Attendance at Well-Child Visits After Reach Out and Read

The TREE Program: Promoting Positive Early Childhood Experiences During Well-Child Visits

This feasibility study evaluated the developmental coaching TREE (Talk Read Engage Encourage) program for historically marginalized children ages 0 to 2 years, embedded within pediatric visits, examining if TREE could enhance caregiver-child interactions and increase pediatric resident report of competency and self-efficacy in coaching caregivers. Using a quasi-experimental design, a convenience sample (n = 167 families) was recruited (79 intervention; 88 control). Follow-up data were obtained from 45% of families (38 intervention; 38 control), impacted by COVID-19 attendance. Analyses demonstrated significant increases in self-reported Parent Verbal Responsivity (d = 0.68; 95% confidence interval [CI] = 0.17 to 1.18; P = .009) by intervention group caregivers. Intervention pediatric residents reported significant increases in promoting positive caregiver-child interactions and confidence in conveying child development (d = -.73; 95% CI = -1.21 to -0.22; P = .003). The TREE program is a promising practice that operationalizes promotion of relational health and positive early childhood experiences within pediatric primary care.

A Pilot Randomized Controlled Trial of Text Messages to Improve Well-Child Visit Attendance After No-Show

OBJECTIVE

Evaluate the effectiveness of text messages to systematically engage parents/guardians ("caregivers") to reschedule a well-child visit (WCV) that was missed ("no-show") and attend that rescheduled WCV visits.

METHODS

Patients <18 years in one of five pediatrics or family medicine clinics, in one health system in the Southeast US, were eligible. Patients without a rescheduled WCV after a no-show were randomized into intervention (text messages) or care-as-usual comparison, stratified by language (English/Spanish). Enrollment occurred May-July 2022. Up to three text messages were sent to caregivers one week apart via REDCap and Twilio, advising how to reschedule the missed appointment by phone or health portal. Primary outcomes were 1) rescheduling a WCV within 6 weeks of no-show and 2) completing a rescheduled WCV within 6 weeks. Risk differences (RD) and odds ratios (OR) were used to evaluate the effect of text messages.

RESULTS

Seven hundred and twenty patients were randomized and analyzed (texts: 361, comparison: 359). The proportion rescheduling WCV after text versus usual care was English: 18.85% versus 15.02%, respectively, and Spanish: 5.94% versus 8.14%, with overall RD+ 1.98% (95% CI: -1.85, 5.81) and OR 1.21 (95% CI: 0.79, 1.84; P-value .38). Completed WCV rates in text or usual care were English: 13.08% versus 6.59%, and Spanish: 5.81% versus 5.94% with texts associated with RD+ 2.83% (95% CI: 1.66, 4.00) and OR 1.86 (95% CI: 1.09, 3.19).

CONCLUSION

Text message follow-up after a no-show WCV may positively impact attendance at WCVs rescheduled in the subsequent 6 weeks.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05086237.

The Effect of Exposure to Reach Out and Read on Shared Reading Behaviors

BACKGROUND

Caregiver-child shared reading improves literacy skills, school readiness, familial relationships, and social-emotional development. This multiyear study seeks to evaluate the effect of exposure to Reach Out and Read (ROR) on caregiver reading frequency and behaviors.

METHODS

Caregivers of children 6 months to 5 years in 427 primary care clinics in North and South Carolina were asked to complete the Reach Out and Read Parent Feedback Survey. Caregivers not previously exposed to ROR were categorized as "new," and those who had previously been exposed to ROR as "returning" to compare reading behaviors between groups.

RESULTS

From 2014 to 2019, caregivers completed 100,656 surveys. Returning caregivers were more likely to report reading or looking at books every day (adjusted odds ratio [AOR] = 1.27; 95% confidence interval [95% CI], 1.22-1.33). Returning caregivers were more likely to perform behaviors like letting the child turn pages (AOR = 1.71; 95% CI, 1.62-1.79), making up stories about the pictures (AOR = 1.46; 95% CI, 1.39-1.53), asking what is happening in the pictures (AOR = 1.39; 95% CI, 1.32-1.47), helping identify things in the pictures (AOR = 1.57; 95% CI, 1.50-1.65), reading to the child 30 minutes every day (AOR = 1.39; 95% CI, 1.33-1.46), and taking the child to the library (AOR = 1.26; 95% CI, 1.20-1.34).

