An exploration of the domain specificity of maternal sensitivity among a diverse sample in the infancy period: Unique paths to child outcomes.

Maternal sensitivity during an observed mother-child clean-up task at 18 months and maternal sensitivity during an observed mother-child free-play task at 18 months were tested as independent predictors of child internalizing symptoms, externalizing symptoms, social competence, and language development at 24 months. Participants (n = 292 mothers) were recruited between 2015 and 2017, and were low-income (mean annual income = $19,136) and racially and ethnically diverse (43.8% Black; 44.2% Latinx). Maternal sensitivity during clean-up was a significant predictor of all social-emotional outcomes, and a unique predictor of child internalizing symptoms. Maternal sensitivity during free-play was a unique predictor of child language. Results suggest that context-specific subtypes of maternal sensitivity may differentially relate to early child outcomes.

Integrating equifinality and multifinality into the of prevention programs in early childhood: The conceptual case for use of tiered models.

Introduced in the context of developmental psychopathology by Cicchetti and Rogosh in the Journal, the current paper incorporates the principles of equifinality and multifinality to support the use of tiered models to prevent the development of emerging child psychopathology and promote school readiness in early childhood. We use the principles of equifinality and multifinality to describe the limitations of applying one intervention model to address all children presenting with different types of risk for early problem behavior. We then describe the potential benefits of applying a tiered model for having impacts at the population level and two initial applications of this approach during early childhood. The first of these tiered models, Smart Beginnings, integrates the use of two evidenced-based preventive interventions, Video Interaction Project, a universal parenting program, and Family Check-Up, a selective parenting program. Building on the strengths of Smart Beginnings, the second trial, The Pittsburgh Study includes Video Interaction Project and Family Check-Up, and other more and less-intensive programs to address the spectrum of challenges facing parents of young children. Findings from these two projects are discussed with their implications for developing tiered models to support children's early development and mental health.

Promoting Cognitive Stimulation in Parents Across Infancy and Toddlerhood: A Randomized Clinical Trial.

OBJECTIVE: To test the impact of the fully integrated Smart Beginnings model on parental support of cognitive stimulation from 6 to 24 months across infancy and toddlerhood. STUDY DESIGN: This was a single-blind, 2-site randomized clinical trial of the Smart Beginnings intervention. Enrollment took place at birth in postpartum units of hospitals in New York City and Pittsburgh, Pennsylvania, with a consecutive sample of 403 mother-infant dyads. Smart Beginnings combines a Video Interaction Project-14-session universal primary prevention program delivered in the pediatric clinic at the time of well-child visits birth-36 months-with potential for Family Check-Up-3-4 sessions targeted secondary prevention home-visiting program. The principal outcome was parental support of cognitive stimulation assessed via parent survey and video-recorded observations of parent-child interactions. Ordinary least squares and mixed effects regressions were conducted. RESULTS: Families were mostly Black/African-American (50%) or Latinx (42%); all were Medicaid eligible (100%). Smart Beginnings significantly promoted cognitive stimulation during infancy and toddlerhood for most survey outcomes across time, including StimQ common total (effect size [ES] = 0.25, P = .01) and READ Quantity (ES = .19, P = .04) and Quality (ES = .30, P = .001). For the observations, the impact of Smart Beginnings varied by time, with significant impacts at 6 (ES = 0.37-.40, P < .001) and 24 (ES = 0.27-.30, P < .001) months, but not 18 months. CONCLUSIONS: Smart Beginnings positively promotes cognitive stimulation from infancy through toddlerhood using the integrated model. This study adds to the body of research showing preventive interventions in pediatric primary care and home visiting can support early relational health including parental support of cognitive stimulation. TRIAL REGISTRATION: NCT02459327.

Pre-pandemic support for shared reading buffers adverse parenting impacts: an RCT in Brazil.

