Clinical analysis of 228 patients with pulmonary fungal diseases i

Clinical analysis of 228 patients with pulmonary fungal diseases
in China
Abstract
Background: Due to the lack of specific clinical manifestations
and imaging features, the diagnosis of pulmonary fungal
diseases is difficult. This study aims to investigate the clinical
features of pulmonary fungal diseases.
Methods: We retrospectively analyzed the demographics, types
of fungus,radiological characteristics,underlying diseases, the
usage of steroid and immunosuppresants, laboratory tests of
228patients with pulmonary fungal disease diagnosed by
pathological examination or laboratory culture from October
2011 to July 2018in Tongji Hospital Affiliated to Tongji
Medical College of Huazhong University of Science and
Technology.
Results: A total of 228 patients, had a median age of 49years,
which included 130 (57%) males and 98(43%) females. The
most common fungal species identified were aspergillus (39.5
%), cryptococcus (18.4%), and mucormycosis (3.5 %).The main
imaging findings were nodules or mass in 144 patients (63.2%),
cavitation in 57 patients (25%),consolidation shadows or ground
glass infiltrates in 15 patients (6.6%), and reverse halo sign in
12 patients (5.3%). The main infection sites were right upper
lobe (26.8%), right lower lobe (21.5%) and the bronchus
infection were 18 (7.9%) persons. For the underlying diseases,
the prevalence of diseases was pulmonary tuberculosis (17.5%),
bronchiectasis (16.2%), diabetes mellitus (9.2%) and the
previous thoracic malignancy (6.6%) was common. The number
of patients using steroid was 50% and the number of patients
using immunosuppressant was 7%.

Conclusions: The imaging findings and the underlying diseases
of patients should be taken into account when making diagnosis
of pulmonary funga1disease for the purpo se to speculate the
probable fungal pathogen and choose the most appropriate
diagnostic tool.
Keywords:Pulmonary fungal disease; pathogen; imaging
manifestation; Underlying disease; Clinical analysis; Chinese
(pneumomycosis; pulmonary mycosis?)invasive mould infection
(IMI)Invasive fungal infections (IFIs),invasive aspergillosis
invasive mold disease, invasive aspergillosis, diabetes mellitus.
1. INTRODUCTION
In environment, the fungi produce small spores that are
routinely inhaled and rapidly cleared from the normal host.
However after long standing inhalation makes people more
vulnerable to get effected .Moreover pulmonary fungal diseases
are an opportunistic infection that predominantly attacks
immunocompromised just as immunocompetent patients,
however extensive utilization of gluccocorticoids and
chemotherapeutics utilizes in patients make the pulmonary
fungal disease no longer an uncommon occurrence. The complex
underlying conditions such as pulmonary tuberculosis,
bronchectasis, COPD and diabetes mellitus in the patients of
pulmonary fungal disease and the non-specific nature of
pathogen can confound identification and lead to under
diagnosis. Due to its vague nature the diagnosis of pulmonary
fungal disease has naturally received the greatest attention.
Therefore, we sought to gain a better understanding of clinical
features of pulmonary fungal disease in China.

2. METHODS
2.1 Study design
A retrospective cohort study was conducted by reviewing the
medical records of patients who had been diagnosed with
pulmonary fungal disease, verified by pathological examination
or histological culture, over a period of 7 years (October 2011
to July 2018) at a university teaching hospital with the aim of
investigating the demographics, types of fungus, sites of
infection, radiologic features, underlying diseases, laboratory
investigations, in addition to the information on steroid and
immunosuppressive medications. Laboratory examinations
including white blood cell (WBC) count, lymphocyte,
neutrophils, albumin, globulin and hemoglobin. The Ethical
Review Committee of Tongji Hospital Affiliated to Tongji
Medical College of Huazhong University of Science and
Technology approved the study.
2.2 Study subjects
Definite(proven) case of pulmonary fungal disease requires
hist0opathological examination or histological culture, and the
case files of patients with evidence of mould infection (e.g.,
hyphae seen on smears, positive culture for a mould) were then
assessed for eligibility within the study. (PFD was defined and
categorized into proven, probable and possible based) All cases
were diagnosed according to the 2008 European Organization
for the Research and Treatment of Cancer/Invasive Fungal
Infections Cooperative Group and the National Institute of
Allergy and Infection Diseases Mycoses Study Group definition
criteria.(or ISDA).
The information about the types of fungus came from the
histopathological examination, as well as fungi culture and
other indirect tests of fungal antigens (galactomannan test),
obtained from various samples, such as biopsy

sample，bronchoalveolar lavage fluid. and sputum.
The infection sites were verified mainly by the puncture site of
pathological biopsy, and two authors also manually screened the
CT images for additional information.
For microbiology data as a source, appropriate laboratory
records were reviewed.
For histopathology, case records of patients with
histology/cytology showing septate hyphae invading tissue were
reviewed to assess eligibility within the study.
Patients were excluded if :1) incompletely recorded data; 2)
lacking inclusion criteria;
3) With lung tumor simultaneously; 4)they had endemic
mycoses (e.g. histoplasmosis), sporotrichosis, penicilliosis,
yeast infections, allergic fungal diseases like allergic
bronchopulmonary aspergillosis, or infection limited to the skin
or eye.
2.3 Assessments
For outcomes analyses,objective to analyze the clinical
manifestations of pulmonary fungal disease in patients with
different underlying diseases and different immune state, we
divided patients into 3 groups. Patients with following
underlying diseases were considered with destruction of lung
structure (group A): pulmonary tuberculosis, bronchiectasis,
previous thoracic malignancy, history of thoracic operation, and
the group B were patients with at least one of the following
factors, that were considered immunocompromised: a history of
immunosuppressive drugs (including corticosteroids), sever
diabetes mellitus with associated organ damage, organ
transplantation or hematopoietic stem cell transplantation,
malignant cancer being on chemotherapy or radiotherapy. If
patients had both A and B factors, it was classified as group C.
Otherwise, the patients without any of these factors were
defined as group D.

2.4 Statistical Analysis
Categorical variables were compared using the Chi- square test
or Fisher’s exact test and continuous variables with t test or
Kruskal-Wallis K sample test where appropriate. Statistical
analysis was executed with SPSS version 25.0 statistical
analysis software. All tests used were two-tailed, and statistical
significance was defined as a P value＜0.05.
3. RESULTS
3.1General data
Two hundred and twenty-eight patients were diagnosed with
pulmonary fungal diseases during the 7-year period between
2011 and 2018. The patients had a median age of 49 years,
which included 130 (57.0%) males and 98 (43.0%) females.
Clear pathogen infection was performed in 155(68.0%) patients.
The identified pathogens included aspergillus (39.5 %),
cryptococcus (18.4%), mucor (3.5 %), coccidioides(2.2%),
candida(1.8%), histoplasma (1.3%) and actinomyces(1.3%).
Chest computed tomography (CT) was performed in 190 (83.3
%) patients before diagnosis of pulmonary fungal infections,
which gave us the required evidence to evaluate the radiological
characteristics of pulmonary fungal infection. Among the 190
patients with CT images, the most frequently observed CT
abnormality was nodules or mass in 144 patients (63.2%),
cavitation in 57 patients (25%), consolidation shadows or
ground glass infiltrates in 15 patients (6.6%), and reverse halo
sign in 12 patients (5.3%).
The main infection sites were right upper lobe (26.8%), right
lower lobe (21.5%), Left upper lobe (14.5%), Left lower lobe
(16.7%) and the bronchus infection were 18 (7.9%) persons. The
numbers of other sites were 9(3.9%), including multiple lung
lobes (8, 3.5%) and pleura (10.4%).
For the underlying diseases, pulmonary tuberculosis (17.5%)
was most dominant followed by bronchiectasis (16.2%),
diabetes mellitus (9.2%), and the previous thoracic malignancy
(6.6%) was common. Treatment with glucocorticoids were

recorded in 114 (50.0%) and the number of the usage of
immunosuppressant such as cyclosporine and azathioprine was
16(7%). A total of 12 patients were administrated
glucocorticoids concomitantly with immunosuppressant.
Of the 228 patients, 195 patients had a clear pathological biopsy
approach. There were 138 patients had pneumonectomy, 36
patients performed transbronchial lung biopsy and 21 patients
underwent percutaneous pulmonary biopsy.
The baseline data are given in Table 1.
TABLE 1 Characteristics of the study participants
Characteristicsa
Total (n =228)
Demographic characteristic
Age, years (Mean±SD)
49.39±12.95
Sex
Male
130（57）
Female
98（43）
Types of fungus
Aspergillus
90(39.5)
Cryptococcus
42(18.4)
Mucormycosis
8(3.5)
Coccidioides(EndemicMycosis)
5(2.2)
Candidiasis
4(1.8)
Histoplasma (EndemicMycosis)
3(1.3)

Actinomyces(not confirmed fungi)
3(1.3)
Unidentified
73(32)
Radiologic findings
Nodule or Mass
144（63.2）
Cavitation
57（25）
Consolidation, Ground glass infiltrates
15（6.6）
Reverse halo sign
12（5.3）
N/A
38（16.7）
Anatomical region
Bronchus
18(7.9)
Lung lobe
Right upper lobe
61(26.8)
Right middle lobe
13(5.7)
Right lower lobe
49(21.5)
Left upper lobe
33(14.5)
Left lower lobe
38(16.7)
Others Metastasize(which organ)
9(3.9)
Missing
7(3.1)