CONCLUSIONS

This study shows a significant association between caregivers' exposure to ROR, high-frequency reading, and positive reading behaviors, and is consistent for all 6 years studied.retain-->.

Reduced health care utilization among young children of immigrants after Donald Trump's election and proposed public charge rule

Widespread fear among immigrants from hostile 2016 presidential campaign rhetoric decreased social and health care service enrollment (chilling effect). Health care utilization effects among immigrant families with young children are unknown. We examined whether former President Trump's election had chilling effects on well-child visit (WCV) schedule adherence, hospitalizations, and emergency department (ED) visits among children of immigrant vs US-born mothers in 3 US cities. Cross-sectional surveys of children <4 years receiving care in hospitals were linked to 2015-2018 electronic health records. We applied difference-in-difference analysis with a 12-month pre/post-election study period. Trump's election was associated with a 5-percentage-point decrease (-0.05; 95% CI: -0.08, -0.02) in WCV adherence for children of immigrant vs US-born mothers with no difference in hospitalizations or ED visits. Secondary analyses extending the treatment period to a leaked draft of proposed changes to public charge rules also showed significantly decreased WCV adherence among children of immigrant vs US-born mothers. Findings indicate likely missed opportunities for American Academy of Pediatrics-recommended early childhood vaccinations, health and developmental screenings, and family support. Policies and rhetoric promoting immigrant inclusion create a more just and equitable society for all US children.

Encouraging Our NICU to "Read-a-Latte": Leveraging a Read-a-Thon to Launch a Quality Improvement Initiative

BACKGROUND

Preterm infants have known impairments in language development relative to infants born at full term, and the language-poor environment of the neonatal intensive care unit (NICU) is a contributing factor. Adapting outpatient literacy programs for the NICU is a potential evidence-based intervention to encourage adult speech exposure to infants through reading sessions during NICU hospitalization.

PURPOSE

To evaluate implementation of a 10-day NICU Read-a-Thon and potential barriers and facilitators of a year-round program aimed at increasing reading sessions for NICU patients.

METHODS

We established an implementation team to execute a Read-a-Thon and evaluated its impact utilizing quantitative and qualitative approaches. Quantitative methodology was used to report number of donated books and infant reading sessions. Qualitative methodology inclusive of interviews, surveys, and source document reviews was used to evaluate the Read-a-Thon.

RESULTS

We received approximately 1300 donated books and logged 663 reading sessions over the 10-day Read-a-Thon. Qualitative evaluation of the Read-a-Thon identified 6 main themes: motivation, emotional response to the program, benefits and outcomes, barriers, facilitators, and future of literacy promotion in our NICU. Our evaluation informed specific aims for improvement (eg, maintaining book accessibility) for a quality improvement initiative to sustain a year-round reading program.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Neonatal units can leverage Read-a-Thons as small tests of change to evaluate barriers, facilitators, and change processes needed to implement reading programs. Process maps of book inventory and conducting a 5 W's, 2 H's (who, what, when, where, why, how, how much) assessment can aid in program planning.

Reach Out and Read Implementation: A Scoping Review

BACKGROUND

Reach Out and Read (ROR) is an evidence-based literacy promotion intervention that leverages the near-universal access to children of primary care practices to promote optimal child development. While several studies document ROR's effectiveness, its implementation remains understudied.

OBJECTIVE

This scoping review examines the existing literature to better understand ROR implementation.

DATA SOURCES

PubMed, ERIC, Web of Science, Academic Search Premier, ProQuest Education Database, and CINAHL.

STUDY SELECTION

We included peer-reviewed English-language papers focusing on ROR in an ambulatory setting in North America.

DATA EXTRACTION

Extracted variables were informed by the Template for Intervention Description and Replication checklist and included publication year, title, author(s), clinic location, study design, study aim, ROR implementation, modifications, implementation assessment, barriers, facilitators, and outcomes.

RESULTS

Seventy-one papers were included, of which 43 were research articles. We identified substantial variation in ROR implementation including differences in components delivered. A considerable number of research articles did not assess ROR implementation. The most common barriers to ROR implementation were at the system level (ie, financing and inadequate time). Modifications and enhancements to ROR are emerging; most address barriers at the clinician and family level.