BACKGROUND: To examine whether (1) a parent-child reading program (Universidade do Bebê [UBB]), conducted in Brazil pre-pandemic can support parenting and parent-child reading 6 months into the pandemic, (2) cognitive stimulation at pandemic onset mediates effects of UBB on these outcomes, and (3) UBB pre-pandemic buffers associations between COVID-19-related distress and parenting/parent-child reading 6 months into the pandemic. METHODS: 400 women, either pregnant or with children 0-24 months, were randomized to UBB (n = 200) or control groups. UBB consisted of monthly parent workshops focusing on parent-child reading and a book-lending library. Assessments pre-pandemic (June-2019) and at pandemic onset (April-2020) included cognitive stimulation. Assessments 6 months into the pandemic (October-2020) included COVID-19 exposure/impact/distress, as well as parenting and parent-child reading. RESULTS: 133 families (n = 69 UBB) contributed data 6 months into the pandemic. Participation in UBB pre-pandemic was associated with parent-child reading but not parenting 6 months into the pandemic. Indirect effects of UBB through cognitive stimulation at pandemic onset were observed for both outcomes. Increased COVID-19-related distress was significantly associated with reduced parenting/parent-child reading 6 months into the pandemic in the control group only. CONCLUSION: Promotion of cognitive stimulation pre-pandemic may have reduced risk for effects of the pandemic on parenting/parent-child reading. CLINICAL TRIAL REGISTRATION: The trial has been registered with the Brazilian Clinical Trials Registry RBR-29RZDH on 05/28/2018. IMPACT: This is the first study showing sustained impacts of a reading aloud intervention beginning in pregnancy and early infancy implemented pre-pandemic. Findings suggest that participation in a reading-aloud intervention buffered associations between COVID-19 distress and parenting/parent-child reading 6 months into the pandemic. Novel empirical evidence suggests that promotion of cognitive stimulation prior to the pandemic may buffer its impacts on parenting and parent-child book reading following onset in low- and middle-income countries. Findings provide important new support for implementation of parent-child reading aloud programs and likely have implications for early childhood development beyond the COVID-19 pandemic for disasters generally.

Maximizing the impact of reach out and read literacy promotion:anticipatory guidance and modeling.

BACKGROUND: Reach Out and Read (ROR) is a multi-component pediatric literacy promotion intervention. However, few studies link ROR components to outcomes. We examine associations between receipt of (1) multiple ROR components and (2) clinician modeling, a potential best practice, with enhanced home literacy environments (EHLEs) among Latino families. METHODS: We conducted secondary analyses of cross-sectional enrollment data from a randomized clinical trial at three urban community health centers between November 2020 and June 2023. Latino parents with infants 6-<9 months old were surveyed about ROR component receipt (children's book, anticipatory guidance, modeling) and EHLE (StimQ2- Infant Read Scale). We used mixed models with clinician as a random effect, adjusting for covariates. RESULTS: 440 Latino parent-infant dyads were included. With no components as the reference category, receipt of 1 component was not associated with EHLE. Receipt of 2 components (standardized beta = 0.27; 95%CI: 0.12-0.42) and 3 components (standardized beta = 0.33; 95% CI: 0.19-0.47) were associated with EHLE. In separate analyses, modeling was associated with EHLE (standardized beta = 0.16; 95%CI: 0.06-0.26). CONCLUSION: Findings support modeling as a core ROR component. Programs seeking to enhance equity by promoting EHLE should utilize such strategies as anticipatory guidance and clinician modeling in addition to book distribution. IMPACT: Reach Out and Read, a multi-component literacy promotion intervention, leverages primary care to promote equity in children's early language experiences. However, few studies link Reach Out and Read components to outcomes. Among Latino parent-infant dyads, we found that implementation of two and three components, compared to none, was associated with enhanced home literacy environments, following a dose response pattern. Parent report of clinician modeling was associated with enhanced home literacy environments. Literacy promotion programs seeking to enhance equity by promoting enhanced home literacy environments should utilize strategies in addition to book distribution, including anticipatory guidance and modeling, to maximize impact.

