A pediatric literacy education program for low socioeconomic, culturally diverse families.

Abstract. The objective of this research project is to describe parent-child activities and literacy experiences of low-income families attending an urban pediatric clinic. These data were used to educate clinic pediatricians about the needs of their patients and to facilitate the implementation of a literacy education program. Two hundred twenty-four primary caregivers of children between the ages of 1 and 5 years who spoke Spanish or English participated in clinic interviews. These low-income, diverse families engaged in many everyday activities that could facilitate the language and literacy development of their children. Barriers to greater literacy orientation among families included lack of access to children's books and limited use of libraries. Families most at risk for low child literacy orientation were recent immigrants (primarily from Mexico) who spoke English as a second language and had not completed high school. The knowledge of everyday parent-child activities, barriers to literacy, and the identification of families at risk for low literacy orientation were used to develop a pediatric literacy program that would meet the needs of the specific clinic population.

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Literacy is a crucial skill in the United States (Neuman, Copple, & Bredekamp, 2000; Snow, Burns, & Griffin, 1998). Demands for increased literacy contribute to the widening gap between the educationally advantaged and disadvantaged (Stedman & Kaestle, 1987). As such, it is important to identify risk factors for poor literacy and to provide literacy opportunities for those families most at risk for poor literacy. The present study describes the literacy activities of parents and their preschool children attending an urban pediatric clinic and a literacy program implemented at the clinic.

The causes of literacy deficits are complex. Familial factors associated with reading difficulties include a family history of reading problems, a home environment characterized by a low level of literacy, less verbal interaction, and a home language other than English (Snow et al., 1998). Lower socioeconomic status (SES) long has been recognized as being associated with academic difficulties (e.g., Pungello, Kupersmidt, & Burchinal, 1996; White, 1982). Risk of school failure and reading difficulties for low SES students may be linked to aspects of the home environment (Snow et al., 1998), including fewer books in the home, parents' lower education levels, and parents not understanding the importance of reading books to their children (McCormick & Mason, 1986). Parent-child book reading is important because it is associated with such emergent literacy skills as letter knowledge, understanding of print concepts, and facility with language (Scarborough & Dobrich, 1994).

Although family characteristics are important for literacy, a host of other conditions also contribute to reading challenges (Snow et al., 1998). For example, some researchers argue that poor readers often come from inferior schools with inadequate educational opportunities because of crowded classes, inadequate supplies and books, and poorly trained teachers (Cook, 1991; Snow et al., 1998). In addition, cultural differences can contribute to less optimal literacy development when teachers and parents have difficulties communicating with one another.

Given the literacy acquisition challenges faced by many families and the complexity of causes of literacy deficits, it is important to identify innovative approaches to literacy education. Common sources of literacy education are educators, librarians, and child development specialists, who recommend that parents engage in a wide range of activities that can facilitate their children's language and literacy development (Neuman et al., 2000). However, parents living in poverty and recent immigrants may have little contact with these professionals. On the other hand, pediatricians often have regular, repeated contact with families long before children enter school, providing a unique opportunity to educate parents about the importance of literacy activities. Moreover, a recent study with a nationally representative sample indicates that parents want to receive more information from their physician regarding the education of their children (Young, Davis, Schoen, & Parker, 1998). Thus, health clinics that target low-income families by providing low or no-cost services may be excellent settings for literacy education (Needleman, Fried, Morley, Taylor, & Zuckerman, 1991).

Although pediatricians are trained in providing information on health promotion (a practice known as anticipatory guidance), empirical evidence suggests that pediatricians may be missing opportunities to provide parents with other important information. For example, a study using a nationally representative sample of parents of young children examined whether physicians had discussed six anticipatory guidance topics (e.g., encouraging learning, crying, sleeping, discipline) with parents and whether parents could use more information on these topics (Schuster, Duan, Regalado, & Klein, 2000). Results indicated that few parents (23 percent) received information on how to promote children's learning. Over half the parents indicated that they could use more information on promoting learning; in fact, parents wanted information on encouraging their children's learning more than on any other topic. Furthermore, the study found that pediatricians were most likely to neglect these discussions with low-income, Hispanic parents with no health insurance. Taken together, these findings indicate that pediatricians can do more to offer important opportunities for early literacy education among hard-to-reach populations.

