A Combined Reach Out and Read and Imagination Library Program on Kindergarten Readiness
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A Combined Reach Out and Read and
Imagination Library Program on
Kindergarten Readiness
Gregory A. Szumlas, MD,a,b Peter Petronio, MS,a Monica J. Mitchell, PhD,a,b Alisha J. Johnson, MPA,a Tiana R. Henry, MEd,a
Thomas G. DeWitt, MDa,b
OBJECTIVES: Sharing
books with preschoolers is known to improve kindergarten readiness. Both abstract
Reach Out and Read (ROR) and Dolly Parton’s Imagination Library (DPIL) have shown positive
effects on book sharing at home. We developed a novel combined ROR/DPIL program and
examined the effect on kindergarten readiness assessment (KRA) scores.
METHODS: At urban ROR primary care sites, patients ,5 years living in the city school district
were enrolled from July 2015 through January 2019 in the ROR/DPIL program when seen for
a clinic visit. The literacy subtest of the KRA was examined for participants entering
kindergarten in the fall of 2016, 2017, and 2018. The “on-track” rate of participants was
compared with nonparticipant groups.
RESULTS: A total of 797 kindergarten-aged ROR/DPIL participants were matched to Ohio KRA
scores for 2016, 2017, and 2018 school years. The percentages of students “on-track” on KRA
literacy subtests increased significantly by cohort (2016, 42.9% [95% confidence interval (CI):
34.9%–50.9%] versus 2017, 50.9% [95% CI: 44.9%–56.9%] versus 2018, 58.3% [95% CI:
53.3%–63.3%], P = .004). ROR/DPIL participants were compared with a proportionate
stratified random sample of 1580 non-ROR/DPIL peers. On-track in literacy did not
significantly differ between groups (2016 [P = .262], 2017 [P = .653], 2018 [P = .656]), nor did
they differ after restricting analysis to economically disadvantaged children (2016 [P = .191],
2017 [P = .721], 2018 [P = .191]).
With these results, we suggest that a program combining literacy anticipatory
CONCLUSIONS:
guidance at clinic visits and more books in the home can potentially improve kindergarten
readiness. Pediatric health care providers can play an important role in promoting
kindergarten readiness through literacy promotion.
a
Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and bCollege of Medicine, University of Cincinnati, WHAT’S KNOWN ON THIS SUBJECT: Sharing books with
Cincinnati, Ohio preschoolers promotes speech and language development,
preliteracy skills, and, ultimately, kindergarten readiness.
Dr Mitchell, Mr Petronio, and Ms Johnson conceptualized and designed the study, collected data, Both Reach Out and Read and Dolly Parton’s Imagination
and performed statistical analysis; Drs Dewitt, Szumlas and Ms Henry conceptualized and designed Library have shown positive influences on the home literacy
the study; and all authors aided in data interpretation, and worked on drafting, reviewing, and environment of preschoolers.
revising the manuscript, approved the final manuscript as submitted and agree to be accountable
for all aspects of the work. WHAT THIS STUDY ADDS: In this early study, we suggest that
when combined and sustained, these two programs have the
DOI: https://doi.org/10.1542/peds.2020-027581 potential for effectively reaching large populations of at-risk
Accepted for publication Feb 19, 2021 children and improving kindergarten readiness.
