Early Literacy Research Library (ELRL) - Article

Literacy Promotion Training and Implementation in Pediatric Continuity Clinics

Caldwell, A., et al. (2020) Literacy Promotion Training and Implementation in Pediatric Continuity Clinics. Academic Pediatrics, 20(7), 1013-1019.,

Access: FREE/Open Access

Publication year


study description

Cross-sectional survey.

core topic(s)

Reach Out and Read (ROR)

Population Characteristics

Medicaid , Medical Providers , Medical Trainees , Poverty/Low-Income , Urban

Exposures, Outcomes, Other

Medical Training/Education , Provider Behaviors and Skills


To describe literacy promotion (LP) training experiences and behaviors of pediatric and internal medicine/pediatrics residents and faculty nationally, and the association between LP training and behaviors.


Reach Out and Read (ROR) training and implementation.

outcomes evaluated

Training experiences and behaviors.


Continuity Research Network clinics located in urban settings serving currently and mostly Medicaid participants.


The Academic Pediatric Association's Continuity Research Network and Reach Out and Read National Center sent an online survey to faculty and residents at participating Continuity Research Network clinics. Respondents were asked about literacy promotion (LP) training experiences and behaviors. Data were analyzed using descriptive statistics, chi-square tests, and logistic regression modeling.

sample size

n=473 (faculty); n=1126 (residents); n=42 (institutions)


Measure of Training Experiences and Behaviors: anonymous online survey addressing participant and site demographics, LP training, the perceived influence of various training modalities, adherence to the ROR model, other ROR experiences (such as fundraising and volunteering), perceptions regarding early literacy efforts, and knowledge regarding ROR.


473 faculty and 1216 residents at 42 institutions participated. More faculty than residents reported completing online Reach Out and Read training (63% vs 45%, P < .0001). More residents reported learning in clinic from others (92% vs 89%, P = .04). Training experiences did not differ otherwise. More faculty reported providing anticipatory guidance (87% vs 77%, P < .0001); modeling shared reading (69% vs 45%, P < .0001); and using books for developmental assessment (80% vs 62%, P < .0001). Both groups (97%) reported distributing books. The training modality most often endorsed as “very/extremely influential” was learning in clinic from others. Some LP behaviors were associated more strongly with online training while others were associated more strongly with in-person training.


Online training and in-person training are both associated with high quality delivery of LP. Faculty members are more likely to have completed online training and to report engaging in the full range of recommended LP behaviors. These data have implications for LP training.


First, this was a cross-sectional survey and thus cannot speak to a causal relationship between training and implementation of the intervention, but rather an association. Further prospective studies will be needed to answer this question, and to explore how variability in training affects patient outcomes. Second, this online survey used a common link and did not send individual survey links to participants. Therefore, respondents could potentially complete the survey more than once. Third, this was a study of pediatric continuity clinic faculty and residents, therefore the findings may not generalize to those outside pediatric residency training programs. Fourth, there is the potential for bias, including social desirability bias and selection bias, which may have impacted the results in a positive direction. In addition, response bias may have contributed to the fact that while the ROR National Center data has shown that 92% of residency programs implement ROR, 99% of this study’s respondents reported that their clinic implements ROR (Reach Out and Read National Center Data, unpublished, 2019). Fifth, terms used to describe various forms of training could be interpreted in various ways, for example, “formal training in continuity clinic” and “formal in-person training” could be interpreted as different training modalities or as overlapping trainings. In addition, while the survey assessed reported frequency of LP behaviors, these estimates were not used in modeling of training predictors and LP behaviors due to difficulty in interpretation and poor clinical utility as there is no established scale for frequency of performance of each given LP behavior in terms of patient outcomes, among others. Finally, site demographic data were obtained from individual respondents and not at a site level. Additionally, demographic data could have been more in depth and included more questions on faculty participants including years in practice. Despite the limitations of this study, this large national survey with a high response rate from faculty (90%) provides the opportunity to make national inferences about pediatric continuity clinics and their providers, and this is the first study to address LP behaviors and training on a national level.