These education efforts should capitalize on the strengths and everyday activities of families, rather than focusing on literacy deficits (Taylor, 1997). This approach suggests the importance of becoming familiar with the everyday patterns of interaction between parents and their children so that literacy activities can be incorporated into activities caregivers are already engaged in with their children. Family literacy education programs also must take into account cultural and language resources, as well as the unique characteristics of the participating families (Claibourne, 2000).

The literacy project discussed in this paper was a collaborative effort that included early childhood educators, child development specialists, literacy specialists, community volunteers, pediatricians and other health care professionals, and parents. The purpose of the collaboration was to utilize a pediatric clinic as an avenue for literacy education for an often difficult-to-reach population of families and their young children. The targeted pediatric clinic in this study was selected because it served a large number of families living below the poverty level, including many recent immigrants and uninsured families. Parents who attended the clinic were surveyed about their family book reading experiences so that pediatricians could tailor this information to the client population.

In summary, the objectives of this project were to: 1) describe the parent-child activities of parents and their preschool children attending an urban pediatric clinic, 2) identify families with low literacy orientation and the barriers to literacy they face, 3) use the information collected to implement basic literacy education activities within this pediatric setting, and 4) highlight the importance of pediatricians as an avenue for literacy education in hard-to-reach populations.

Method

Procedure

Undergraduate and graduate student interviewers were recruited and trained to conduct a 15-minute structured interview in Spanish and English. The introduction to the interview, and each interview question, was read from a standard protocol; several questions were open-ended, but the majority were close-ended. Across a five-month period, interviewers visited the waiting room of a public health clinic that offered services to low-income families on a sliding fee scale. At the time of the interviews, the clinic was not participating in a literacy education program, and no special emphasis was placed on anticipatory guidance to encourage learning. Interviewers approached adults who were with a child who appeared to be between the ages of 1 and 5 years, in clockwise order around the waiting room. Participants were asked if they would be willing to participate in a brief interview regarding activities that parents and children enjoy doing together because the clinic intended to add activities for young children. They were told that they did not have to participate, that participating would not delay their doctor's appointment, that their child would receive the same care that he or she usually received, whether or not they agreed to participate, and that their answers would be confidential. In order to be eligible for this study, the participant had to be a primary caregiver for a child aged 1 to 5 years, and had to speak Spanish or English.

Measures

The interview on book reading experiences was based on interviews used in previous research (High et al., 1999; Needleman et al., 1991), and included the following information: demographic information, favorite activities with the child, activities done the previous day, bedtime routines, and specific questions about adult and child book-reading activities. The interview was initially translated into Spanish, and then translated back into English, to test the accuracy of the translation. Demographic items were close-ended and included ethnicity, primary language, country of origin, household size, household composition, respondent's relationship to target child, and the birthplaces of child, mother, and child's maternal grandmother. Because participants may have been reluctant to give information on some demographic issues, questions referring to income and education were asked at the end of the interview. Following the initial demographic questions, several open-ended questions focused on what activities the caregiver and child most enjoyed doing together, what bedtime routine they might have, and whether the child had engaged in specific activities the previous day. Each of these questions was coded on the basis of whether reading was mentioned. The favorite activity question also was coded into 11 categories representing the main activities that caregivers enjoyed with their children (see Table 1).