LIMITATIONS

This review was limited to published English language papers focusing on ROR.

CONCLUSIONS

ROR implementation varies across studies, and many did not assess implementation. Consistent reporting and assessment of ROR implementation could create opportunities to better understand the mechanisms underlying ROR's effects and inform other early childhood interventions that seek to promote optimal development at the population level.

Clinician Perceptions on Literacy Promotion in Pediatric Continuity Clinics

OBJECTIVE

We describe LP perceptions of pediatric and internal medicine/pediatrics residents and faculty and determine the relationship between LP training and perceptions of LP. Reach Out and Read (ROR) is a widely implemented evidence-based literacy promotion (LP) intervention. Recent data have shown that there is variability in both LP training for pediatric residents and implementation of ROR. However, little is known about the perceptions regarding LP and the relationship with training.

METHODS

Faculty and residents at participating sites completed an anonymous online survey on LP perceptions and training. Data were analyzed using descriptive statistics, chi-square tests, and logistic regression modeling.

RESULTS

A total of 473 faculty and 1216 residents at 42 pediatric training programs participated. Faculty versus resident status was a significant predictor of almost all perception questions. Most faculty (65.3%) and residents (44.3%) completely agreed that it is the job of pediatricians to assess and encourage reading (P < .0001). Most faculty (69.6%) and residents (51.5%) completely agreed that LP is as important as advice about car seats, bike helmets, and "back-to-sleep" (P < .0001). More faculty (65.8%) than residents (46.6%) completely agreed with the statement "discussing sharing books with children at health supervision visits can be an effective early intervention strategy" (P < .0001). More faculty (34%) compared to residents (18.2%) completely agreed they felt confident modeling reading for parents during the visit (P < .0001).

CONCLUSIONS

Faculty status predicted most favorable LP perceptions, while continuity clinic training and learning in-clinic from others predicted some favorable LP perceptions.

Statewide Analysis Reveals Period of Well-Child Visit Attendance for Earlier Diagnosis of Autism Spectrum Disorder

OBJECTIVE

To explore the relationship between well-child visit (WCV) attendance during early childhood and age at autism spectrum disorder (ASD) diagnosis using data drawn from a statewide all-payer claims database.

STUDY DESIGN

We used a correlational study design with longitudinal data drawn from the Virginia All-Payer Claims Database. All children born in 2011 with a diagnosis of ASD were included (n = 253). Survival analysis determined the impact of WCV attendance on ASD diagnosis at each American Academy of Pediatrics-recommended early childhood visit, and the 5-year visit.

RESULTS

Survival analysis revealed a significant impact of WCV attendance at the 24-month, 3-, and 4-year visits on earlier ASD diagnosis. Children who attended the 24-month visit were diagnosed nearly 10 months earlier than those who did not. Overall, children with ASD attended fewer than 50% of visits during early childhood.

CONCLUSIONS

Promoting consistent WCV attendance during early childhood is an actionable strategy for improving early identification of ASD. Further exploration is needed to determine barriers to visit attendance and the impact of patterns of early childhood WCV attendance on age of ASD diagnosis. Development and implementation of interventions to promote adherence to the American Academy of Pediatrics-recommended visits is needed.

Chronic pediatric diseases and risk for reading difficulties: a narrative review with recommendations