Address correspondence to Gregory A. Szumlas, MD, Division of General & Community Pediatrics,
MLC 2011, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229. To cite: Szumlas GA, Petronio P, Mitchell MJ, et al. A
E-mail: greg.szumlas@cchmc.org Combined Reach Out and Read and Imagination Library
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Program on Kindergarten Readiness. Pediatrics. 2021;
147(6):e2020027581
Copyright © 2021 by the American Academy of Pediatrics
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PEDIATRICS Volume 147, number 6, June 2021:e2020027581 ARTICLEArriving at kindergarten ready to child visits for children from birth to and letter naming fluency.29–31
learn is vitally important. Not only has age 5. At ROR clinics, pediatric Finally, an urban school district found
it been shown that children who start providers discuss the importance of that DPIL participants scored better
behind often stay behind, but reading, model age-appropriate on the language and math sections of
adequate kindergarten readiness is reading techniques, and provide its validated kindergarten readiness
also strongly correlated with later a book for the child to take home.17 indicator than nonparticipants.32
achievement.1–3 Unfortunately, only Through regularly scheduled well-
Although both programs show
50% to 75% of children in the United child visits, ROR practitioners have
promising results, each has relative
States enter kindergarten ready to unique, repeated encounters with
strengths and weaknesses. ROR
learn, with children from families during this critical period of
delivers reading guidance during the
economically disadvantaged brain development. Additionally, ROR
critical early years and reaches
households at particular risk for poor tends to operate in clinics reaching
children at higher risk for poor
kindergarten readiness.4–6 underserved populations.18 Families
kindergarten readiness but only
who participate in ROR are more
Sharing books with preschoolers provides a small library over the
likely to read and share books with
promotes speech and language 5 years of exposure. DPIL provides
their children, enjoy reading together,
development, preliteracy skills, and a significant library but does not
and feel that sharing books is an
ultimately kindergarten readiness. routinely give in-person guidance to
important activity.19–23 Older
The American Academy of Pediatrics caregivers. To capitalize the strengths
toddlers and preschoolers exposed to
recommends that pediatricians of the individual programs, we piloted
ROR exhibit higher expressive
promote reading from birth, and it a novel ROR and DPIL combination
language, receptive language, and
has even been suggested that literacy program (ROR/DPIL) administered
vocabulary scores than peers not
be treated as a distinct developmental through the existing ROR structure in
exposed to the program. This effect is
domain.7,8 Researchers in multiple our city and sought to assess the
attributed to the increased time ROR
studies have demonstrated that effect of this integration on
families spend sharing books with
reading aloud with young children kindergarten readiness.
their children.19–22
promotes the foundational skills
The Ohio Kindergarten Readiness
necessary for later reading success.9
DPIL promotes literacy by delivering Assessment (KRA) is administered
In recent functional studies,
books to the homes of preschoolers. early in the kindergarten year to
researchers have shown that sharing
In the United States, there are .1500 students attending Ohio public
books with young children activates
active affiliates reaching parts of all schools. The KRA is designed to
and reinforces the pathways
50 states, with .1.5 million enrollees. measure academic readiness across
associated with literacy skills, further
Once enrolled, children from birth to four domains: language and literacy,
supporting the importance of book
age 5 receive an age-appropriate social foundations, mathematics, and
sharing.10–12 Children who are
book mailed directly to their home physical well-being and motor
exposed to a strong literacy
monthly, building a library of up to 60 development.33 Analysis has revealed
environment have better academic
books.23 Books are carefully selected that the KRA is a valid predictor of
outcomes.13,14 In short, children who
to meet the developmental needs of third grade reading achievement. In
are read with frequently and have
particular age groups and expose particular, the language and literacy
ready access to print materials do
families to a diversity of themes, art, subtest (KRA literacy) has a strong
better in school. Unfortunately,
and cultures. Books typically contain predictive relationship with future
children living in poverty often have
reading tips to help the family reading achievement. Researchers
limited access to books and
maximize learning and interaction show that 66% of children on-track in
experience less shared reading and
around the title.24 It has been shown literacy on the KRA pass the third
exposure to language.15,16
that DPIL participants experience grade reading test, compared with
Reach Out and Read (ROR) and Dolly increased frequency of reading at only 33% of children not on-track.34
Parton’s Imagination Library (DPIL) home, greater family engagement and We hypothesized that children
are two programs developed to interest around books, and a home exposed to ROR/DPIL will be more
promote book sharing in literacy environment enhanced by the ready for kindergarten, as assessed
preschoolers. ROR emphasizes significant number of books by KRA literacy scores, compared
caregiver education whereas DPIL delivered.25–28 DPIL participants also with those who were not exposed to
concentrates on providing books. show evidence of improved skills the combined program. We aimed to
ROR is a primary care–based nation- directly related to kindergarten compare the KRA literacy on-track
wide program that makes guidance readiness, namely letter rate of sequential ROR/DPIL cohorts
on reading a standard part of well- identification, phonologic awareness, and secondarily analyze comparisons
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2 SZUMLAS et alto school district averages, matched Intervention and percentage of housing units with
cohorts, and low socioeconomic At all clinics, ROR continued to .1 person per room.35 Index scores
status (SES) matched cohorts. operate its established standard were split into quartiles, with the
model. At well-child visits, all children lower quartiles having a higher
5 years and under received an age- concentration of families with
METHODS appropriate book and guidance on socioeconomic risk.