Following the activity recall questions, caregivers were asked close-ended questions on specific book reading questions, including frequency of reading with their child, child's enjoyment of reading, and child's requests to read together. The interview also included questions regarding the caregivers' history of book reading as a child and the frequency and enjoyment of reading. These questions were rated on a four-point scale, where 4 indicated greater frequency or enjoyment of reading. Ownership of children's books was rated on a five-point scale, where 1 indicated owning no children's books and 5 indicated owning greater than 25 children's books. Ownership of adult books was rated on a four-point scale, with 1 reflecting owning fewer than five adult books and 4 indicating owning more than 100 adult books. Library use was rated on a four-point scale, where 1 indicated never having been to the library and 4 indicated going to the library weekly.

The Setting

The clinic provides prenatal and pediatric primary care services to underserved families and children in a large, urban area. Patients without private insurance or Medicaid are billed according to a sliding-fee scale, based on family size and reported monthly income. No one is refused care for inability to pay. Fifty-six percent of the staff at the clinic are Hispanic; all the staff are bilingual in Spanish and English, except one who speaks English and Vietnamese. Two of the four pediatricians at the clinic are Hispanic and bilingual. The clinic has two Hispanic, Spanish-speaking translators and employs 18 resident physicians, 67 percent of whom speak both Spanish and English.

Participants

Ninety-six percent (N = 224) of those meeting eligibility criteria agreed to be interviewed. The high response rate may be due to the fact that the clinic is important for the families, and a high level of trust flourished at the clinic. Forty-nine percent of the interviews were conducted in Spanish. Eighty percent of the participants reported they were the target child's mother; 19 percent were the child's father; one was a grandparent and one was a foster parent. Fifty-nine percent reported that they were Hispanic whites, 35 percent were non-Hispanic whites, 3 percent were African American, 1 percent were Native American, and 1 percent were Asian or Pacific Islander. One percent did not classify themselves in the previous categories. Of those of Hispanic origin, 83 percent were from Mexico. The remaining were from Venezuela (5 percent), Guatemala (3 percent), El Salvador (3 percent), Honduras (< 1 percent), Chile (< 1 percent), Brazil (< 1 percent), Spain (< 1 percent), and Argentina (< 1 percent). Fifty-one percent of the sample reported that their child was first or second generation in the United States, meaning that either the parent or the parent and the child were born outside the United States.

Thirty-eight percent of the participants reported that they had not completed high school, 25 percent had completed high school, 28 percent had completed some college or technical training past high school, and 9 percent had completed a college degree. Median household size was 4; household size ranged from 2 to 13 people. Mean income per month for the participants' families was $1,399 (SD = $742), with $1,200 the median income. Sixty-eight percent reported receiving aid from the federal Women, Infants and Children (WIC) program, and 35 percent received Medicaid. Fifty-four percent of the sample consisted of two-parent families living as nuclear families, 30 percent as two-parent families living with adult friends or relatives, 9 percent as single-parent families living as nuclear families, and 8 percent as single-parent families living with adult friends or relatives.

Results

Results focused on parents' favorite activities with their children, children's book reading experiences, and parents' own reading experiences. These results helped educate pediatricians about family strengths and obstacles in relation to literacy education in the young children they serve. In addition, the information guided the literacy education efforts implemented at the clinic.

Favorite Activities

An analysis of favorite activities was conducted for two reasons: 1) so that the pediatricians would be able to recommend ways to incorporate emergent literacy activities into activities that caregivers were already doing with their children, and 2) as an indicator of the extent of reading and other emergent literacy practices in the home. Results indicated many opportunities for caregivers to incorporate informal literacy practices into favorite activities (see Table 1). Playing and Gross Motor Play were the most commonly mentioned favorite activities. Reading Books and Media Activities also were mentioned fairly frequently. Furthermore, parents reported enjoying teaching their children, including teaching specific skills such as how to write as well as encouraging verbal skills by singing songs, playing verbal games, and rhyming.

