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The Role of Clinic Culture in Implementation of Primary Care Interventions: The Case of Reach Out and Read

  • Tracy M. King
    Correspondence
    Address correspondence to Tracy M. King, MD, MPH, Division of General Pediatrics and Adolescent Medicine, Johns Hopkins School of Medicine, 200 N Wolfe St, Room 2072, Baltimore, Maryland 21287
    Affiliations
    Division of General Pediatrics and Adolescent Medicine, Johns Hopkins School of Medicine, Baltimore, Md (Dr King); Department of Surgery, University of Missouri–Columbia School of Medicine, Columbia, Mo (Dr Muzaffar); and Family and Community Health Division, University of Pennsylvania School of Nursing, Philadelphia, Pa (Dr George)
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  • Samar Muzaffar
    Affiliations
    Division of General Pediatrics and Adolescent Medicine, Johns Hopkins School of Medicine, Baltimore, Md (Dr King); Department of Surgery, University of Missouri–Columbia School of Medicine, Columbia, Mo (Dr Muzaffar); and Family and Community Health Division, University of Pennsylvania School of Nursing, Philadelphia, Pa (Dr George)
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  • Maureen George
    Affiliations
    Division of General Pediatrics and Adolescent Medicine, Johns Hopkins School of Medicine, Baltimore, Md (Dr King); Department of Surgery, University of Missouri–Columbia School of Medicine, Columbia, Mo (Dr Muzaffar); and Family and Community Health Division, University of Pennsylvania School of Nursing, Philadelphia, Pa (Dr George)
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      Objective

      Reach Out and Read (ROR) is a primary care–based intervention supported by considerable evidence regarding its efficacy. Implementation of ROR, however, varies across participating sites. The objective of this study was to identify practice attributes associated with variability in ROR implementation.

      Methods

      Twenty primary care providers and 70 support staff from 7 clinics in Baltimore, Maryland, participated in semistructured interviews. Sites were purposefully selected on the basis of the perceived success of their ROR program implementation. All interviews were transcribed and inductively analyzed to identify themes. Themes were compared to predictors postulated by a conceptual model for team effectiveness across a variety of workplace settings.

      Results

      Only one theme (integration of ROR procedures) addressed the design of ROR implementation within clinics. Nearly all other themes identified group processes and group psychosocial traits broadly reflective of clinic culture. At struggling sites, staff found their jobs burdensome and communication lacking. They demonstrated disrespect for patients and families. In this context, they experienced difficulty integrating ROR into their daily routines. Staff at successful sites worked as a team and expressed strong commitments to their communities. Integration of ROR at these sites tended to occur smoothly. Providers from all sites reported strong pressures to increase productivity, and thought that these pressures impaired their ability to deliver high-quality primary care.

      Conclusions

      Clinic culture influences the implementation of an efficacious primary care intervention. Characteristics of clinic culture therefore need to be identified and taken into account in future efforts to improve its implementation.