Supporting responsive parenting in real-world implementation: minimal effective dose of the Video Interaction Project.

BACKGROUND: The Video Interaction Project (VIP) is a healthcare-based intervention that provides real-time video-feedback of parent-child play and reading interactions to families with children aged 0 to 36 months. Although evidence from randomized controlled trials demonstrates improved early relational health, including responsive parenting, after three to five VIP visits, the minimal effective dose in real-world implementations is unknown. This study aimed to determine the minimal effective dose of VIP during a real-world implementation for changing responsive parenting behaviors. METHODS: We performed a longitudinal prospective study of 183 dyads at a public hospital pediatric clinic. Responsive parenting behaviors were assessed with an observational checklist utilized as part of standard VIP practice at baseline and two follow-up VIP visits. RESULTS: Multilevel models adjusted for baseline sociodemographics (child's sex and age, and maternal education) and time between visits showed that responsive parenting behaviors during parent-child reading and play significantly increased after a single VIP visit (Cohen's d = 0.52, p < 0.05) with additional impact following completion of a second visit (cumulative for 2 visits: d = 0.76, p < 0.05). CONCLUSIONS: A single VIP visit is associated with increased responsive parenting behaviors. Findings support offering VIP widely, regardless of capacity to ensure attendance at multiple visits. IMPACT: This is the first study showing the minimal effective dose of the Video Interaction Project (VIP) for increasing responsive parenting behaviors. Responsive parenting behaviors increased by over 22% following a single VIP visit, with a cumulative increase of 37% following the second visit compared to baseline. Findings have important implications for implementation and scalability of pediatric-based preventive programs that support early relational health through activities such as reading and play.

Enhancing early language and literacy skills for racial/ethnic minority children with low incomes through a randomized clinical trial: The mediating role of cognitively stimulating parent-child interactions.

Parenting is a critical mediator of children's school readiness. In line with this theory of change, data from the randomized clinical trial of Smart Beginnings (tiered Video Interaction Project and Family Check-Up; N = 403, treatment arm n = 201) were used to examine treatment impacts on early language and literacy skills at child age 4 years (nLatinx = 168, nBlack = 198, nMale = 203), as well as indirect impacts through parental support of cognitive stimulation at child age 2 years. Although results did not reveal direct effects on children's early skills, there were significant indirect effects for early literacy (ß = .03, p = .05) and early language (ß = .04, p = .04) via improvements in parental cognitive stimulation. Implications for interventions targeting parenting to improve children's school readiness beginning at birth are discussed.

Impacts of a tiered intervention on child internalizing and externalizing behavior in the context of maternal depression.

Greater maternal depressive symptoms are consistently associated with higher levels of behavioral difficulties in children, emerging in early childhood and with long-lasting consequences for children's development. Interventions promoting early relational health have been shown to have benefits for children's behavior; however, these impacts are not always realized in the context of maternal depression. This study examined whether tiered programs could address this limitation by focusing on both parenting, through universal primary prevention, and psychosocial stressors and parent mental health, through tailored secondary prevention. Analysis of a randomized controlled trial (RCT) of the Smart Beginnings (SB) intervention was conducted to determine whether SB attenuated the association between maternal depression and early childhood internalizing and externalizing behaviors. Maternal depression significantly predicted both internalizing and externalizing behaviors in linear regression models. Further, there was a significant interaction between maternal depression and treatment group, such that among mothers with higher depressive symptoms, the SB treatment attenuated the magnitude of the association between depression and child behavior. Findings suggest that while parenting support is important for all families, it may be particularly critical for those with higher levels of depression and underscores the need to consider multidimensional family processes in both research and clinical practice.

Tiered Universal and Targeted Early Childhood Interventions: Enhancing Attendance Across Families with Varying Needs.

