Early Literacy Research Library (ELRL) - Article

A Mixed-Methods Investigation Examining Site-level Variation in Reach Out and Read Implementation

Jimenez, M.E., et al. (2023) A Mixed-Methods Investigation Examining Site-level Variation in Reach Out and Read Implementation. Academic Pediatrics, In Press, Corrected Proof.,

Access: Institutional Access

Publication year


study description

Convergent mixed-methods design.

core topic(s)

Reach Out and Read (ROR)

Population Characteristics

Medical Providers , Poverty/Low-Income , Race, Ethnicity, and Culture , Urban

Exposures, Outcomes, Other

Anticipatory Guidance , Community , Implementation and Evaluation , Parent-Provider Relationships/Interactions , Provider Behaviors and Skills , Provider Knowledge, Attitudes, and Beliefs


Reach Out and Read (ROR) is an evidence-based early childhood intervention that has been implemented at scale, yet description of ROR implementation is inconsistent. This study engages implementation science to examine ROR delivery and site-level variation.


Reach Out and Read (ROR) implementation.


Community health centers (CHCs) that serve low-income Latino families.


As part of an ongoing clinical trial, we conducted a mixed-methods study in 3 community health centers (CHCs) that serve low-income Latino families. We integrated quantitative parent survey data, qualitative data from monthly key informant interviews with ROR site leaders over 1 year, and in-depth interviews with 18 additional clinicians. At enrollment, parents reported whether they received a children's book, guidance on reading, and modeling from clinicians. We analyzed quantitative data using descriptive statistics, and qualitative data iteratively engaging emergent and a priori codes drawn from the Template for Intervention Description and Replication Checklist.

sample size

n=300 (parents)


Measure of Quantitative Data: survey administered to parents including questions about the following:

    • receipt of a book
    • anticipatory guidance about reading
    • modeling about reading
    • exposure to a literacy-rich clinic environment


Measure of Qualitative Data: structured and semi-structured interviews analyzed using the Template for Intervention Description and Replication Checklist (TIDieR), adapted to suit ROR to focus on the following:

    • why each CHC implements ROR (mission or goal for implementing ROR).
    • what components each CHC implements as ROR; how much each CHC implements the different components (percent of parents receiving component).
    • how the CHC deliver these components.


Three hundred Latino parents (mean age: 31; 75% ≤HS education) completed surveys. The mean child age was 8 months. Overall, most parents reported receiving a book (84%) and guidance (73%), but fewer experienced modeling (23%). Components parents received varied across CHCs. Two themes emerged to explain the variation observed: 1) differences in the perceived purpose of shared reading and book delivery aligned with variation in implementation, and 2) site-level barriers affected what components were implemented.


Because of substantive variation in ROR implementation across sites, systematic descriptions using established frameworks and corresponding measurement to characterize ROR implementation may enhance our understanding of mechanisms underlying ROR's effects, which clinicians and policymakers can use to maximize ROR's impact.


First, we relied on parent and clinician report to assess ROR implementation, which may be subject to social desirability and recall bias. However, triangulation across sources (ie, clinicians, parents) and methods (ie, quantitative and qualitative) helps guard against these biases and is a notable strength. While direct observation was not possible due to pandemic restrictions, it would strengthen future work. In this regard, work by Needlman et al is notable in its use of observation to examine ROR implementation, in particular modeling, which we identified as a key area of variation.31 Second, the study focused on Latino families from under-resourced communities and CHCs that serve them, thus our findings may not transfer to all settings. Third, data on how much support each CHC receives from the state ROR chapter and specific information on training were unavailable. Such factors can function as important barriers and facilitators and will be important to examine in future work. Fourth, while we were able to characterize variation in implementation of ROR components using an established implementation science framework, we did not examine to what extent parent and clinician characteristics affect variation or link variation in components to parenting and child outcomes. This work is beyond the scope of this study but will be the subject of future research using the current study as a foundation.