Latino Parents’ Experiences with Literacy Promotion in Primary Care: Facilitators and Barriers

Abstract

Objective:

Literacy promotion is a pediatric standard of care in which clinicians provide guidance on shared reading. Latino parents are more likely to hear advice to read with children but are less likely to do so. We sought to understand literacy promotion from the perspective of Latino parents and to identify facilitators and barriers.

Methods:

We purposively sampled Latino parents who participated in Reach Out and Read (ROR) for a qualitative, semi-structured interview study. We identified themes using immersion/crystallization and achieved thematic saturation after 21 interviews.

Results:

Two-thirds of participants had less than high school education; half of whom had not completed 8^th grade. The mean child age was 16.4 months. Primary facilitators of engagement were advice from a pediatrician during a clinical encounter and receipt of the ROR book. Barriers identified included: (1) parents’ perceptions that their children were not developmentally ready and that their children’s behavior (e.g., activity) indicated they were not interested in shared reading; (2) self-perceived limited literacy and/or English proficiency; (3) parenting demands occurring in the context of poverty; and (4) continued child media use despite advice from pediatricians to choose alternate activities such as shared reading instead.

Conclusions:

Parent-clinician relationships are central to ROR’s impact but clinicians need to pay more attention to factors in a child’s broader environment to strengthen literacy promotion. Specifically clinicians should emphasize skill building during the clinical encounter (e.g., sharing knowledge about child development and modeling) and work collaboratively with other stakeholders to address poverty-related stressors.

Introduction

The American Academy of Pediatrics identifies literacy promotion as an essential component of pediatric care.¹ Past work suggests many pediatricians embrace literacy promotion;² however, little work has sought direct input from parents regarding their perspectives on pediatric literacy promotion, particularly from underserved groups like parents from low-income Latino backgrounds. This perspective is important given that Latino parents are more likely to report hearing advice about shared reading, but are less likely to engage in this activity compared to families from other ethnic groups.^3,4 Given the persistent disparities in school readiness faced by low-income Latino children,⁵ the public health ramifications of this inequity,⁶ and evidence that shared reading improves literacy, language, and social-emotional outcomes,^7–10 direct exploration of how Latino parents perceive literacy promotion and the barriers they face is needed to inform efforts to promote equity.

Reach Out and Read (ROR) is a widely disseminated primary care literacy promotion program that promotes equity in school readiness and serves many children from low-income Latino backgrounds.^11–16 Founded in 1989 by pediatricians at one clinic,¹⁷ ROR has been implemented in more than 5,000 clinics and reaches 25 percent of children ages 0 to 5 years who live within 200% of the federal poverty level.¹⁸ Several studies, many of which included or focused on families from low-income Latino backgrounds, demonstrate that ROR is well received, enhances home literacy environments, and improves child language outcomes.^{11–16,19,20,21} Other work among Latino families has yielded mixed results and highlights the need for additional investigation.^22,23 While Latino parents exposed to ROR in one study reported increased access to children’s books compared to a non-randomized control arm, parents in the intervention arm did not report reading more often than those in the control arm.²³ Still other work suggests that despite the important benefits of ROR, low-income Latino children remain at elevated risk for reading problems at Kindergarten entry.²⁴

To date the literature on primary care based literacy promotion has mainly focused on evaluating the efficacy of ROR. Few studies have leveraged qualitative methods to understand Latino parents’ experiences with literacy promotion and gain insight into facilitators and barriers. Such information can provide unique insight into essential aspects of ROR from parents’ perspectives and targets for enhancement, which can be useful to clinicians who engage in literacy promotion. In this study, we sought to address these gaps by conducting qualitative semi-structured interviews with Latino parents who had participated in ROR.

Methods

Study design

This qualitative study employed in-depth, semi-structured interviews nested within a larger mixed methods intervention framework study²⁵ to learn from participants’ experiences with ROR.²⁶ We used qualitative methods to inform the development of an enhanced literacy promotion intervention^27,28 and deepen our understanding of the results of a randomized controlled trial (RCT). To develop the interview guide, we followed the approach recommended by McCracken,²⁹ that begins with a detailed literature review and includes an iterative process of self-reflection followed by data collection and analysis. Our interdisciplinary team consisted of members with backgrounds in pediatrics, anthropology, sociology, and community-based research as well as research assistants trained in qualitative methods.