Underlying diseases b
Bronchiectasis
37（16.2）
Diabetes mellitus
21（9.2）
COPD
6（2.6）
Pulmonary tuberculosis this is not mentioned a lot in previous
studies
40（17.5）
Previous thoracic malignancy
15（6.6）
History of thoracic surgery
9（3.9）
Previous extrathoracic malignancy
7（3.1）
Steroid use c
114（50）
Immunosuppresants used
16（7）
Laboratory tests, (Mean±SD)(Mean value is in mg/l)
White blood cell (μl)
9.72±4.92
Lymphocyte (×10*9/L)
1.35±1.17
Neutrophil (×10*9/L)
8.62±9.68
Albumin, g/dL
38.22±5.14
globulin, g/dL
28.97±6.23
Hemoglobin, g/dL
123.72±20.83
a Data is represented as n (%) or as the mean ± standard

deviation
b Some patients had more than 1 underlying medical problem.
c Prolonged Steroid Used-At a mean minimum dose of 0.3
mg/kg/day of prednisone equivalent for > 3 weeks.(≥3 weeks in
past 60 days)
dImmunosuppressants include methotrexate, cyclosporin,
azathioprine, cyclophosphamide, tacrolimus, mizoribine,
occurring in the past 90 days.
COPD, Chronic obstructive pulmonary disease
3.2 Differences between bronchus and non-bronchus infections
A comparison of patients with infection of bronchus and those
without infection of bronchus is shown in Table 2.Due to a lack
of the site of pathological examination, 7 cases (1 pulmonary
aspergillosis patient, 3 pulmonary cryptococcosis patients, and
3 other pulmonary fungal infection patients) were not involved.
Among the 221 patients, 18 in the trachea group and 203 in the
non-trachea group. The mean age of the patients with infection
of trachea was 51.06±18.34 years, older than non-bronchus
group (P = 0.013). The types of fungus showed no difference
overall, but further investigation found aspergillus (P = 0.033)
and cryptococcosis (P = 0.021) were more inclined to present in
non-bronchus group.
For the predisposing factors, underlying diseases of previous
extrathoracic malignancy seemed that had a higher probability
of infecting the bronchus (P = 0.001). And the blood routine
tests suggested lower hemoglobin (P = 0.016) and neutrophil
percentage (P = 0.024) in the bronchus group.
The radiological presentations were non-specific in the different
groups, as well as the information on steroid and
immunosuppressive medications.
TABLE 2 Clinical manifestations (Features)of infection of
trachea

Characteristicsa
Bronchus
(n=18)
non- Bronchus
(n = 203)
P value
51.06±18.34
49.17±12.88
0.013*
Sex
P＞0.05
Male
11（61.1）
114（56.2）
Female
7（38.9）
89（43.8）
Types of fungus
Aspergillus
12(85.7)
77（56.2）
0.033*
Cryptococcus
0

39（28.5）
0.021*
Mucormycosis
1(7.1)
7（5.1）
P＞0.05
Coccidioides
0
5（3.6）
P＞0.05
Candidiasis
1(7.1)
3（2.2）
P＞0.05
Histoplasma
0
3（2.2）
P＞0.05
Actinomyces
0
3（2.2）
P＞0.05
Underlying diseasesb
Bronchiectasis
1（5.6）
35(17.2)
P＞0.05
Diabetes mellitus
3（16.7）
18(8.9)
P＞0.05
COPD
2（11.1）

4(2)
P＞0.05
Pulmonary tuberculosis
1（5.6）
38(18.7)
P＞0.05
1（5.6）
14(6.9)
P＞0.05
History of thoracic operation
0
9(4.4)
P＞0.05
4（22.2）
3(1.5)
0.001*
Steroid usec
7（38.9）
104(51.2)
P＞0.05
3（16.7）
12(5.9)
P＞0.05
Laboratory tests, (Mean±SD)
7.25±3.96
10.1±4.94
P＞0.05
1.15±0.48

1.37±1.23
P＞0.05
5.48±3.62
9.08±10.11
P＞0.05
Albumin, g/dL
34.94±6.22
38.59±4.81
P＞0.05
globulin, g/dL
30.79±7.99
28.65±5.59
P＞0.05
Hemoglobin, g/dL
114.5±29.47
125.42±18.51
0.016*
aData are represented asn (%) or as the mean ± standard
deviation
bSome patients had more than 1 underlying medical problem.
cAt a mean minimum dose of 0.3 mg/kg/day of prednisone
equivalent for > 3 weeks.
*P ＜0.05
3.3 Differences between the different type of fungal
As the research above shows, the chief type of fungal were
aspergillosis (n = 90), cryptococcosis (n = 42) and
mucormycosis(n = 8). Then an analysis was performed to
examine the differences between 3 types of fungi (Table 3).
Among the 140 patients, radiologic findings that nodule or mass

(P<0.05) and cavitation (P =0.041) showed different distribution
in 3 groups.And the lobar distribution of infection site showed
difference (P<0.05). As the underlying diseases,pulmonary
tuberculosis(P =0.021), bronchiectasis(P =0.005), and diabetes
mellitus(P =0.013) were more inclined to occur in aspergillosis
group, what means that aspergillus largely infected persons with
those diseases.what's more, the lowest hemoglobin values(P
=0.002) and albumin values(P =0.008) were more likely to
occur in the group of mucormycosis.
There were no statistically significant differences between the
subgroups with 3 types of fungi cases with regard to the
information on steroid and immunosuppressive medications.
TABLE 3Clinical manifestationsFeatures of 3 types of fungi
Characteristics(n=140) a
Aspergillosis (n=90)
Cryptococcosis (n = 42)
Mucormycosis (n=8)
P value
50.57±12.75
44.13±19.4
44.13±19.4
P＞0.05
Sex
P＞0.05

Male
47（52.2）
27（64.3）
5（62.5）
Female
43（47.8）
15（35.7）
3（37.5）
Radiologic findings
Nodule or Mass
53(72.6)
34(94.4)
2(28.6)
P<0.05*
7(9.6)
2(5.6)
1(14.3)
P＞0.05
Cavitation
23(31.5)
8(22.2)
5(71.4)
0.041*
Reverse halo sign
8(11)
0
0
P＞0.05
Infection site

P<0.05*
Bronchus
12（13.5）
0
1(12.5)
Lung lobe
Right upper lobe
29(32.6)
5(12.8)
2(25)
Right middle lobe
4（4.5）
1(2.6)
0
Right lower lobe
12（13.5）
13(33.3)
0
Left upper lobe
18（20.2）
3(7.7)
0
Left lower lobe
13（14.6）

15(38.5)
1(12.5)
Others(Multiple Lobes or burst)
1（1.1）
2(5.2)
4(50)
Bronchiectasis
21(23.3)
1(2.4)
1(12.5)
0.005*
Diabetes mellitus
8(8.9)
5(11.9)
4(50)
0.013*
COPD
5(5.6)
0
1(12.5)
P＞0.05
21(23.3)
3(7.1)
3(37.5)
0.021*
7(7.8)
2(4.8)

0
P＞0.05
History of thoracic operation
5(5.6)
0
1(12.5)
P＞0.05
1(1.1)
1(2.4)
0
P＞0.05
Steroid usec
46(51.1)
16(38.1)
6(75)
P＞0.05
5(5.6)
5(11.9)
1(12.5)
P＞0.05
9.71±4.86
9.42±4.7
10.46±4.8
P＞0.05
1.24±0.77
1.77±2.24
1.63±0.79

P＞0.05
8.68±10.17
8.3±9.35
8.05±5.08
P＞0.05
Albumin, g/dL
38.01±5.09
40.18±5.03
35.09±4.24
0.008*
globulin, g/dL
28.28±5.59
28.04±4.28
35.52±7.61
P＞0.05
Hemoglobin, g/dL
118.93±21.9
132.23±20.16
115.75±19.9
0.002*
aData represented as n (%) or as the mean ± standard deviation
*P ＜0.05
3.4 Differences between the different underlying diseases
It showed that aspergillus (P =0.004) and cryptococcus (P
=0.004) largely infected those patients with destruction of lung

structure and/or immunocompromised, and nodule or mass (P
=0.001) was mostly found in healthy individuals without
underlying disease. what is more, the laboratory tests pointed
out those patients with destruction of lung structure and
immunocompromised had the lowest lymphocytes percentage (P
=0.018) and the highest neutrophilic granulocyte percentage(P
=0.017).
TABLE 4Clinical manifestations of the underlying diseases
(Patients characteristic)
Characteristicsa
(n=228)
group A
(n=34)
group B
(n=72)
group C
(n=52)
group D
(n=70)
P value
47.41±16.87
47.14±13.83
51.73±10.09
50.96±11.34
P＞0.05

Sex
P＞0.05
Male
20(58.8)
42(58.3)
29(55.8)
39(55.7)
Female
14(41.2)
30(41.7)
23(44.2)
31(44.3)
Types of fungus
Aspergillus
17（85）
23（48.9）
26（72.2）
24（46.2）
0.004*
Cryptococcus
1（5）
15（31.9）
5（13.9）
21（40.4）
0.004*

Mucormycosis
0
3（6.4）
4（11.1）
1（1.9）
P＞0.05
Coccidioides
0
1（2.1）
0
4（7.7）
P＞0.05
Candidiasis
1（5）
3（6.4）
0
0
P＞0.05
Histoplasma
1（5）
1（2.1）
0
1（1.9）
P＞0.05
Actinomyces
0
1（2.1）
1（2.8）
1（1.9）
P＞0.05
Radiologic findings

Nodule or Mass
23（74.2）
45（76.3）
25(56.8)
51(91.1)
0.001*
Consolidation
2(6.5)
4(6.8)
5(11.4)
4(7.1)
P＞0.05
Cavitation
11(35.5)
18(30.5)
18(40.9)
10(17.9)
P＞0.05
Reverse halo sign
3(9.7)
5(8.5)
3(6.8)
1(1.8)
P＞0.05
Lobar distribution
P＞0.05
Bronchus
2(6.1)
6(8.6)
1(2)
9(13.4)

Lung lobe
Right upper lobe
13（39.4）
17(24.3)
15(29.4)
16(23.9)
Right middle lobe
0
4(5.7)
4(7.8)
5(7.5)
Right lower lobe
7(21.2)
13(18.6)
8(15.7)
21(31.3)
Left upper lobe
5（15.2）
15（21.4）
8（15.7）
5（7.5）
Left lower lobe
6（18.2）
12（17.1）
11（21.6）
9（13.4）

