The human brain is constantly learning from birth. Some of this learning occurs automatically because the brain has specific built-in faculties for it. However, other forms of learning require adaptation of existing pathways in the brain to different functions, as is the case of reading.1 Although reading is a complex process, most children can master it under adequate conditions.

Reading contributes to the development of regions of the brain involved in cognition, improves emotional variables and stimulates play and imagination. Children who are read to regularly by their parents learn to read before their peers, achieve a larger vocabulary and perform better academically. In addition, this shared activity promotes parent–child bonding.2

In early childhood, many activities can support the correct development of reading skills, such as word games, reading aloud3 or the availability of children's books. In a society in which technology is growing in importance and being introduced at increasingly early ages,4 the option of reading to children can be one of many strategies to help them improve their academic performance and provide an atmosphere conducive to the expression of emotions.5

The development of reading skills does not depend solely on the school, but it is also intimately associated with the household and social environment. In settings characterised by low income, low literacy and marginalisation, reading aloud is practiced less frequently,6 as this skill is closely associated with parental educational attainment. In addition, the number of children's books in the household tends to be lower in low-income areas.7

Considering these inequalities that exist from childhood based on socioeconomic status, a group of paediatricians and nurses in Boston instituted the organisation Reach Out and Read (ROR) in 1989, which serves more than 4.7 million children per year. Among its objectives are to promote reading aloud to children and select and provide children's books.8 The efficacy of these interventions has been described in different studies.9–11 Since then, other associations with similar objectives have been established in other countries, involving a growing number of paediatricians in the promotion of reading from an early age.12,13

The existing literature demonstrates that participation in reading promotion programmes (encouraging reading and providing children's books) improves reading habits in childhood.14 This supports the hypothesis that recommending reading to children from birth from the primary care setting can promote adequate emotional development.15 It also shows that it enhances parent–child interactions.16 It shows that parent–child reading is particularly important for parents that were never read to as children or even for those that report not enjoying reading,17 and concludes that interventions that increase the time that parents spend reading with their children achieve improvements in academic performance.18 Other projects, like the one carried out in our study, have demonstrated that reading helps mitigate the effects of poverty.19,20 However, other lines of research have failed to demonstrate the efficacy of these interventions, suggesting the need of implementing more intensive programmes in low-income, low-literacy areas.21,22

The aim of our study was to assess an intervention to promote reading in a low-income neighbourhood. The intervention was implemented in what is known as an area in need of social transformation (ANST), defined by the local government as a specific, geographically demarcated urban area whose population is affected by a constellation of structural problems associated with severe poverty and social exclusion, including clear and significant housing insecurity, school absenteeism and failure, high unemployment rates, inadequate hygiene and sanitation and social disintegration.23

A total of 346 children participated in the study. Four were lost to follow-up, all in the intervention group. In 1 case it was due to refusal to participate and in 3 due to transfer to a different primary care centre. Thus, 342 children completed the intervention and were included in the analysis. Of these 342, 188 were in the control group and 154 in the intervention group. In general, we found no statistically significant differences in the sociodemographic characteristics of the 2 groups, save in the parental educational attainment, which was higher in the control group (58.1% of parents were illiterate or had only completed primary education in the control group compared to 69.5% in the intervention group; P=.03) (Table 1).

Our study found some differences in the ranking of reading among the leisure activities of children, with a greater preference in the intervention group. Although both groups were the same in terms of the proportion that ranked reading first or second among the activity options, we found statistically significant differences between groups in the proportion of participants for who reading was the least preferred activity, which was 33.9% in the control group compared to 18.8% in the intervention group (P=.003) (Table 2) (Fig. 1).

Figure 1.

Ranking of reading in leisure activity preferences. Total sample.

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We performed the same analysis focusing on children that resided in ANSTs. There were nearly no differences in the sociodemographic characteristics of the intervention and control groups, except in ethnicity, with a higher proportion of Romany participants in the control group (46.1% vs. 32.3%; P=.036) (Table 3).

In the analysis of children residing in ANSTs, we also found an improvement in the ranking of reading in the intervention group compared to controls (40% in the control group ranked reading the least favourite compared to 23.5% in the intervention group GI; P=.014; OR, 2.17 [1.16–4.05]), with a higher probability of reading being the least favourite activity in the group that was not exposed to the intervention (Table 4) (Fig. 2).

Figure 2.

Ranking of reading in leisure activity preferences. Residents of ANSTs.