Child Book Reading Experiences

Six variables were used as measures of child book reading orientation: 1) whether reading was mentioned as a favorite activity with the child, 2) whether reading was mentioned as part of a bedtime routine, 3) whether the child was read to (or looked at books with someone) the previous day, 4) the frequency with which the child asked to be read to (or indicated a desire to share books), 5) the frequency with which the child read (or looked at books) on their own, and 6) the child's enjoyment of reading. Preliminary analyses examined the frequency of these book reading activities in the families' daily routines. When the researchers considered whether reading was mentioned as one of the three favorite activities, 39 percent of the respondents reported that reading was one of their favorite activities with their child. Seventy-six percent of the participants reported that their child had been read to the previous day. The majority of the reading occurred with the child's parent; however, 21 percent of the reading occurred with another relative, such as a grandparent, cousin, or sibling. Of the 53 percent of the participants who reported they had a bedtime routine for the child, 57 percent reported that reading (or looking at books) was part of that bedtime routine. Thus, 30 percent of the participants, overall, reported reading to their child at bedtime.

Seventy percent of the participants reported that their children read (or looked at books) on their own daily. Forty-nine percent of the participants reported that their child asked to be read to or indicated a desire to look at books together daily. Most participants also reported that their child enjoyed reading or looking at books. However, 21 percent of the respondents indicated that their child never or rarely asked to be read to, nor indicated a desire to look at books, and nine percent of the participants reported that their child either did not like to be read to or was indifferent to reading.

Adult Book Reading Experiences

Several variables were included as measures of adult book reading experiences: the frequency with which adults were read to as children, the adults' self-described reading skills, enjoyment of reading, frequency of reading, and the number of adult books owned. Thirty-seven percent of the participants reported that they were never or rarely (less than a few times per month) read to as children. Four percent of the participants reported that they could not read, or that their reading skills were weaker than average. Twenty-nine percent of the participants reported that they did not like reading or only liked reading a little bit. Thirteen percent of the participants reported never or rarely reading, 15 percent reported reading a few times per month, and 34 percent of them reported reading on a daily basis. Finally, 28 percent of the participants reported that they owned fewer than five adult books.

Families Most at Risk for Low Child Literacy Orientation

Because one of the goals of this research project was to encourage pediatricians to educate parents about the importance of literacy activities with young children, the researchers attempted to describe the participants who were most at risk for low child text-based literacy orientation (see Table 2). Thus, we chose the bottom 25 percent of the sample on a composite variable that reflected children's book reading experiences. The following variables were converted to Z-scores and averaged to compute the composite variable: frequency of child reading alone, frequency that the child requested being read to, child's enjoyment of reading, and number of children's books the family owned. Cronbach's alpha indicated that the internal reliability of the composite variable was acceptable (alpha = .71).

Seventy-eight percent of those falling in the bottom quartile on the composite variable were first or second generation immigrants to the United States, primarily of Latino origin. A one-way analysis of variance, with the literacy composite as the dependent variable, and generation in the United States (first and second generation vs. later generation) revealed that first and second generation immigrants scored significantly lower on child literacy orientation than did those who had lived in the United States longer, [F(1,283) = 80.17,p < .001]. Fifty-seven percent of the parents in the at-risk group had received less than a high school education. Seventy-five percent of them reported that they received their education outside of the United States. Eighty percent of those in the bottom quartile on the literacy composite reported that English was not their primary language.

Those most at risk for low child literacy orientation also reported low adult literacy orientation. For example, 56 percent of those in the bottom quartile on the child literacy composite reported owning less than five adult books. Forty-six percent of them reported that they were never or rarely read to as children, and 25 percent reported that they rarely or never read as adults.

Another barrier to greater child literacy orientation may be the lack of access to children's books. Nine percent of the participants reported that they owned fewer than three children's books. Thirty-eight percent reported that they owned fewer than 11 children's books. In addition, 61 percent of the participants reported that they had never been to the library. Caregivers gave the following reasons for not using the library more frequently: 36 percent of the participants reported that their child was too young for the library, 26 percent of the participants reported that they had no information about the library, 17 percent of the respondents indicated that finding transportation to the library was difficult, 17 percent of the participants reported that they did not have the time to go to the library, and 6 percent of the participants reported that they did not go to the library because of a language barrier.

