Feasibility and Acceptability of an Online Family Literacy Program in an Under-Resourced Community during the COVID-19 Pandemic

Abstract

Objective:

To examine the feasibility and acceptability of an online family literacy program (FLP) among low-income Latino families during the COVID-19 pandemic.

Methods:

We conducted a mixed methods pilot study. Latino parent-child dyads participated in an 8-week online FLP conducted on video conferencing software, developed through a cross-sector healthcare-education partnership. We conducted surveys and structured observation to assess feasibility and acceptability, and in-depth interviews to gain insight into the context of participants’ experiences during the pandemic.

Results:

The 35-participating parent-child dyads all identified as Latino, 83% reported limited English proficiency, and 60% of parents did not achieve a high school diploma. Nearly two-thirds of families participated in at least half of the sessions. On average, parents welcomed, liked, approved, and found the program appealing. While 86% experienced a technology problem at least once during sessions, all were resolved with minimal assistance. During qualitative interviews, we identified 3 themes that provide insight into their experiences with the FLP within the broader context of the pandemic: (1) Disruption in family routine and financial strain caused by COVID-19 intensified family stress, (2) The forced transition to remote learning highlighted the inequities experienced by Latino pre-school children, (3) The FLP empowered parents and enhanced health and education experiences.

Conclusion:

Latino families had high participation levels in an online FLP and found it acceptable. Additional work is needed to understand how similar primary care programs can be leveraged to promote optimal development during a time of heightened need.

INTRODUCTION

One-third of US children ages 0 to 8 years are dual language learners (DLL), children who acquire two or more languages, and who have a home language other than English.¹ In the US, most DLLs come from low-income Latino backgrounds and experience inequities in school readiness.^2,3 Poor school readiness predicts long-term poor academic achievement,⁴ which is linked to high-risk health behaviors and fewer employment opportunities with health-promoting benefits (e.g., health insurance).^5,6

The COVID-19 pandemic has disproportionally affected low-income children of color and intensified educational inequities.⁷ For example, public preschool enrollment dropped significantly among this population.^8,9 Such negative effects highlight the need to leverage opportunities in healthcare to promote school readiness. Primary care, in particular, is an innovative setting to promote school readiness, because of its near-universal access and clinicians’ frequent contact with children and their families.² The American Academy of Pediatrics Bright Futures guidelines identifies school readiness as a priority topic, and parents seek information from pediatric professionals on this topic.^10,11 Cross-sector education-health partnerships that combine the expertise of teachers and pediatricians and leverage the near-universal access to children offered by primary care have the potential to capitalize on this opportunity, but such programs are rare and understudied.

Family literacy is the way in which families promote reading skills in their homes through daily routines such as storybook reading.^{12, 13, 14} Family Literacy Programs (FLP) teach parents to incorporate literacy activities into family routines. FLPs improve home literacy and child outcomes.¹² However, there are relatively few published studies focused on low-income, Latino families specifically.^15,16 Previous work has found low participation and engagement from parents and children from this community in part due to barriers including parents’ work schedules and time constraints.^16,17 Successful FLPs^18,19 have acknowledged the contributions of families to children’s learning, used families’ heritage language, connected with families’ existing knowledge, provided a forum to share experiences, and incorporated topics that are important for the whole family.¹⁹ For example, one pilot study introduced literacy activities through food and eating routines.¹⁶ To date, there is a paucity of work that has focused on the feasibility of online FLPs developed through cross-sector partnerships between educators and pediatricians.

In this mixed methods pilot study, we examine the feasibility and acceptability of an online FLP developed by educators and pediatricians for Latino DLLs entering Kindergarten and their families. We also explored parents’ experiences during COVID-19 to gain insight into the broader context in which the FLP was implemented.

METHODS

Program Development

Our interdisciplinary team, which included members with backgrounds in education, linguistics, and medicine developed an 8-week FLP, entitled “Ready and Healthy for Kindergarten” in partnership with educators from a local charter school. We initially developed and pilot tested the program in-person as described elsewhere.²⁰ Due to pandemic-related precautions, we modified the program to be conducted online. The program focuses on three goals: (1) Enhancing children’s English and Spanish language and literacy skills prior to kindergarten, (2) Encouraging children’s use of Spanish to maintain their heritage language, and (3) Empowering parents to play an active role in their children’s education and health.