Setting and sample

Study activities occurred at a Federally Qualified Health Center (FQHC) that serves a largely low-income Latino population in New Brunswick, NJ. Seventy-one percent of patients served by the FQHC identify as Latino, 68% report they are best served in a language other than English, and 84% have incomes at or below the federal poverty level. The FQHC is a pediatric residency training site and has a well-established ROR program. The FQHC has a literacy-rich waiting room that includes a reading zone with children’s books and tables for literacy activities. Providers complete the ROR online training including videos and handouts from the Leyendo Juntos initiative. Consistent with the population served by the FQHC, the ROR program only purchases bilingual (English/Spanish) books and clinicians distribute books during clinical encounters.

We used a purposive sampling strategy to build a study sample consisting of Latino parents who participated in ROR that was suited to answer the following research questions: (1) What are Latino parents’ experiences with literacy promotion (operationalized as ROR)? (2) What aspects of the ROR program (e.g., waiting room experience, book distribution, clinician-parent interaction) act as facilitators? (3) What are remaining barriers?

We leveraged an ongoing RCT where parents received ROR as part of the usual care arm. The RCT excluded parents who were not the primary caregiver of the child and who were ≤18 years old. All participants in this article were selected from the eighty-one parents in the usual care arm. We purposively sampled only Latino parents from this group. Consistent with standard qualitative research procedures,³⁰ we analyzed data iteratively and refined our sampling strategy to enhance our understanding of the research questions. Since perspectives on barriers may differ based on the frequency in which parents engage in shared reading with their children, we used data from the RCT on shared reading frequency and further refined our sampling strategy to ensure representation of parents who read several days per week by the end of the RCT and parents who did not. We recruited participants and conducted interviews until we achieved thematic saturation, when no new themes are identified.³¹ Qualitative research guidelines and studies support that a sample of 20 participants is sufficient to achieve thematic saturation.^29,32,33

Data collection

We collected demographic information and reports of shared reading frequency as part of the larger study. We offered participants the option of in-person interviews but all chose phone interviews. We conducted interviews in Spanish or English based on the participants’ preference. Team members explained the purpose of the study and that participation was voluntary. After the participant provided verbal consent, the interview began. The interviewer asked participants to focus on the child who participated in the ROR program as part of the larger RCT. In general, the interviewer followed the guide (Figure 1), but also modified the order of questions and included unplanned prompts based on emerging information. Interviews were recorded and transcribed verbatim. The interviewer also took detailed field notes and prepared written reflections after interviews. Interviews took place from November 2018 to March 2019. The median interview time was 35.3 minutes.

Figure 1:

Interview Guide Example Questions

Analysis

Each interview was analyzed as it was completed.³⁴ We used an immersion-crystallization approach in which three study team members (JV, MJ, PS) read and listened to each interview in the language in which it was conducted and reviewed field notes several times to identify important concepts.³⁴ Three team members (JV, MJ, PS) then read each interview using an editing coding style attending to and highlighting elements of interest including key terms, description of parents’ experiences with their pediatrician, and other passages with direct relevance to literacy promotion. The three team members met at least weekly to review each transcript, reflect on patterns in each individual interview, and resolve discrepancies in coding with informal contact in between. We sought connections to identify themes through persistent engagement with the interview text and regular team discussion. This process was followed again by an immersion-crystallization approach to identify additional themes that we may have missed. We searched for disconfirming evidence in the data and collected additional data to ensure we achieved saturation. We used debriefing as a strategy to discuss emerging themes and seek insight from community members and other researchers and establish trustworthiness.³⁵

This project was approved by the Rutgers Biomedical Health Sciences Institutional Review Board.

Results

Table 1 summarizes demographic information. Twenty mothers and one father participated. All participants identified as Latino, with 57.1% from Mexico. Most (90.5%) chose Spanish for the interview. Two-thirds had less than a 12^th grade education. On average parents reported reading to their children approximately 3 days/week (Range: 0 to 7 days/week). The mean child age was 16.4 months at the time of the interview. We identified five themes that provide insight into key drivers of ROR’s impact and barriers that remained despite ROR. We summarize themes with representative quotations below and provide additional supporting quotations in Table 2.

Table 1.