Others
0
3(4.3)
4(7.8)
2(3)
7.94±3.96
10.2±4.95
10.63±5.11
9.38±5.02
P＞0.05
1.34±0.69
1.24±0.77
1.36±2.03
1.46±0.76
0.018*
5.92±4.13
9.09±7.92
10.15±12.67
8.26±10.5
0.017*
Albumin, g/dL
39.35±5.36
38±4.99
37.98±4.4
38.1±5.74
P＞0.05

globulin, g/dL
28.89±7.98
29.76±6.39
27.86±5.21
29.01±5.88
P＞0.05
Hemoglobin, g/dL
124.39±22.48
123.01±22.43
122.58±14.91
125.01±22.42
P＞0.05
aData are represented as n (%) or as the mean ± standard
deviation
*P ＜0.05
3.5 Differences between lobe infections
An analysis was performed to examine the differences between
different lobe infections (Table 3). Among the 194 patients,
right upper lobe (61, 31.4%) was the most likely to occur
pulmonary fungal diseases, followed by right lower lobe (49,
25.3%), left lower lobe (38, 19.6%).And the site with the lowest
probability was right middle lobe (13, 6.7%).
For the types of fungus, the number of unidentified fungus were
64, of the 130 patients that had a clear fungal type, the data
were statistically significant (P< 0.05), and further analysis
found that aspergillus (P =0.001), cryptococcus(P =0.001) and
coccidioides(P< 0.05) had a different probability of infection in
different lung lobes.
For the underlying diseases, bronchiectasis (P =0.025) and
diabetes mellitus (P =0.004) may attributable to the different
pulmonary lobe infections.

TABLE 5Clinical manifestations of infection of different lobe
Characteristicsa
n=194
Left upper lobe
(n=33)
Left lower lobe
(n=38)
Right upper lobe
(n=61)
Right middle lobe
(n=13)
Right lower lobe
(n=49)
P value
47.88±16.74
48.95±11.67
51.35±12.64
50.38±8.27
48.43±11.68
0.639
Sex
0.386
Male

17(51.5)
21(55.3)
35(57.4)
4(30.8)
30(61.2)
Female
16(48.5)
17(44.7)
26(42.5)
9(69.2)
19(38.8)
Types of fungus
Aspergillus
18(81.8)
13(43.3)
29(74.4)
4（50）
12（38.7）
0.001*
Cryptococcus
3（13.6）
15（50）
5（12.8）
1（12.5）
13（41.9）
0.001*
Mucormycosis
0

1（3.3）
2（5.1）
0
0
P＞0.05
Coccidioides
0
0
0
3（37.5）
2（6.5）
＜0.05*
Candidiasis
0
1（3.3）
0
0
2（6.5）
P＞0.05
Histoplasma
1（4.5）
0
0
0
2（6.5）
P＞0.05
Actinomyces
0
0
3（7.7）
0
0
P＞0.05
Radiologic findings

Nodule or Mass
21(67.6)
25(78.1)
41(73.2)
9(81.8)
39(86.7)
P＞0.05
1(3.2)
4(12.5)
6(10.7)
1(9.1)
1(2.2)
P＞0.05
Cavitation
11(35.5)
10(31.3)
17(30.4)
2(18.2)
10(22.2)
P＞0.05
Reverse halo sign
3(9.7)
1(3.1)
5(8.9)
0
3(6.7)
P＞0.05

5(15.2)
7(18.4)
16(26.2)
1(7.7)
6(12.2)
P＞0.05
Bronchiectasis
8(24.2)
13(34.2)
7(11.5)
2(15.4)
5(10.2)
0.025*
Diabetes mellitus
7（21.2）
5（13.2）
4(6.6)
0
0
0.004*
1(3)
2(5.3)
5(8.2)
1(7.7)
5(10.2)
P＞0.05
History of thoracic Surgery
1(3)
0
3(4.9)
0

4(8.2)
P＞0.05
0
2(5.3)
0
0
1(2)
P＞0.05
COPD
1(3)
0
1(1.6)
0
1(2)
P＞0.05
Steroid usec
21(63.6)
19(50)
29(47.5)
8(61.5)
20(40.8)
P＞0.05
2(6.1)
2(5.3)
2(3.3)
1(7.7)
4(8.2)
P＞0.05

11.12±4.79
10.18±4.96
8.8±4.73
10.46±4.4
10.65±4.96
P＞0.05
1.18±0.78
1.73±2.37
1.18±0.57
1.08±0.64
1.53±0.85
P＞0.05
9.21±5.12
9.87±14.56
7.04±4.91
14.39±21.45
9.47±8.89
P＞0.05
Albumin, g/dL
38.81±3.95
39.45±4.88
38.19±4.66
38.26±3.92
38.52±5.78
P＞0.05
globulin, g/dL
27.50±4.25
28.76±6.00
29.42±5.83
29±5.73
28.42±6.24
P＞0.05

Hemoglobin, g/dL
124.36±14.74
129.08±17.62
123.44±21.16
124.23±15.41
127.75±17.48
P＞0.05
aData is presented as n (%) or as the mean ± standard deviation
*P ＜0.05
4. DISCUSSION(From here on delete)
Several observations from our study have relevant implications
with regards to pulmonary fungal disease.
As expected, Aspergillus spp. (39.5%) were responsible for the
majority of pulmonary fungal disease, followed by cryptococcus
(18.4%), mucor (3.5 %), and coccidioides (2.2%). This rate is
similar to the frequency of
This has been noted previously and may related to
Some radiologic features might be indicative of the possibility
of a pulmonary fungal infection. Radiographic signs and
patterns, their specific imaging features and possible

association with certain pulmonary fungal infections are
described in Table 1. Consolidation is one of the more common
radiologic manifestations of a pulmonar y infection. However,
none of these patterns are specific for fungal infections in
general or for any particular fungus and can be seen in other
diseases.In our study,the most frequently observed CT
abnormality was nodules or mass (63.2%), cavitation (25%) ,
consolidation shadows or ground glass infiltrates (6.6%), and
reverse halo sign (5.3%).And the main infection sites were right
upper lobe (26.8%) and right lower lobe (21.5%). Fungal
infections are an important consideration in the differential
diagnosis of necrotizing and non-necrotizing granulomatous
inflammation in the lung. However, fungal infections are not
always associated with granulomatous disease, especially in the
immunocompromised host, or in small biopsies, where
granulomas might not have been sampled.
A key finding from the present work was that pulmonary
tuberculosis wasan important underlying condition, found in
17.5% of the subjects in this study. Previous reports have also
noted this link.Furthermore,
It suggests that DM and rheumatol ogic conditions be considered
as risk factors for pulmonary fungal infection and demonstrates
that pulmonary fungal infection should not be ruled out in
patients whose chest features on CT do not fit the conventional
criteria.(not for real use in article just an assumption)
Previous reports have also noted this link.
5. CONCLUSION
There are some limitations to this study. First,ours was a non-
interventional study and lack of attributing symptom and

treatment outcomein patients with pulmonary
fungaldisease.Second,we collected data only for patients with
pulmonary fungaldisease and not for those without fungal
infections, thus, we were unable to calculate the attributable
risk for mortality due to pulmonary fungaldisease, which would
have been a novel result from the current study. In addition, the
single-center study may not be sufficient,further evaluation in a
multi-center, prospective, randomized controlled study is
required.
Despite these limitations, this study provides a valuable insight
into
ACKNOWLEDGMENTS
REFERENCES
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Exploration of a Blended Learning Approach to
Reading Instruction for Low SES Students in Early
Elementary Grades

Rachel Schechter, Paul Macaruso, Elizabeth R. Kazakoff &
Elizabeth Brooke
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10.1080/07380569.2015.1100652
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Computers in the Schools, 32:183–200, 2015
Published with license by Taylor & Francis
ISSN: 0738-0569 print / 1528-7033 online
DOI: 10.1080/07380569.2015.1100652
Exploration of a Blended Learning Approach
to Reading Instruction for Low SES Students in
Early Elementary Grades
RACHEL SCHECHTER
Lexia Learning, A Rosetta Stone Company, Concord,
Massachusetts, USA
PAUL MACARUSO
Community College of Rhode Island, Warwick, Rhode Island,
USA
ELIZABETH R. KAZAKOFF and ELIZABETH BROOKE
Lexia Learning, A Rosetta Stone Company, Concord,
Massachusetts, USA

This study investigated the potential benefits of a blended
learning
approach on the reading skills of low socioeconomic status
students
in Grades 1 and 2. Treatment students received English
language
arts instruction that was both teacher-led and technology-based.
Comparisons were made with control students who received the
same English language arts instruction without the blended
learn-
ing component. Results showed significantly greater
pretest/posttest
gains on a standardized reading assessment for the treatment
students compared to the control students. The greatest discrep-
ancy occurred in reading comprehension. A sub-analysis of low-
performing English language learner students in the treatment
group revealed the largest reading gains. At posttest, these
students
performed at the level of non-English language learner students
in
the control group. Results indicated a blended learning approach
can be effective in enhancing the reading skills of low socioeco-
nomic students.
© Lexia Learning, A Rosetta Stone Company.
This is an Open Access article. Non-commercial re-use,
distribution, and reproduction
in any medium, provided the original work is properly
attributed, cited, and is not altered,
transformed, or built upon in any way, is permitted. The moral
right of the named author(s)
have been asserted.
This research was funded by Lexia Learning, A Rosetta Stone
Company. The researchers