The FLP manual was adapted for online sessions. In-class materials were converted to a slideshow that was screen shared. We incorporated in-home activities for families. We arranged contactless pick-up for backpacks with health-related Spanish picture books and with school supplies. All sessions were conducted remotely using online conference software provided by Rutgers University. The participants used their own devices and internet access to participate. Team members assisted parents in downloading the software onto their devices and provided technical support throughout the program.

The FLP uses health topics including nutrition, physical activity, and sleep to introduce foundational early literacy skills endorsed by the National Early Literacy Panel (Supplemental Table 1).²¹ Parents and children participated in 8-weekly 1-hour sessions that were led by bilingual early educators. Educators followed the manual and materials as a guideline for their English and Spanish use. However, they tailored their use of each language based on participants’ needs. The educators reviewed the manual, slides, and materials in advance and debriefed with our team’s literacy expert after sessions.

The workshops used an interactive discussion and activity-based format. Each session had a children’s book related to the health theme that was used for a guided read-aloud. Letters and sight words were based on these books and the themes and were introduced and reviewed during sessions. Songs related to the health theme to encourage language development and movement breaks were interspersed throughout to model helpful learning habits. The parents were encouraged to assist the child and participate throughout the session (e.g., helping their child write out letters, joining in dancing and singing).

During one workshop, one of two bilingual pediatricians from the FQHC who participated in the development of the program volunteered for a question-and-answer session with parents. One-way text messages were sent in either Spanish or English based on parent preference to remind families to review the letters and words twice weekly.

Study Design

For this study, we used an intervention mixed methods study design.²² We used quantitative program data (e.g., attendance) and direct observation of the workshops to examine feasibility, and then conducted in-depth qualitative interviews to understand parents’ experiences and program acceptability. Given that we implemented the program during the pandemic, we also asked parents in the interviews to share their experiences during this time to understand the broader context.

Participants and setting

We recruited parent-child dyads from a local Federally Qualified Health Center (FQHC), which serves mostly patients from low-income backgrounds via clinician referral. Approximately 70% of the patients served by the FQHC identify as Hispanic/Latino. We also recruited participants from our partner charter school site, which serves a similar population using flyers. Inclusion criteria were the following: (1) Children entering Kindergarten (age 4 and 5 years), (2) Preferred language Spanish or English/Spanish bilingual, (3) Parent or legal guardian, (4) age ≥ 18, and (5) willing to accept text messages. Children were excluded if their parents reported they were not entering Kindergarten. The study took place from June - September 2020.

Data Collection

We collected survey data on demographic characteristics and home language use. We maintained records on enrollment, attendance, and program completion. During observation, a bilingual research assistant collected information on technology barriers experienced by families. For the purposes of this study, participation was defined as session attendance. At the end of the program, parents completed the Acceptability of Intervention Measure (AIM).²³ The AIM consists of 4 statements that assess acceptability and are scored from 0–4, (0 completely disagree to 4 completely agree). We then conducted in-depth interviews with 15 parents online in their preferred language. To ensure we explored the perspectives of participants with different educational backgrounds and varying attendance in sessions, we used demographic and attendance data to purposively sample parents for interviews to ensure diversity in these areas. We developed the interview guide based on literature review and our team’s experiences while implementing the program (Supplemental Table 2).^24,25 At the start of each interview, the team member described the purpose of the study and the interview, explained that participation was voluntary, and informed parents that the interview would be recorded. The interview began once the participant provided verbal consent. Interviewers generally followed the interview guide but added follow-up questions and probes based on the interview flow and information shared. All interviews were transcribed verbatim. Interview participants received a $25 gift card as compensation. The median interview time was 42 minutes (interquartile range 36 –51 minutes).

Analysis

We summarized quantitative data using descriptive statistics including counts, measures of central tendency, and spread. For qualitative data, we analyzed data iteratively. The interviewer took detailed field notes and wrote reflections after each interview. At least two additional team members independently read the transcript in the language it was conducted and listened to each recording multiple times. Two team members then coded data using an editing approach, in which codes are allowed to emerge from the data.²⁶ We resolved disagreements in coding through consensus. Example codes included technology use, barriers faced by the underserved community, and virtual school. During frequent team meetings, we discussed the interview data, interviewer reflections, and coded text. Through this iterative process, we identified themes that provided insight into participants’ experiences with the FLP and the pandemic more broadly.