shared reading. Although all children
Study Design Data Analysis
received ROR, only children in CPS zip
We conducted a quasi-experimental codes were eligible for the Our analysis included only ROR/DPIL
intervention study comparing the intervention and were offered DPIL participants who could be accurately
KRA literacy scores of ROR/DPIL enrollment as part of the ROR visit. matched to a CPS KRA score. We
participants attending a Cincinnati Families enrolled in DPIL and linked CPS KRA results to ROR/DPIL
Public School (CPS) kindergarten consented to participation by paper records having documented parental
with those of nonparticipant CPS form. Parents could choose to enroll consent using approximate string
peers. We initiated ROR/DPIL July in DPIL and receive books but not matching (ie, fuzzy matching).36
2015 and analyzed KRA literacy consent to the evaluation portion of Fuzzy matches have the capability to
scores of participants entering the program. We entered enrollment find approximate matches between
kindergarten in 2016, 2017, and forms centrally into a study database strings or groups of strings
2018. Institutional review board and and the DPIL book order system. (accounting for subtle spelling
CPS approval was obtained. Children in DPIL then received a book differences and special characters)
delivered monthly to the home via and provide a value that represents
mail until their fifth birthday as the strength of each match. Records
Participants and Setting were matched on first name, last
administered by the national DPIL
We recruited participants at all 23 program. At subsequent clinic visits, name, and birth date by using the
ROR clinics in Cincinnati. Clinics providers continued ROR for all Fuzzy Lookup add-on tool for
spanned multiple health care patients, and for those in DPIL, Microsoft Excel. Exact matches were
systems, caring for ∼15 000 patients confirmed enrollment, captured automatically included into KRA
0 to 5 years, with .30 000 ROR visits address changes, and encouraged cohorts. Fuzzy matches were further
yearly. Most practices were in urban families to read their DPIL books. evaluated by using sex, race,
areas of Cincinnati, served a high guardian, and address. KRA scores
proportion of Medicaid patients, and Outcome and Measures were not included if the assessment
were federally qualified health was incomplete (n = 24) or was
The primary outcome measure was
centers. Beginning July 2015, any a retest for a repeated year of
the language and literacy subtest of
patient age ,5 visiting a ROR clinic kindergarten (n = 10). In the event of
the KRA. A scaled score .263
was eligible for participation if they a retest, the participant’s original KRA
indicates a student is “on-track” for
resided in zip codes that score was selected.
kindergarten.
encompassed the CPS district. There In our primary analysis, we compared
were no other eligibility KRA literacy performance of ROR/
Measure of SES
requirements. DPIL cohorts entering kindergarten in
Aided by the Community Building
fall 2016, 2017, and 2018. In our
As of January 2019, active ROR/ Institute of Xavier University, we
secondary analysis, we compared
DPIL enrollment was 10 848. More geocoded student residential
KRA literacy performance of ROR/
than 95% of parents approached addresses to determine census tract.
DPIL participants to (1) that year’s
agreed to participate, with a retention We then identified SES quartiles for
school district average performance,
rate of 91% from program enrollment census tracts as tabulated by Maloney
(2) a 2:1 stratified non-ROR/DPIL
to kindergarten entry. Three cohorts and Auffrey in The Social Areas of
matched comparison group of class
of ROR/DPIL participants were Cincinnati. This method calculates
peers, and (3) a 2:1 stratified
included in the kindergarten SES index scores using census tract
comparison with both intervention
assessment. In total, 3247 enrollees metrics from the 2005–2009
and comparison restricted to
were eligible for kindergarten American Community Survey, which
economically disadvantaged children.