would like to thank the research associates at Lexia Learning,
Carrie Moran and Jordan Jacobs,
as well as the teachers, students, and staff at the elementary
school in Massachusetts.
Address correspondence to Elizabeth R. Kazakoff, Lexia
Learning, A Rosetta Stone Com-
pany. E-mail: [email protected]
183
184 R. Schechter et al.
KEYWORDS reading, blended learning, low SES, technology,
En-
glish language learners
The National Institutes of Health have long recognized high
illiteracy
rates among elementary school children. According to The
National Center
for Education Statistics’ (2011) Nation’s Report Card (2011),
data indicate
that 34% of fourth graders read below a basic level on tests of
reading skills
and more strikingly, around 50% of Black and Latino students
read below a
basic level. Students who were eligible for free/reduced lunch
and/or were
English language learners (ELLs) were also more likely to be
low performers
on reading assessments. Reading comprehension has long been
identified as
an essential component of reading success (National Reading
Panel, 2000)

and becomes increasingly more important as children move into
the upper
elementary grades and beyond. In addition, early identification
of reading
difficulty is critical and most children who have not received
quality reading
intervention by Grade 3 never catch up with their typically
achieving peers
(Torgesen, Rashotte, & Alexander, 2001). Given the severity of
these literacy
problems, there is a need for more research on interventions to
improve
reading skills, including reading comprehension, particularly in
the early
elementary grades (Toste et al., 2014).
Historically, computer-assisted instruction (CAI) has been
found to be
a valuable supplementary aid to support reading acquisition,
particularly for
struggling students (see MacArthur, Ferretti, Okolo, & Cavalier,
2001). CAI
allows students to work at their own pace so that they can
receive sufficient,
independent practice that may not be possible within a
traditional classroom
setting (Johnson, Perry, & Shamir, 2010). Individualized
instruction, together
with use of pictorial displays and consistent, positive feedback
provided by
CAI, is often highly effective and motivating (Saine,
Lerkkanen, Ahonen,
Tolvanen, & Lyytinen, 2011).
A meta-analysis by Cheung and Slavin (2013) investigated the
use of CAI

for struggling readers. Overall, a small, positive effect of CAI
on acquisition
of reading skills was found (effect size = .14). The largest
effect sizes were
obtained in small-group studies, while comprehensive models
produced the
smallest effect sizes. Based on this analysis, additional studies
on CAI and
reading are needed in order to validate the effectiveness,
generalizability,
and areas of impact of these interventions (see Chambers et al.,
2008).
Most previous research on CAI in elementary grades has
focused on
early reading skills. For instance, a number of studies have
examined the ef-
fects of CAI on phonological awareness. Positive effects have
been reported
for students in general (Cassady & Smith, 2004; de Graaff,
Bosman, Hassel-
man, & Verhoeven, 2009; Macaruso & Rodman, 2011b; Savage
et al., 2013;
Segers & Verhoeven, 2005; Wild, 2009), as well as for students
identified as at
risk or low performers (Hecht & Close, 2002; Lonigan et al.,
2003; Macaruso
& Walker, 2008; Mitchell & Fox, 2001; Mioduser, Tur-Kaspa,
& Leitner,
Blended Learning Approach to Reading 185
2000). In addition to phonological awareness, some studies have
found evi-

dence that CAI benefits acquisition of word attack (i.e., letter-
sound) knowl-
edge (Macaruso, Hook, & McCabe, 2006; Segers & Verhoeven,
2005), word
identification skills (Hecht & Close, 2002; Macaruso &
Rodman, 2011b; Saine
et al., 2011; Shelley-Tremblay & Eyer, 2009; van Daal &
Reitsma, 2000), and
rapid naming/word fluency (Johnson, Perry, & Shamir, 2010;
Saine et al.,
2011).
Relatively few studies have investigated the benefits of CAI for
read-
ing comprehension, particularly in the early elementary grades.
Studies ad-
dressing reading comprehension have typically utilized a
blended learn-
ing approach that includes intensive intervention programs that
incorporate
teacher-led instruction along with CAI. A blended learning
approach is de-
fined by a student learning, in part through a self-controlled
digital con-
tent delivery method, combined with traditional, teacher-led
instruction in
a classroom setting (Staker & Horn, 2012). In one study
Chambers et al.
(2008) used Success for All with first graders who were non-
native speakers
of English and from low socioeconomic status (SES) families.
Success for
All is a year-long program with over 100 minutes per day of
instruction, in-
cluding whole class lessons, computer-assisted tutoring groups,
multimedia

activities, and individual daily tutoring. Students in the
intervention program
were found to make significant gains in word attack, word
identification,
passage-level fluency, and reading comprehension. Similar
outcomes were
reported by Torgesen, Wagner, Rashotte, Herron, and
Lindamood (2010) us-
ing two computer-based intervention programs—Read Write and
Type and
Lindamood Phoneme Sequencing—with at-risk first graders.
The year-long
programs included four 50-minute sessions per week of small
group instruc-
tion with teachers recruited and trained to implement the
interventions. Sig-
nificant effects of the interventions were found in phonological
awareness,
word attack, rapid naming, word identification, and reading
comprehension
(see also Cassady & Smith, 2005; but see Paterson, Henry,
O’Quin, Ceprano,
& Blue, 2003, for an exception).
In the current study, we examined the efficacy of a blended
learning
approach for children in early elementary grades as compared to
control
students. Like Chambers et al. (2008), this study considered
students from
low-SES families, including ELL students. In conducting this
study, we as-
sessed the benefits of blended learning in the context of a
typical daily
classroom schedule, which closely reflected authentic use
patterns found in

school-based implementations.
THE BLENDED LEARNING APPROACH
The blended learning approach in the current study integrated
Lexia Read-
ing Core5 (Core5) into the school’s basic curriculum for
English language
arts (ELA) instruction. The curriculum, LEAD21 (Wright
Group, n.d.), is a
comprehensive program for kindergarten through Grade 5 that is
aligned
with Common Core State Standards (National Governors
Association for Best
Practices & Council of Chief State School Officers, 2010). The
LEAD21 pro-
gram addresses literacy-based skills (phonemic awareness,
phonics, fluency,
vocabulary, language acquisition, comprehension, and writing)
and other
essential 21st-century skills (e.g., communication and
collaboration). Cur-
riculum units rotate through various themes in conjunction with
the larger
areas of humanities, science, and social studies. Readings
assigned in each
grade link multiple topics with a mixture of nonfiction and
fiction texts.
LEAD21 provides Theme Readers and Differentiated Readers in
paper and
ebook format, which can be used with interactive whiteboards.

Recently released in school systems, Core5 integrates online
activities,
ongoing assessment to guide instruction, and targeted resources
for teacher-
led instruction as well as independent offline work. Core5 was
developed
as an enhanced version of an earlier technology-based program
called Lexia
Reading. The earlier program focused strongly on building
phonological
awareness and word attack skills for words in isolation, as well
as in con-
text. Macaruso and Walker (2008) found that Lexia Reading
helped develop
phonological awareness in kindergartners, with the greatest
benefits seen in
students identified as low performers at pretest. Follow -up
studies showed
significant gains in word reading for a larger sample of students
identified
as low performers (Macaruso & Rodman, 2011b), and in both
phonological
awareness and word reading for ELL students (Macaruso &
Rodman, 2011a).
Core5 provides systematic and personalized instruction through
six
strands of reading skills: phonological awareness, phonics,
structural analy-
sis, automaticity/fluency, vocabulary, and comprehension. The
content aligns
with recommendations from the National Reading Panel (2000)
and Com-
mon Core State Standards. Core5 contains activities organized
into 18 levels:

preschool (Level 1), kindergarten (Levels 2–5), first grade
(Levels 6–9), sec-
ond grade (Levels 10–12), third grade (Levels 13–14), fourth
grade (Levels
15–16), and fifth grade (Levels 17–18). Each level consists of
five activities
(four in Level 1) with multiple units designed to address various
combina-
tions of the six strands listed previously. Table 1 provides a
summary of
Core5’s contents by strand.
The student experience begins with an embedded auto-
placement test,
which is used to place students at an initial level consistent with
their reading
ability. For example, a second-grade student may place in any
level, including
Level 6 (below grade level), Level 10 (in grade level) or Level
13 (above
grade level). After completing the auto-placement, students
begin working
on activities within the level where they are placed. Students
progress to
subsequent units and levels only when they demonstrate mastery
of the
content, which is 90%–100% accuracy. However, if students
struggle in a
unit, a system of automatic branching moves them to a
scaffolded practice
TABLE 1 Summary of Core5’s Contents

Strand Content
Phonological awareness Rhyming, blending and segmentin g
syllables and
sounds, manipulating sounds
Phonics Upper- and lower-case letters, alphabetizing,
letter/sound correspondence, six syllable types,
syllable division
Structural analysis Prefixes, roots, and suffixes; spelling rules;
Greek
combining forms
Automaticity/fluency Foundational concepts, high-frequency
words,
paragraph level text
Vocabulary Categorizing, spatial concepts, advanced adjectives,
multiple meanings, shades of meaning, synonyms,
antonyms, similes, metaphors, idioms, analogies, affix
and root meanings
Comprehension Listening comprehension, picturing, signal
words,
strategies for narrative and informational text (main
idea, details, prediction, inferences, conclusion,
cause/effect, compare/contrast, summarizing,
paraphrasing, perspective, fact/opinion)
task with fewer stimuli and more structure. If students continue
to struggle,
they receive direct, targeted instruction that explicitly addresses
the type of
error the student made when attempting to master the reading

skill. After
successful completion of all activities in a level, students are
promoted to
the next level. Motivating visual graphics include progress bars
that fill up
as students successfully complete units within an activity,
allowing students
to monitor their own progress through the program. Core5 also
maximizes
time-on-task by providing immediate feedback after each
response without
distraction or delay.
Teachers have access to online reports that identify students
who are
struggling with a particular skill. Those students are flagged for
individual
or small group instruction. Core5 offers skill-specific materials
called Lexia
Lessons that provide step-by-step instruction following the
gradual release
of responsibility model for a teacher or paraprofessional to
address students’
skills. Upon completion of all units in an activity, students have
access to
Skill Builders—paper and pencil tasks developed to build
automaticity and
extend the skills presented in the activity. Students can
transition between
Lexia Lessons, Skill Builders, and the online program as
directed by the
teacher.
A key component of Core5 is the availability of online reports
that
include actionable data and are updated in real time. One

