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Download the full text: Hutton_2021_Randomized Trial of a Mobile App Introduced During Well Visits to Enhance Guidance for Reading with Young Children
study descriptionRandomized trial.
core topic(s)Pediatric Primary Care , Shared Reading
Population CharacteristicsMedicaid , Poverty/Low-Income , Race, Ethnicity, and Culture
Exposures, Outcomes, OtherClinic-Based Programs and Interventions , Implementation and Evaluation , Language and Literacy Development , Parent-Provider Relationships/Interactions , Provider Behaviors and Skills , Rx for Sucess , Technology and Digital/Screen-Based Media , Validity, Reliability, Feasibility, and Acceptability
metric(s)ScreenQ Measure of Screen-Based Media Use (ScreenQ)
SharePR Measure of Shared Reading Quality (SharePR)
objectivesTo estimate feasibility, usability and efficacy of a mobile parenting app (Rx for Success; RxS) to enhance reading guidance provided to parents of young children during well-visits.
exposureRx for Sucess (RxS).
outcomes evaluatedRxS feasibility, usability, and efficacy.
settingFamilies were recruited during well-visits at a pediatric primary care clinic affiliated with a children’s hospital in the Northeastern United States, serving largely families of low-SES and minority race and/or ethnicity (90% Medicaid insurance, 71% Hispanic).
methodsThis trial was conducted at a clinic serving primarily families of Hispanic ethnicity and low-socioeconomic status (SES) where Reach Out and Read (ROR) is standard practice. It involved 252 parent-child dyads in 2 age groups (~6-months old, ~18-months old) randomized during well-visits to receive RxS or a children's book modeling alternatives to screen time (Control) by research coordinators. RxS involves videos, activities and “push” messages. Follow-up assessments were conducted approximately 6 months later, including impression and use, shared reading behaviors, child language and screen time.
sample sizen=252 (parent child dyads total); n=217 (dyads completed both visits)
Measures of Feasibility, Reliability, and Usability:
- Demographics including parental smartphone characteristics.
- Parental attitudes toward shared reading and family history of reading difficulties using items from published research.
- 6 items from the Reading and Parental Verbal Responsivity subscales of the StimQ2 home cognitive environment survey (infant and toddler versions) including shared reading frequency.
- SharePR, a 10-item measure of shared reading quality with young children (eg, lap sitting, child-directed speech).
- ScreenQ-I/T, a 10-item survey reflecting AAP screen time guidelines, involving access, frequency, content and co-viewing.
- LENA Snapshot (Language Environment Analysis), a report-based measure of expressive and receptive language validated for age 6 months and older, generating a standard score.
resultsA total of 217 dyads completed both visits (110 RxS, 107 Control). Time to introduce RxS was under 3 minutes and 32% of parents experienced largely minor performance issues. Parent impression of RxS was favorable for both age groups at baseline and follow-up, though use was infrequent, attributable to a desire for more relevant and updated content. Significant findings favoring RxS included shared reading as a favorite activity, more frequent shared reading reported at 12 months and higher language scores at 24 months. Screen time was equivalent between cohorts, exceeding American Academy of Pediatrics guidelines.
conclusionsA mobile app introduced to parents of young children from low-SES backgrounds was feasible during well-visits, rated as helpful, and effective to enhance shared reading at younger and language at older ages. While a potentially impactful enhancement to ROR, features needing improvement were identified.
limitationsRxS was administered by a CRC and results may not generalize to pediatric providers. The sample largely involved families from low-SES and Hispanic/Latinx backgrounds, which may also not be generalizable. Due to the distinct nature of Intervention/Control materials and usage/impression surveys, it was not possible to blind the CRC to cohort assignment, though participants and biostatisticians were blinded. RxS was a preliminary version involving limited content, which likely influenced performance, use and impression. However, these were largely favorable and provided insights for refinement. Encouraged nonreading behaviors (eg, talking/singing) may have impacted language outcomes, though reading was reported as most inspired by RxS use. Given privacy and time constraints, health literacy was not measured and may have impacted use. LENA Snapshot is a report measure prone to bias, yet is validated across the study age range and feasible during clinic visits. 26 SharePR and ScreenQ-I/T are not formally validated measures, yet are based on versions validated for older children,24,25 reflect AAP guidelines and are grounded in evidence-based conceptual models.1,28 Findings involving reading frequency used a threshold of 15 minutes rather than a continuous variable, which is justified given the skewed nature of score distributions, reflects a widely recommended level that is familiar to families, and was determined a priori for logistic modeling. Control families were given a children’s book providing parenting guidance related to screen time, introducing a potential confounder, though its content largely involves active/outdoor play with only one spread mentioning reading. Further, screen time was statistically equivalent between cohorts at both ages, suggesting a negligible effect, and differences in reading and language outcomes may have been larger favoring RxS if controls had been given a book without parenting guidance.