Back to Sleep: An Educational Intervention With Women, Infants, and Children Program Clients
* Department of General Pediatrics, Children’s National Medical Center, Washington, DC
Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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Objective. The incidence of sudden infant death syndrome (SIDS) is 2 to 3 times higher in the black population compared with the US population as a whole. Prone sleeping is also twice as prevalent in black infants. Standard modes of communication (media, brochures) regarding the Back to Sleep (BTS) campaign have been less effective with blacks. The objective of this study was to determine whether a 15-minute educational intervention is effective in changing sleep position practice among black parents.
Methods. A trained health educator led 15-minute sessions about safe infant sleep practices for groups of 3 to 10 parents of young infants who attended a Women, Infants, and Children clinic in Washington, DC. We performed pre- and postsession surveys, asking about sleep position, reasons for choosing a sleep position, and knowledge of the relationship between sleep position and SIDS. We then interviewed parents 6 months after the intervention and compared this group with a group of parents at a different Women, Infants, and Children site who did not receive the intervention.
Results. A total of 310 parents/caregivers participated in sessions from October 2001 to July 2002. Mothers comprised 84.5% of the participants, fathers 6.5%, and other relatives 9.0%. Parents had a mean age of 26.2 years (range: 15–64; standard deviation: 8.3), and 76.5% had graduated from high school. For 51%, this was their first child. Before the intervention, more than half (57.7%) of infants reportedly slept on their back, with the remainder sleeping back/side or side (15%) and prone (17.3%). Approximately 85% (266) of infants were sleeping in the same room as the parents. Only 28.1% of parents initially believed that prone sleeping definitely increases the risk of SIDS. Infants were more likely to be placed supine when previous children were placed supine or when parents had more than a high school education. Parents were also more likely to place infants supine when they believed that prone increases the risk of SIDS, they had previous knowledge of BTS, and they were aware that the American Academy of Pediatrics recommends supine position for infants. Sleep position was not affected by where the infant slept, number of parents in the home, presence of a grandmother in the home, or presence of smokers in the home. Immediately after the intervention, 85.3% planned to place infants on the back, and 55.7% now believed that prone definitely increases the risk of SIDS. When compared with a control group of parents 6 months after the intervention, parents who attended the educational intervention were more likely to place their infants on the back (75% vs 45%), less likely to bedshare (16% vs 44.2%), less likely to cite infant comfort as a reason for sleep position (14.5% vs 29.2%), and more likely to be aware of BTS recommendations (72.4% vs 38.9%).
Conclusions. A 15-minute educational session with small groups of black parents is effective in informing parents about the importance of safe sleep position and in changing parent behavior. The effect of the intervention is sustained throughout the first 6 months of life, when the infant is at the highest risk for SIDS.
Key Words: sudden infant death syndrome • risk reduction • intervention • sleep position • WIC
Abbreviations: AAP, American Academy of Pediatrics • SIDS, sudden infant death syndrome • BTS, Back to Sleep • WIC, Women, Infants, and Children
Since the American Academy of Pediatrics’ (AAP’s) initial recommendation to place all healthy infants on their back or side to reduce the risk of sudden infant death syndrome (SIDS)1 and the subsequent educational campaign Back to Sleep (BTS), the incidence of SIDS in the United States declined 40% to 0.67 deaths per 1000 live births in 1999 from 1.2 per 1000 live births in 1992.2 However, the rate of decline in SIDS for black infants has not kept pace with that in white infants; black infants die of SIDS at more than double the rate of white infants.2,3 It is unclear why this racial disparity exists; however, it exists across all educational and income categories and is worsening, despite the overall decline in SIDS rates. This racial disparity is greatly reflected in the District of Columbia, where three quarters of the children are black.4 In Washington, DC, the rate of SIDS was 1.2 per 1000 live births in 1998 (State Center for Health Statistics, District of Columbia Department of Health), almost double the national rate, and this rate continues to be high. In 2001, there were 9 reported SIDS deaths in Washington, DC, a city with 
7700 live births per year (State Center for Health Statistics, District of Columbia Department of Health).