Literacy is a major social determinant of health, rooted in skills that develop during early childhood. Children arriving at kindergarten unprepared to learn to read are more likely to have low reading proficiency thereafter. General and health literacy are highly correlated, affecting understanding of health conditions, treatment adherence, and transition to self-care and adult healthcare services. The American Academy of Pediatrics (AAP) recommends literacy and school readiness promotion during well-visits and neurodevelopmental surveillance is emphasized across primary and subspecialty care. While genetic and environmental risk factors for reading difficulties are well-established, risks related to complex and chronic medical conditions are less appreciated and under-researched. This review applies an eco-bio-developmental framework to explore literacy across five complex chronic conditions affecting millions of children worldwide: asthma, cancer, congenital heart disease, epilepsy, and sickle cell disease. In each, integration of an efficient reading brain network may be impacted by direct factors, such as ischemia, anesthesia, and/or medications, and also indirect factors, such as altered parent-child routines, hospital stays, and missed school. By integrating literacy into care management plans for affected children, pediatric primary care and specialty providers are poised to identify risks early, target guidance and interventions, and improve academic and health outcomes. IMPACT: While genetic and environmental risk factors for reading difficulties are well-established, risks related to complex and/or chronic medical conditions such as asthma, cancer, congenital heart disease, epilepsy, and sickle cell disease are substantial, less appreciated, and under-researched. General and health literacy are highly correlated, with implications for the understanding one's health condition, treatment adherence, and transitioning to self-care, which is especially important for children with complex and/or chronic illness. Pediatric primary care and specialty providers are poised to integrate reading and literacy into care management plans for children with complex and/or chronic illness, including early screening, guidance, support, and interventions.

"First Five" Quality Improvement Program Increases Adherence and Continuity with Well-child Care

The American Academy of Pediatrics Bright Futures recommends routine well-child care as optimal care for children. This quality improvement project aimed to increase adherence to the "First Five" visits after newborn follow-up at 2, 4, 6, 9, and 12 months-by 25% (50% or higher) and continuity with providers by 20% (64% or higher) between 2013 and 2016.

METHODS

Retrospective data collection identified a quality gap, in which only 25% had the required well-child visits by the first year. We interviewed parents/caregivers of 12- to 15-month-old children for their perspectives on access to care, scheduling, and the medical home concept. Plan-Do-Study-Act cycles targeted modification of electronic medical record templates, scheduling, staff and parental education, standardization of work processes, and birth to 1-year age-specific incentives. We then piloted interventions in one of our clinic's pod/subgroup. Process and outcome measures were analyzed using descriptive statistics, a run chart, and a 2-sample % Defective Test.

RESULTS

Parent/caregiver interviews revealed that only 6% knew what a medical home was, and only 40% "almost always saw the same provider for care." At baseline in 2012, we documented completion of all 5 visits in only 25% of the children; <10% of those children had consecutive visits with the same provider. After multiple Plan-Do-Study-Act cycles and pilot, our "First Five" well-child care adherence rose to 78%, and continuity increased to 74% in 2018 (P < 0.001 for adherence, P < 0.001 for continuity).

CONCLUSION

A multifaceted, evidence-based approach improved both well-child care adherence and provider continuity.

Cross-Sector Approach Expands Screening and Addresses Health-Related Social Needs in Primary Care

OBJECTIVES

During infancy, the American Academy of Pediatrics Bright Futures fourth edition health supervision guidelines recommend frequent well-child visits (WCVs) in which providers are expected to screen for and address maternal depression, intimate partner violence (IPV), and health-related social needs (HRSN). We spread an evidence-based approach that implements these recommendations (Developmental Understanding and Legal Collaboration for Everyone; DULCE) with 3 aims for 6-month-old infants and their families: 75% receive all WCVs on time, 95% are screened for 7 HRSNs, and 90% of families with concrete supports needs and 75% of families with maternal depression or IPV receive support.

METHODS

Between January 2017 and July 2018, five DULCE teams (including a community health worker, early childhood system representative, legal partner, clinic administrator, pediatric and behavioral health clinicians) from 3 communities in 2 states participated in a learning collaborative. Teams adapted DULCE using Plan-Do-Study-Act cycles, reported data, and shared learning monthly. Run charts were used to study measures. The main outcome was the percent of infants that received all WCVs on time.

RESULTS

The percentage of families who completed all WCVs on time increased from 46% to 65%. More than 95% of families were screened for HRSNs, 70% had ≥1 positive screen, and 86% and 71% of those received resource information for concrete supports and maternal depression and IPV, respectively.

CONCLUSIONS

Quality improvement-supported DULCE expansion increased by 50% the proportion of infants receiving all WCVs on time and reliably identified and addressed families' HRSNs, via integration of existing resources.

Clinician Experiences With Reach Out and Read: An Exploratory Qualitative Analysis

BACKGROUND

Enhanced literacy and increased vocabulary related to Reach Out and Read (ROR) are well described. Less is known about clinicians' experience with the program.

OBJECTIVE

Understand clinician experiences of implementing ROR.