Discussion

The purpose of this project was to gain information about the literacy and book reading experiences of families attending an urban health clinic in order to educate pediatricians about the specific literacy needs of their clinic population. The information was further used to design pediatric literacy education efforts for this specific clinic. Families attending the clinic reported that they engaged in many daily activities that could potentially facilitate the literacy and language development of their children. On the other hand, there were clear obstacles to literacy development, including the lack of children's and adult books in many homes and limited use of libraries. This discussion will describe how the feedback from parents guided the selection of culturally appropriate books for clinic clients, the use of anticipatory guidance for parents based on daily activities, and the decision to implement a clinic library. It also describes how other early childhood professionals might implement a similar literacy program specifically designed for the families in their communities.

Four main components characterize the pediatric literacy program implemented in the clinic. The first component, termed anticipatory guidance, involves the physician discussing ways to encourage emergent literacy skills in children. The second component involves each child being given a new book at each well-child checkup. The third component is the establishment of a library at the clinic, with adult and children's books in various languages. The final component is referral to other services and resources in the community. Each of these is described in more detail below.

Parental guidance regarding the development of emergent literacy skills and the importance of sharing books with children are critical components of the pediatric literacy education program. In the clinic, guidance does not simply focus on the importance of "reading" to a child, but instead focuses on the importance of everyday activities for literacy and learning. Although the parents in this research reported having good reading skills, many also reported reading infrequently and not enjoying reading, which might indicate poor reading abilities. Furthermore, those families most at risk included immigrant parents who were less educated and owned few books. Thus, rather than emphasizing reading per se, which may be difficult and less enjoyable for these parents, pediatricians discuss how language skills, book sharing, and print awareness can be incorporated informally into everyday activities. For example, parents are encouraged to identify in their native language letters on signs and products in their homes. Other options available for parents with weak reading skills include sharing simple picture books with their child, oral storytelling, and simply speaking with their child and naming objects during daily events such as mealtimes, bathing, dressing, and playing. Establishment of these informal literacy experiences in which children participate can facilitate emergent literacy skills (Baker, Serpell, & Sonnenschein, 1995; Snow & Tabors, 1996). Additionally, adults who struggle with reading can increase their own literacy skills. Caregivers reported these as favorite activities to do with their child--thus, the pediatricians at the clinic focus on the ways these activities can be incorporated with emergent literacy experiences. In addition, over a third of the families surveyed lived with adult family or friends; therefore, the clinic pediatricians emphasize book sharing with other caregivers and older siblings. This may be important for families in which the demands of everyday living make it difficult for parents to read regularly to their children.

For the literacy education program, developmentally and culturally appropriate books were selected for the clinic families, based on information gained from the interviews. Since 50 percent of the families interviewed reported that Spanish was their primary language, most of the books purchased were in English and/or Spanish. Children receive a book at each well-child checkup, beginning at age six months. At the clinic, caregivers choose what language book their child receives. The most popular books are books that contain both English and Spanish words. The books available for the youngest children are picture books and books with pictures of animals, with few or no words. The books selected incorporated the everyday activities that many families reported, reflected culturally appropriate objects that would be familiar to the families, and did not require reading skills. The majority of families surveyed after the implementation of the program identified receiving books as important in helping prepare their children for school.

As recommended by research on emergent literacy and reading (Adams, 1990; MacLean, Bryant, & Bradley, 1988; Wagner, Torgesen, & Rashotte, 1994), concepts of phonemic awareness are also important components of the program. Between the 15- and 24-month well-child examinations, children are intentionally given books that rhyme. Between the 36-month and the 60-month visit, at least one alphabet book is given. Parents are also encouraged to sing songs, and to repeat rhymes, poems, and stories that are culturally significant to them. Research shows that one component of phonemic awareness, the ability to understand rhyme, is related to emergent reading abilities (MacLean et al., 1988). Parents reported in the clinic interviews that they engaged in many of these activities already, and so pediatricians emphasize the importance of these activities to language and literacy skills. This helps parents to see the connection between everyday, fun parent-child activities and learning and literacy.