Epidemiologic risk factors for SIDS include black race, young parental age, low socioeconomic status, low parental educational level, and lack of prenatal care. In the District of Columbia, 75.1% of the children are black, 14.8% are born to teenage mothers, 30.2% live below the federal poverty threshold, and only 59% of pregnant women receive adequate prenatal care.4 These families are those for whom the Back to Sleep (BTS) campaign, for unclear reasons, has been least effective in changing behavior. Black families are more likely to place infants prone for sleep.5–7 In one study, it was found that one third of SIDS deaths could be attributed to prone sleeping.5 Despite this, black parents are more likely to report being advised to place infants prone in the hospital after delivery5 and may be less likely to receive appropriate sleep position counseling by their infant’s physician.8 It is important that parents receive appropriate verbal and written counseling regarding sleep position, because written material alone is often ineffective in changing behavior.9
The purpose of this project was to provide current information regarding SIDS risk reduction to current and prospective parents and senior caregivers (eg, grandparents, great aunts) in Washington, DC. To that end, we developed a collaboration with the Women, Infants, and Children (WIC) program to reach parents and senior caregivers. WIC is the Special Supplemental Nutrition Program for Women, Infants, and Children, which provides food assistance and nutrition education to pregnant and lactating women and their infants who are considered at risk for nutritional deficiency because of low income and/or medical or dietary risk. As part of the nutritional and safety counseling for the families, we developed and evaluated an educational intervention regarding SIDS risk reduction.
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METHODS |
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Current and prospective parents and other adult caregivers (eg, grandparents, aunts, uncles, cousins) of young infants were targeted during a 15-minute educational intervention in the WIC clinic at Children’s National Medical Center. The clientele served by this WIC site is largely black. This specific intervention was part of an educational program aimed toward improved fetal and infant nutrition, appropriate nutrition for pregnant and lactating women, and infant safety. The educational sessions were a prerequisite to obtaining food vouchers. A trained health educator led a small group (3–10 people) discussion regarding safe infant sleep practices. Topics discussed included sleep position, bedsharing/co-sleeping, and smoke avoidance. Emphasis was placed on developing a curriculum that was culturally sensitive. Because it is common in this community for multiple adults to care for an infant, all potential caregivers were welcomed to the sessions.
Participants completed written questionnaires regarding behavioral intent before and immediately after the discussion. Although the educational sessions were a prerequisite to obtaining food vouchers, completion of questionnaires was voluntary. Participants were also asked whether they would be willing to participate in a follow-up telephone survey; no incentive was provided for follow-up, and 20.6% declined additional participation.
Families who had indicated that they would be willing to participate in a follow-up telephone survey were telephoned 6 months after the infant’s birth to determine infant sleep practices. In addition, a comparison group of 113 families from other WIC sites in Washington, DC, with similar client demographic characteristics were interviewed when the infant was 0 to 12 months of age. Outcome measures included intended and reported infant sleep practices and knowledge of BTS recommendations. The institutional review board of Children’s National Medical Center approved this study.
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RESULTS |
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Participant Demographics and Household Characteristics
A total of 310 parents/caregivers from 282 households participated in educational sessions from October 2001 to July 2002. Mothers comprised 84.5% of the participants, fathers comprised 6.5%, and other relatives comprised the rest. Participants had a mean age of 26.2 years (range: 15–64; standard deviation: 8.3), and 76.5% had graduated from high school. Approximately half (52.9%) of the infants had 1 parent in the home; 42.6% lived with both parents. A grandmother or great-aunt lived in 37.4% (116) of the households. For 51% of families, this was their first child. Among families with previous children, 119 (43%) of 277 children had slept supine, 67 (24.2%) side, and 91 (32.9%) prone. Sleep position of previous children was directly correlated with birth year, with infants born before the AAP recommendation of nonprone sleeping (1992) and the BTS campaign (1994) more likely to sleep prone (P = .0002; Table 1).