Demographic Characteristics of Study Population (N=21)

Language of Interview
English	2 (9.5%)
Spanish	19 (90.5%)
Child’s gender
Male	14 (66.7%)
Female	7 (33.3%)
Child’s age, m (range)	16.4 (12–23)
Parent’s age, y (range)	31.5 (25–42)
Parent’s Education
Less than 8th grade	6 (28.6%)
9th–12th grade	8 (38.1%)
≥ High School diploma or GED	7 (33.4%)

Table 2:

Themes and representative quotes

Theme 1: Receiving advice from a pediatrician, a trusted messenger, and a children’s book facilitated parent engagement with literacy promotion	“I feel good talking to his pediatrician because they show me how the kids need to develop so that it’s easier for them to learn in school.” Participant 2 “Well it seems good to me that they do those check-ins with my son. I appreciate that they’re able to give us a book… I tell my kids that they have to take care of it, that they have to read the book because the pediatrician gave it to him.” Participant 5
Theme 2: Parents interpret children’s developmental milestones and behavior as lack of interest in shared reading or readiness for this activity despite pediatricians ‘ advice to read with their children	“I think that it’s because of his age. He’ll grab the books, he’ll hold the book, he’ll say “ahh” like he’s trying to talk. But then he’ll move away and, because of his age, he sees it as playtime. He’ll throw it. Like he wants to identify [what’s in the book] but play. The two things at once.” Participant 16 “Sometimes it can be fun and sometimes no because they only listen to you for a little bit and then they get antsy and they run away.” Participant 7
Theme 3: Parents reported that their own language and/or literacy skills limited their ability to help their children	“Sometimes with some books I feel that I’m not useful because my problem is that I can’t read English.” Participant 8 “Yes, [when I read to him] I look it up on my phone to understand what the book is saying and explain the pictures more.” Participant 1
Theme 4: Complex parenting demands and competing priorities occurring in the context of poverty took precedence over activities like shared reading	“I don’t have much time with him because I work and, well, it’s only at night that we spend time together.” Participant 14 “I live alone with him and I think that’s part of it. I have to give him time and I have to also give time to my daughter.” Participant 16
Theme 5: Parents allowed media use despite their concerns about health effects and advice from pediatricians to choose other activities like shared reading instead	“She [pediatrician] tells us, well, she says that I have to read more, spend more time with my daughter. I have to read more, not give her my phone and all of that.” Participant 2 “We mostly use TV. For example, children’s videos that show how to be organized, that we have to obey mom and dad and that we have to share. The videos show him things like that…” Participant 3

Theme 1: Receiving advice from a pediatrician, a trusted messenger, and a children’s book facilitated parent engagement with literacy promotion

Trusted messenger

Many parents wanted to discuss shared reading with their child’s pediatrician and child development more broadly. Participants reported trust in the pediatrician’s advice regarding this topic since they could provide information that would help a child’s brain develop (“desarollar su cerebro”).

“I like talking to the pediatrician a lot. In my country, a doctor will never talk to you about reading. And reading is strange to kids, it’s not something intuitive. It’s good that in this country they teach kids how to read because it helps their development a lot. So it’s good that doctors do this …” Participant 20

Some parents directly attributed reading with their child to their pediatrician’s advice. Parents also expressed a desire for more guidance on how to prepare their child for school.

“The truth is that I would really like them [pediatrician] to help me with this part about how to prepare my daughter to go to school.” Participant 1

The gift of a book

Parents expressed gratitude that their pediatrician cared enough about their child’s development that they would give them a children’s book. Having a ROR book in the house facilitated shared reading by presenting opportunities for children to initiate this activity and for other family members to read with the child. Multiple participants reported that other children in the household read the ROR book to the child.

“Well right now, her brothers read the book to the baby. In fact, sometimes the baby will grab the book and bring it to them.” Participant 3

Theme 2: Parents interpret children’s developmental milestones and behavior as lack of interest in shared reading or readiness for this activity despite pediatricians’ advice to read with their children

Children need to be developmentally ready for shared reading

Some parents delayed reading aloud with their children until they observed certain milestones like sitting up and handling the book. Parents who did not read regularly with their child commonly reported that they would start reading aloud with their child once they began talking.

“I try to read to her but my daughter still doesn’t do advanced things. I’ll play with her and all of that but… but that’s it. Since she’s going to start talking soon, she’ll be able to tell me what she wants to do.” Participant 2

Child behavior indicates that children are not interested in shared reading

Parents described how shared reading experiences did not always meet their expectations once they reached their homes. These experiences influenced the extent to which shared reading occurred. Parents interpreted behaviors that are within the realm of typical development for a young toddler (e.g., walking away during shared reading) as an indication that children were not interested. Participants interpreted distractibility, high activity level, or interest in other activities as lack of interest in shared reading.