DESIGN/METHODS

This study was a collaboration between ROR and the Academic Pediatric Association's Continuity Research Network. Participants completed an anonymous online survey to evaluate Literacy Promotion activities and training, and were asked "What has been the most meaningful experience you have encountered with using ROR?" and "Is there anything else you would like to add?" Responses were evaluated by researchers and 4 themes were generated through discussion. All responses were divided and coded by researchers working in pairs and subsequently by all researchers until consensus was reached. Data were organized into themes.

FINDINGS

Responses were provided by 592 (35%) participants. Qualitative analysis revealed benefits to participation in ROR within 4 themes: 1) Child/Family Impact (60%): "Seeing a child read for the first time" 2) Physician Impact (16%): "I... use the books... to connect with patients." 3) Impact on clinic practice (25%): "I... enjoy modeling for parents and use the books to assess... development" 4) Social Determinants of Health (2%): "The books... are an invaluable resource to our under-served population."

CONCLUSION

Clinicians who implement ROR report positive impact on patients, families, and their own satisfaction and methods in practice. Clinicians value that the program addresses social determinants of health and facilitates developmental surveillance. Further study is needed to understand how clinician's perspectives affect and are affected by their experiences.

Preventing Childhood Toxic Stress: Partnering With Families and Communities to Promote Relational Health

By focusing on the safe, stable, and nurturing relationships (SSNRs) that buffer adversity and build resilience, pediatric care is on the cusp of a paradigm shift that could reprioritize clinical activities, rewrite research agendas, and realign our collective advocacy. Driving this transformation are advances in developmental sciences as they inform a deeper understanding of how early life experiences, both nurturing and adverse, are biologically embedded and influence outcomes in health, education, and economic stability across the life span. This revised policy statement on childhood toxic stress acknowledges a spectrum of potential adversities and reaffirms the benefits of an ecobiodevelopmental model for understanding the childhood origins of adult-manifested disease and wellness. It also endorses a paradigm shift toward relational health because SSNRs not only buffer childhood adversity when it occurs but also promote the capacities needed to be resilient in the future. To translate this relational health framework into clinical practice, generative research, and public policy, the entire pediatric community needs to adopt a public health approach that builds relational health by partnering with families and communities. This public health approach to relational health needs to be integrated both vertically (by including primary, secondary, and tertiary preventions) and horizontally (by including public service sectors beyond health care). The American Academy of Pediatrics asserts that SSNRs are biological necessities for all children because they mitigate childhood toxic stress responses and proactively build resilience by fostering the adaptive skills needed to cope with future adversity in a healthy manner.

Early literacy training among medical students

BACKGROUND

The American Academy of Pediatrics regards literacy promotion as essential. Medical professionals are in a key position to promote children's early literacy, however this requires knowledge of existing literacy programmes. This study describes medical student training, awareness, experiences, and attitudes towards early literacy and the 'Reach Out and Read' (ROR) initiative.

METHODS

An anonymous online survey was sent to all medical students at a medical school in the Midwest with two campuses. Data were analysed using descriptive statistics.

RESULTS

We received data from 275 medical students. Almost half (46.5%) had completed their paediatric clerkship, 22.9% had observed ROR, and only 2.9% had received any training. Most (67%), wanted to learn more about early literacy, and 59% expressed a desire for more ROR training. Most respondents expressed preference for learning from residents and faculty in clinic followed by online training. 47% agreed that it was a role of medical students to assess and encourage reading.

DISCUSSION

Medical students understand the importance of early literacy in primary care and emphasising this during clinical encounters. Most are eager to learn more about early literacy promotion and ROR. This interest decreases during third and fourth year so targeting the first 2 years of medical school is an important strategy. Providing formal literacy promotion training and education for medical students should be considered during this critical time in their education.

Read, speak, sing: Promoting early literacy in the health care setting

This statement will help health care providers assess and advise on early literacy with families in almost any practice setting. It defines emergent literacy skills, including early language learning and storytelling, and explores the benefits of reading, speaking, and singing with infants and toddlers for both children and caregivers. Book sharing at bedtime and other language-related routines positively affect family, relational, and social-emotional health. Early exposure to any language, when spoken at home, can benefit literacy learning in other languages children may encounter. Specific recommendations for clinicians counselling families on early literacy are included.