The Rutgers Biomedical Health Sciences Institutional Review Board approved this study.

RESULTS

Demographic characteristics are summarized in Table 1. All families identified as Latino and were predominantly from Mexico. More than half of the parents did not achieve a high school diploma. In fact, more than a third achieved less than an eighth-grade education. Eighty-three percent reported limited English proficiency and 63% of the parents reported an annual family income less than $25,500, which coincides with the poverty level for a family of four. More enrolled parents from the FQHC compared to the charter school reported limited English proficiency (94% vs. 74%), educational achievement less than high school diploma (81% vs. 42%), and family income less than $25,500 (75% vs. 53%).

Table 1.

Demographic information of entire sample and sample participating in qualitative interviews

	All participants (n=35)	Interview participants (n = 15)
Parent age, MEAN (range)	34.6 (22–48)	34.9 (22–46)
Parent age, # of participants (%)
18–29	9 (26%)	3 (20%)
30–39	18 (51%)	8 (53%)
40+	8 (23%)	4 (27%)
Parent Ethnicity
Mexico	26 (74%)	11 (73%)
Other Spanish-speaking country*	9 (26%)	4 (27%)
Parent Education
Less than 8th grade	13 (37%)	6 (40%)
HS, no diploma	8 (23%)	2 (13%)
HS graduate	8 (23%)	3 (20%)
1 or more years college or higher	6 (17%)	4 (27%)
Parent English proficiency
Not at all	13 (37%)	6 (40%)
Not Well	12 (34%)	4 (27%)
Well	4 (11%)	1 (7%)
Very well	6 (17%)	4 (27%)
Child’s Level of English Use
Speaks like a native	12 (34%)	6 (40%)
Speaks almost like a native	12 (34%)	4 (27%)
Has difficulty speaking	3 (9%)	1 (7%)
Can barely speak	8 (23%)	4 (27%)
Understands like a native	14 (40%)	7 (47%)
Understands most	12 (34%)	3 (20%)
Has difficulty understanding	5 (14%)	2 (13%)
Can barely understand	4 (11%)	3 (20%)
Child’s Level of Spanish Use
Speaks like a native	13 (37%)	3 (20%)
Speaks almost like a native	7 (20%)	3 (20%)
Has difficulty speaking	14 (40%)	9 (60%)
Can barely speak	1 (3%)	0 (0%)
Understands like a native	22 (63%)	7 (47%)
Understands most	8 (23%)	6 (40%)
Has difficulty understanding	4 (11%)	2 (13%)
Can barely understand	1 (3%)	0 (0%)
Family Income
Less than $25,500	22 (63%)	11 (73%)
Greater than $25,500	10 (29%)	3 (20%)
No answer	3 (9%)	1 (7%)
Child age, # of participants (%)
4	12 (34%)	6 (40%)
5	23 (66%)	9 (60%)
Number of siblings, # of participants (%)
0–1	15 (43%)	7 (47%)
2–3	17 (49%)	6 (40%)
4+	3 (9%)	2 (13%)
Attendance M(Q1,Q3)	6.5 (3.5,7)	7 (4,7.5)

^*Honduras, Ecuador, Dominican Republic

Feasibility and acceptability

Fifty-nine families were approached and 46 met eligibility criteria. 35 were enrolled (76%). Five families declined participation. The reasons were lack of time (n=3), parent’s work schedule (n=1), and lack of interest (n=1). We could not reach 6 families who had initially expressed interest. Out of the enrolled families, 89% completed the program defined here as survey completion. Throughout the program, 66% of families participated in at least half of the sessions. Half of the parent-child dyads attended 7 or 8 out of the 8 sessions. Figure 1 depicts the attendance of the 35 parent-child dyads in the 8-week program. Direct observation indicated that 86% of families experienced a technical difficulty at least once during the FLP. 57% of these technical issues were related to the video feature of the conference software as illustrated in Figure 2. Most issues were resolved with basic technical assistance from our team. At the conclusion of the FLP, parents rated the program as acceptable (Table 2).

Figure 1. Attendance of parent-child dyads.

Figure 2. Barriers to Technology during the FLP.

Table 2.

