Read, speak, sing: Promoting literacy in the physician’s office
Posted: Nov 1 2006 | Reaffirmed: Jan 30 2017
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A Shaw; Canadian Paediatric Society, Community Paediatrics Committee
Paediatr Child Health 2006;11(9):601-6
Low literacy is an important issue affecting the health of millions of Canadians. At its root, it is a paediatric problem. New evidence suggests that physicians can have a positive role in promoting literacy among their young patients. Physicians need to be aware of the scope of this problem, provide anticipatory guidance to families, and promote reading to babies and children in their practices. Recommendations and strategies are discussed.
Key Words: Literacy; Reading
The objectives of the present statement are to:
- Review the current status of literacy in Canada and its impact on health;
- Discuss current evidence-based research on how literacy develops;
- Review current evidence for the role of physicians in literacy promotion; and
- Provide practical resources to enable physicians to promote literacy in their practices.
Low literacy is a severe and pervasive problem in Canada, affecting nine million working-age adults . It has important health, social and economic consequences . New understanding of the neurobiology of learning indicates that literacy achievement is closely linked to language exposure in infants and toddlers. Parents and caregivers play a crucial role in shaping the early experiences that lay down the foundation for later reading skills .
Because of their early and frequent contact with families, physicians have a unique opportunity to support parents in this role by encouraging them to read daily with their babies and children . Preschoolers who are read to are significantly more likely to have the literacy skills required for early school success .
The present position statement, a revision of a previous Canadian Paediatric Society position statement , reviews the latest information regarding physicians’ role in promoting literacy. Peer-reviewed studies have shown that when physicians discuss literacy development with parents and provide them with tools such as children’s books, they can have positive effects on families’ attitudes toward reading, reading frequency and preschool language scores . Strategies and resources for incorporating literacy promotion into standard anticipatory guidance will be discussed.
The present statement provides recommendations that are graded based on the available evidence (Appendix) . A search of the electronic literature was conducted using MEDLINE and PsychINFO databases for the period of 1995 to June 2006 for child (zero to 18 years of age) studies in English and French using the subject headings of reading, literacy and illiteracy.
The literacy landscape in Canada
There is a crisis of low literacy in Canada. Alarmingly, 42% of Canadians 16 to 65 years of age do not have the minimum literacy skills for coping with everyday life and work in a knowledge-based economy and society (the skill level typically required for high school completion in Canada). Among that 42%, 15% struggle with any printed material. The results among certain groups are even more troubling. Low literacy skills are found among 80% of prison inmates, 60% of immigrants (compared with 37% of native-born Canadians) and 18% to 38% (depending on the region of the country) of youth aged 16 to 25 years. Among Aboriginal people 15 to 49 years of age, 17% have less than a grade 9 education. Because literacy skills are like muscles that are maintained and strengthened through regular use, average proficiency in prose literacy appears to decrease with age, leaving 80% of seniors with inadequate literacy skills .
Literacy influences health both directly and indirectly, and is closely related to nearly all the major determinants of health identified by Health Canada. Low literacy is, at its root, a paediatric problem. It becomes manifest in school when some children fail to learn to read and write at the same pace as their peers. It is estimated that 5% to 15% of schoolchildren have reading delays . Most children who have not mastered reading by the end of grade 3 will never catch up . This leads to school failure and early school leaving, which in turn puts young adults at higher risk for poor outcomes. Promoting literacy is a key part of practicing preventive medicine  (Table 1).
Not only is promoting literacy good medicine, it also makes economic sense. Literacy problems cost Canada 10 billion dollars per year . People with low literacy skills are twice as likely to be unemployed, and up to 50% of adults with low literacy levels live in low-income households. A 2004 Statistics Canada report  states that a 1% rise in literacy scores relative to the international average would be associated with an eventual 2.5% relative rise in labour productivity and a 1.5% rise in gross domestic product per person. Low literacy is an issue Canadians cannot afford to ignore.
Health consequences of low literacy
Direct effects of low literacy on health
Incorrect use of medications
Failure to comply with medical directions
Errors in administration of infant formula
Safety risks in the community, the workplace and at home
Indirect associations between low literacy and health
Higher rates of poverty
Higher than average rates of occupational injuries
Higher degrees of stress
Unhealthy lifestyle practices such as:
Limited access to and understanding of health information
Innappropriate use of medical services
Literacy and language development
At birth, a baby’s brain contains 100 billion neurons. Shortly after birth, the brain produces trillions more connections between neurons than it ultimately uses. Synapses that are stimulated by frequent use during the early years are preserved, and those that are seldom used are eliminated by a process called pruning. Early experiences, especially everyday interactions with parents, shape the brain architecture that supports learning later in life .