component of
the online report is monthly Performance Predictors that show
students’
percent chance of reaching end-of-year, grade-level benchmark
(i.e., com-
pleting all activities at the students’ grade level). For each
Performance
Predictor, online reports also present a Prescription of Intensity
(i.e., rec-
ommended weekly minutes of online work) designed to improve
the stu-
dents’ chance of reaching benchmark. For students who need
additional sup-
port to reach benchmark, suggestions and materials for targeted
instruction
are provided. In the current study, we examined the efficacy of
a blended
learning approach, including Core5, for children in early
elementary grades
as compared to control students within the context of a typical
daily class-
room schedule.
METHOD
Participants
The current study was conducted in an urban elementary school
in west-
ern Massachusetts. Students in two first-grade classes and two
second-grade

classes were invited to participate in this study. For each grade,
one class
was randomly assigned to the treatment group and the other
class to the
control group. Teachers in the treatment and control classes had
comparable
qualifications. Three teachers had master’s degrees in education
(one treat-
ment, two control) and one teacher had a Bachelor of Science
degree. The
two treatment teachers had 6 and 12 years of teaching
experience, and the
two control teachers had 9 and 15 years of teaching experience.
There were 47 students in treatment classes and 41 in control
classes.
Of these students, two treatment and three control students were
eliminated
from analyses because they were absent at posttest. The final
sample con-
sisted of 45 treatment students (23 male, 22 female) and 38
control students
(14 male, 24 female). Dates of birth were made available for 30
treatment
and 27 control students. There was no difference (p > .05)
between treatment
and control students in mean age: 86.8 months (SD = 8.6) and
85.7 months
(SD = 9.3) for treatment and controls, respectively. Most
students in each
group were Hispanic: 89% treatment, 82% control. The
remaining students
were Black (9% treatment, 13% control) or White (2%
treatment, 5% con-
trol). Nearly all students (95%) qualified for free or reduced
lunch. Fourteen

treatment and seven control students were classified as Limited
English Pro-
ficiency. For the purpose of this study, these students were
considered ELL.
Due to the additional oral language challenges associated with
ELL students,
separate analyses were conducted for this group. Two treatment
students
received special education services. Results were nearly
identical with the
two special education students in or out of the analyses, so they
remained
in the analyses.
Materials and Procedures
As described previously, both treatment and control classrooms
used LEAD21
as the ELA curriculum. This curriculum had been used at the
school for
three years prior to the study. In LEAD21, concepts, skills, and
strategies
are introduced through whole class instruction, and then
students rotate
through small group instruction and individual activities to
reinforce lessons.
As described above, Core5 includes an online program along
with integrated
teacher-led Lexia Lessons and paper and pencil independent,
student-led
activities (Skill Builders) as appropriate. Teachers took part in a

half-day
orientation session prior to implementation, where they were
trained in best
practices for integrating the online learning and offline
instructional materials
of Core5 into their classroom instruction.
Core5 served as part of the blended learning component of the
ELA
instruction for treatment classes. Each treatment classroom had
six computers
and students used the online program as a center activity
following a rotating
schedule. Teachers were instructed to have students use the
online program
in accordance with recommended minutes (20 to 80 per week,
depending
on risk) based on the Prescriptions of Intensity. Treatment
students began
using Core5 in October 2012 and continued into June 2013.
During the time
when treatment students were using Core5, control students
were engaged
in regular ELA instruction, resulting in all students receiving
150 minutes per
day of ELA instruction.
Over the course of the study, the students in the treatment group
showed
strong use of Core5’s online program: Their average login time
was 85 min-
utes per week. Looking across all student sessions, the
minimum and max-
imum times were 28 and 203 minutes per week, respectively.
These strong
use patterns resulted in over 90% of students meeting usage

recommenda-
tions for at least three months and 62% met usage
recommendations for five
or more months.
As part of ongoing monitoring, two members of the research
team visited
the treatment classes in February 2013 to observe students using
the online
program. During the session, 12 students were observed in each
classroom.
Independent observations were made at two time points in a
session. For the
first-grade class, there was 88% (21/24) agreement across time
points. The
observations agreed upon by both raters were as follows: 15
cases in which
students were engaged with the program, four cases in which
students were
seated but not engaged, and two cases in which students were
not seated.
Raters disagreed on three cases, where students were seated but
it was
unclear if they were engaged with the program. For the second-
grade class
there was 100% (24/24) agreement that all students were
engaged with the
program.
In addition to observations and data analysis, interviews were
conducted
to assess use of Core5 as part of classroom instruction. Both
teachers of the
treatment classes reported that the online program was a key
center activity
and they used the Lexia Lessons when students were struggling

with specific
skills in the online program. The first-grade treatment teacher
said she printed
out lessons (with directions) for parents to use at home. The
Skill Builders
were used as morning activities in the first-grade class and as
homework for
second graders. The second-grade teacher reported that when all
students
had mastered a skill in the online activities, she used that
information to
direct her whole class instruction to other skill areas.
Measures
The Group Reading Assessment and Diagnostic Evaluation
(GRADE), Level
1 (first grade) or Level 2 (second grade) (Williams, 2001) was
administered
to treatment and control students as a pretest in September 2012
and as a
posttest in May 2013. Separate forms of the GRADE were used
at pretest and
posttest. Both levels of this assessment contain two domains:
Vocabulary and Comprehension. The Vocabulary domain
consists of
two subtests—Word Reading and Word Meaning. On Word
Reading, the
student hears a word spoken by the tester (e.g., “here”) and is
asked to

select one of four words (e.g., have, had, here, he) that matches
the spo-
ken word. This subtest contains 20 items in Level 1 and 28
items in Level
2. On Word Meaning, the student sees a word (e.g., drum) and
selects
one of four pictures that represents the meaning of the word
(e.g., gum,
drawer, door, drum). This subtest contains 27 items in both
Level 1 and
Level 2.
The Comprehension domain consists of two subtests—Sentence
Com-
prehension and Passage Comprehension. Sentence
Comprehension requires
the student to read a sentence silently (e.g., Paul had five
______________ in
his pocket.) and select one of four words (e.g., shiny, minutes,
money,
pennies) that best completes the meaning of the sentence. This
subtest
contains 19 items in both Level 1 and Level 2. On Passage
Comprehen-
sion, the student reads a passage silently and then answers three
ques-
tions (Level 1) or four questions (Level 2) about the passage.
Questions
are presented in a four-choice format and the passage remains in
view
while the student answers the questions. The questions address
factual in-
formation, identifying the gist of the passage, and making
inferences from
the passage. This subtest contains 24 items in Level 1 and 28
items in

Level 2.
The GRADE was administered to each class in two sessions in
accor-
dance with test guidelines. Each session lasted between 30–45
minutes. The
Word Reading and Sentence Comprehension subtests were given
in the first
session, and the Word Meaning and Passage Comprehension
subtests were
given in the second session.
Raw scores on the Word Reading and Word Meaning subtests
were
added to obtain a Vocabulary Composite score, and raw scores
on the Sen-
tence and Passage Comprehension subtests were added to obtain
a Com-
prehension Composite score. Adding these two composite scores
results in
a Total Test score. The GRADE provides standard scores for the
Total Test
TABLE 2 Advances in Core5 Over the School Year
Placement level
Number of
students
No change
(%)

Advanced to next
grade level of
material (%)
Advanced more
than one grade
level of material
(%)
Two grades below 18 (40%) 0 83 17
One grade below 18 (40%) 17 72 11
In grade level 9 (20%) 22 78 0
score and the composite scores. Separate analyses were
conducted for Total
Test, Vocabulary, and Comprehension composite standard
scores.
RESULTS
The first section examines the extent to which treatment
students advanced
in Core5 over the school year. The second section compares
treatment and
control groups in terms of pretest and posttest scores on the
standardized
assessment, and the third section provides sub-analyses for ELL
students.
Advances in Core5 for Treatment Students
In general, treatment students were able to systematically
complete activities
and advance in Core5 over the school year (see Table 2). Of the
18 students

who started in Core5 two grade levels below their grade in
school (e.g., a
second grader placed in a kindergarten level), 83% advanced to
the next
grade level of material and 17% advanced more than one grade
level of
material over the school year, ending the year in their grade
level of material.
Most of the students (81%) who started one grade level below
or in grade
level were able to advance to the next grade level or beyond.
Overall,
20% of students finished their grade level material and reached
end-of-year
benchmark.
Comparison of Treatment and Control Students
Table 3 presents mean pretest and posttest standard scores on
the GRADE
for the treatment and control groups. Independent t tests showed
that there
were no significant differences between groups at pretest on
Total Test scores
(t(81) = 0.80, p = .43) and for each domain: Vocabulary (t(81) =
0.19, p =
.85) and Comprehension (t(81) = 0.73, p = .47). These results
indicate that
the two groups showed comparable literacy skills prior to
initiation of the
treatment program.
One-sample t tests revealed that both groups showed significant
gains
in Total Test scores: treatment (t(44) = 7.50, p < .01); control
(t(37) = 5.10,

TABLE 3 GRADE Standard Scores for All Students
Treatment
(N = 45)
Control
(N = 38)
Pretest Posttest Pretest Posttest
Mean SD Mean SD Mean SD Mean SD d
Total test 91 17.1 106.6 14 93.9 14.8 102.9 14.1 0.53
Vocabulary 93.7 20.8 105.6 11.4 94.5 16 105.1 12.1 0.09
Comprehension 91.7 13.9 105.9 14.5 93.8 11.9 100.8 15 0.52
p < .01). However, the extent of gain was larger for the
treatment group
(15.6) than the control group (9.0). An independent sample t
test showed
that the difference in gain scores favoring the treatment group
was significant
(t(81) = 2.38, p = .02). In addition, an analysis of covariance
comparing Total
Test scores at posttest using Total Test pretest scores as
covariates confirmed
the significant group effect (F (1, 80) = 5.23, p = .03). An effect
size of .53
was obtained when comparing mean gain scores for the two
groups. This
effect size is moderate.

