Early Literacy Research Library (ELRL) - Article

The Role of Clinic Culture in Implementation of Primary Care Interventions: The Case of Reach Out and Read

King, T.M., Muzaffar, S., George, M. (2009) The Role of Clinic Culture in Implementation of Primary Care Interventions: The Case of Reach Out and Read. Academic Pediatrics, 9(1), 40-46.,

Access: Institutional Access

Publication year


study description


core topic(s)

Reach Out and Read (ROR)

Population Characteristics

Medical Providers

Exposures, Outcomes, Other

Implementation and Evaluation , Provider Behaviors and Skills


The objective of this study was to identify practice attributes associated with variability in ROR implementation.


Reach Out and Read (ROR).

outcomes evaluated

Effectiveness of ROR implementation and clinic culture.


Clinic sites participating in ROR throughout Greater Baltimore, MD.


Twenty primary care providers and 70 support staff from 7 clinics in Baltimore, Maryland, participated in semi structured interviews. Sites were purposefully selected on the basis of the perceived success of their ROR program implementation. All interviews were transcribed and inductively analyzed to identify themes. Themes were compared to predictors postulated by a conceptual model for team effectiveness across a variety of workplace settings.

sample size

n=20 (primary care providers); n=70 (support staff); n=90 (total); n=7 (clinics)


Measures of Effectiveness: we used a qualitative framework described by Cohen and Bailey, which conceptualizes team effectiveness as a function of group processes, group psychosocial traits, design factors, and environmental factors. In this model, group processes, group psychosocial traits, and design factors have both direct and indirect influences on team effectiveness, while environmental factors influence effectiveness only indirectly.


Measures of Adherence: 20-item Site Observation Scale created by the National ROR Program to assess adherence to the ROR model using items ranging from book distribution to parent provider interactions.


Only one theme (integration of ROR procedures) addressed the design of ROR implementation within clinics. Nearly all other themes identified group processes and group psychosocial traits broadly reflective of clinic culture. At struggling sites, staff found their jobs burdensome and communication lacking. They demonstrated disrespect for patients and families. In this context, they experienced difficulty integrating ROR into their daily routines. Staff at successful sites worked as a team and expressed strong commitments to their communities. Integration of ROR at these sites tended to occur smoothly. Providers from all sites reported strong pressures to increase productivity, and thought that these pressures impaired their ability to deliver high-quality primary care.


Clinic culture influences the implementation of an efficacious primary care intervention. Characteristics of clinic culture therefore need to be identified and taken into account in future efforts to improve its implementation.


First, the qualitative data consist of participant self reports; we did not attempt to verify the accuracy of any individual’s responses. Second, the small number of participating sites and the purposeful nature of their selection limits the generalizability of this study. However, our goal was not primarily one of generalizability but rather of relevance and credibility.