Acceptability of Intervention Survey among study population

Acceptability of Intervention Measure (AIM) question	AIM mean score (range)* n= 31 parents
The program met my approval.	3.4 (3–4)
The program was appealing to me.	3.3 (3–4)
I liked the program.	3.4 (2–4)
I welcome what I learned in the program.	3.3 (2–4)

^*0 = Completely disagree; 1 = Disagree, 2 = Neither agree or disagree, 3 = Agree, 4 = Completely agree

Interviews

We identified three themes that yield insight into parents’ experiences with the FLP and the pandemic, representing the broader context during which the FLP was implemented.

Theme 1: Disruption in family routine and financial strain caused by COVID-19 intensified family stress.

Participants described how the pandemic created disarray and unsettled typical family routines. Parents who lost their jobs shared how they lost structure during the day as noted by one parent.

“You know I feel like the structure is pretty much gone.”

The lack of structure had an unsettling effect on children, and parents observed how children took on new habits. In many cases, parents noted a marked increase in their use of electronic devices. Parents reported that the disruption of routines and increase in media use affected their child’s sleeping patterns. They also noted how their children’s increased technology use reflected their own.

“Because to be honest with you, my son really likes the phone, and he would get the phone and fall asleep at 2:00 in the morning... It was until he was so exhausted that he’d fall asleep on the bed. The phone was left on as he slept because he was already tired. So now I realize … it started with me, and they will see the routines that I have, and so they will also follow it.”

Just as job loss for parents altered the structure of their day, in-person instruction played an important role in children’s routines. The sudden transition from in-person to virtual school made unprecedented demands on parents as children tried to learn at home.

“I could say, chaos. Just because I feel like none of us were prepared for this, especially teachers. And for kids, at the age that my son is, I don’t think they really understand the fact that we learn through doing something and like watching a video is actually class time, learning time.”

The loss of structure and disruptions intensified the immense stress caused by the virus itself. Some families contracted COVID-19 themselves or knew close family members who had, and one parent reported losing loved ones in her home country. Many parents voiced their fear about spreading the virus at home to their children.

“The truth is that this disease changed our lives completely because now we can no longer go out into the streets without worry, one goes out with fear of getting sick or that you are going to bring the disease from work to the children. The truth is that this disease changed our lives a lot, I think that not just us but everyone”

Parents described the challenges of navigating the tension between financial pressure, caregiving, and health concerns.

“My mom got the virus and she’s just recovering from it, so I have to take care of my mom. And I’m basically the one that provides for my family at this point, so it has changed a lot in so many ways where now I don’t go out to work. I have to stay home most of the time to be here with them and help them out in whatever they need. Sometimes I do have to go to my job and be there, but I try to go as early as possible so I can come home and take care of my family here.”

Even with these challenges, it created an opportunity for families to spend more time together and create new habits together including going on walks and completing household tasks as a team.

“I try to make it the same here, for example, with everyday things, cleaning together, putting things together, organizing the house, because sometimes they would have to go to school and I was left to do it on my own, but now we do it as a team.”

Theme 2: The forced transition to remote learning highlighted the inequities experienced by Latino pre-school DLLs.

Virtual school forced parents to play a teaching role and to reconstruct their homes as learning environments. Spanish-speaking parents found this transition to be difficult due to language barriers. Parents reported limited communication with teachers during remote learning. One parent shared her experience with her child’s school where the teacher did not attempt to communicate with her child’s class once the pandemic began. There was no organized effort to facilitate any virtual interaction among the class, and this social isolation had a negative impact on some of the children’s wellbeing.

“With the older ones, yes, they had video calls. They liked it when the teacher did that, but my little girl, was never offered video calls ... For her it was only the packet... she wanted to see her teacher. But no, not with her. Only the older ones.”

Language posed a major barrier for some parents. The materials provided to families by the school were in English, making it difficult for them to utilize the resources and teach their children at home.

“That was the hardest part, that the materials were only in English. And there are things that one might translate, but it does not have the same meaning. Well, I would put it in the translator. And sometimes I would translate, and I wouldn’t really understand what it was asking of me and I left that one, and continued with the other one.”

Another parent described their concerns that language barriers would interfere with learning.

“Because since I don’t speak English, and they are used to it in English. Everything would need to be explained…. I can’t explain to them in English… they don’t learn like that.”