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In the subset of participants residing in ANSTs, the percentage that reported more than 1h of screen was 54.7% in the control group compared to 56.5% in the intervention group, a difference that was not statistically significant (Table 4).

When it came to ownership of children's books, excluding those provided by the programme, 87.5% of families in the control group had some at home compared to 77.6% in the intervention group. This percentage dropped to 38.4% (control group) and 25.8% (intervention group) when it came to households with more than 10 children's books, and the difference was not statistically significant.

Only 11% of children in the control group and 6% in the intervention group visited the public library.

In the multivariate analysis of the data for the entire sample, the variables that had an effect on the ranking of reading as the least favourite activity were lack of exposure to the intervention (OR, 2.06; 95% CI, 1.19–3.58) and Romany ethnicity (OR, 2.37; 95% CI, 1.38–4.09). In the multivariate analysis of the subset residing in ANSTs, we also found that the variables with an effect on reading being ranked least favourite were lack of exposure to the intervention (OR, 2.00; 95% CI, 1.06–3.77) and Romany ethnicity (OR, 1.86; 95% CI, 1.01–3.41).

Our results show a small improvement in the appreciation of reading relative to other activities available to the children under study. Although reading was hardly the preferred activity, as there is a broad range of leisure activities available to children aged 2 years, children in the intervention exhibited greater preference for reading relative to other activities compared to children in the control group.

We did not find improvement in any of the other outcomes (screen time, availability of children's books in the home and visiting the public library). Even the presence of children's books in the home (excluding those given to families as part of the programme) and the number of books was lower in the intervention group compared to the control group. This could be explained by the difference in parental educational attainment between groups, with a higher attainment in the control group.

On one hand, our study supports the results of other authors that have evaluated the efficacy of reading promotion programmes delivered in primary care paediatric clinics,25 as we found some improvements in terms of the priority children gave reading among the different activities available to them. On the other hand, as observed in similar studies, there was not improvement in other variables that could have changed with the intervention.

The analysis of screen time did not reveal a decrease in the intervention group, as it was actually greater compared to the control group. The exposure of children to technology has been increasing, and it is also starting at increasingly early ages. Today, children are immersed in the digital era.4 The duration of screen time found in our study exceeded the maximum recommended by the American Academy of Pediatrics (AAP) and the Asociación Española de Pediatría de Atención Primaria (Spanish Association of Primary Care Paediatrics, AEPap),26 which recommend limiting screen time to less than 1h a day in children aged 2–5 years and always under adult supervision. Overconsumption of audiovisual media keeps children from spending enough time in free play, which is of utmost importance to healthy development. In addition, early exposure to digital media before age 3 years is associated with an increased risk of attention deficit during childhood.27 Therefore, we need to develop new strategies to reduce exposure to digital media and mitigate the adverse effects of this exposure.

The approach we used to assess the impact of the intervention differed in comparison to other studies, as we assessed the interest in reading as opposed to the endpoints used by other authors, such as the number of days a week that parents read to the child, the daily practice of reading aloud to children at bedtime28 or parental preferences as to how to spend the time devoted to their children (parent–child reading versus other activities).

One of the limitations of the study was the lack of random allocation, as the research team decided not to exclude any child born in 2015 from the intervention. Since all participants received services at the same primary care centre, there was the risk that excluding some of the children from the intervention as it was underway could have led to contamination bias by inspiring participants in the control group to buy books. Another limitation was that since it was the parents that carried out the intervention following the advice received by paediatricians and with the help of the books provided at the clinic, the part of the intervention involving reading aloud to the children was not delivered in a homogeneous manner. Both of these limitations can be remedied in future studies by random allocation to groups and by delivering the intervention at the primary care centre, for instance by creating reading workshops for children.

Since this programme was implemented at an ANST, it made children's books adequate for the age of the participants (6 months–2 years) available in every household of children included in the intervention group. We also implemented the protocol of recommending reading aloud in early childhood in the context of the healthy child programme, explaining to parents the benefits that this practice offers children.

This study opens a new line of research in Spain, where national associations similar to ROR have yet to be established. In the area where we conducted the study, where there is a high percentage of adults that did not complete secondary education, tools like this programme, designed to promote academic achievement in childhood, must become a widespread and routine practice. But it is also essential that the necessary resources and structure are provided to carry out these programmes from primary care clinics, which are already overwhelmed offering on-demand medical care, limiting the time that can be devoted to health promotion.

Funding for this project was obtained through the Amparo Prósper grant, awarded during the 19th conference of Primary Care Paediatricians of Andalusia.

The authors declare that they have no conflict of interest.