One-sample t tests were also used to examine standard score
gains
in each domain separately. The treatment group showed
significant gains
in Vocabulary (t(44) = 4.51, p < .01) and Comprehension (t(44)
=
6.59, p < .01). The control group also showed significant gains
in both
domains—Vocabulary (t(37) = 6.42, p < .01) and
Comprehension (t(37) =
3.24, p < .01). The two groups showed similar gains in
Vocabulary (treat-
ment: 11.9; control: 10.6), whereas gains were greater for the
treatment group
(14.2) than for the control group (7.0) in Comprehension. As
might be ex-
pected, independent sample t tests showed no significant group
difference
in Vocabulary (t(81) = 0.42, p = .67) but a significant group
difference in
Comprehension (t(81) = 2.33, p = .02). Analyses of covariance
comparing
posttest scores using pretest scores as covariates confirmed the
significant
group effect in Comprehension: (F (1, 80) = 4.89, p = .03).
Effect sizes com-
paring mean gain scores for the two groups were .09 and .52 in
Vocabulary
and Comprehension, respectively. While the effect size in
Vocabulary is low,
the effect size in Comprehension is moderate.
Sub-analyses for ELL Students. This section examines the
performance
of ELL students. Table 4 compares GRADE scores for ELL

students in the
treatment group (N = 14) with ELL students in the control group
(N = 7). At
pretest, the Total Test mean scores for both groups were low,
falling more
than one standard deviation below the normed mean (100).
There were no
significant group differences at pretest on Total Test scores
(t(19) = .12, p
= .86) or scores in each domain: Vocabulary (t(19) = .17, p =
.87) and
Comprehension (t(19) = 0.15, p = .88).
TABLE 4 Standard Scores on the GRADE for ELL Students
Treatment (N = 14) Control (N = 7)
Pretest Posttest Pretest Posttest
Mean SD Mean SD Mean SD Mean SD D
Total (N = 21) 82.7 17 102.9 11.8 84.1 16.9 96.3 22.8 0.85
Vocabulary 83.8 15.8 100.4 8.3 82.6 16.1 97.4 13.9 0.21
Comprehension 88.1 12.4 102.4 14.5 89.0 14.2 93.6 23.0 0.75
Significant gains in Total Test scores were found for both ELL
groups:
treatment (t(13) = 8.30, p < .01); control (t(6) = 3.33, p = .02).
The extent
of gain was more dramatic for the treatment group (20.2) than
the control
group (12.2). However, due to low power associated with small
sample sizes,

the difference in gain scores failed to reach significance (t(19)
= 1.88, p =
.08). An effect size of .85 was obtained when comparing mean
gain scores
for the two groups. This effect size is high.
Both ELL groups showed significant gains in Vocabulary. The
treatment
group showed a gain of 16.6 (t(13) = 5.17, p < .01) and the
control group’s
gain was 14.8 (t(6) = 7.45, p < .01). The difference in gain
scores was not
significant (t(19) = 0.37, p = .72). The effect size of .21 in
Vocabulary is low.
In the area of Comprehension, the treatment group show ed a
significant gain
of 14.3 (t(13) = 4.89, p < .01) whereas the control group’s gain
of 4.6 was
not significant (t(6) = 0.81, p = .45). The difference in gain
scores failed to
reach significance due to limited power (t(19) = 1.71, p = .10);
however,
the effect size of .75 in Comprehension falls in the moderate-to-
high range.
Overall, ELL students in the treatment group demonstrated
substantial
gains on the GRADE. Total Test scores improved from more
than one stan-
dard deviation below the normed mean (82.7) to above the
normed mean
(102.9). Figure 1 compares gains made by ELL students in the
treatment
group with non-ELL students in the control group. At pretest,
ELL treatment
students scored significantly below non-ELL control students

(t(43) = 2.82, p
< .01). By posttest, ELL treatment students closed the
performance gap and
showed nearly identical scores to non-ELL control students
(t(43) = 0.39,
p = .70).
DISCUSSION
This study examined the efficacy of a blended learning
approach, combin-
ing teacher-led and technology-based ELA instruction to teach
reading to
low SES and ELL students in Grades 1 and 2. Comparisons were
made with
a control group receiving the same ELA instruction without the
blended
learning component. All students in treatment and control
groups received
FIGURE 1 GRADE total test standard score changes for ELL
treatment and non-ELL control
students.
the same total amount of ELA instructional time. Blended
learning was im-
plemented in the context of a typical classroom schedule to
mirror use
patterns of school-based blended learning programs. Treatment
and control
groups did not differ on pretest scores on a standardized test of
reading

skills and both groups made significant gains in reading.
However, results
indicated that treatment students demonstrated gains that were
significantly
higher than gains achieved by the control students, particularly
in the area
of reading comprehension. An ELL sub-sample displayed even
greater gains
than the group as a whole, with a high effect size, but the
results failed to
reach significance due to a small sample size. These findings
demonstrate
the potential benefit of integrating digital instruction into an
ELA curriculum
utilizing a blended learning approach for low SES and ELL
students and
strengthen previous reports showing benefits of computer-aided
instruction
for ELL students (Chambers et al., 2008; Macaruso & Rodman,
2011a).
It is encouraging that both groups made substantial gains in
standard
scores regardless of whether they participated in the treatment.
This progress
can be attributed to the fact that the LEAD21 program used in
the school
was comprehensive, addressing the five components of reading,
in conjunc-
tion with theme-based readers that likely contributed to gains in
vocabulary
and comprehension. To find significant differences in gains
when the tradi-
tional curriculum is strong further reinforces the effectiveness
of a carefully
structured and implemented blended learning model over the

traditional cur-
riculum. Notably, the treatment students demonstrated better
performance in
posttest reading comprehension after using Core5 as a part of
the ELA cur-
riculum. This finding supports previous studies by both
Chambers et al.
(2008) and Torgesen et al. (2010) that effectively used a
blended learning
approach to bolster the reading comprehension abilities in early
elementary
grades. Successful early intervention in reading comprehension
is particularly
valuable for supporting reading growth in later grades.
As discussed previously, Cheung and Slavin’s (2013) meta-
analysis has
shown that CAI studies have produced modest outcomes with
generally low
effect sizes. One possible reason for this is that some studies
inadequately
integrated the technology component into the classroom
curriculum. For
instance, Paterson et al. (2003) failed to find benefits of the
Waterford Early
Reading Program in a large scale kindergarten study. Unlike
Paterson et al.,
however, other studies have reported significant benefits of the
Waterford
Early Reading Program in early elementary grades (Cassady &
Smith, 2004,

2005; Hecht & Close, 2002). According to Cassady and Smith
(2005), the null
findings of Paterson et al. (2003) were related to low levels of
effort or interest
on the part of the teachers in actively integrating the materials
into their
instructional literacy program. In a more recent study of
students in grades
K–5, Ness, Couperus, and Willey (2013) did not include the
teacher-led
aspects of the program Lexia Reading as part of the
implementation model.
Intervention students received no additional support from the
teachers, either
through the use of the performance data to guide instruction or
through any
targeted offline instruction. The study found no significant
benefits of the
intervention program; however, as noted earlier, studies of
Lexia Reading
have reported positive outcomes when the program was
implemented with
fidelity (Macaruso & Rodman, 2011b; Macaruso & Walker,
2008).
Although there have been positive outcomes with a blended
learning
approach, the use of this approach in the typical classroom
raises some
challenges that should be considered; including the time it takes
to plan for
students of all the ability levels, the intensity of instructional
time for each
student, and the amount of professional development for the
teacher. Pre-
vious studies showing benefits of a blended learning approach

for reading
comprehension involved substantially more intensity than
commonly found
in the regular classroom setting. In the Torgesen et al. (2010)
study, students
spent 200 minutes a week in small group specialized
instruction, primar-
ily held outside the classroom reading block. All teachers had
previously
worked with the researchers and received an additional 18 hours
of preser-
vice training plus biweekly three-hour staff meetings for the
duration of the
school year. In the Chambers et al. (2008) study, tutors had
intensive sup-
port, including pre-training, follow-up support, in-classroom
visitations from
both school facilitators and Success for All trainers, and a
comprehensive
training manual. Tutors also utilized real-time tutor support in
the form of
video vignettes of intervention strategies. The time commitment
for at-risk
students was also intense, with daily 20-minute, one-on-one
sessions, until
they reached their classroom reading level.
The blended learning approach used in the current study was
less time
intensive for both student and teacher and required less
specialized teacher
training than the above studies. Students spent an average of 80

minutes
a week with the computer-based components of the instructional
interven-
tion depending on their personal usage prescription (usage
targets ranged
from 20–80 minutes per week, depending on overall risk level).
Foorman
and Torgesen (2001) suggested that intervention for at-risk
students must be
intensive. Although increased intensity usually implies more
time, it could
be argued that the specific targeting of individualized skill
needs serves a
similar purpose and allows students to make significant
progress without re-
quiring them to spend more time. As noted previously,
treatment and control
students all received the same total amount of ELA instructional
time. In ad-
dition, students were identified in the online program as
needing additional
support and flagged for specific lessons that targeted their
personal skill
gaps. Because the targeted lessons in this program provide
highly structured
language, they can be delivered without additional training by a
teacher or
an aide. This less time intensive approach to teacher training
and student
daily lessons is more aligned with the realities that teachers
face in a typical
classroom setting.
It is important to consider unique elements of this blended
learning
model which may have contributed to student growth over and