Theme 3: The FLP empowered parents and enhanced health and education experiences.

Parents identified the bilingual format as a major strength that allowed them to participate alongside their children. The FLP also distributed books in Spanish to facilitate reading at home.

“Yes, those books we read every day. In Spanish…. they are the first ones. “

The FLP fostered discussion about health themes each week including sleep and nutrition. The program also invited physicians to join a session to allow for questions and answers. Parents expressed how they enjoyed this aspect because it provided access to a healthcare professional and an opportunity to address some of their concerns during these unprecedented times.

“I really liked that they included the doctor because I was curious to know if children presented some stress due to this situation”

Synchronous instruction from the teacher was another key component of the program highlighted by parents. Parents observed how it allowed them to collaborate with teachers, learn alongside their children, and assist them during sessions.

“The fact that they [the teachers] actually involve the parents as well. They require an adult, one of the parents, to be there. And it kinda works in the fact that he doesn’t understand something, the teacher, or the person saying, or the other classmate saying, he’ll ask me and it’s okay and to ask me since I’m right next to him.”

Parents described the interactive component of the FLP as informative. They learned educational habits to practice in the home such as shared reading.

‘The family literacy program was very engaging… in that 45 minutes … we were able to get a lot of information from it. And then in the virtual preschool we weren’t able to interact with the teachers as much.’

Another parent expressed how the activities taught her to put what she learned into practice.

“Well with what I learned there, we should put it into practice, and that helps a lot.”

Along these lines, another parent expressed how she learned how to encourage literacy and how to meet her child’s social-emotional needs.

“We learned that before the kids go to sleep we should tell them a story, talk with them, show them how to control themselves when they are mad… Also we learned that they need love, that they need us to hug them…”

DISCUSSION

We found that an online FLP developed through a cross-sector education-health partnership implemented during the COVID-19 pandemic was feasible and acceptable among a sample of Latino families. Our findings provide insight into how the pandemic intensified educational inequities for Latino preschoolers and the potential for similar primary care-based programs to help mitigate these impacts. The FLP was highly attended, and parents identified the online, synchronous format and access to professionals during the sessions as key drivers of acceptability. Establishing the feasibility and acceptability of this online program in the broader context of the COVID-19 pandemic opens opportunities for additional research to understand how similar programs might play a role in addressing inequities in school readiness that have intensified.

We found that implementing an online FLP among Latino families was feasible even during the pandemic. Like other historically marginalized groups, Latino communities suffered disproportionally during the pandemic.²⁷ For young Latino children, this situation intensified inequities in school readiness, including reduced opportunities for preschool participation. Our qualitative data illustrates how parents with limited English proficiency had difficulty accessing school materials and teaching their children during virtual school due to language barriers. Given the near-universal access and frequent contact with pediatric clinicians, primary care presents a unique opportunity to help mitigate these inequities. Our findings highlight the feasibility of implementing similar programs in this setting and leveraging online platforms. Two-thirds of the families participated in at least four of the eight sessions and most technological barriers were resolved with minimal assistance. These findings indicate that such a program can be implemented virtually in this community.

We found that this program was also highly acceptable. During the qualitative interviews, parents highlighted the bilingual aspect of the program because it encouraged use of their home language. Parents also noted the importance of the interactive nature of the FLP. Parents shared how the format empowered them to play a bigger role in their child’s education through live instruction and an interactive process, unlike their previous experiences with virtual school. Previous bilingual FLPs received similar feedback where in which parents enjoyed being alongside their children in a learning environment to better facilitate learning in both English and their home language.^28,16

This study has certain limitations. This pilot study assessed the feasibility and acceptability of the FLP. While this is an important step in the intervention development process, future larger studies will need to examine impacts on child and parenting outcomes.²⁹ Further, given that the study population came from low-income, Latino backgrounds these study results may not transfer to other settings.

Despite these limitations, we found that an online bilingual FLP developed by educators and healthcare professionals was feasible and acceptable. The COVID-19 pandemic has intensified inequities in school readiness for Latino DLLs, which increases the need for innovative programs that can leverage pediatric professionals’ near-universal access and frequent contact with children and their families. Cross-sector partnerships offer an opportunity to move beyond traditional silos to promote optimal developmental outcomes for all children.