Early language skills, which are the foundation for later reading ability, are based primarily on language exposure. Children with greater exposure to language have larger expressive vocabularies. Both language exposure and rate of expressive language development vary by socioeconomic status, with economically advantaged children being exposed to and saying more than twice the number of words as children from poor families at three years of age .
Not only is the amount of language exposure important, but so is the quality. Of all parent-child activities, the richest language exposure occurs during reading, especially when dialogic reading (when the parent uses questions to encourage the child to participate beyond being a passive listener) occurs . Children’s books are essential tools for providing caregivers with developmentally appropriate language to use with children and for facilitating baby talk, the exaggerated, sing-song speech that babies prefer. In 1985, the National Commission on Reading concluded that “reading aloud by parents is the single most important activity for building the knowledge required for eventual success in reading” .
Book exposure among infants and toddlers promotes the development of early literacy skills, including book orientation, narrative structure, listening ability, attention span, page turning and print recognition. It is speculated that a love of books develops when children associate reading with the cozy comfort of their parent’s attention and warm lap.
New information: further evidence for the role of physicians
Since the publication of the original edition of the present position statement in 2002 , the evidence supporting the role of physicians in literacy promotion has been further confirmed and expanded. The bulk of the research has focused on the Reach Out and Read (ROR)  model for clinic-based literacy intervention, a United States-based program serving 2.5 million children annually at 3000 clinics and health centres. Its three components are anticipatory guidance regarding literacy development by paediatric providers at each well-child visit; the provision of a new, developmentally appropriate book at each visit; and literacyrich waiting rooms including volunteers who demonstrate book sharing. ROR has been studied in more than a dozen peer-reviewed articles .
Current literature suggests the following:
- Parents want information from physicians about learning . Nearly one-half of parents who do not read daily believe it would be helpful to discuss literacy with their paediatrician . (Level of Evidence III)
- Parents receiving the ROR intervention are four to 10 times more likely to read frequently (at least three days/week) to their children. The effect is greatest among the poorest families, suggesting the intervention is most beneficial to those who need it the most . (Level of Evidence II-1)
- Parents often place more importance on reading to their children when a book is given by a paediatrician . (Level III). The distribution of books enhances the effectiveness of literacy intervention beyond what is achieved by anticipatory guidance alone . (Level II-2)
- Preschoolers receiving the intervention have higher receptive  and expressive  language scores on standardized tests. (Level II-1)
- There is a dose-response relationship between exposure to a literacy promotion intervention and desired literacy-related behaviours . (Level II-2)
- Parents rate physicians who demonstrate reading aloud and give books as more ‘helpful’ . (Level II-2)
The current studies available are not immune to methodological issues. None are properly randomized trials, and studies that relied on parent self-reporting were open to possible selection bias and interviewer bias . The studies looked mainly at low-income American families in largely Spanish-speaking populations. The applicability to Canadian families is unknown.
As well, the ultimate research question (“Does literacy promotion by health care providers prevent elementary school reading problems?”) has yet to be answered either by case-control or longitudinal studies or by randomized controlled trials. Nonetheless, the currently available findings suggest that literacy interventions by paediatricians have positive results that are linked, in theory, to the ultimate goal of literacy promotion and school success .