above the
traditional ELA curriculum. Effective instruction involves clear
goals for the
student, content that is explicit, systematic, and scaffolded with
immedi-
ate modeling and corrective feedback, familiar instructional
routines, and
ongoing monitoring of student performance (Foorman &
Torgesen, 2001;
Foorman et al., 2003; Scammacca et al., 2007; Vaughn, Denton,
& Fletcher,
2010). This description of effective instruction can seem
overwhelming to
teachers of underperforming students who have not yet mastered
concepts
presented at lower levels. Teachers may not be as familiar with
the scope
and sequence of material typically taught in earlier grades, so it
is difficult
to provide material that is systematic and targeted at each
student’s specific
level, give immediate feedback, monitor student performance,
and intervene
when necessary. Technology offers a platform to deliver an
individualized
learning path, as well as provide the teacher with performance
data to help
target teacher-led instruction and monitor progress.
Additionally, scripted
lessons can allow teachers to target instructional content that is
less familiar
to them when necessary.
The individualized, systematic, and structured approach of the
Core5
program was particularly effective in accelerating the reading

growth of ELL
students, a majority of whom started well below grade level at
the beginning
of the year. As discussed above, the ELL treatment students had
a growth of
20 standard score points as compared to a gain of 12 standard
score points
for ELL control students. By the end of the year, ELL treatment
students had
closed the gap and were performing at the levels of non-ELL
students in
the control group. ELL students are often exposed primarily to
grade-level
material in the standard classroom but need to begin reviewing
skills at a
lower level. The initial placement tool in the Core5 program is
designed to
start students on skills at the appropriate level and then
systematically move
them into grade level skills. Another benefit of online learning
is that students
are not able to remain passive in their learning. Instead, they
are required
to respond and interact with material. This forced active
response may work
to counteract a classroom-based phenomenon for ELL students
where they
are less likely to engage in classroom discussion than their
native English
speaking peers (Mohr & Mohr, 2007; Pappamihiel, 2002).

Limitations and Future Directions
A main limitation of the current study is that overall sample
size is relatively
small. However, integrity in the study design was maintained as
classrooms
in the same grade were randomly assigned to treatment and
control. While
significant findings were obtained for the sample as a whole,
the subsamples
of ELL students were too small to reach significance. Future
studies will aim
to address larger samples of interest in underperforming
populations, par-
ticularly ELL students, as considerable academic skill gaps
remain between
ELL and non-ELL students (Grantmakers in Education, 2011).
CONCLUSION
A blended learning program integrated into a strong ELA
curriculum was
shown to be more effective in bolstering the reading skills of
low SES and
ELL students than the same ELA curriculum without the
advantages of digital
technology. Previous studies that failed to find significant
benefits tended to
perceive digital technology as operating in a vacuum instead of
playing an
important role in driving the ELA curriculum. Results of the
current study in-
dicate that digital technology can leverage teachers’ time,
allowing teachers
to identify and address areas of need through a time efficient
but individual-

ized data-driven approach that can be implemented within the
schedule and
time constraints of a typical classroom.
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Vol.:(0123456789)
Education Tech Research Dev
https://doi.org/10.1007/s11423-020-09785-2
1 3
R E S E A R C H A R T I C L E
An investigation of blended learning to support reading
instruction in elementary schools
Paul Macaruso1 · Shani Wilkes2,3 · Jen Elise Prescott2,4
© The Author(s) 2020
Abstract
Research is needed to address the possible benefits of blended

learning as a form of read-
ing instruction in elementary schools. Blended learning
combines teacher-led instruction
with digital technology. We had an opportunity to evaluate the
effects of blended learning
for students in kindergarten through fifth grade within a charter
school network. Adminis-
trators in three schools chose to adopt a blended learning
program during the 2016–2017
school year. There were 2217 students in the treatment schools.
Treatment students were
compared to 1504 students in three control schools where the
standard form of instruc-
tion was maintained. Prior to implementation of blended
learning, treatment students per-
formed significantly below control students on a standardized
reading test. At the end of
the school year, treatment students showed greater gains on the
reading test than control
students and group differences disappeared. Further analyses
revealed that reading gains
were uniform across grades and ethnic categories. These
outcomes point to the viability of
using blended learning for reading instruction in elementary
schools.
Keywords Blended learning · Literacy · Elementary school ·
Reading proficiency
Introduction
When students fail to read proficiently as they reach the end of
elementary school, they
often face persistent struggles through the rest of their academic
career, and such students
have particularly high attrition rates in high school (Fiester

2013). According to a recent
U.S. government report, only 37% of fourth graders scored at or
above a proficiency level
on the National Assessment for Educational Proficiency
(National Center for Education
Statistics 2017). Reading outcomes for U.S. students from low
socioeconomic status (SES)
* Shani Wilkes
[email protected]
1 Community College of Rhode Island, Warwick, USA
2 Lexia® Learning, a Rosetta Stone® Company, 300 Baker Ave,
Suite 320, Concord, MA 01742,
USA
3 Present Address: Combined Jewish Philanthropies, Boston,
MA, USA
4 Present Address: Massachusetts Bay Transit Authority,
Boston, MA, USA
http://crossmark.crossref.org/dialog/?doi=10.1007/s11423-020-
09785-2&domain=pdf
P. Macaruso et al.
1 3
backgrounds are even more disturbing. Just 22% of these
students scored at or above a
proficiency level in fourth grade (National Center for Education
Statistics 2017). Given the
present situation, educators need to identify and promote the
most effective forms of read-
ing instruction in elementary schools, especially for students
from low SES backgrounds.

Literature review
Digital technology
One possible way of enhancing reading instruction in
elementary schools is to utilize digi-
tal technology to a greater extent. In fact, the use of computers
in education dates back at
least 40 years (see reviews by Cheung and Slavin 2013;
MacArthur et al. 2001). However,
whether the use of technology in classrooms is actually
beneficial continues to be a topic
of debate. In an early review and meta-analysis, Torgerson and
Zhu (2004) reported null
findings regarding the benefits of information and
communications technology (ICT) for
reading comprehension. More generally, Cuban (1986) argued
that because teachers are
not well-versed in effectively using technology to advance
learning, students benefit more
from traditional instruction. Even today, less than a third of
teachers responded that digital
technology supports innovation in their classrooms (Herold
2019). In a recent meta-anal-
ysis of studies on computer applications in education, Chauhan
(2017) reported moderate
benefits of technology use in elementary schools, finding that
overall, applications showed
more promise when offered in informal settings (e.g., at home
or in community centers)
compared to classroom use.
As a recent example of a technology-based study, Putman
(2017) investigated the ben-
efits of a popular digital program iStation (https ://www.istat

ion.com/Readi ng) to build
reading skills in kindergarten students. The study compared
students who did or did not
use iStation in their classrooms and found that students who
used iStation showed higher
performance than non-users on basic reading skills such as
letter-sound knowledge. Within
classrooms using iStation, the authors identified a relationship
between level of teachers’
literacy support and performance on higher level reading skills.
It was suggested that per-
haps the best form of reading instruction should couple the use
of technology with quality
teacher-led instruction.
Blended learning
The integration of teacher-led instruction with digital
technology is the hallmark of
blended learning, which has been gaining popularity in
elementary schools (Christensen
et al. 2013). In a recent review, Pytash and O’Byrne (2018)
describe blended learning as
combining face-to-face instruction with online learning.
Students have flexibility in access-
ing digital tools at various locations and times, and teachers can
utilize online activities
to adapt their instruction to meet individual students’ needs,
including those at-risk for
academic failure. In fact, teachers can make use of real -time
performance data offered in
the digital component to provide individualized instruction. As
pointed out by Shanahan
and Lonigan (2010), individualized instruction that targets skill
gaps can offer promising
results for at-risk students experiencing early literacy struggles.

As highlighted by Repetto, Spitler, and Cox (2018), the
opportunity to use digital tools
offers at-risk students a chance to have some control over their
learning, and can provide an
environment that is more engaging and thus instill more
motivation in students. However,
https://www.istation.com/Reading
An investigation of blended learning to support reading…
1 3
given that it is a relatively new pedagogical approach, there is
not a great deal of research
on blended learning in elementary schools and with at-risk
students (Pytash and O’Byrne
2018; Repetto et al. 2018).
There have been studies of instructional programs that include
elements of blended
learning in middle and high schools. For example, Lenhard et
al. (2013) compared two
programs to improve reading comprehension in sixth graders.
One approach was teacher-
directed and taught multiple strategies to build summarization
skills, whereas the sec-
ond approach used a digital program conText to provide
constructive feedback on writ-
ten summaries. The latter approach, which contained features of
blended learning in that
program use was embedded in the English Language Arts (ELA)
curriculum as part of
regular classroom instruction, was found to have a stronger

impact on reading comprehen-
sion scores than the teacher-directed approach. In a large-scale
randomized control study,
Swanlund et al. (2012) examined the use of Read 180 (https
://www.hmhco .com/progr ams/
read-180-unive rsal) in five schools with students in grades six
through nine. As part of
Read 180, students were first administered an assessment tool
designed to place them at
the appropriate reading level in the program. Students were then
instructed with a blended
learning type model which began with daily whole group
lessons. This was followed
by rotations among small group instruction, use of the digital
program and independent
reading. The program featured three days of professional
development in which teachers
learned about program components, classroom management,
providing small group les-
sons and how to use digital reports to differentiate instruction
for students. Swanlund et al.
reported that professional development support and teacher
practices in the classroom were
rated medium/high, but the actual amount of student usage of
the digital technology fell in
the low/medium range. Overall, reading outcome measures
revealed a small but significant
difference favoring treatment over control classes.
A few studies have addressed features of blended l earning in
elementary schools (Cham-
bers et al. 2008; Torgesen et al. 2010). For instance, Chambers
et al. (2008) used Success
for All (https ://www.succe ssfor all.org/) with first grade
students from low SES families.
Success for All is a school-wide instructional program that