      Key Words

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      References

      1. Reach Out and Read. Available at: http://www.reachoutandread.org/about.html. Accessed October 23, 2008.

        • Needlman R.
        • Fried L.E.
        • Morley D.S.
        • et al.
        Clinic-based intervention to promote literacy. A pilot study.
        Am J Dis Child. 1991; 145: 881-884
        • High P.
        • Hopmann M.
        • LaGasse L.
        • et al.
        Evaluation of a clinic-based program to promote book sharing and bedtime routines among low-income urban families with young children.
        Arch Pediatr Adolesc Med. 1998; 152: 459-465
        • Golova N.
        • Alario A.J.
        • Vivier P.M.
        • et al.
        Literacy promotion for Hispanic families in a primary care setting: a randomized, controlled trial.
        Pediatrics. 1999; 103: 993-997
        • High P.C.
        • LaGasse L.
        • Becker S.
        • et al.
        Literacy promotion in primary care pediatrics: can we make a difference?.
        Pediatrics. 2000; 105: 927-934
        • Sanders L.M.
        • Gershon T.D.
        • Huffman L.C.
        • et al.
        Prescribing books for immigrant children: a pilot study to promote emergent literacy among the children of Hispanic immigrants.
        Arch Pediatr Adolesc Med. 2000; 154: 771-777
        • Jones V.F.
        • Franco S.M.
        • Metcalf S.C.
        • et al.
        The value of book distribution in a clinic-based literacy intervention program.
        Clin Pediatr (Phila). 2000; 39: 535-541
        • Mendelsohn A.L.
        • Mogilner L.N.
        • Dreyer B.P.
        • et al.
        The impact of a clinic-based literacy intervention on language development in inner-city preschool children.
        Pediatrics. 2001; 107: 130-134
        • Sharif I.
        • Rieber S.
        • Ozuah P.O.
        • et al.
        Exposure to Reach Out and Read and vocabulary outcomes in inner city preschoolers.
        J Natl Med Assoc. 2002; 94: 171-177
        • Silverstein M.
        • Iverson L.
        • Lozano P.
        An English-language clinic-based literacy program is effective for a multilingual population.
        Pediatrics. 2002; 109: E76
        • Weitzman C.C.
        • Roy L.
        • Walls T.
        • et al.
        More evidence for reach out and read: a home-based study.
        Pediatrics. 2004; 113: 1248-1253
        • Needlman R.
        • Toker K.H.
        • Dreyer B.P.
        • et al.
        Effectiveness of a primary care intervention to support reading aloud: a multicenter evaluation.
        Ambul Pediatr. 2005; 5: 209-215
        • Institute of Medicine
        Crossing the Quality Chasm: A New Health System for the 21st Century.
        National Academy Press, Washington, DC2001
        • Flay B.R.
        • Biglan A.
        • Boruch R.F.
        • et al.
        Standards of evidence: criteria for efficacy, effectiveness and dissemination.
        Prev Sci. 2005; 6: 151-175
        • Fixsen D.L.
        • Naoom S.F.
        • Blase K.A.
        • et al.
        Implementation Research: A Synthesis of the Literature. FMHI Publication 231.
        University of South Florida, Louis de la Parte Florida Mental Health Institute, National Implementation Research Network, Tampa, FL2005
        • Cabana M.D.
        • Rand C.S.
        • Becher O.J.
        • et al.
        Reasons for pediatrician nonadherence to asthma guidelines.
        Arch Pediatr Adolesc Med. 2001; 155: 1057-1062
        • Leslie L.K.
        • Weckerly J.
        • Plemmons D.
        • et al.
        Implementing the American Academy of Pediatrics attention-deficit/hyperactivity disorder diagnostic guidelines in primary care settings.
        Pediatrics. 2004; 114: 129-140
        • Flores G.
        • Lee M.
        • Bauchner H.
        • et al.
        Pediatricians’ attitudes, beliefs, and practices regarding clinical practice guidelines: a national survey.
        Pediatrics. 2000; 105: 496-501
        • Cohen S.G.
        • Bailey D.E.
        What makes teams work: group effectiveness research from the shop floor to the executive suite.
        J Manage. 1997; 23: 239-290
        • Bettenhausen K.L.
        Five years of groups research: what we have learned and what needs to be addressed.
        J Manage. 1991; 17: 345
        • Sofaer S.
        Qualitative methods: what are they and why use them?.
        Health Serv Res. 1999; 34: 1101-1118
        • George M.
        • Apter A.J.
        Gaining insight into patients’ beliefs using qualitative research methodologies.
        Curr Opin Allergy Clin Immunol. 2004; 4: 185-189
        • Strauss A.L.
        • Corbin J.M.
        Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory.
        2nd ed. Sage Publications, Thousand Oaks, CA1998
        • Morgan D.L.
        Why things (sometimes) go wrong in focus groups.
        Qual Health Res. 1995; 5: 516-523
        • Cohen M.Z.
        • Kahn D.L.
        • Steeves R.H.
        Hermeneutic phenomenological research: a practical guide for nurse researchers.
        Sage Publications, Thousand Oaks, CA2000
        • Patton M.Q.
        Enhancing the quality and credibility of qualitative analysis.
        Health Serv Res. 1999; 34: 1189-1208
        • Institute of Medicine
        The State of Quality Improvement and Implementation Research: Expert Views—Workshop Summary.
        National Academies Press, Washington, DC2007