This study examined whether a two-tiered parenting program, which provides universal primary prevention along with targeted secondary prevention only for families with increased needs, would have mutually beneficial impacts on attendance across two program components. A secondary analysis of the Smart Beginnings (SB) randomized controlled trial was conducted. SB takes place from birth to age 3 and combines universal delivery of the Video Interaction Project (VIP) with targeted delivery of the Family Check-Up (FCU) for families identified as having increased risks following yearly screening. The current study analyzed whether attendance in VIP in the first six months was associated with FCU attendance for eligible families at six months, and whether FCU attendance at six and 18 months was associated with subsequent VIP attendance. Analyses included logistic and mixed-effects Poisson regression, as well as group-based trajectory analysis. VIP attendance predicted later FCU attendance (AOR = 5.43, p < .01), and FCU attendance predicted later VIP attendance (IRR = 1.35, p < .01) and a high-stable VIP attendance trajectory (AOR=14.98, p < .01). Findings provide strong support for the ability of tiered models to engage parents, to promote effective and efficient service delivery to reduce disparities in school readiness, and their potential to overcome common barriers to attendance and scaling by addressing the heterogeneity of risk among low-income families.

Collateral benefits from a school-readiness intervention on breastfeeding: A cross-domain impact evaluation.

This study evaluated the collateral, or unanticipated, impacts of Smart Beginnings (SB), a two-site, tiered intervention designed to promote responsive parenting and school readiness, on breastfeeding intensity in a low-income sample. Impact analyses for the SB intervention were conducted using an intent-to-treat design leveraging a two-arm random assignment structure. Mothers assigned to the SB intervention group were more than three times more likely to give breastmilk as the only milk source at infant age 6 months than mothers assigned to the control group at one site, an effect not evident at the other study site. As development and growth are the two most salient domains of child health, understanding how interventions impact subsequent parenting practices across both domains is critical to address long-term economic and racial/ethnic disparities. Implications of the findings are discussed for improving the efficacy of interventions based on paediatric primary care.

Effects of maternal trauma and associated psychopathology on atypical maternal behavior and infant social withdrawal six months postpartum.

Maternal psychopathology given a history of maltreatment and domestic violence exposure increases the risk for child psychopathology. Infant social withdrawal is one warning sign of adverse developmental outcomes including child anxiety and depression. It remains unclear how maternal trauma-related psychopathology might affect infant social withdrawal six-months postpartum. METHODS: One-hundred ninety-five women and their six-month-old infants were studied in an at-risk community sample. Maternal trauma history, posttraumatic stress (PTSD) and major depressive (MDD) disorders were assessed. Maternal and infant behaviors were coded from videotaped interactions. RESULTS: Maternal trauma was correlated with atypical maternal behavior (AMB) and infant social withdrawal (p ≤ .001). PTSD and MDD, and comorbid PTSD/MDD predicted increased AMB (p ≤ .001) but only maternal MDD was predictive of infant social withdrawal (p ≤ .001). Effects of maternal MDD on infant withdrawal were mediated by AMB. CONCLUSIONS: At six-months postpartum, maternal MDD was associated with infant withdrawal. AMB is an important target for early intervention.

Breastfeeding and Responsive Parenting as Predictors of Infant Weight Change in the First Year.

OBJECTIVE: To test breastfeeding duration and responsive parenting as independent predictors of infant weight change from birth to 12 months, and to test the moderating effect of a tiered parenting intervention on relations between breastfeeding and responsive parenting in relation to infant weight change. METHODS: Mother-infant dyads (N = 403) were participants in the ongoing Smart Beginnings (SB) randomized controlled trial testing the impact of the tiered SB parenting model that incorporates two evidence-based interventions: Video Interaction Project (VIP) and Family Check-Up (FCU). The sample was low income and predominantly Black and Latinx. Responsive parenting variables (maternal sensitivity and intrusiveness) came from coded observations of mother-infant interactions when infants were 6 months. Continuous weight-for-age (WFA) z-score change and infant rapid weight gain (RWG) from 0 to 12 months were both assessed. RESULTS: Longer breastfeeding duration was significantly associated with less WFA z-score change. The relationship between breastfeeding duration and WFA z-score change was significant only for infants in the intervention group. Intrusive parenting behaviors were also associated with greater WFA z-score change after accounting for breastfeeding duration. CONCLUSIONS: This study is one of the first to test both breastfeeding and parenting in relation to infant weight gain in the first year. Findings may have implications for family-focused child obesity prevention programs.