includes ongoing professional
development, parental involvement and cooperative learning
exercises among students.
The program is highly intensive, combining whole-class
instruction, multi-media activities
and use of digital technology. Data tools provide feedback on
how individual students are
learning and where they need additional instruction. Individual
tutoring sessions are incor-
porated into the program. The authors reported that
participation in Success for All led to
significant benefits on various measures of reading—word
identification, passage fluency
and reading comprehension.
Core5
Some recent studies have been conducted with a program called
Lexia® Core5® Reading.
Core5 is a fully-blended learning program which synchronizes
the use of digital technol-
ogy and offline materials employed by teachers in delivering
their lessons. In an initial,
small-scale experiment conducted by Schechter et al. (2015), it
was found that first and
second grade students from a low SES school who used Core5
showed greater gains than
control students on a standardized test of reading skills.
O’Callaghan et al. (2016) con-
ducted a randomized controlled trial with 4- to 6-year old
children and reported that those
who used Core5 showed greater improvements on tests of
phonological skills than control
children. Prescott et al. (2017) examined the effects of Core5
across elementary grades in

https://www.hmhco.com/programs/read-180-universal
https://www.hmhco.com/programs/read-180-universal
https://www.successforall.org/
P. Macaruso et al.
1 3
a low SES school and found that improvements varied as a
function of grade, with greater
gains for students in earlier grades compared to later grades.
Building upon these studies, the present study aimed to
investigate the effects of Core5
across grades using large samples of elementary school
students. The opportunity to carry
out this investigation occurred within a charter school network
during the 2016–2017
school year. Some schools in the network elected to use Core5
and served as treatment
schools while others decided to maintain their standard form of
instruction and became
control schools. Although we were unable to randomly assign
schools to treatment and
control conditions, the use of charter schools within the same
network offered us a chance
to compare schools with many similarities. Each school was
governed by the same net-
work-level administrators who regulate enrollment, oversee
professional development, and
offer a limited number of recommendations for curriculum,
educational technology and
assessments. All schools in the present study employed the same
English Language Arts
(ELA) curriculum and assessment tool. Finally, the ethnic

profile across treatment and con-
trol schools was quite similar. Details about the curriculum,
assessment tool and ethnic
profiles are provided in the Methods section. Thus, in the
context of a charter school net-
work we had an opportunity to assess possible benefits of the
blended learning program
across multiple grades using comparable treatment and control
schools.
Research studies have found the academic performance of
students attending charter
schools is similar to students attending public schools. As
highlighted in a report sponsored
by the U.S. Department of Education (Gleason et al. 2010),
charter school students show
large discrepancies in reading and math scores nationwide. In
an extensive review of stud-
ies comparing charter schools to public schools, Blazer (2010)
concluded that most studies
that used strong methodological designs did not find advantages
for charter schools over
public schools. Just as many studies reported higher scores for
public schools as studies
that reported higher scores for charter schools. Thus, it is safe
to say that the difficulties in
achieving reading proficiency that apply to public schools apply
to charter schools as well.
Notably, one of the treatment schools in the present study had a
high percentage of stu-
dents from low SES backgrounds. As indicated earlier, these
students may be considered at
greater risk for not achieving reading proficiency.
Research questions

1. Does use of Core5 as part of blended learning support
reading development in elemen-
tary school students compared to students receiving traditional
instruction?
2. If there are benefits of blended learning over traditional
instruction, do the benefits differ
as a function of grade?
3. If there are benefits of blended learning over traditional
instruction, do the benefits differ
as a function of ethnic category?
Method
Design
This study utilized a quasi-experimental research design. Six
charter schools located in the
southeast United States were included in this study. Three of the
schools were in the treat-
ment group. Administrators in these schools had some concerns
about the less proficient
1 3
readers in their schools and decided to make a change to their
ELA curriculum and adopt
Core5. Each of the treatment schools implemented Core5 for the
first time during the
2016–2017 school year. Three other charter schools maintained
their traditional form of

instruction and served as the control group. These latter schools
were selected for the study
because, in aggregate, they showed a similar ethnic profile to
the treatment schools (see
Table 2).
Participants
Overall, there were 2217 students in the treatment group and
1504 students in the con-
trol group. These students were in kindergarten through fifth
grade. All students who com-
pleted the Northwest Evaluation Association (NWEA) Measure
of Academic Progress
(MAP) Reading test (Measure of Academic Progress Reading
Test 2016) in both Fall 2016
and Spring 2017 were included in the study. As seen in Table 1,
there were highly similar
percentages of students across grades in the treatment and
control groups. Table 2 breaks
down the treatment and control schools in terms of ethnic
category and provides informa-
tion regarding SES status for each school. The treatment and
control schools showed simi-
lar distributions across ethnic categories, with the largest
percentage of students being His-
panic. There was wide variation across schools in terms of
percentage of students receiving
Table 1 Percentages in each
grade for the treatment and
control groups
Treatment group Control group
Number Percentage Number Percentage

Kindergarten 415 18.7 275 18.3
First grade 408 18.4 275 18.3
Second grade 363 16.4 264 17.6
Third grade 373 16.8 233 15.5
Fourth grade 332 15.0 240 16.0
Fifth grade 326 14.7 217 14.4
Table 2 Percentages in each ethnic category and receiving
free/reduced price lunch for the treatment and
control groups
Other included Unspecified (70.1%), Asian (27.4%) and
American Indian (2.5%). Percentages for free/
reduced price lunch are based on publicly available
demographic information for the participating schools
Treatment group Control group
School 1 (%) School 2 (%) School 3 (%) School 4 (%) School 5
(%) School 6 (%)
Ethnic category
Hispanic
(n = 2149)
69 46 72 37 69 49
White (n = 717) 13 32 13 22 13 28
Black (n = 494) 7 11 7 28 7 14
Other (n = 361) 11 11 8 13 11 9
Free/reduced
lunch
1 63 80 1 32 70

P. Macaruso et al.
1 3
free/reduced price lunch. The highest percent (80%) was found
in one of the treatment
schools.
English Language Arts
Each school in this study used Wonders (https ://www.mhedu
catio n.com/prek-12/progr am/
wonde rs-2020/MKTSP -BGA07 M0.html) as part of their ELA
curriculum. Wonders offers
teacher-led instruction in foundational reading skills (e.g.,
phonological awareness, phon-
ics, word analysis) as well as text comprehension and daily
writing activities. It includes, as
options, activities in Spanish and the use of digital technology
for assessment purposes and
to support reading instruction. For students in third through
fifth grade, Reading Plus (https
://www.readi ngplu s.com/) was added to the curriculum.
Reading Plus is a digital program
mainly designed to help inefficient readers improve their silent
reading fluency. It includes
an assessment tool used to assign texts to students at their
reading level as well as elements
of adaptive instruction—e.g., modified text to reduce processing
demands—aimed to offer
a personalized learning experience. The program also provides
strategies to support vocab-
ulary growth and text comprehension and said to boost
motivation by allowing students a

choice of which texts to read. Table 3 provides a comparison of
the instructional programs
used in the treatment and control schools.
Core5
For students in treatment schools, Core5 was incorporated into
the ELA curriculum. Core5
provides a fully-blended learning model which combines
systematic, structured activities
within the digital component and offline materials for teachers
to use in planning their les-
sons. The offline materials include Lexia Lessons®
administered to students when they
struggle with specific skills in the digital component, and
paper-and-pencil tasks called
Lexia Skill Builders® for students to work on independently to
build automaticity and gen-
eralize skills beyond the digital component. Together,
components of Core5 offer students
an individualized learning path to acquire reading skills.
Contents in the digital compo-
nent target six strands of reading: phonological awareness,
phonics, structural analysis,
automaticity/fluency, vocabulary, and comprehension.
Activities in the strands address
the Common Core State Standards (National Governors
Association Center for Best Prac-
tices—Council of Chief State School Officers 2010) and are
organized into 18 levels: pre-
school (Level 1), kindergarten (Levels 2–5), first grade (Levels
6–9), second grade (Levels
10–12), third grade (Levels 13–14), fourth grade (Levels 15–
16), and fifth grade (Levels
Table 3 Comparison of instructional programs for the treatment

and control schools
Treatment schools Control schools
Kindergarten Core5, Wonders Wonders
First grade Core5, Wonders Wonders
Second grade Core5, Wonders Wonders
Third grade Core5, Wonders, Reading Plus Wonders, Reading
Plus
Fourth grade Core5, Wonders, Reading Plus Wonders, Reading
Plus
Fifth grade Core5, Wonders, Reading Plus Wonders, Reading
Plus
https://www.mheducation.com/prek-12/program/wonders-
2020/MKTSP-BGA07M0.html
https://www.mheducation.com/prek-12/program/wonders-
2020/MKTSP-BGA07M0.html
https://www.readingplus.com/
https://www.readingplus.com/
1 3
17–18). Students begin the digital component with an embedded
assessment that automati-
cally places them in a level consistent with their reading ability.
Students are required to
complete each unit of an activity with 90%–100% accuracy
before moving to subsequent
units. For students who struggle in a unit, the program utilizes
an adaptive branching rule
to move them to a scaffolded task with fewer stimuli and more
structure. If students con-

tinue to struggle, the program provides direct instruction that
explicitly addresses the errors
they made. Once students have successfully completed all
activities at the standard, non-
scaffolded step in a level, they are automatically advanced to
the next level.
Implementation training and support
To support their implementation of Core5, teachers in the
treatment schools were given
an opportunity to participate in Lexia’s Implementation Support
Service Package (ISP).
The ISP contains three training modules. The first is a “launch”
module which instructs
teachers on how to efficiently get started with Core5 and
reviews key components of Core5
including its scope-and-sequence and instructional materials.
The second module called
“data coaching” addresses progress monitoring in Core5,
identifying students at-risk for
reading difficulties, and planning instruction to target skill
gaps. The data coaching module
is offered around two months after the start of Core5. The third
module called “instruc-
tional materials” focuses on implementing Core5 as part of a
blended learning model
and looks in more depth at the instructional materials (e.g.,
Lexia Lessons) available for
teachers when planning offline lessons. The instructional
materials module is offered any
time following the data coaching module. Administrators at
each treatment school decided
which training modules to receive. Two treatment schools
received the launch and data
coaching modules, and the third treatment school received the

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