Physicians and health care professionals are encouraged to promote literacy by:
- Addressing low literacy as a child health problem beginning at birth and continuing through adulthood. (Grade B)
- Inquiring about family literacy orientation at regular health care visits. Questions could include the frequency of book sharing, access to children’s books in the home, use of books in children’s routines and caregivers’ literacy levels. (Grade I)
- Including literacy promotion in their routine clinical practice. Interventions should include: anticipatory guidance regarding literacy development (Tables 2 and 3); provision of tools such as developmentally appropriate books (Table 4), if possible, or library card applications and a prescription to read a fun book; and referral to adult literacy services as required. (Grade B)
- Encouraging parents and all child care providers to look at books daily with their children beginning at birth and to create and maintain a literacy-rich environment for their children both at home and in all other child care settings (eg, daycare, preschool). For caregivers with low literacy skills or who speak a nonlocal language, singing, storytelling and talking about pictures in their native language should be encouraged. (Grade B)
- Encouraging families to get a library card and visit the library regularly. (Grade I)
- Ensuring that clinic waiting areas encourage literacy. Culturally and age-appropriate reading materials, posters, information on literacy resources, and volunteer readers are ways to accomplish this. Infection control policies, such as the removal of visibly soiled books or cleaning book covers after use, should be considered. (Grade I)
Physicians and health care professionals should advocate for:
- The inclusion of anticipatory guidance regarding the importance of reading to children in standard health maintenance guidelines. (Grade B)
- Training in literacy development and promotion for paediatric and family medicine residents through education governing bodies such as the Royal College of Physicians and Surgeons of Canada and university postgraduate medical education departments. (Grade I)
- Alliances between physicians and literacy promotion organizations, such as the National Literacy Secretariat (http://www.hrsdc.gc.ca/eng/workplaceskills/LES/index.shtml), ABC Canada (http://www.abc-canada.org/), and the Canadian Language and Literacy Research Network (http://www.cllrnet.ca/index.html) to develop a national literacy promotion strategy. Physicians should work with childcare providers and literacy specialists at the community level to promote literacy locally. Contacting the local library to obtain library card applications is an appropriate first step. (Grade I)
- An inventory, compiled by the Canadian Paediatric Society, of literacy resources available to physicians nationally and locally. (Grade I)
- Government and private sector funding for the purchase of children’s books to be given out at well-child visits. (Grade B)
- The appropriate allocation of funding for quality research in the prevention of low literacy. (Grade I)
Development milestones of early literacy*
Interaction with parents
6 to 12 months
Reaches for book.
Looks at pictures, vocalizes, pats picture.
Parents holds child comfortably, face-to-face gaze.
12 to 18 months
Holds book with help.
No longer mouths right away.
Child gets upset if parent won’t give up control of book.
18 to 36 months
Turns one page at a time.
Names familiar pictures.
Parent asks “What’s that?” and gives the child time to answer.
3 years and older
Holds book without help.
Describes simple actions.
Parents asks questions like “What’s happening?”
*Adapted from reference 
|TABLE 3 |
Examination room techniques
Modified from reference 
What children like in books
Modified from reference 
Level of evidence
Evidence obtained from at least one properly randomized controlled trial.
Evidence obtained from well-designed controlled trial without randomization.
Evidence obtained from well-designed cohort or case-controlled analytical studies, preferably from more than one centre or research group.
Evidence obtained from comparisons between times and places, with or without the intervention. Dramatic results in uncontrolled experiments could also be included in this category.
Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.
There is good evidence to recommend the clinical preventive action.
There is fair evidence to recommend the clinical preventive action.
The existing evidence is conflicting and does not allow a recommendation to be made for or against use of the clinical preventive action; however, other factors may influence decision-making.
There is fair evidence to recommend against the clinical preventive action.
There is good evidence to recommend against the clinical preventive action.
There is insufficient evidence to make a recommendation; however, other factors may influence decision-making.
*Data from reference . Note: The task force recognizes that, in many cases, patient-specific factors must be considered and discussed, such as the value the patient places on the clinical preventive action, its possible positive and negative outcomes and the context or personal circumstances of the patient (medical and other). In certain circumstances where the evidence is complex, conflicting or insufficient, a more detailed discussion may be required.
This position statement was reviewed by the Canadian Paediatric Society’s Public Education Subcommittee and the Community Paediatrics Committee.
PSYCHOSOCIAL PAEDIATRICS COMMITTEE
Members: Minoli Amit MD (board representative); Stacey Belanger MD; John LeBlanc MD (chair); Alan Murdock MD
Liaison: Rose Geist MD,
Consultant: Alyson Shaw MD
Principal author: Alyson Shaw MD
- Statistics Canada. Building on our competencies: Canadian results of the International Adult Literacy Skills Survey. 2003. http://www.nald.ca/fulltext/booc/booc.pdf. (Version current at October 10, 2006).
- ABC Canada. Report Summary: International Adult Literacy Skills Survey (IALSS). 2005.
- Baker DW, Parker RM, Williams MV, Clark WS, Nurss J. The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health 1997;87:1027-30.
- McCain M, Mustard JF. Reversing the Real Brain Drain: Early Years Study Final Report. Ontario Children’s Secretariat, Publications Ontario, 1999.