Father involvement in infancy predicts behavior and response to chronic stress in middle childhood in a low-income Latinx sample.

Fathers' involvement in early childhood is important for children's physical, emotional, and cognitive development, particularly in low-income families. However, little is known about the longitudinal relations between early father involvement and children's later physiological responses to chronic stress and behaviors impacted by stress in the context of poverty. These issues are particularly important among Latinx immigrant families who face significant psychosocial and poverty-related risk. In the current study, we examined the relationship between father involvement in infancy and physiological chronic stress in the middle childhood period, as measured through hair cortisol concentration (HCC), and several behavioral measures (attention problems, working memory) in a Latinx immigrant sample with low income. Father involvement in infancy predicted children's later HCC, and working memory in second to third grade. Father involvement also moderated the effect of HCC on working memory, such that increased HCC predicted better working memory when fathers were not involved. These findings suggest that the fathers' involvement in infancy has lasting impacts on health and behavior and that associations between physiological and behavioral measures of stress may be moderated by differences in early father involvement.

Sociodemographic and Psychosocial Predictors of VIP Attendance in Smart Beginnings Through 6 Months: Effectively Targeting At-Risk Mothers in Early Visits.

Past research on predictors of participation in early childhood parenting programs suggest that families experiencing higher levels of sociodemographic adversity (e.g., younger maternal age, single parenthood, lower income or education) are less likely to participate in parenting programs. This is significant, as it may indicate that those most in need of additional support are the least likely to receive it. Data from a randomized control trial (RCT) of Smart Beginnings, an integrated, tiered model for school readiness, were used to explore predictors of attendance in Video Interaction Project (VIP) through 6 months. VIP is a primary preventive intervention delivered in tandem with pediatric well-child visits, aimed at reducing income-based disparities in early child development through promotion of responsive parent-child interactions. Using Poisson distribution models (N = 403; treatment arm, n = 201), we find that demographic, socioeconomic status (SES), and psychosocial variables are associated with program attendance but not always in the expected direction. While analyses show that first-time mothers have higher levels of program attendance as expected, we find that less-educated mothers and those with lower parenting self-efficacy have higher levels of attendance as well. The latter findings may imply that the VIP intervention is, by some indicators, effectively targeting families who are more challenging to engage and retain. Implications for pediatric-based interventions with population-level accessibility are discussed.

Play in Mexican-American mothers and toddlers is frequent, multimodal, and rich in symbolic content.

Play offers rich opportunities for toddlers to develop motor, social, cognitive, and language skills, particularly during interactions with adult caregivers who may scaffold toddlers to higher levels of play than toddlers achieve on their own. However, research on play has narrowly focused on children from White, middle-income backgrounds, leaving a dearth of knowledge about dyadic play in diverse cultural communities. We videorecorded 222 Mexican-American mothers playing with their 2-year-old toddlers with a standard set of toys. Play behaviors were coded as nonsymbolic or symbolic (play type) and as expressed through manual, verbal, or multiple channels (play modality). Play between toddlers and mothers was frequent, high in symbolic content, and toddler play closely corresponded with mother play in type and modality: Toddlers' nonsymbolic play related to mothers' nonsymbolic play; toddlers' symbolic play related to mothers' symbolic play; toddlers' manual play related to mothers' manual play; and toddlers' multimodal play related to mothers' multimodal play. Play in Mexican-American mothers and toddlers is frequent, multimodal, and symbolically rich, offering new directions for future research and practice.