“…I thought it would be easier. I thought I’d sit down and he’d sit down with me and would look at the book and pay a lot of attention. But that’s not how it is because he’s still a baby. Once he starts showing a little bit of interest I think that little by little he’ll start liking it more.” Participant 17

Theme 3: Parents reported that their own language and/or literacy skills limited their ability to help their children

Despite ROR anticipatory guidance, multiple parents expressed a lack of confidence in their ability to read with their child or contribute to their school readiness based on their English proficiency or their own literacy skills. This lack of confidence limited the frequency of shared reading with children.

“Well, I read him the little bit that I know because I don’t know how to read well.” Participant 19

Theme 4: Complex parenting demands and competing priorities occurring in the context of poverty took precedence over activities like shared reading

Parents described overwhelming demands and life circumstances that took precedence over shared reading. Common demands included caring for other children, work schedules, and other household responsibilities.

“What gets in the way of reading? Well, right now I can’t sit to read with her because I have a sick child and they come to the house for his therapies so I don’t have much time to be with her reading.” Participant 15

Conditions like housing insecurity limited parents’ opportunities to establish shared reading routines despite their desire to do so.

“Sometimes, you know. I’m weak, I’m homeless. I [have] a lot of things going on, like a lot. So sometimes, even if I want to [read], like, either I’m not in the mood because either I’m depressed or I get, yeah, it’s too much right now going on.” Participant 21

Theme 5: Parents allowed media use despite their concerns about health effects and advice from pediatricians to choose other activities like shared reading instead

Parents expressed concerns that media use could result in adverse health effects (e.g. vision). They also expressed concern regarding the amount of time children spend on devices and how it can displace other activities.

“Well, like I said, with technology, I try to make sure they don’t spend too much time on it because it can become addictive. So I don’t want them to use technology for too long.” Participant 3

However, parents noted entertainment and potential educational value of television, tablets, and phones.

“I’ll put on the learning channel that’s made for babies on the cell phone.” Participant 17

Participants juxtaposed the advice they received from their pediatrician on media use with the advice their pediatrician provided on shared reading. Specifically, parents reported hearing advice from their pediatrician to choose activities like shared reading over screen time.

“She tells me to read books. Not to have him watch TV or give him the cell phone because that’s bad. That we should only read books.” Participant 10

Despite this advice, nearly all the parents continued to allow children to use devices and one directly challenged the idea that young children cannot benefit from media use.

“They say tablets are supposed to make kids boring …and lazy but in my book, I don’t see that and my son is smart. Like my son started off… without a book in his hands, he started off with a tablet and he knew his ABCs by 9 months and he knew his 123s by almost 8 months so it was like, you know, you can’t really say from being in front of a tablet that will be bad for them cause it actually learning too as well.” Participant 6

Discussion

The current study provides insight into how low-income Latino parents experience the ROR model and remaining barriers from a perspective that has been largely underexplored. Latino parents in our sample shared narratives that demonstrate how ROR builds on the parent-clinician relationship and may even contribute to it. The themes from this study also add to the existing literature by illustrating how ROR is nested within the broader context of a child’s environment and suggesting how attention to context can further strengthen ROR. Our findings have direct implications for clinicians who engage in literacy promotion such as incorporating additional skill building into anticipatory guidance. They also highlight barriers that cannot be addressed in the medical office alone and opportunities for clinicians to work collaboratively with stakeholders from other sectors to build on ROR’s impact.

Our findings illustrate how the parent-clinician relationship provided an opening for the ROR message and enhanced credibility for the idea that shared reading with infants, an activity that was not always normative or intuitive based on parents’ own experiences, could indeed be helpful. Our findings also suggest that ROR may help to enhance this relationship through the gift of a book and holistic attention on the child’s needs. Like a study that occurred among a similar sample,²¹ parents expressed gratitude that their pediatrician cared enough about their family to give them a book and take interest in their child’s development. The interplay between ROR, the parent-clinician relationship, and child outcomes represents an important direction for future research on literacy promotion.

