Pediatricians Reach Out and Read to young patients

Supporters say literacy promotion has a place in primary care.

By Delia O'Hara, amednews correspondent. March 26, 2001.

Every chance he gets, Peter Noronha, MD, perches on a tiny chair in the waiting room of the busy Chicago pediatric clinic he helps run and reads simple stories from slim, colorful books to any child who will listen.

It is, he says, one of the most important parts of his job.

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Dr. Noronha, associate head of pediatric education and program director of pediatric residents' training at the University of Illinois at Chicago Medical School, believes that books are as important a medical tool as his stethoscope in the clinic where he serves mostly low-income families. That is why he is a regional trainer for Reach Out and Read, a physician initiative developed 12 years ago by two Boston pediatricians.

ROR, which in those dozen years has quietly become one of the most important preschool literacy programs in the country, takes the view that literacy is a public health issue, that children who love to read will have better, healthier lives, and that physicians can and should provide anticipatory guidance about why and how to share books with preschool children of families that might not naturally view reading as an enjoyable activity.

Physicians in the ROR program not only counsel parents; they also give one new book at every well-child visit from the age of 6 months to 5 years. That way every child in their care owns at least 10 books by the time he or she enters kindergarten.

"We are trying to institute literacy promotion as part of primary care," says Perri Klass, MD, a pediatrician, author of six books, including two novels, and medical director at the ROR national center in Boston. "It's about knowing and loving books."

Studies show that when parents read to their children, they are likely to do well in school, says Barry Zuckerman, MD, now the chair of the Dept. of Pediatrics at Boston Medical Center. He and his colleague Robert Needlman, MD, are the founders of ROR. Studies also show that young people who do well in school are less likely to drop out, to become pregnant at a very young age, to take drugs and to get in trouble with the law.

ROR also has the capability of improving relationships within families and of building children's self-esteem. When parents read to their children, not only is the parent-child bond strengthened, but children also come to associate reading with parental affection and approval.

Research has shown that three factors affect whether parents do in fact read to their children -- having enough discretionary income to buy books, having bookstores in their area and having a tradition of reading to their children. "Reach Out and Read overcomes all three of those barriers," Dr. Zuckerman says.

Books as icebreakers

Physicians already have plenty to cover with parents during well-child visits, but ROR has developed techniques by which the new book the pediatric patient receives at every visit becomes not simply one more topic to bring up with parents, but a tool that allows the physician to assess developmental milestones.

"You don't have to ask a 4-year-old if he knows his colors. You give him the book and say, 'What color is the balloon?' " Dr. Klass says. "You can hear from his response how well he is putting sentences together. Most [physicians] say that they hear a lot of things they weren't hearing before [they started using the books as icebreakers]. ... After you've done this for a while, it doesn't feel right to walk in without a book."

Where do these books come from? Scholastic Inc., the well-known children's publisher, "has a good list," Dr. Klass says, including many in Spanish and others portraying minority children. Scholastic also provides grants to ROR. But local ROR programs can choose their own books, and eventually they must find their own funding sources.

Volunteers who read to children in the waiting rooms, modeling how to read for families and including siblings who might not be part of the program right now, are an important component of ROR.

Lois Carlson, a former schoolteacher, volunteers at the University of Illinois at Chicago clinic four hours once a week. "I'm getting my kid fix," she laughs. Other volunteers in the program include medical students and undergraduates.

Large ROR programs like the one Dr. Noronha helps oversee might have to pay a portion of their coordinator's salary -- Dr. Noronha pays about one-quarter of coordinator Jessica Brach's salary. But for most programs, Dr. Klass says, the cost of the books the physicians give away is the major expense.

Dr. Noronha also solicits donations of used books to leave out in the waiting rooms. That's a continuing effort, he says, because the books tend to disappear quickly.

In fact, that phenomenon was the genesis of ROR.

As a young physician, Dr. Zuckerman brought his own children's used books into his waiting room. When young patients made off with them, a colleague advised him to stop the practice. "I said, 'That's the opposite of the way to go. Why not give them books of their own?' " he recalls.

The program has spread "like wildfire," Dr. Zuckerman says, with more than 1,000 sites in all 50 states, the District of Columbia and Puerto Rico. ROR is a component in more than half the residency programs in the country, including the one at UIC. When his students go off to start their own practices, they tend to incorporate ROR into them without a second thought, Dr. Noronha says.

Dr. Zuckerman says that physicians who get involved in the program "love it."

In the first place, he says, it's simple to do. Then, they know "the value to children's health and well-being of learning and being able to read. The parents and children say 'thank you' -- nobody says 'thank you' when they get a shot.

"And it gives doctors an opportunity to translate their personal values into their clinical practice. Doctors wouldn't be doing what they're doing if their parents hadn't read to them. This reaches a group that might not have had that experience."

As for himself, "it's the most satisfying thing I've done in my career," Dr. Zuckerman says.

ADDITIONAL INFORMATION:

Literacy offers patients a building block to better health

The Reach Out and Read early literacy program has a "very, very important" role to play in the long-term campaign for improved health literacy, says AMA Trustee Herman Abromowitz, MD, who also serves as the president of the American Medical Association Foundation. Together the AMA and the Foundation have undertaken a major initiative to promote health literacy.

ROR not only increases basic reading skills but also "builds better communication and eventually better relationships between physicians and their patients," Dr. Abromowitz says.

Facility with reading is the basis of health literacy, the ability to understand and act on information that pertains to maintaining one's health. Studies have shown that patients with poor reading skills are twice as likely as capable readers to report poor health and to be hospitalized. When they do become involved with the health care system, these patients often lack the skills to follow directions or read appointment slips and prescription labels, studies show.

The foundation has founded a Signature Program on Health Literacy, and offers a Health Literacy Introductory Kit, a self-study program designed to raise awareness among physicians about the prevalence of patients with low health literacy, and the problems that can arise between physicians and patients because of this difficulty.

"We take the problem of health literacy very seriously. It affects about 90 million Americans and costs about $73 billion annually," Dr. Abromowitz says.