectiveness of these trainings on the reading skills of children with hearing impairment. One of the issues discussed in hearing impaired children is how phonological information is acquired in these children. In other words, what prohibits hearing loss from full reading and writing acquisition is a flaw in phonological processing of the written words. The permanent lack of auditory stimulation significantly interferes with the internalization of precise representations of spoken words (which is the expression of spoken words), including the growth of awareness of the phonological structure of those words [11]. Phonological awareness skills grow less well in the hearing impaired than normal children, and phonological awareness in hearing impaired students may be less specialized, due to the inability of the hearing impaired child to understand all the phonetic distinctions heard by the hearing attendant [12]. Considering the importance of reading skill in deaf and hearing impaired children, it is important to use methods that can improve the reading skills of these people. Regarding the lack of studies in this field and in order to evaluate the proper methods for improving the reading skills of deaf and hearing impaired children, this study aimed to evaluate the effectiveness of phonological awareness training on improving reading skills in children with hearing impairment.

Methods
The present study was a quasi-experimental study with pretest and posttest and control group. This study was carried out to evaluate the effect of phonological awareness training on improvement of reading performance in primary school children with hearing impairment in Baharestan City, Tehran Province, Iran. study population comprised all 65 primary school children with hearing impairment in Baharestan City. A random sampling method was used to enroll 40 subjects. 20 subjects were assigned in the intervention group (11 boys and 9 girls) and 20 in the control group (11 boys and 9 girls). The study subjects should have completed the first grade without history of psychosis or intellectual deficits. The instruments used in this research were phonological awareness test [13] and facial reading test [14]. The phonological awareness test has 10 subscales. In each subscale, two to three words are given. First, the subject is trained on how to do each section. Then the images of that section are presented to the subject. If the respondent answers the requested item, he will receive a score of 1, and if he or she does not respond or gives an incorrect answer, the score will be 0. The Cronbach α coefficient of phonological awareness test is 98% [13]. female students) in five educational districts in Tehran, Sanandaj, and Tabriz. The α coefficient of reading and dyslexia was obtained as 81% [14]. After selecting students, they were taken phonological reading and knowledge tests and then the experimental group received 10 sessions of phonological awareness group training and the control group did not receive any training. The phonological awareness training includes skills such as recognizing words with the same initial voice or the same ending voice, as well as phonemic and syllabic discovery. The content of the sessions is briefly summarized in Table 1. It should be noted that success was considered in the whole reading not in each section separately. After completing the phonological awareness training sessions, the subjects of both groups received the reading and phonological knowledge test and the results were recorded and analyzed by Mann-Whitney U test and Wilcoxon test in SPSS 19.

Results
The results of phonological reading and phonological awareness tests are presented in Table 2. Based on the results, with regard to phonological awareness, the average score of all subscales in the posttest increased and the  difference is not statistically significant.

Discussion
The purpose of this study was to evaluate the effectiveness of phonological awareness skills training on reading skills and phonological awareness of children with hearing impairment.
The results of this study show that phonological awareness training improves the reading and phonological awareness of children with hearing impairment. These findings are consistent with the research by Ramus et al. and Soleimani, reporting that phonological awareness is influential in reading skills [5,9]. The results of this study are also consistent with Habibi-Kaleybar et al. research, reporting that phonological awareness training has an impact on the reading skills of children with dyslexia [10]. To explain the results of our study, one of the phases of the word recognition is identification of the word's letters and sounds. As long as the child cannot properly recognize and read the word in terms of its appearance, he or she will never be able to reach the level of understanding and meaning of the word, because in the first stage it is difficult to read the word itself [15]. Understanding the letters in any language is an essential requirement for reading. Therefore, the acquisition and use of such knowledge in the cognitive structure of a person helps him in reading accurately and quickly, also a small amount of phoneme structure can increase the errors and reduce reading speed, and mental reading can be difficult [15].
In perceptual dysfunction, the child attempts to find the relationship between the shape, letters, and sound of the concept each time, and since this relationship has not been completely formed, the reading becomes interrupted [16] and the child makes mistakes. Several problems, such as fast reading, interruptions, and hang on the words, affect the speed and fluidity of reading [17]. In linguistic dysfunction, the normal procedure fails to recognize the form of the word to then transform it into sound and meaning. Thus, the phonological awareness training approach aims at helping children to recognize the appearance of the word and raise their level of phonological awareness. This training will ultimately lead to the correct reading of the word. In fact, it seems that the use of phonological awareness with the ability to identify words sounds is an essential skill for the  development of spelling through understanding the spoken language units of the phoneme and syllables as well as making a meaningful and correct connection between words and sounds. Also, sound awareness helps the child to correctly classify spoken words and then write them down [17]. All of these issues indicate the importance of identifying problems in the phonological awareness of children with hearing impairment and implementing timely intervention programs. Phonological awareness allows the individual to manipulate the phonological components of the language and thereby convert the phoneme into a text and understand the meaning of the text [18]. Accordingly, the acquisition and use of such knowledge in the person's cognitive structure helps him or her to read correctly and promptly [18]. Phonological awareness skills are a strong predictor of reading skills, and it is even said that this skill is stronger in predicting reading skills than intelligence, vocabulary, and listening comprehension [19]. Another finding of this study was the effectiveness of phonological awareness training on phonological awareness of students with hearing impairment. It should be said that phonological awareness can be improved by improving the accuracy and subsequent improvement of phonological awareness by increasing student awareness of letters and sounds, syllables, communication between phrases and sounds, recognizing first letters, middle and end words, phoneme combinations, and phonemic manipulation. In fact, phonological awareness is the ability to hear and manipulate the smallest unit of sound in a language, and is the key to learning to read for children. Therefore, the training of phonological awareness increases the phonological awareness skill, and one can gain knowledge about the structure of voice and phonological speech, which in turn results in improved reading skills [20]. The vocabulary awareness training used in this study includes a task that is quantifiable in the phonological awareness test, so training these skills can improve phonological awareness in these children.
We also found that phonological awareness training is more effective on phonological aware-ness of girls than boys. The results of this study are consistent with the research by Moura et al., which showed that phonological awareness training has a greater effect on girls than boys [21]. Also, the results of Chipere's research showed that phonological awareness is generally better in girls than boys. The results of these studies show that the increase in phonological awareness skills in girls is easier than boys [22]. In explaining the results, we can point out the overall superiority of girls in verbal intelligence compared to boys. This superiority, which is rooted in girls' brain structures, help them to benefit more from phonological trainings [23].
In the end, it should be noted that this research has also some limitations, including the use of available sampling method, absence of followup, and use of only children in the sample. It is recommended that in future studies, follow-up courses be used to assess sustainability of the trainings, i.e. the effectiveness of treatment over time, also different levels of deafness be examined individually. It is also suggested that the effectiveness of this treatment be compared with other treatments and trainings.

Conclusion
The current research shows the strong link between phonological awareness and reading success. According to the findings, phonological awareness training improves reading skill in hearing impaired primary school children.