- Needlman R, Klass P, Zuckerman B. Reach out and get your patients to read. Contemp Pediatr 2002;19:51-69.
- US Department of Education, National Center for Education Statistics. The Condition of Education 2003 (NCES 2003-067). http://nces.ed.gov/fastfacts/display.asp?id=56. (Version current at October 11, 2006 ).
- Canadian Paediatric Society, Psychosocial Paediatrics Committee [Principal author: Peter Nieman]. Promoting literacy in the physician’s office. Paediatr Child Health 2002;7:398-403.
- Needlman R, Silverstein M. Pediatric interventions to support reading aloud: How good is the evidence? J Dev Behav Pediatr 2004;25:352-63.
- Canadian Task Force on Preventive Health Care. New grades for recommendations from the Canadian Task Force on Preventive Health Care. CMAJ 2003;169:207-8.
- Needlman R, Zuckerman B. Fight illiteracy: Prescribe a book. Contemp Pediatr 1992; 9:41-60.
- American Academy of Pediatrics, Department of Community Pediatrics. Literacy Promotion. Technical Assistance.
- Public Health Agency of Canada. How does literacy affect the health of Canadians?
- Adult Literacy Survey of Statistics Canada. Ottawa: Statistics Canada, 1995.
- Coulombe S, Tremblay J-F, Marchand S. Literacy scores, human capital and growth across 14 OECD countries. Statistics Canada, 2004. http://www.statcan.ca/Daily/English/040622/d040622d.htm (Version current at October 11, 2006 ).
- Hart B, Risely TR. Meaningful Differences in the Everyday Experience of Young American Children. Baltimore: Paul Brookes Publishing Company, 1995.
- Hoff-Ginsberg E. Mother-child conversation in different social classes and communicative settings. Child Dev 1991;62:782-96.
- Senechal M. The differential effect of storybook reading on preschoolers’ acquisition of expressive and receptive vocabulary. J Child Lang 1997;24:123-38.
- Reach Out and Read: Making Books Part of a Healthy Childhood. Reach Out and Read National Centre. http://www.reachoutandread.org (Version current at October 11, 2006).
- Young KT, Davis K, Schoen C, Parker S. Listening to parents. A national survey of parents with young children. Arch Pediatr Adolesc Med 1998;152:255-62.
- Kuo A, Franke T, Rgalado M, Halfon N. Parent report of reading to young children. Pediatrics 2004;113:1944-51.
- High P, Hopmann M, LaGasse L, Linn H. Evaluation of a clinicbased program to promote book sharing and bedtime routines among low-income urban families with young children. Arch Pediatr Adolesc Med 1998;152:459-65.
- Needlman R, Fried LE, Morley DS, Taylor S, Zuckerman B. Clinicbased intervention to promote literacy. A pilot study. Am J Dis Child 1991;145:881-4.
- Golova N, Alario A, Vivier P, Rodriguez M, High P. Literacy promotion for Hispanic families in a primary care setting: A randomized controlled trial. Pediatrics 1999;103:993-7.
- Sanders LM, Gershon TD, Huffman LC, Mendoza FS. Prescribing books for immigrant children: A pilot study to promote emergent literacy among the children of Hispanic immigrants. Arch Pediatr Adolesc Med 2000;154:771-7.
- Jones VF, Franco SM, Metcalf SC, Popp R, Staggs S, Thomas AE. The value of book distribution in a clinic-based literacy intervention program. Clin Pediatr 2000;29:535-41.
- High PC, LaGasse L, Becker S, Ahlgren I, Gardner A. Literacy promotion in primary care pediatrics: Can we make a difference? Pediatrics 2000;104:927-34.
- Mendelsohn AL, Mogliner LN, Dreyer BP, et al. The impact of a clinic-based literacy intervention on language development in inner-city preschool children. Pediatrics 2001;107:130-4.
- Sharif I, Reiber S, Ozuah PO. Exposure to Reach Out and Read and vocabulary outcomes in inner city preschoolers. J Natl Med Assoc 2002;94:171-7.
- Weitzman CC, Roy L, Walls T, Tomlin R. More evidence for Reach Out and Read: A home-based study. Pediatrics 2004;113:1248-53.
- Klass PE, Needlman R, Zuckerman B. Reach Out and Read Program Manual, 3rd edn. Boston: Reach Out and Read National Center, 2005.
Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.