The Protective Effect of Prenatal Social Support on Infant Adiposity in the First 18 Months of Life.

OBJECTIVE: To determine whether prenatal social support was associated with infant adiposity in the first 18 months of life in a low-income, Hispanic sample, known to be at high risk of early child obesity. STUDY DESIGN: We performed a longitudinal analysis of 262 low-income, Hispanic mother-infant pairs in the control group of the Starting Early child obesity prevention trial. Prenatal social support was measured using an item from the Maternal Social Support Index. We used multilevel modeling to predict weight-for-length z-score trajectories from birth to age 18 months and logistic regression to predict macrosomia and overweight status at ages 6, 12, and 18 months. RESULTS: High prenatal social support was independently associated with lower infant adiposity trajectories from birth to age 18 months (B = -0.40; 95% CI, -0.63 to -0.16), a lower odds of macrosomia (aOR = 0.35; 95% CI, 0.15-0.80), and a lower odds of overweight at ages 12 (aOR = 0.28; 95% CI, 0.10-0.74) and 18 months (aOR = 0.35; 95% CI, 0.14-0.89). Prenatal social support was not significantly associated with overweight status at age 6 months. CONCLUSIONS: Prenatal social support may protect against excessive infant adiposity and overweight in low-income, Hispanic families. Further research is needed to elucidate mechanisms underlying these associations and to inform preventive strategies beginning in pregnancy.

Parent Dosing Tool Use, Beliefs, and Access: A Health Literacy Perspective.

OBJECTIVES: To assess parent decision-making regarding dosing tools, a known contributor to medication dosing errors, by evaluating parent dosing tool use, beliefs, and access, and the role of health literacy, with a focus on dosing cups, which are associated with an increased risk of multifold overdose. STUDY DESIGN: Cross-sectional analysis of data collected for randomized controlled study in 3 urban pediatric clinics. English/Spanish-speaking parents (n = 493) of children ≤8 years of age enrolled. OUTCOMES: reported tool use, beliefs, and access. Predictor variable: health literacy (Newest Vital Sign; limited [0-3], adequate [4-6]). Multiple logistic regression analyses conducted. RESULTS: Over two-thirds of parents had limited health literacy. Oral syringes (62%) and dosing cups (22%) were most commonly used. Overall, 24% believed dosing cups were the best tool type for dosing accuracy; 99% reported having access to ≥1 dosing tools with standard measurement markings. Parents with limited health literacy had greater odds of dosing cup use (limited vs adequate: aOR = 2.4 [1.2-4.6]). Parents who believed that dosing cups are best for accuracy had greater odds of dosing cup use (aOR = 16.3 [9.0-29.3]); this belief mediated health literacy-effects on dosing cup use. CONCLUSIONS: Factors associated with dosing tool choice, including parent health literacy and beliefs are important to consider in the design of interventions to reduce dosing errors; future larger-scale studies addressing this issue are needed.

Links between Shared Reading and Play, Parent Psychosocial Functioning, and Child Behavior: Evidence from a Randomized Controlled Trial.

OBJECTIVE: To investigate pathways by which interventions that promote shared reading and play help prevent child behavior problems. We examined whether family processes associated with the family investment pathway (eg, parental cognitive stimulation) and the family stress pathway (eg, mothers' psychosocial functioning) mediated impacts of a pediatric-based preventive intervention on child behavior. STUDY DESIGN: The sample included 362 low-income mothers and their children who participated in a randomized controlled trial of the Video Interaction Project, a pediatrics-based preventive intervention that promotes parent-child interactions in the context of shared reading and play. Parent-child dyads were randomly assigned to group at birth. Three mediators-parental cognitive stimulation, maternal stress about the parent-child relationship, and maternal depressive symptoms-were assessed at child ages 6 and 36 months. The outcome, child externalizing behaviors, was assessed at 36 months. We used a series of path analytic models to examine how these family processes, separately or together, mediated the impacts of the Video Interaction Project on child behavioral outcomes. RESULTS: Intervention impacts on child behavior were mediated by enhancements in cognitive stimulation and by improvements in mothers' psychosocial functioning. A sequential mediation model showed that Video Interaction Project impacts on cognitive stimulation at 6 months were associated with later decreases in mothers' stress about the parent-child relationship and that this pathway mediated intervention impacts on child behavioral outcomes at 3 years of age (P = .023). CONCLUSIONS: Using an experimental design, this study identifies pathways by which parent-child interactions in shared reading and play can improve child behavioral outcomes. TRIAL REGISTRATION: Clinicaltrials.gov: NCT00212576.

