Table 1:

Themes and representative quotations

Theme	Quotations
Traditionally, literacy promotion focused on enhancing preliteracy skills and school readiness. Over time, this outcome has evolved to include fostering early relational health as a foundational goal that underlies its effects on preliteracy skills and school readiness.	“So thinking, you know, the old or the traditional logic model used to be like, you know, you read books to kids, kids learn more words. The more words they know, the more likely they are to have success with formal reading. But I think understanding… that like development occurs within the context of relationships and for a brain to develop to its full potential it really needs to feel safe … so… sharing books with kids can also be a way to promote like a feeling of a safe and stable nurturing environment even in the midst of other chaos…” “I think that Reach Out and Read… has started off as a program that’s centered in the primary care setting, it’s connecting families with children’s books and giving that advice on the best way to share those books with the child and you know sensibly for the point of increasing that child early literacy right but also to… enhance that bond between the parent or caregiver and the child… that early relational health piece that bond that you’re building and nurturing and fostering between parent, caregiver and the child is really fundamental to so many aspects of their life.”
Core components include a (1) trusted clinician delivering (2) a strength-based, family-centered message while (3) modeling developmentally informed shared reading interactions.	“So, it takes advantage of that relationship that providers have …with the parents and also, the fact that it sets that different tone for the visit. It aids in so many different areas to be able to have a warming connection with the family.” “This is truly strength based. The message here is truly that your voice is the center of your baby’s world your baby wants to be in your arms look how she turns to you when you talk this is a strength-based incredibly positive message for parents …” “When you model in the exam room you often find yourself saying ok she’s sort of interested in me telling her what the pictures are now let’s see how she reacts when you do it. Ooo look how she turns to you. I’m ok but you’re the one that she’s really paying attention to and you know I think it’s a good way into helping parents feel that first of all they have this great power and potential.”
Additional components that are adaptable to setting and context include literacy-rich clinical environments and referrals to other community resources	“In some of our clinics, we have the best literacy rich waiting rooms, which are great to have, but not all clinics can do that. For whatever reason, some clinics might even not be allowed to put posters on the wall. You know, so like that really differs from clinic to clinic. Ideally kids are sitting in a waiting room filled with books and filled with posters about reading instead of a TV on.” “And of course, addressing all the basic needs issues, right? It’s a little silly to be talking about reading when the family has just told you that they are homeless now because they got kicked out of their apartment or they lost their jobs or whatever the case may be, right? Like, you can’t… you can talk about reading all you want, but if you’re not addressing basic needs as well, then you know that’s not going to help either.”
Experts diverged on the extent to which providing a children’s book during literacy promotion is essential, but there was congruence that the book should be culturally tailored if provided and book provision is insufficient on its own.	“But number one is like you have to give the book… You want to make sure that the family has the means to do the intervention when they leave your office? So, you have to get the children’s book. That’s a core component.” “I don’t think the book is essential because I think it’s the smallest component of Reach Out and Read. Which I know sounds silly, but I think the biggest component is the person giving the message and how they deliver it. And I think the book is the reminder of that message.” “… Reach Out and Read is not a book provision program, … it works because it’s… more than book provision… It’s like, here’s a book. let’s open it and look at it with your kid. In a way that models those behaviors, because reading with young children is not always intuitive and doesn’t always look like reading…so it’s, you know, maybe it’s I didn’t read a single word on this page. I just opened a book and let the kid, like, move the pages. Or I made animal noises and I didn’t read any of the words and so I think …another way that it works is helping families to understand what is developmentally appropriate for their child’s interaction with the book at a given phase so that they don’t over or under expect something from their kid and then get frustrated…”