Early Literacy Research Library (ELRL) - Article

Improving Adherence to Reach Out and Read: A Bookmark Intervention

Obus, E.A., Brito, N.H., Sanlorenzo, L., Rea, C., Engelhardt, L., Noble, K.G. (2017) Improving Adherence to Reach Out and Read: A Bookmark Intervention. Journal of Pediatrics and Pediatric Medicine, 1(1), 1-7.,

Access: FREE/Open Access

Publication year


study description

Bookmark intervention study.

core topic(s)

Reach Out and Read (ROR)

Population Characteristics

Infant/Newborn , Kindergarten , Medical Providers , Poverty/Low-Income , Toddler/Preschool , Urban

Exposures, Outcomes, Other

Clinic-Based Programs and Interventions , Implementation and Evaluation , Provider Behaviors and Skills


This study examines how the addition of a modest addendum to the well-established pediatric primary care program, Reach Out and Read (ROR), is associated with increased clinician adherence to ROR and caregiver home literacy behavior.


Reach Out and Read (ROR) and bookmark intervention.

outcomes evaluated

Clinician adherence to ROR and caregiver literacy behaviors.


4 ambulatory care clinics located in the Harlem and Washington Heights neighborhoods of New York City that are part of the Columbia University Medical Center Ambulatory Care Network, and provide healthcare to predominantly low income families.


"All clinics received standard ROR training. Two of the four clinics received additional ROR training and bookmarks with age-specific advice about reading aloud with children...Primary caregivers of pediatric patients between the ages of six months to five years were recruited from waiting rooms to complete a questionnaire regarding their demographic information and literacy-promoting behaviors. In addition to caregivers, primary care providers – including residents, attendings, and nurse practitioners – were recruited to complete a questionnaire regarding their application of the ROR program. Caregivers and primary care providers were recruited before and after the intervention; thus different groups of caregivers and primary care providers completed the questionnaires across time points."

sample size

n=180 (caregiver questionnaires, before and after); n=59 (provider questionnaires, before); n=51 (provider questionnaires, after)


Measure of Literacy Behavior in Primary Caregivers: orally administered questionnaires about their demographic information, literacy-based beliefs, and literacy-based practices.


Measure of ROR Adherence in Providers: email administered questionnaires about how often they remembered to distribute books, gave counseling and modeled appropriate reading behavior, and how familiar they were with ROR and applying it.


In SFY 2018, the developmental screening percentage at non-ROR sites was 33% vs 47% at ROR sites (p<0.0001), in SFY 2019 non-ROR sites were 36% vs 48% at ROR sites (p<0.0001). The EPSDT visit percentage in SFY 2018 was 50% at non-ROR sites vs 69% at ROR sites and in SFY 2019 was 51% at non-ROR sites vs 72% at ROR sites.


Thus the addition of a modest training and bookmark intervention to the ROR program was associated with caregiver report of both increased clinician adherence to ROR and increased caregiver literacy behavior. The bookmark intervention may be an inexpensive way to improve the effects of the ROR program.


It was not longitudinal within individuals, which limits our ability to draw conclusions about the causative associations amongst the bookmark intervention, adherence to ROR protocols, and home literacy outcomes. Additionally, we collected post-intervention data at only one time point, 9 months after the implemented of the intervention, therefore we were unable to test how soon after implementation increased adherence and home literacy behaviors began. Future studies should seek to determine how quickly the bookmark intervention improves these outcomes. Furthermore, our data consist entirely of self-report measures. The use of more objective data sources in future studies, such as clinical records of book distribution, could improve reliability and validity. Finally, the small number of clinics limits the generalizability of our results. In the future we hope to study the effects of the bookmark addendum to ROR on a larger scale.