In the clinic interviews, parents reported playing with their children as a favorite activity; thus, pediatricians explain how emergent literacy skills can be incorporated into play. For example, pediatricians recommend that parents verbally label toys ("doll," "ball," etc.) in their primary language as they engage in play activities. Parents are encouraged to label the objects, while sharing books, to promote verbal skills. As an extension of this book-sharing activity, parents can verbally label common objects with their children to facilitate vocabulary development. For example, parents are encouraged to read food labels on boxes and cans to their children.

The education program also focuses on dialogic reading, a process wherein the caregiver interacts with the child while sharing books, and the words on the page are less important than the discussion surrounding the pictures. Dialogic reading leads to improvement in the development of language skills (Arnold & Whitehurst, 1994). The adult reader prompts the child with questions that focus on the pictures in the book, such as "What color is the apple?" and praises the response. More sophisticated questions for older children compare the events in the story to the child's life (e.g., "The children are at a birthday party. Have you ever been to a birthday party?"). This type of reading may be less intimidating and more enjoyable to parents with poor literacy skills. The physician models this technique, pointing out objects, colors, and actions in the books, and then encourages the parent to look at the book with the child. This practice supports previous research that indicates that if parents are to be successfully involved in education programs with which they are unfamiliar, they must be given opportunities to become skilled in these areas with the support of providers (Harry, Rueda, & Kalyanpur, 1999).

Given that the majority of families reported that they had not been to the library and many had few books at home, it was determined that a library would be an important addition to the clinic. The library now has over 3,000 donated books in Spanish and English for adults, adolescents, and children. Donations were solicited from Eagle Scout projects, book drives, and charitable organizations. Parents, siblings, and the children attending the clinic can wait for their appointment in the library, read together, and check out books. Volunteer librarians and a part-time, bilingual clinic librarian read aloud to children and model dialogic reading techniques. A monthly bilingual story time is offered, and many preschool-age children attend regularly, even if they do not have a clinic appointment.

Parents indicated in the interviews that they did not have information about library services. Therefore, librarians also help parents locate the closest public library to their home and complete an application for a library card, if they are interested. They also explain that public library cards are free, that no proof of citizenship is required, that books in the library may be checked out for free, and that books are available in other languages, particularly children's books. They mention that children of all ages, including infants, are welcome at the library. It was important to incorporate this basic information, because the parents interviewed did not think the library would have books in their language and were concerned that their children were too young to go to the library.

Although the pediatric clinic is unable to provide adult literacy education, the clinic does provide literacy information and referrals to other community organizations. For example, physicians and other clinic staff were educated about English learning and adult literacy programs that are available in the community so that they can advise parents about them. Parents are informed about free, bilingual Head Start programs when their child is old enough to attend. Head Start has a strong literacy component, as well as a parent involvement component; moreover, few of the children most at risk for low literacy orientation attended preschool. Finally, the pediatric clinic also houses a clinic for the federal Women, Infants, and Children (WIC) program. Since no proof of U.S. citizenship is required for enrollment in WIC, many of the families who attend the pediatric clinic are also able to receive food vouchers from the WIC clinic.

Innovative education approaches to promoting literacy development should include collaborative relationships with pediatricians and other health care professionals. Early childhood programs might survey their parents on which clinics and pediatricians are being used for their children's health care needs. Health care providers then could be contacted about implementing a literacy education program. The initial advisory committee for this program included physicians, hospital representatives, early childhood professionals, nurses, children's bookstore owners, hospital volunteer coordinators, child life specialists, and fundraising personnel. The national Reach Out and Read (ROR) organization inspired these efforts by providing detailed information on how to start and fund a program. Their program served as the model from which the program described here was built. The ROR organization is available to train volunteers and physicians about their roles and responsibilities. In addition, they have an application process that, when completed, makes a new program eligible for free books.