between the school years of encompasses family income,
2016–2017, 2017–2018, and education level, percentage of For the CPS average, we used KRA
2018–2019. Of these, 797 (25%) unskilled and semiskilled workers, literacy scores for all students
ROR/DPIL participants were linked percentage of children living in enrolled in CPS for that academic year
to CPS KRA scores. married-couple, family households, as published in the CPS KRA Report.37
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PEDIATRICS Volume 147, number 6, June 2021 3This average includes every CPS eligible for kindergarten during the cohort. In Figure 1, we graphically
student and does not exclude children 3 years examined. This included 147 represent program exposure.
in the intervention group. of 388 children (38%) in 2016–2017,
Kindergarten Readiness and
271 of 1179 (23%) in 2017–2018, Program Impact
We created a proportionate stratified
and 379 of 1680 (23%) in
random sample of non-ROR/DPIL Cohort Effect
2018–2019. We were unable to
students to ensure demographic and KRA literacy results were evaluated
identify KRA scores for the remaining
socioeconomic characteristics were via the percent “on-track” metric
2450 participants. Demographics of
similar between groups. Three (scaled score .263) between three
KRA matched ROR/DPIL participants
variables (race, SES quartile, KRA cohorts. The percentage of students
cohorts are summarized in Table 1.
year) were combined to create the on-track differed significantly by
stratum. Of the 797 ROR/DPIL It is important to note that each cohort (2018–2019, 58.3% [95%
participants matched to KRA scores, participant differed in duration of confidence interval (CI):
we excluded 7 because of missing exposure to the DPIL component of 53.3%–63.3%] versus 2017–2018,
data (4 SES, 3 race). We used the ROR/DPIL. All participants were 50.9% [95% CI: 44.9%–56.9%]
stratum proportions for the potentially exposed to ROR from birth versus 2016–2017, 42.9% [95% CI:
remaining 790 ROR/DPIL but were only exposed to DPIL from 34.9%–50.9%], X2 [2, n = 797] =
participants to create the date of enrollment. Exposure to DPIL 10.83, P = .004, Fc [Cramer’s V
proportionate sample of non-ROR/ was calculated as interval between measure] = 0.12). The results
DPIL students (n = 1580) from a pool date of DPIL enrollment and represent a difference of 8 percentage
of 7270 CPS records that consisted of kindergarten entry. Average length of points between cohorts 1 and 2 (P =
all completed KRA scores within CPS exposure to DPIL was 8.6 months for .125, Fisher’s exact test), 7.4
from the 2016, 2017, and 2018 the 2016–2017 cohort, 16.8 months percentage points between cohorts 2
school years, excluding the known for the 2017–2018 cohort, and and 3 (P = .066, Fisher’s exact test),
797 ROR/DPIL participants. We 24.5 months for the 2018–2019 and 15.4 percentage points between
randomized selections within the
stratum. The ratio of non-ROR/DPIL
students to ROR/DPIL participants TABLE 1 Demographic and Enrollment Characteristics of ROR/DPIL Graduates in CPS Kindergarten
was 2:1. Specifically, for every ROR/ Classrooms
DPIL participant, there were 2 non- Variable 2016–2017 2017–2018 2018–2019 Total
ROR/DPIL comparisons with (n = 147) (n = 271) (n = 379) (n = 797)
identical race, SES quartile, and KRA n % n % n % n %
year. Finally, for the third analysis, Sex
both the intervention group and the Female 85 57.8 130 48.0 177 46.7 392 49.2
2:1 matched comparison group were Male 62 42.2 141 52.0 202 53.3 405 50.8
restricted to members of low SES Race
Black or African American 109 74.1 199 73.4 301 79.4 609 76.4
quartiles 1 and 2.
