Early Literacy Research Library (ELRL) - Article

Effects at 12 months of a primary care intervention using finger puppets to support early language promotion: a pilot study

Domek, G. J., Szafran, L. H., Allison, M. A., Kempe, A., Jimenez-Zambrano, A., Silveira, L., & Camp, B. W. (2023). Effects at 12 months of a primary care intervention using finger puppets to support early language promotion: a pilot study. Children and Youth Services Review, 155, 107172.,

Access: Institutional Access

Publication year


study description


core topic(s)

Early Literacy , Early Relational Health , Pediatric Primary Care

Population Characteristics

Medical Providers , Poverty/Low-Income

Exposures, Outcomes, Other

Clinic-Based Programs and Interventions , Parent-Child Relationships/Interactions


To determine if introducing finger puppets in the primary care setting during infancy improves parenting and language outcomes at 12 months.


Finger puppet intervention

outcomes evaluated

Maternal depression, the cognitive home environment, and child language


University-affiliated primary care clinic that serves a primarily low-income and minority population of families


Intervention cohorts were enrolled at ages 2 (early) and 6 (late) months, given a puppet, and followed two weeks later to assess dosage. High dosage was defined as using the puppet daily. At 12 months, a usual care cohort was enrolled and outcome measures were collected for all participants.

sample size

154 families


  • Maternal depression: Patient Health Questionnaire (PHQ-9), a nine-question self-administered screening instrument assessing the diagnostic criteria for depressive disorders.
  • Cognitive home environment: StimQ questionnaire based on a structured interview with the primary caregiver
  • Preverbal skills: was assessed with the Communication and Symbolic Behavior Scales Developmental Profile Infant-Toddler Checklist (CSBS-DP-IT Checklist)
  • Vocabulary development: was measured using the MacArthur-Bates Communicative Development Inventories infant short forms (CDI SFs), parent-report instruments containing an 89-word English and 104-word Spanish checklist assessing vocabulary comprehension and production in children 8–18 months


There were no differences between early and late intervention outcomes. In intention-to-treat analysis, the intervention cohorts scored better than usual care on the Availability of Learning Materials (ALM) (5.50 vs. 5.02, p = 0.04) and Parental Involvement in Developmental Advance (PIDA) (8.30 vs. 7.58, p = 0.02) StimQ-T subscales and receptive vocabulary (CDI SF English) (61.0 vs. 50.1, p = 0.05). In per protocol analysis, high dosage scored better than low dosage and usual care on the StimQ-T ALM (5.83, 5.08, 5.02, p = 0.01), preverbal communication (CSBS-DP-IT) (72.3, 57.2, 59.2, p = 0.01), and receptive vocabulary (CDI SF English) (73.4, 56.1, 50.1, p = 0.0002).


Finger puppets distributed in infancy were associated with an enhanced cognitive home environment and better preverbal and receptive language at 12 months, especially for families using the puppet daily. Additional study should determine if impacts are generalizable and maintained.


While research assistants could not be blinded to the study cohort, they were blinded to dosage designation. Both sociodemographic and cumulative risk comparisons were made between study cohorts with the only significant difference being that more families enrolled at 6 months spoke a primary language other than English or Spanish, although our small sample size may have made it difficult to detect other differences. Another limitation is that we could not include one-quarter of intervention families in the per protocol analysis because we were unable to reach them for the follow-up phone survey.