While past work has largely focused on literacy promotion in the office setting, in this study parents described barriers that occur at different levels of influence and demonstrate why clinicians need to understand families’ broader context when implementing ROR. These findings highlight opportunities for equity promotion by clinicians. At the parent-child interaction level, parents in our sample described how shared reading experiences did not always meet their expectations once they reached their homes based on observations of their children’s development or behavior. This underscores the importance of tailoring literacy guidance to a child’s developmental stage³⁶ and modeling shared reading. For example, clinicians can alert parents to expect that a toddler may be very active and distractible during shared reading but even brief experiences provide an opportunity for joint attention around the book and exposure to vocabulary. At the parent level, some parents questioned their capacity to support their child’s literacy development based on their own limited English proficiency and/or literacy skills. These findings illustrate the importance of providing guidance in parents’ preferred language and using literacy promotion as an opportunity to promote bilingualism. Clinicians can also build confidence among parents highlighting how even simple routines like talking about pictures can benefit children.

At the community level, parents described complex parenting demands and competing priorities that occurred in the context of poverty and acted as powerful barriers to shared reading. Put simply, it is difficult for parents to engage in shared reading if their basic needs are not met. Our findings underscore the importance of integrating primary care literacy promotion with efforts occurring at the community level like Help Me Grow, which provides enhanced access to poverty-reducing resources and developmental enrichment that can support optimal child development and family wellbeing.³⁷ In this way, clinicians delivering ROR can work collaboratively with stakeholders from other sectors to promote equity in school readiness by connecting families to these resources.

Unlike past qualitative research on ROR, our study occurred when mobile technology is nearly ubiquitous. Our findings are consistent with other work in which parents who were mostly non-Latino and all English-speaking expressed tension about child media use.³⁸ Parents in our sample continued to allow children to use mobile devices despite concerns about health effects and in some cases believed it could be educational. Our findings suggest that literacy promotion may provide an opening to explore child activities more broadly including media use. While it is important for pediatricians to highlight the lack of evidence behind educational applications particularly in this young age group, it is also important to note that parents may observe rote learning. Pediatricians might use this opportunity to explore parents’ tension as experts have suggested,³⁸ discuss different types of learning, and identify how activities like shared reading affect learning differently than media use. These findings also highlight the need for further research regarding what parents value in early learning and understanding how to align with best practices in early education.

We used a rigorous qualitative approach building on a larger study to provide insight into facilitators of ROR and remaining barriers from the perspective of Latino families. As such, this study addresses key gaps left by previous work. However, this study is still subject to certain limitations. First, our study focused on Latino parents from one FQHC so our findings may not transfer to all settings. Future work might examine to what extent these themes generalize to other settings and to what extent findings differ across different racial/ethnic, linguistic, and socioeconomic groups. Second, our results may be subject to recall and social desirability bias. We did not observe the clinical visits so we do not know to what extent providers’ guidance included information on the identified barriers such as child temperament and English proficiency. The goal of this study was to examine the perspective of Latino parents and in doing so elevate the voice of a group whose perspective is too often marginalized. Future work that includes direct observation of the clinical encounter would make an additional contribution. Furthermore, while we assessed participation in ROR at the initial study visit we do not have information on the number of subsequent ROR visits or books received by parents and therefore cannot examine whether themes differ based on the amount or intensity of ROR exposure. Third, we did not formally assess parents’ English proficiency or literacy level, but the goal of this study was to explore parents’ perspectives on the barriers that they encounter. Fourth, all interviews were conducted by phone which could have potentially limited opportunities for rapport building and observing non-verbal cues. However, this approach facilitated participation and honored the expressed preference of participants in our sample.

Despite these limitations, we directly explored Latino parents’ experiences with ROR and identified themes with clear implications for clinicians who participate in literacy promotion and researchers who study it. Our findings illustrate the power of the parent-clinician relationship as it pertains to ROR and opens the door to future study on the extent to which ROR may further enhance this relationship. Clinicians can use the results of our study to enhance literacy promotion guidance specifically by highlighting reasonable developmental and behavioral expectations, empowering parents with limited English proficiency and/or literacy skills through modeling and use of language appropriate guidance and books, and addressing the new milieu of media saturation as part of this guidance. Finally, our findings uncover opportunities to build on ROR’s impact by working collaboratively with stakeholders from other sectors (e.g., social services, education) to support parents’ capacity to engage in shared reading and promote the shared goal of equity in school readiness and health.

What’s new:

We identified themes from the perspective of Latino parents on important aspects of literacy promotion and barriers parents encounter. Clinicians can use this information to enhance their literacy promotion guidance and identify opportunities to work collaboratively with other stakeholders.

Abbreviations

FQHC

Federally Qualified Health Center

RCT

Randomized Controlled Trial

ROR

Reach Out and Read