White 10 6.8 19 7.0 32 8.4 61 7.7
Hispanic 16 10.9 23 8.5 14 3.7 53 6.6
Descriptive statistics and x2 tests
Other or multiracial 12 8.2 30 11.1 32 8.4 74 9.3
were used to evaluate KRA literacy SES quartile
performance (on-track and not on- SES 1 68 46.3 109 40.2 133 35.1 310 38.9
track) between the three independent SES 2 41 27.9 82 30.3 121 31.9 244 30.6
KRA cohorts (2016–2017, 2017–2018, SES 3 31 21.1 55 20.3 93 24.5 179 22.5
SES 4 5 3.4 24 8.9 31 8.2 60 7.5
and 2018–2019). In addition, Fisher’s
SES unknowna 2 1.4 1 0.4 1 0.3 4 0.5
Exact tests were performed to Length of exposure
evaluate differences in KRA literacy ,1 y 64 43.5 36 13.3 17 4.5 391 49.1
status between ROR/DPIL participants 1y 25 17.0 215 79.3 151 39.8 226 28.4
and the stratified comparison groups 2 or more years 1 0.7 15 5.5 210 55.4 117 14.7
Could not be determinedb 57 38.8 5 1.8 1 0.3 63 7.9
within each cohort.
x2 analyses were used to compare differences in sex, race, and SES quartile by cohort year. Results were nonsignificant
for sex (X2 [2, n = 797] = 5.48, P = .064) and SES quartile (X2 [6, n = 793] = 9.78, P = .134). but race differed significantly by
cohort [X2 (6, n = 797) = 13.19, P = .040, Fc = 0.09]. Post hoc analyses indicated that race in the 2018–2019 cohort
RESULTS differed significantly from the 2016–2017 [X2 (3, n = 526) = 10.35, P = .016, Fc = 0.14] and 2017–2018 [X2 (3, n = 650) =
8.67, P = .034, Fc = 0.12] cohorts because of variability in the Hispanic population from year to year.
Study Sample a SES quartiles could not be determined by the Community Building Institute of Xavier University for individuals with
incorrect or missing home addresses.
We matched KRA scores to 25% (n = b Length of Exposure was calculated on the basis of date of enrollment into DPIL. Data were not available for all
797) of the 3247 ROR/DPIL children participants.
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4 SZUMLAS et alROR Exposure results for ROR/DPIL participants
ROR/DPIL Exposure who were on-track in literacy
versus the comparison group
Age of Enrollee (Years)
0 1 2 3 4 5
within each cohort year are
illustrated in Figure 3. Differences
ROR/DPIL Enrollees
Kindergarten Aged
2016–2017 Cohort 147 enrollees matched
(n = 388)
8.6 mo
to KRA scores (38%) between groups are indicated as
deltas (D). On-track percentages for
2017–2018 Cohort 271 enrollees matched
16.8 mo the comparison group exceeded
(n = 1179) to KRA scores (23%)
2018–2019 Cohort 379 enrollees matched
ROR/DPIL participants by 6.2
24.5 mo
(n = 1680) to KRA scores (23%) percentage points in 2016–2017
and 1.9 percentage points in
FIGURE 1 2017–2018. In 2018–2019, ROR/
ROR/DPIL exposure by cohort.
DPIL participants were on-track
more frequently than the comparison
cohorts 1 and 3 (P = .002, Fisher’s ROR/DPIL participants. On-track group by 1.6 percentage points.
exact test). percentages on KRA literacy for the Fisher’s Exact tests (Bonferroni
district were consistently higher than adjusted a = .0167) did not indicate
Comparison With CPS Averages those of ROR/DPIL; however, the significant differences between
The percent of ROR/DPIL difference was smaller for each groups for any of the cohort years
participants on-track in literacy subsequent cohort (14.8%, 7.9%, and (P = .262, P = .653, and P = .656,
was compared with the overall 3.2%, respectively). respectively).
