Video Abstract
The COVID-19 pandemic exacerbated the ongoing adolescent mental health crisis in part by disrupting connections to schools, communities, and primary care. Reading has been shown to support mental health by fostering identification with narratives, situations, or characters and promoting empathy. Inspired by Reach Out and Read, we developed Turning Pages, a program designed to enhance the clinic experience for adolescents by offering books during annual physicals in a primary care clinic. The clinic serves a diverse population of 1750 adolescent and young adult patients, with approximately 40% covered by California’s Medicaid program. Patients and clinicians recommended books that were meaningful during their adolescence, and we partnered with a local bookshop to curate a diverse and inclusive collection. At the start of each visit, medical assistants invited patients to select a book and offered an optional survey assessing program impact. A total of 326 books were acquired through the support of various grants and donations. Between May 2023 and January 2024, 295 books were distributed to adolescent patients. Of the 65 patients who completed the survey, 98% appreciated receiving a book, 81% felt it improved their clinic experience, and 68% reported feeling more connected to their medical team. Institutional support and positive feedback from patients, clinicians, and staff have ensured ongoing funding for the program. Turning Pages demonstrates potential as a sustainable program that enhances the clinic experience and strengthens connections to care.
Introduction
It is well-documented that the COVID-19 pandemic exacerbated the already ongoing adolescent mental health crisis in part by disrupting connections to schools, communities, and primary care clinics.1,2 This loss of connection to primary care is further highlighted by US Census Bureau data, which show that 26.4% of households reported at least 1 child or adolescent missed or delayed a preventive visit due to COVID-19.3
Research indicates that increased engagement with books can positively impact mental health, particularly when opportunities for healthy social connection are limited.4 Reading can help compensate for the lack of social support, a factor linked to suicide risk, by fostering identification with narratives, situations, or characters.5 It has also been shown to enhance the ability to understand other mental states, promote prosocial behavior, and cultivate social-emotional skills while encouraging youth dialogue to support well-being.6–8 Moreover, with a record number of book bans across the United States, disproportionately targeting books about marginalized young people, there is an urgent need for spaces that encourage engagement with diverse lived experiences.9,10
Reach Out and Read is a national early literacy program endorsed by the American Academy of Pediatrics (AAP) that provides books during well-child visits for children aged 5 years or younger. Reach Out and Read is a comprehensive literacy program in which book distribution is paired with modeling and guidance about reading by pediatricians, with numerous studies demonstrating positive impacts on child development.11–15 A recent AAP policy statement highlights that promoting literacy in primary care can improve a child’s life trajectory and help mitigate stress and adverse experiences.16 Extending components of the Reach Out and Read model to adolescents by introducing books during annual visits may enhance their health care experience and positively influence their life trajectory. Given that reading for pleasure has been linked to improved well-being and emotional connection4–8 and that positive relationships with caring adults foster adolescent health and development,17 we developed Turning Pages, a reading program designed to strengthen adolescents’ connection to primary care at the University of California, San Francisco (UCSF) Adolescent and Young Adult Medicine Clinic.
The UCSF Adolescent and Young Adult Medicine Clinic offers primary care to patients aged 11 to 25 years, primarily from San Francisco. The clinic serves a diverse population of 1750 adolescent and young adult patients, with approximately 40% covered by California’s Medicaid program. In line with national trends, our clinic experienced a 37% decrease in patients presenting for annual physicals in 2020 compared with 2019, dropping from 637 to 403. Although the number of physicals has since improved, it has not fully returned to prepandemic levels, with 576 physicals in 2023.
To provide a broader context to our clinic population, the California Reading Coalition has identified a reading crisis in the state, with San Francisco Unified School District ranking in the bottom 10% of 287 districts in 2022.18 Data from the California Assessment of Student Performance and Progress revealed that 89% of students in San Francisco County did not meet the standard for English Language Arts/Literacy for the 2022–2023 academic year.19 Given this context, it is vital to offer youth opportunities and encouragement to engage with reading across educational, clinical, and community settings. We posited that sharing diverse books with our patients would enhance their clinic experience and foster a stronger connection with their medical team.