Discharge Instruction Comprehension and Adherence Errors: Interrelationship Between Plan Complexity and Parent Health Literacy.

OBJECTIVE: To examine associations between parent health literacy, discharge plan complexity, and parent comprehension of and adherence to inpatient discharge instructions. STUDY DESIGN: This was a prospective cohort study of English/Spanish-speaking parents (n = 165) of children ≤12 years discharged on ≥1 daily medication from an urban, public hospital. Outcome variables were parent comprehension (survey) of and adherence (survey, in-person dosing assessment, chart review) to discharge instructions. Predictor variables included low parent health literacy (Newest Vital Sign score 0-3) and plan complexity. Generalized estimating equations were used to account for the assessment of multiple types of comprehension and adherence errors for each subject, adjusting for ethnicity, language, child age, length of stay, and chronic disease status. Similar analyses were performed to assess for mediation and moderation. RESULTS: Error rates were highest for comprehension of medication side effects (50%), adherence to medication dose (34%), and return precaution (78%) instructions. Comprehension errors were associated with adherence errors (aOR, 8.7; 95% CI, 5.9-12.9). Discharge plan complexity was associated with comprehension (aOR, 7.0; 95% CI, 5.4-9.1) and adherence (aOR, 5.5; 95% CI, 4.0-7.6) errors. Low health literacy was indirectly associated with adherence errors through comprehension errors. The association between plan complexity and comprehension errors was greater in parents with low (aOR, 8.3; 95% CI, 6.2-11.2) compared with adequate (aOR, 3.8; 95% CI, 2.2-6.5) health literacy (interaction term P = .004). CONCLUSIONS: Parent health literacy and discharge plan complexity play key roles in comprehension and adherence errors. Future work will focus on the development of health literacy-informed interventions to promote discharge plan comprehension.

Perspectives on shared reading among a sample of Latino parents.

BACKGROUND: Paediatric professionals promote shared reading to facilitate school readiness, yet relatively few studies examine how parents from underserved communities consider this issue in their daily lives. We sought to understand shared reading within the broader context of parenting among Latino parents. METHODS: We conducted in-depth interviews, purposively sampling Spanish-speaking, Latina mothers of children aged ≤3 years from an urban Federally Qualified Health Center. Interviews were recorded, transcribed, and analysed iteratively. We allowed themes to emerge from data rather than impose an a priori framework. We sought disconfirming evidence within interviews and collected additional data to ensure no new themes were identified (saturation). RESULTS: We achieved saturation after 12 interviews. The median child age was 1.4 years. We identified four major themes: (a) All participants reported engaging in literacy promoting activities such as conversations, storytelling, play, and singing even if they did not read to their children daily. (b) Parents' attitudes regarding early learning and development influenced the extent to which parents engaged in shared reading with their child. (c) Participants described feelings that they ought to read daily with their children but were not and cited a variety of barriers. (d) Parents who engaged in frequent shared reading described it as a joyful and relaxed experience; parents who did not engage in shared reading described reading as instructing children or engaging in drills (e.g., teaching letters). CONCLUSION: Urban, Latina mothers who did not read regularly with their children nonetheless recognized its importance suggesting that existing programmes have raised awareness even among underserved families. Refinement of messaging may be needed to move past raising awareness to facilitating shared reading for some parents.