CPS district percentages for each
respective cohort year.37 As seen Comparison With Stratified Comparison Comparison of Low SES ROR/DPIL
in Fig 2, deltas (D) indicate the Group Participants and Low SES Stratified
difference between district and Demographics of ROR/DPIL and non- Comparisons
ROR/DPIL results. District ROR/DPIL stratified group samples In total, 551 participants remained in
percentages do not exclude are summarized in Table 2. The the low SES 1 and 2 quartiles for the
ROR/DPIL group, and 1102 remained
in the low SES quartiles for the
comparison group. The racial
Gap District ROR/DPIL breakdown of both groups was 80.8%
Black or African American, 7.3%
80% Hispanic, 6.0% white, 5.3%
multiracial, and 0.7% Asian; the SES
70% Δ –3.2%
breakdown was 55.7% SES 1 and
Δ –14.8% Δ –7.9% 44.3% SES 2; and the test year
60% breakdown was 19.8% for
2016–2017, 34.1% for 2017–2018,
50% and 46.1% for 2018–2019. Sex
remained similar between groups
40% (ROR/DPIL [52.1% male, 47.9%
61.5% 58.3% female] versus comparison [52.9%
30% 57.7% 58.8% male, 47.1% female]). The ROR/DPIL
50.9%
20% 42.9% participants outperformed the
comparison group by 1.9 percentage
10% points in 2017–2018 and 5.3 in
2018–2019 (Fig 3). Fisher’s exact
0% tests (Bonferroni adjusted a = .0167)
2016–2017 2017–2018 2018–2019 did not indicate significant
differences between groups for any of
Cohort Year the cohort years (P = .191, P = .721,
and P = .191, respectively). In
FIGURE 2
Percentage of ROR/DPIL participants on-track in KRA literacy versus CPS district comparison. District
Figure 4, we illustrate the low SES
results do not exclude ROR/DPIL participants. District samples sizes for years 2016–2017, 2017–2018, comparison in the context of district
and 2018–2019 were 2690, 2659, and 2718, respectively. performance.
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PEDIATRICS Volume 147, number 6, June 2021 5TABLE 2 Demographic Characteristics of ROR/DPIL Graduates, a Stratified Comparison Group of Non- the stratified 2:1 comparison group
ROR/DPIL Participating Kindergarteners, and the Total CPS District KRA Cohort increased by 8.3%. When restricted
Variable ROR/DPIL Graduates Matched to Non-ROR/DPIL Total CPS to the lower SES 1 and 2 groups,
Stratified Stratified District ROR/DPIL participants increased the
Comparison Groupa Comparison Groupb KRA Cohortc on-track rate in literacy on the KRA
n (%) n (%) n (%) by 19.7%, whereas the comparison
Sex group increased by 6.6%.
Female 388 (49.1) 774 (49.0) 3893 (48.3)
Male 402 (50.9) 806 (51.0) 4174 (51.7) In all three cohort comparisons, the
Race initial 2016–2017 ROR/DPIL cohort
Black or African 611 (77.3) 1222 (77.3) 4856 (60.2) lagged behind the district comparison
American in the on-track rate on the KRA
White 61 (7.7) 122 (7.7) 1956 (24.2)
literacy; however, participation in
Hispanic 55 (7.0) 110 (7.0) 469 (5.8)
Other or multiracial 63 (8.0) 126 (8.0) 786 (9.7) ROR/DPIL suggested a closing of that
KRA test year literacy gap during the 3 years of this
2016–2017 145 (18.4) 290 (18.4) 2690 (33.3) evaluation. The 2016–2017 ROR/
2017–2018 267 (33.8) 534 (33.8) 2659 (33.0) DPIL cohort lagged the district
2018–2019 378 (47.8) 756 (47.8) 2718 (33.7)
comparison by 14.8%, whereas the
SES quartile
SES 1 307 (38.9) 614 (38.9) 2364 (29.3) 2018–2019 ROR/DPIL cohort was
SES 2 244 (30.9) 488 (30.9) 2213 (27.4) only 3.2% lower on-track in literacy.