Methods and Process
In March 2023, we received a $2000 UCSF Patient Care Fund award to purchase books, bookmarks, and a bookshelf to launch the Turning Pages program. In addition, we were awarded $1000 from the Shenkin Family Fund for Humanistic Medicine, $2000 from the Adolescent and Young Adult Health Research Network, and $2500 in philanthropic support to replenish and expand our book collection. During March and April 2023, we invited clinic team members and patients to recommend books that shaped their lives or were meaningful during adolescence. To ensure a diverse and inclusive collection, we consulted with a local independent bookshop, selecting books that would appeal to a wide range of ages, developmental stages, cultures, and literacy levels reflective of our clinic’s diverse population. The collection included fiction, nonfiction, poetry, and graphic novels. A committee of 3 clinicians (2 adolescent medicine physicians and 1 social worker) reviewed the books to determine appropriateness for our patients based on reading level, content, and themes, referencing Common Sense Media recommendations when available.20
From May 2023 to January 2024, we curated a book collection categorized by reading level (for ages 11 years and up, 14 years and up, and 18 years and up). At the start of each visit, medical assistants invited adolescent patients presenting for annual physicals to select a book. We also designed and printed bookmarks, distributed with each book, featuring a quick response (QR) code linking to an anonymous survey hosted on RedCap. Medical assistants encouraged patients to scan the QR code using their phones to complete the survey or provided a paper version if needed. The survey, developed in consultation with UCSF Adolescent and Young Adult Medicine clinicians, collected demographic information (age, gender, race, and ethnicity) and included 3 Likert-style questions assessing the program’s impact on the clinic experience, along with open-ended questions for book recommendations and general feedback. On a rolling basis, we reviewed the recommendations and incorporated most of them into our collection. The survey took an average of 3 minutes to complete. This study was deemed exempt from review by the institutional review board.
Outcomes
A total of 326 books were purchased at an average cost of $15 per book. Between May 2023 and January 2024, 446 patients attended annual physicals, with 295 patients (66%) receiving a book. Books were not offered to every patient primarily because the process had not yet been fully integrated into the clinic’s protocol. Many staff members described how patients and families expressed excitement and gratitude for the books. In addition, several clinicians reported using the books as a starting point for richer discussions with patients including their individual interests. Because of the initial success and enthusiasm for the Turning Pages program among patients, clinicians, and staff, the UCSF Adolescent and Young Adult Medicine leadership committed to its continuation, with the UCSF Development Office establishing a dedicated gift fund to facilitate ongoing donations. Additionally, we partnered with a local community bookshop to ensure our collection remains well-stocked.
Of the patients who received a book, 65 (22%) completed the survey. Participants’ ages ranged from 12 to 25 years, with a median age of 18 years. Demographics of the survey sample are detailed in Table 1 and were closely aligned with the overall clinic demographics during the same period. Ninety-eight percent of respondents either strongly agreed or agreed that they appreciated the book they were given. Additionally, 81% strongly agreed or agreed that the program enhanced their clinic experience, whereas 16% neither agreed nor disagreed. Sixty-eight percent of respondents strongly agreed or agreed that the program made them feel more connected to their medical team, with 29% neither agreeing nor disagreeing. Survey comments included “Great way of giving more knowledge!,” “It’s really cool!,” “It’s awesome!,” “Keep it up,” “I really liked it,” “Thanks for the book! It was super sweet of y’all:),” “Really cool program,” “More books!,” “I hope this program stays!,” “Great program:),” “It was a pleasant surprise,” “Amazing program,” and “Please continue the program!”
Self-Reported Participant Demographics
N = 65 (22% Response Rate) . | n . |
---|---|
Gender identities | |
Female | 36 |
Male | 24 |
Nonbinary | 4 |
Genderqueer | 1 |
Race | |
African American/Black | 5 |
Asian | 26 |
Declined to answer | 3 |
Native Hawaiian/Other Pacific Islander | 1 |
Other | 9 |
Unknown | 1 |
White | 28 |
Median age | 18 |
N = 65 (22% Response Rate) . | n . |
---|---|
Gender identities | |
Female | 36 |
Male | 24 |
Nonbinary | 4 |
Genderqueer | 1 |
Race | |
African American/Black | 5 |
Asian | 26 |
Declined to answer | 3 |
Native Hawaiian/Other Pacific Islander | 1 |
Other | 9 |
Unknown | 1 |
White | 28 |
Median age | 18 |
Abbreviation: N, total sample size; n, subgroup of total population.