Lisez, parlez, chantez : la promotion de l'alphabétisation précoce dans le milieu de la santé

Le présent document de principes aidera les dispensateurs de soins à évaluer l'alphabétisation précoce dans les familles et à leur donner des conseils, et ce, dans presque tous les contextes d'exercice. On y définit les habiletés d'alphabétisation émergente, y compris l'apprentissage précoce du langage et des récits oraux, et on y explore les bienfaits de la lecture, de la parole et de la chanson auprès des nourrissons et des tout-petits, tant pour eux que pour les adultes qui en sont responsables. La lecture partagée au coucher et d'autres habitudes liées au langage ont un effet positif sur la santé familiale, relationnelle et socioaffective. L'exposition précoce à la langue parlée à la maison peut contribuer à l'alphabétisation dans les autres langues auxquelles l'enfant pourrait être exposé. On y trouve enfin des recommandations particulières pour les cliniciens qui conseillent les familles en matière d'alphabétisation précoce.

Reach Out and Read and developmental screening: using federal dollars through a health services initiative

Oklahoma established the first health services initiative (HSI) to expand Reach Out and Read (ROR), increase developmental screening and improve the quality of well-child visits (Early and Periodic Screening, Diagnostic and Treatment (EPSDT)). ROR uses a book in the exam room to assess development and parent-child interaction, however, little is known about the relationship between this training and using a formal developmental screening tool. The purpose of this study is to see if using federal funding would facilitate ROR expansion and if this expansion would improve developmental screening and EPSDT visits in Oklahoma. Medicaid billing data for state fiscal year (SFY) 2018 and 2019 were analyzed. Standard statistical methods were used to analyze the data descriptively to determine the proportion of developmental screenings performed and EPSDT visits. Comparisons were made between ROR and non-ROR sites. Nine new ROR sites were added with 26 new providers/staff and 130 providers/staff at existing sites trained in ROR from Novenber 2018 to June 2019. In SFY 2018, the developmental screening percentage at non-ROR sites was 33% vs 47% at ROR sites (p<0.0001), in SFY 2019 non-ROR sites were 36% vs 48% at ROR sites (p<0.0001). The EPSDT visit percentage in SFY 2018 was 50% at non-ROR sites vs 69% at ROR sites and in SFY 2019 was 51% at non-ROR sites vs 72% at ROR sites. HSIs are an effective way to fund ROR. Additional funding allowed for increased ROR sites and training. ROR sites are more likely to perform developmental screenings and EPSDT visits.

Parent-provider paediatric literacy communication: A curriculum for future primary care providers

BACKGROUND

Reach Out and Read promotes early literacy and school readiness by incorporating book delivery and anticipatory guidance into well-child visits. There is a need to train future healthcare providers in the knowledge and skills to communicate with parents/caregivers about early childhood literacy. We developed and evaluated a curriculum to improve learners' knowledge, attitudes, and skills towards the incorporation of parent-provider literacy communication into well-child visits.

METHODS

Family medicine residents (n = 30), physician assistant students (n = 36), and medical students (n = 28) participated in a curriculum consisting of service learning, online didactic training, objective structured clinical exams (OSCEs) and a debriefing session. Standardized patients (SPs; 6 months to 5 years) and standardized patient caregivers were recruited and trained. Learners were evaluated on their abilities to offer books to patients, provide anticipatory guidance, and demonstrate parent-provider communication skills. Knowledge, attitudes, and satisfaction were collected pre- and post-curriculum.

RESULTS

Significant increases in total knowledge were observed after completing curriculum activities (p < 0.001). All attitudes improved after training (p < 0.05). All learners (100%) recommended that caregivers talk back and forth with their 6‑ to 12-month-old babies and make eye contact. Few (18.2%) learners recommended playing games like 'peek-a-boo' while reading. When caregivers evaluated learners' basic parent-provider communication skills, all reported that the learners treated them with respect and used plain language.

DISCUSSION

Our curriculum extends beyond previous studies by measuring recommended books, anticipatory guidance, and communication skills using paediatric SPs and standardized patient caregivers. Curriculum activities can be tailored to best promote parent-provider literacy communication training in other programs.