Early Literacy Research Library (ELRL) - Article

Evaluation of a Clinic-Based Program to Promote Book Sharing and Bedtime Routines Among Low-Income Urban Families With Young Children

High, P., Hopmann, M., LaGasse, L., Linn, H. (1998) Evaluation of a Clinic-Based Program to Promote Book Sharing and Bedtime Routines Among Low-Income Urban Families with Young Children. Archives of Pediatrics & Adolescent Medicine, 152(5), 459-465. ,

Access: FREE/Open Access

Publication year


study description

Comparison of cross-sectional groups.

core topic(s)

Reach Out and Read (ROR)

Population Characteristics

Medical Trainees , Poverty/Low-Income , Urban

Exposures, Outcomes, Other

Anticipatory Guidance , Child Behaviors and Skills , Home Routines , Parent Behaviors and Skills


To evaluate a program of anticipatory guidance in which pediatric residents and nurse practitioners in a continuity practice gave parents books for their young children along with developmentally appropriate educational materials describing why and how to share the books and promoting reading as part of a bedtime routine.


Reach Out and Read (ROR).

outcomes evaluated

Book sharing and bedtime routines.


Subjects were recruited from the hospital-based primary care pediatric practice of Hasbro Children’s Hospital, Providence, RI. The practice serves as a provider of primary care for mostly low-income families from the surrounding multiethnic urban communities.


Comparison of 2 cross sectional groups using consecutive, structured, face-to-face or telephone interviews of parents. One group was a historical control or a comparison group (group1). The other was the intervention group (group2), which included families who had received 2 book and educational materials for the children as part of the program to promote book sharing and bedtime routines...Before the institution of the program to promote book sharing and bedtime routines, the parents in 51 families with healthy children 12 to 38 months of age who regularly attended continuity clinics conducted by the house staff were interviewed; these families constituted group 1. Group 1 included a low-income population of Hispanic, African American, and non-Hispanic white families. Group 2 included 100 families with similar sociodemographic characteristics with healthy 12- to 38- month-old children who had received 2 books and educational materials at all 6- to 36-month well-child visits as part of the program.

sample size

n=51 (Group 1); n=100 (Group 2); n=151 (total)


Measure of Book Sharing and Routines: Interview questionnaire based on Needlman 1993 and the Sleep Habits Questionnaire:

    • “what are your child’s 3 favorite things to do other than eating or sleeping?”
    • “what are your 3 favorite things to do with your child”
    • how many trucks, cars, dolls, blocks, and books child had in the home; parental reading habits; total number of books at home.
    • behavioral concerns; bedtime struggles; night walking; parent child cosleeping.
    • practices of physicians and parent satisfaction.

Measure of Child Centered Literacy Orientation (CCLO) Scores: whether or not the parent responded positively to 1 or more of the following questions:

    • “what are your child’s 3 favorite things to do other than eating or sleeping?”
    • “what are your 3 favorite things to do with your child”
    • “How many nights each week do you share books with your child to prepare your child for sleep?”


The intervention was found to be effective in promoting child-centered literacy activities. When asked open ended questions, 4 (8%) of the parents in group 1 and 21 (21%) of the parents in group 2 said 1 of their child’s 3 favorite activities included books(P=.04); 11(22%)of the parents in group 1 and 42 (42%) of the parents in group 2 said 1of their 3 favorite activities with their child was book sharing (P=.01); and 10 (20%) of the parents in group 1 and 35 (35%) of the parents in group 2 said that they share books 6 or 7 times a week at bedtime (P =.05). By mentioning 1 of these 3 important child-centered book sharing activities, 17 (33%) of the parents in group 1 and 69 (69%) of the parents in group 2 (P ,.001) demonstrated positive child centered literacy orientation. A multiple logistic regression analysis controlling for parental education, ethnicity, and reading habits, as well as for the sex and age of the children, found child-centered literacy orientation more likely to be present in group 2 than in group 1 families, with an odds ratio (OR) of 4.7 (95% confidence interval [CI], 2.1-10.5; P,.001). Book sharing as part of a bedtime routine was more frequent in group 2 (mean±SD,3.9±2.6 nights per week) than in group 1 (mean±SD,2.5±2.7 nights per week ;P=.002); however, no significant differences in prolonged bedtime struggles, parent-child cosleeping, frequent night waking, or how children fell asleep were found between the groups. Instead, in multivariate analysis, bedtime struggles occurred more often with younger parents(P=.03)and fewer children at home (P=.02), while parent-child cosleeping (P,.001) and frequent night waking (P=.04) were less likely to occur when children usually fell asleep alone in their own beds.


This simple and inexpensive intervention by pediatric house staff, consisting of the provision of children’s books and educational materials at well child visits, resulted in increased enjoyment of and participation in child-centered book-related activities in low-income families. Primary care providers (ie, physicians and nurse practitioners) serving underserved pediatric populations may have a unique opportunity to promote child centered literacy in at-risk groups.


The source of possible error within the study was the measurement of literacy orientation by asking parents about their practices and preferences rather than by observing the home environment and parental behaviors in the home. Parents were, however, not told of our interest in literacy, and the questions used to determine CCLO or asked early in the interview, before questions about parental reading, library cards, or books in the home. The questions were open-ended, and no prompts specific to reading or given. The same research assistant interviewed parents in both groups, so interviews were conducted and scored consistently . However, because of the study design, the research assistant was not blinded to the group or study hypothesis. Because the interview was highly structured with specific prompts for key variables, the interviewer was given almost no leeway in interviewing parents, so we believe the lack of blinding had little effect. The study design was not randomized, because the study was an evaluation of a new clinic wide program, so no controls were used as the comparison group (Group 1). Every effort was made to select similar subjects for the two study groups. The samples in the African American subgroup and the subgroup of parents who were married or living together were small, limiting the power of analysis of CCLO . Therefore, the non significant findings for these subgroups should be interpreted with caution. In Group 2, the children were younger and the parents were more educated. However we controlled for this variation in the multivariate analysis.