Lessons Learned
Previous studies have shown that adolescents are experiencing a mental health crisis, often feeling disconnected and alienated from traditional social supports, with a low rate of established medical homes.1–3 Additionally, books have been shown to alleviate feelings of social isolation by fostering identification with narratives, plots, or characters.4–8 As such, reading programs like Turning Pages may help promote a sense of connection and improve mental health outcomes. Our study suggests that this program is sustainable, enhances the clinic experience, and could be adapted for other primary care settings, particularly for adolescent populations. At a time when reading has become increasingly politicized and controversial, our focus on including books that appeal to a broad and diverse audience is especially crucial.9,10
Based on our experience piloting this program, we recommend that clinics invite patients to suggest books that have been meaningful to them and partner with a bookshop or library experienced in selecting books for adolescents and young adults. This collaboration can help build a collection that resonates with and reflects the diversity of the clinic’s population. We also suggest stocking a variety of genres, including fiction, nonfiction, graphic novels, and poetry, to cater to a wide range of tastes and interests. Additionally, organizing the collection by reading level helps to ensure patients receive books appropriate for their developmental stage. Notably, our collection consisted entirely of English-language books, as that is the primary language of our patient population; however, clinics should consider including books in the primary languages spoken by their patients.
Our low survey response rate raises the risk of nonresponse bias because if only highly engaged participants completed the survey, our results might overestimate satisfaction with the program and fail to capture the perspectives of less engaged or dissatisfied participants. The low response rate thus limits generalizability since our findings might not be representative of our entire patient population. In light of these limitations, we recommend that other clinics intending to measure outcomes integrate the survey process more seamlessly into clinic workflows. This could involve automated reminders for medical assistants to offer the survey and for patients to complete it. Additionally, some nonrespondents may have challenges with literacy, which could have hindered their participation. This insight could inform needs assessments and guide clinics’ allocation of resources when introducing a reading program.
Conclusions
Our preliminary data suggest that adolescents appreciated the addition of Turning Pages to their clinic experience, and the program may serve as a valuable model for dissemination to other clinical settings. Our clinic is enthusiastic about continuing the program based on these encouraging findings. Moreover, Turning Pages has been incorporated into our institution’s fundraising efforts, and donations are consistently received to support its sustainability. Moving forward, we plan to pair books with information about library e-reader apps and community literacy resources. We will also include bookplates featuring clinician headshots and biographical details to strengthen patients’ connection with their medical team.
Acknowledgments
This work was supported by the Health Resources and Services Administration of the US Department of Health and Human Services under cooperative agreement [U8DMC45901], the Maternal and Child Health Bureau Leadership Education in Adolescent Health Training Grant [T71MC00003], the Clifford Attkisson Clinical Services Research Training Program T32 of the National Institute of Mental Health [MH018261], the UCSF Patient Care Fund, and the Shenkin Family Fund for Humanistic Medicine. Portions of these findings were previously presented at the Society for Adolescent Health and Medicine Annual Meeting, San Diego, March 15, 2024. We extend our thanks to the patients, staff, and clinicians of the UCSF Adolescent and Young Adult Medicine Clinic for their engagement with Turning Pages. Finally, we express our gratitude to Christopher’s Books for their continued collaboration and support in sustaining the program.
Dr Sinha conceptualized and designed the study, drafted the initial manuscript, designed the data collection instruments, collected data, carried out the initial analyses, and critically reviewed and revised the manuscript. Drs Buckelew and Ozer critically reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
CONFLICT OF INTEREST DISCLOSURES: The authors have no conflicts of interest to disclose.
FUNDING: This work was supported by the Health Resources and Services Administration of the US Department of Health and Human Services under cooperative agreement [U8DMC45901]; the Maternal and Child Health Bureau Leadership Education in Adolescent Health Training Grant [T71MC00003]; the Clifford Attkisson Clinical Services Research Training Program T32 of the National Institute of Mental Health [MH018261]; the University of California, San Francisco Patient Care Fund; and the Shenkin Family Fund for Humanistic Medicine. The funder/sponsor did not participate in the work.
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