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Of the participants, 246 (79.4%) agreed to participate in a follow-up telephone survey. Of these, 98 (39.8%) had disconnected or incorrect telephone numbers, and 72 (29.3%) did not answer despite multiple attempts. A total of 76 (30.8%) families were contacted; all agreed to participate in the follow-up survey. The subgroup of 76 families was similar to the large intervention group with regards to racial/ethnic background, parental educational level, household income, and infant birth order.
Behavior, Knowledge, and Attitudes Before Intervention
Before the intervention, 90% (276) of parents co-slept or planned to co-sleep (defined as sleeping in the same room as their infant), and 21% (65) planned to bedshare (defined as sharing the same sleep surface, most commonly an adult bed) with the infant. Almost half (41.9% [130]) of participants reported that there was at least 1 smoker in the home. In approximately one fourth (25.5% [79]) of the families, at least 1 parent smoked; 61 families had 1 parent who smoked; and an additional 18 had 2 parents who smoked. Neither co-sleeping nor bedsharing was associated with the number of parents who smoked.
More than half (183 [57.7%]) of participants reported placing or intending to place their infant supine, with another fourth (75 [25%]) placing infants on the back/side or side and the remainder placing them prone (52 [17.3%]). Only 28.1% of parents believed that prone sleeping definitely increases the risk of SIDS. Infants were more likely to be placed supine when previous children were placed supine (P < .0001) or when parents had more than a high school education (P = .03). Parents were also more likely to place infants supine when they believed that prone increases the risk of SIDS (P = .0013), they had previous knowledge of BTS (P = .007), and they were aware that the AAP recommends supine position for infants (P < .0001). Sleep position was not affected by where the infant slept, number of parents in the home, presence of a grandmother in the home, or presence of smokers in the home.
Behavior, Knowledge, and Attitudes Immediately After Intervention
Immediately after the intervention, 85.3% of parents planned to place infants on the back, compared with 57.7% preintervention (P < .0001). Only 11.4% (35) of parents planned to place infants on the side, and 3.3% (10) planned to place infants side/prone. No parents planned to place infants exclusively prone after the intervention. When asked about the relationship between the prone position and SIDS, 55.7% of parents believed that prone definitely increases the risk of SIDS, a 2-fold increase from before the intervention (P < .0001). The percentage of parents who recognized supine as the AAP-recommended position also increased from 44.2% to 86.1% (P < .0001; Table 2).
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Behavior, Knowledge, and Attitudes 6 Months After Intervention
The 76 intervention families and the 113 comparison families were similar with regard to racial/ethnic background, parental educational level, parental marital status, household income, and infant’s birth order (Table 3). Families in the comparison group were less likely (32.7%) to have a grandparent or great-aunt in the household than those in the intervention group (42.1%; P = .01). The average age of infants was 20.1 weeks in the intervention group and 25.1 weeks in the comparison group.
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Infants in the intervention group were less likely to sleep in the same room with the parents (P = .0006) and less likely to have shared a bed with the parent the night before the interview (P < .0001) than the comparison group (Table 4). They were also more likely to be placed supine than those in the comparison group (P = .0005). When asked why infants were placed in a particular sleep position, parents in the intervention group were more likely to cite SIDS as a reason (P < .0001) and less likely to cite infant comfort (P = .02) or suggestion of a family member or friend (P = .001).
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When infants in the intervention group first came home after delivery, they were more likely to be placed exclusively supine by parents (82.9%) than comparison infants (59.3%; P = .008). In addition, although not statistically significant, there is a suggestion that parents who received the intervention were less likely to change the infant’s position from supine. One infant in the intervention group changed from supine to prone, compared with 7 in the comparison group.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Although BTS has been tremendously successful in changing parent and child care provider behavior with regard to safe infant sleep environment, behavior change has been more difficult to effect in black families. The standard forms of communication used by BTS (brochures, media) have been less effective in this group. In addition, nurses and physicians who serve black communities may be less inclined to discuss sleep position or more likely to recommend prone.5,8 Alternative methods of communication are necessary to eliminate the racial disparity that presently exists in SIDS.