SES 3 179 (22.7) 358 (22.7) 2027 (25.1) In the remaining two comparisons,
SES 4 60 (7.6) 120 (7.6) 1394 (17.3) the ROR/DPIL cohort outperformed
SES unknown 0 (0.0) 0 (0.0) 69 (0.9)
the comparisons in the third year. The
a n = 790.
b
2016–2017 ROR/DPIL cohort lagged
n = 1580.
c n = 8067; aggregate of 2016–2017, 2017–2018, and 2018–2019 CPS KRA cohorts. the 2:1 stratified comparison by 6.2%
but in 2018–2019 ROR/DPIL
outperformed by 1.6%. Especially
DISCUSSION 2017–2018, and 2018–2019. ROR/ notable, the 2016–2017 ROR/DPIL
In this study, we sought to examine DPIL cohorts improved the on-track cohort lagged the low SES stratified
the effect of a novel combined ROR/ rate on the KRA literacy by 15.4% comparison by 7.8% but
DPIL program on kindergarten between the first kindergarten cohort outperformed the comparison by
readiness as measured by the KRA of 2016–2017 and the third 5.3% in 2018–2019. This early result
literacy. Findings supported the kindergarten cohort of 2018–2019, is encouraging by suggesting
potential long-term benefits of the incremental yearly increase a significant effect on the at-risk
participation in ROR/DPIL. We found suggesting a dose effect, whereas the population.
a significant difference in school district increased by 3.8%. In The ROR/DPIL pilot also revealed
performance on the KRA literacy the second comparison, ROR/DPIL promise in operational success.
between cohorts 2016–2017, cohorts improved by 16.1%, whereas During a 42-month period, ROR/DPIL
practices enrolled 14 799 children in
DPIL and provided reading guidance
Gap Comparison group ROR/DPIL during .90 000 ROR visits. More
than 320 000 books were distributed
Stratified Comparison Low SES Stratified Comparison to homes. Geocoding revealed most
80% 80%
program enrollees lived in areas of
70% 70% high poverty. ROR/DPIL illustrated
60% Δ –1.9%
Δ 1.6% 60% Δ 5.3% that pediatric health care providers
Δ –6.2% Δ 1.9%
50% 50% Δ –7.8% are an effective way to reach a large
40% 40% number of children and deploy
30% 56.6% 58.2% 30%
48.3% 52.8% 50.9% 48.1% 50.0% 50.2% 55.5% interventions touching the important
20% 42.1% 20% 43.6%
35.8%
early years of development.38,39
10% 10%
0% 0%
Additionally, because most ROR
2016–2017 2017–2018 2018–2019 2016–2017 2017–2018 2018–2019 practices reach a high percentage of
Cohort Year Cohort Year
underserved patients, combining
FIGURE 3 DPIL, or other programs, with ROR
Percentage of ROR/DPIL participants on-track in KRA literacy versus stratified comparison groups. has the potential to greatly enhance
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6 SZUMLAS et alGap forms had incomplete consents, so
District
scores were unattainable. Third,
children within the CPS district can
Low SES comparison group
choose to attend an alternative
Low SES ROR/DPIL private or charter school. Fourth, the
population enrolled tends to be
highly mobile, resulting in enrollees
80%
frequently moving out of the CPS
70% Δ –11.3% Δ –6.0%
Δ –14.1% Δ –21.9% Δ –10.7% Δ –8.8% district. Finally, accurately matching
60%
to KRA scores was difficult. We erred
50%
on the side of more accurate
40%
matching, so differences in names
30% 57.7% 58.8% 61.5%
48.1% 50.0% 50.2% 55.5% used to enroll in ROR/DPIL versus
20% 43.6%
35.8% CPS could result in no match.
10%
0% Despite its limitations, this study
2016–2017 2017–2018 2018–2019 provides evidence that programs such
Cohort Year and ROR and DPIL can be effectively
deployed using pediatric health care
FIGURE 4
Percentage of low SES ROR/DPIL participants and low SES stratified comparison group on-track in providers on a scale capable of
KRA literacy versus CPS district. influencing the health and
development of children at
a population level. Key strengths of
enrollment of vulnerable populations. a change in the local literacy this study include the solid trend in
This pilot revealed that this model environment, resulting from the flood improvement in the on-track rate on
can be successfully implemented and, of books into the community, could
the KRA literacy for ROR/DPIL
using a ROR structure that exists have impacted even nonenrolled
groups, and, because of a strong
similarly in other regions, shows children, both factors potentially
matching procedure, we are confident
potential for successful spread. reducing the measured impact of that the scores included in the
Previous researchers have shown that ROR/DPIL. Finally, we are unable to analysis for the ROR/DPIL cohorts
ROR anticipatory guidance is critical identify exact causes for KRA literacy are participants. This is the first
and, when associated with other improvement in ROR/DPIL investigation into this combined
literacy resources, has an augmented participants. There are several program and the positive effects
effect on the home literacy possibilities based on program
observed warrant further
environment.40 Marrying a literacy design: more books in the home,
investigation into the extent and
program traditionally in the pediatric more motivation to read, and more
mechanism of impact on kindergarten
medical realm (ROR) with one that is reminders to read. Furthermore, we readiness.