The program described here also has been successful at raising funds from local businesses for books. The present program is funded by the national ROR center, the Primary Children's Medical Center Foundation, and the Starbucks Foundation, and has received book donations from local schools and churches. Through interviews or parent surveys, a pediatric literacy program, as reported in this article, can be designed to meet the needs of a specific clinic population. Furthermore, research on the ROR program indicates that parents who received anticipatory guidance on early literacy and an age-appropriate book at well-child visits rated their physician as more helpful (Jones et al., 2000) and reported greater enjoyment of reading with their child (High et al., 1999; Needleman et al., 1991). In a survey of families completed after the program was implemented, one mother indicated she appreciated "advice on how to teach kids letters, reading, numbers, and writing." Another said that the anticipatory guidance "motivated her to read books."

One obstacle to developing a clinic-based literacy program might be concerns about the commitment of pediatricians to promote literacy skills as part of their routine health care procedures. However, there are a number of reasons to recruit physicians to participate in literacy education efforts. Ideally, physicians are concerned about the overall well-being of their patients, not just their health. They also understand the critical connection between early literacy, language development, and school and life success. This literacy guidance takes place at well-child checkups, where the focus is on promoting healthy development, rather than simply reacting when a child is sick. The success of ROR on a national level also indicates that pediatricians are committed to literacy intervention (Fitzgerald-Rice, Needleman, Klass, & Zuckerman, 1995). Currently 1,000 pediatric practices are involved in formalized literacy programs. The present clinic serves as a training site for 18 residents; thus, future health professionals will be aware of, and educated in, the implementation of a literacy program. Data collected for this program revealed a 90 percent compliance rate for pediatricians and residents distributing books and discussing these important literacy practices. Moreover, resident physicians rated this literacy program as one of the top three services that they provide at the clinic, after well-child checkups and immunizations.

In summary, reading is fundamental to the success of children in the United States. Health care providers are a valuable and underutilized resource for the promotion of early childhood literacy skills. Educators, librarians, parents, and health professionals can collaborate on early literacy education projects, since each of these groups is invested in children's development and welfare. This article offers evidence for the adaptation of a literacy program whereby pediatricians discuss book sharing and give developmentally and culturally appropriate books to children at well-child checkups. Collaborative literacy education efforts in clinical and educational settings can offer innovative ways to address the national problems of illiteracy and school failure, and help children toward the goal of literacy.

Table 1
Caregivers' Responses Explaining Their Three Favorite Activities
To Do With Their Child

Category of Response (with examples)          Percentage of Responses

Playing (with toys; pretend play)                       25%
Gross Motor Play (dance, hike, bike)                    25%
Read Books                                              13%
Media (watch TV, videos)                                10%
Caretaking (bathe, feed)                                 6%
Teaching Specific Skills (numbers, writing)              5%
Creative Skills (art, music)                             4%
Verbal Skills (sing songs, talking games)                4%
Go Places (shopping, museum)                             4%
Other Activities (cooking, collecting)                   4%
Religious Activities                                     1%

Table 2
Characteristics of Those Families Most At Risk for Low Child
Literacy Orientation

First Generation (Parent)              80%
Latino Origin                          80%
English As a Second Language           82%
Child Does Not Attend Preschool        82%
Educated Outside of United States      76%
Less Than High School Education        57%
Own < 5 Adult Books                    56%
Parent Never/Rarely Read to As Child   47%
Read a Few Times per Month or Less     44%

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Marissa Diener Cheryl Wright Jennifer Julian Department of Family & Consumer Studies, University of Utah Carrie Byington Department of Pediatrics, University of Utah

Authors' Note: This research was supported by a grant from the Primary Children's Medical Center Foundation. The authors wish to thank the undergraduate research assistants who helped collect and code the data, as well as the parents and children who participated, and the clinic staff for making this project possible. For more information on the Reach Out and Read program, see their Web site at: www.reachoutandread.org