This format of using small groups of WIC clients to convey medical information was effective in increasing knowledge and changing behavior in black parents. Parents who had participated in the intervention were more likely to be aware of the relationship between sleep position and SIDS and were more likely to place their infants supine from the time of delivery. Although the proportion of initially prone sleepers was similar in the intervention and comparison groups, there were many more side and back/side sleepers in the latter group. The primary effect on sleep position was for potential side sleepers to be placed supine from the time of birth. This is important, because it is often difficult for parents to change the infant’s sleep position to supine when another position was used previously.10 In addition, intervention infants were more likely to continue to sleep supine throughout the first 6 months of life (when 90% of SIDS occurs). This is especially noteworthy, because 22% of infants who begin sleeping in the nonprone position after hospital discharge will change to the prone position between 2 and 4 months of age.10
Friends and family members often influence health decisions in black families.7,11 However, the small-group format with WIC clients was successful in empowering parents to use health professional advice rather than advice from family or friends in making a sleep position decision. It also effectively decreased parental concerns about decreased arousal thresholds in infants who sleep supine, because parents who received the intervention were less likely to cite infant comfort as a reason for sleep position. Unfortunately, other misconceptions, such as the fear of choking or aspiration with supine, were not affected by our intervention.
This small-group format also resulted in a decrease in the number of families who bedshare. The practice of co-sleeping (sleeping in the same room as an infant) is very common, especially in the first few months of an infant’s life. The proportion of bedsharing (sleeping on the same sleep surface, most commonly an adult bed) infants in the United States has increased in the past few years12 and is high in black families.5,9,13 Infant death during bedsharing is particularly high among blacks and may be an important contributor to the racial disparity seen in SIDS.14 Bedsharing may pose an especially increased risk of SIDS when parents are smokers,15–17 and supine sleep position may be less protective when associated with bedsharing.14 Because bedsharing may also increase the risk of unexpected infant death from entrapment, overlying, or accidental suffocation,18,19 any discussion about safe infant sleep environment should include discussion about the potential dangers of bedsharing.
Although an analysis to determine cost-effectiveness of this intervention is beyond the scope of this article, 1 study has estimated that approximately one third of SIDS deaths could be prevented if infants are placed supine.5 Given this and that this intervention is not costly, even an increase in supine sleeping by 10% would be extremely cost-effective.
The success of this intervention can be largely attributed to 2 factors. The health educator who led the discussions is black and has always lived in Washington, DC. She was quickly accepted by the participants as someone who was both knowledgeable about medical questions and familiar with the culture of the community. In addition, this collaboration with a publicly funded program (WIC) was enormously successful in identifying and targeting a high-risk population. Receipt of WIC food vouchers was contingent on attending the safe sleep session. We therefore were able to disseminate the information to all expectant and new parents, many of whom likely would not receive this information elsewhere. Up to now, medical professionals have been only variably successful in changing safe infant sleep practices in the black community. Community health educators and governmental agencies such as WIC may provide successful alternative routes of health promotion.
This study has the apparent limitations inherent in parental reporting. Parents may have been reluctant to admit to prone positioning, thus leading us to underestimate the incidence of prone sleeping for both the intervention and control groups. However, it is unlikely that underreporting of prone sleeping is sufficient to explain the results reported. In addition, even if the impact of this program is exaggerated by parental reporting, this intervention is nonetheless cost-effective. It will be important to correlate reported parental practice with actual practice, and we hope to do so with home health nurse visits in the near future.
