How do we as family physicians benefit not only the health outcomes of the children we serve but also their broader development? How can we help position our young patients to succeed as they enter and go through school? And how can we do these things while providing essential family medicine care? I (Dr. Reddy) have been a family physician for 23 years, serving communities in Salinas, Calif. For much of that time, I have integrated literacy promotion efforts in my daily practice that have accomplished both of these goals.
Why? The health benefits to young children are clear. Reading aloud to children during infancy supports cognitive development and strengthens parent-child relationships, in addition to profoundly influencing language development through childhood and even long-term literacy.1,2 (See “Children's literacy facts.”) But I have found that integrating a reading program that actually gives children books during their visits benefits my work as well.
First, a little bit about the program I use: In most communities there are organized efforts to promote children's literacy. Some work specifically with medical practices. I use Reach Out and Read (ROR), which is among the most well known. ROR was founded more than 25 years ago and promotes early literacy and school readiness to young children and their families at almost 5,000 program sites in all 50 states. It trains and encourages practices to advise parents on the importance of reading and to provide developmentally and culturally appropriate books at every well-child visit. (See “Reach Out and Read.”)
REACH OUT AND READ
The Reach Out and Read model has been evaluated rigorously in 15 peer-reviewed studies,1 which show the following:
Significantly improved language development at 24 months,2
Increased likelihood of parents to read with their child regularly and to report that their child has a more positive attitude toward reading,
Increased parent-child interactions and reading activities at home,
Reduced electronic media exposure among infants.3
Note: These studies were conducted among populations at higher risk of reading failure, including low-income and immigrant families.
In our practice, during the first visit when the child is 6 months old, and increasingly even at 4 months, I explain to the parents what future exams will involve, including the fact that we will give their child a new book at each checkup until age 5. That means they will begin school with a home library of at least eight to 10 books.
Of course, anyone can tell parents to read to their children, and you don't necessarily need a program to do that. What ROR does is provide a framework for explaining the evidence base and how to read to children as well as providing the books. Since implementing the program, our clinics have realized both unexpected and predicted benefits for our patients, their families, the larger community, our staff, and ourselves.
CHILDREN'S LITERACY FACTS
66 percent of children from low-income U.S. families are not read to daily.1
More than one third of all children do not begin kindergarten with the skills they need to learn to read.2
By the end of third grade, more than 60 percent of children above the poverty threshold and 80 percent of children below the poverty threshold do not develop reading proficiency.3
Benefits for patients and the practice
I find that the principal benefit of this program is that it facilitates a richer exam. Introducing an appropriate book at the start of the checkup can have a calming effect on the child and allows us to engage before the physical exam begins. If the patient is old enough, I encourage him or her to look through the books available and select one, which gives me a chance to speak with the parents while the child is distracted. Incorporating a book into visits also allows me to directly observe and assess the child's cognitive and speech milestones as well as motor skills. Not only does the program allow our physicians to derive more satisfaction from our interactions with child patients and young families, but it also enhances the children's visits. I certainly feel less discomfort about the trauma caused by a vaccination when the child walks out with a book and a smile.
The visit is also an opportunity for the physician to personally read to the patient in the exam room and instruct parents on why and how to read to their child at home. ROR also offers reading tips for parents, including training videos. The videos make the point that even parents who can't read to their child, either because of language or literacy barriers, can emphasize the importance of reading by interacting with the book, pointing to pictures, or telling a story. Given children's increased exposure to electronic media, I also take this opportunity to discuss sleep routines, sleep structure, and the effect of screen time on sleep quality. This introduces a shift from instructing parents to “creating real-time learning experiences.”3
An unexpected benefit to our focus on literacy has been an improved standing with our own staff. The program shows them we are willing to “do the right thing.” Also, it's easy to overlook that our staff are often the parents of young children. In staff meetings consumed by discussions of process-oriented details that involve improving clinical quality, service, or productivity, it is refreshing to be able to talk about what ROR is trying to accomplish within the practice and remind our staff that the time spent reading to their own children will make a big difference.
While the steps for participating in local literacy programs may differ, ROR requires potential partners to fill out an online application. It asks for each practice to designate a “medical consultant” and “program coordinator,” provide basic data on your patient panel (such as the number of well-child visits), and create a written plan for buying enough books to cover your expected well-child patients for the first year of participation. For more information, see the ROR website.
Managing the program has not been time-consuming in our two-site, five-clinician practice. (See “Price of literacy.”) I've even found it feasible to extend the service to children older than 5. I do have a dedicated staff person, often an MA or an authorizations and referrals coordinator, who keeps inventory and reports book usage. For promotion, we created a sticker with our practice name and logo for the back of each book.
PRICE OF LITERACY
The time and financial costs of a children's literacy program can vary. We spend about $1,500 per year serving 30 percent of our child patients:
Average cost per book: $2.
Book sourcing: 1 hour per month.
Book labeling and storage maintenance: 1 hour per month.
Logging books given to patients: 10 minutes per day.
Note: Estimates don't include the cost of labels, which can be negligible. We make our own on a color printer for roughly $15 every couple of years.
There are several low-cost ways to buy books. The ROR program offers an extensive selection of books, catalogued by age, that are available at discounted prices. The program may also supplement practice budgets through book grants. I have also found it easy to shop online and on the clearance tables of local stores to find quality books at low prices. The warehouse retail chains often have boxed sets of books at year-end that are of great value. Websites such as Books by the Bushel also have been helpful in stretching my book dollar. In our private practice, I buy the books as I would any other practice purchase. Most community clinics can fundraise, and some large academic medical centers and organized groups such as Kaiser Northern California purchase books for their own sites. Being an advocate for childhood literacy will net you a surprising number of supporters – and potential program contributors – within and outside of your organization.
Physicians' time is increasingly consumed by bureaucratic tasks even as we are expected to be visionary change managers for our practices. When families see that we choose to spend our time and practice income on enhancing parent-child interactions, they respect us for going above and beyond. Encouraging children's literacy has made my job easier, and I feel like a true partner to my patients and their families.