not (DPIL) was an operational cannot draw conclusions on the exact
success that was able to reach a large impact of each individual program.
number of children in need with Although ROR had been in operation CONCLUSIONS
potentially amplified effects. and the change was the addition of Participants in the ROR/DPIL
DPIL, it is unknown how much program, which combined repeated
Although highly encouraging, the program effect was due to DPIL, ROR, guidance on sharing books at
results of this analysis need to be or synergy between the two preschool well-child visits with
interpreted with appropriate context. programs. a sustained influx of books in the
First, we could not control for
home, significantly improved
exposure to other programs Additionally, the number of
performance on the KRA literacy of
promoting kindergarten readiness or participants matched to a CPS KRA
entering kindergarteners over the
for preschool participation, although score was significantly lower than the
3 years of the program. The gap in
there was no other known total number of enrollees. This is
kindergarten readiness of program
widespread programming. Similarly, explained by multiple factors. First,
participants compared with the
the cause of improvement in school district boundaries do not
overall school district results was
comparison groups is unknown. conform to zip codes, so some
closed in the 3 years of this program.
Regarding our program, unmatched enrollees, who were recruited by zip
ROR/DPIL participants could be code, did not live within the CPS Both the ROR and DPIL have evidence
included in comparison groups, or district. Second, some enrollment of effectiveness in promoting literacy
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PEDIATRICS Volume 147, number 6, June 2021 7in preschoolers. With this early gives pediatric health care providers would like to thank ROR, DPIL, and
study, we suggest that when tools to make a significant difference the providers and staff of the Greater
combined and sustained, these in the lives of their patients and Cincinnati Reach Out and Read
two programs have the potential should be considered an element of Coalition for their hard work in
for effectively supporting the standard care. making this project a success.
development of preliteracy skills of
large populations of at-risk children, ACKNOWLEDGMENTS ABBREVIATIONS
improving kindergarten readiness, We thank Every Child Capital, in Fc: Cramer’s V measure
and, ultimately, success in school particular Leslie Maloney and CI: confidence interval
and life. Primary care practices are Greg Landsman, not only for the CPS: Cincinnati Public Schools
positioned to influence the literacy financial support of this pilot DPIL: Dolly Parton’s Imagination
developmental trajectory of children program but also for their tireless Library
long before they are served by other advocacy. We would also like to KRA: Kindergarten Readiness
educational services. The integration thank the CPS District for their Assessment
of early childhood literacy promotion collaboration on this project and ROR: Reach Out and Read
programs, such as ROR and DPIL, contributions that will support the SES: socioeconomic status
as a routine part of primary care program into the future. Finally, we
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by a grant from Every Child Capital venture philanthropic fund.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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PEDIATRICS Volume 147, number 6, June 2021 9A Combined Reach Out and Read and Imagination Library Program on
Kindergarten Readiness
Gregory A. Szumlas, Peter Petronio, Monica J. Mitchell, Alisha J. Johnson, Tiana R.
Henry and Thomas G. DeWitt
Pediatrics originally published online May 24, 2021;
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Downloaded from www.aappublications.org/news by guest on September 7, 2021A Combined Reach Out and Read and Imagination Library Program on
Kindergarten Readiness
Gregory A. Szumlas, Peter Petronio, Monica J. Mitchell, Alisha J. Johnson, Tiana R.
Henry and Thomas G. DeWitt
Pediatrics originally published online May 24, 2021;
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