Targeted educational opportunities for low-income black parents are effective in increasing knowledge and awareness of SIDS risk factors and changing parental behavior with regard to infant sleep position and bedsharing. The effects of the intervention are sustained throughout the infant’s first 6 months of life. Similar private-public collaborations should be encouraged as a means of providing important medical information to parents.
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ACKNOWLEDGMENTS |
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This work was supported by a grant from the Gerber Foundation.
We thank Jayasri Janakiram, Sonia Pessoa, and Inge Mauger, WIC nutritionists, for their collaboration in developing the educational inservice; and the WIC staff at Children’s National Medical Center, Children’s Health Center-Shaw, Children’s Health Center at Dorchester, and Children’s Health Center at Good Hope Road for cooperation and assistance with patient recruitment. In addition, we are grateful to Joana Iglesias for assistance in data collection and database management.
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FOOTNOTES |
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Received for publication Mar 26, 2003; Accepted Jul 22, 2003.
Reprint requests to (R.Y.M.) Department of General Pediatrics, Children’s National Medical Center, 111 Michigan Ave, NW, Washington, DC 20010. E-mail: rmoon{at}cnmc.org
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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- AAP Task Force on Infant Positioning and SIDS. Positioning and SIDS.
Pediatrics.1992; 89
:1120
–1126
[Abstract/Free Full Text] - Hoyert DL, Arias E, Smith BL, Murphy SL, Kochanek KD. Deaths: final data for 1999. Natl Vital Stat Rep.2001; 49 :1 –113[Medline]
- Mathews T, MacDorman M, Menacker F. Infant mortality statistics from the 1999 period linked birth/infant death data set. Natl Vital Stat Rep.2002; 50 :1 –28[Medline]
- Every Kid Counts in the District of Columbia, 8th Annual Fact Book. Washington, DC: DC KIDS COUNT Collaborative for Children and Families; 2001
- Hauck FR, Moore CM, Herman SM, et al. The contribution of prone sleeping position to the racial disparity in sudden infant death syndrome: the Chicago Infant Mortality Study.
Pediatrics.2002; 110
:772
–780
[Abstract/Free Full Text] - Pollack HA, Frohna JG. Infant sleep placement after the Back to Sleep campaign.
Pediatrics.2002; 109
:608
–614
[Abstract/Free Full Text] - Willinger M, Ko C-W, Hoffman HJ, Kessler RC, Corwin MJ. Factors associated with caregivers’ choice of infant sleep position, 1994–1998: the National Infant Sleep Position Study.
JAMA.2000; 283
:2135
–2142
[Abstract/Free Full Text] - Ray BJ, Metcalf SC, Franco SM, Mitchell CK. Infant sleep position instruction and parental practice: comparison of a private pediatric office and an inner-city clinic. Pediatrics.1997; 99(5) . Available at: www.pediatrics.org/cgi/content/full/99/5/e12
- Moon RY, Omron R. Determinants of infant sleep position in an urban population.
Clin Pediatr (Phila).2002; 41
:569
–573
[Abstract/Free Full Text] - Ottolini MC, Davis BE, Patel K, Sachs HC, Gershon NB, Moon RY. Prone infant sleeping despite the "Back to Sleep" campaign.
Arch Pediatr Adolesc Med.1999; 153
:512
–517
[Abstract/Free Full Text] - Ellen JM, Ott MA, Schwarz DF. The relationship between grandmothers’ involvement in child care and emergency department utilization. Pediatr Emerg Med.1995; 11 :223 –225
- Willinger M, Ko CW, Hoffman HJ, Kessler RC, Corwin MJ. Trends in infant bed sharing in the United States, 1993–2000: the National Infant Sleep Position study.
Arch Pediatr Adolesc Med.2003; 157
:43
–49
[Abstract/Free Full Text] - Brenner RA, Simons-Morton BG, Bhaskar B, Revenis M, Das A, Clemens JD. Infant-parent bed sharing in an inner-city population.
Arch Pediatr Adolesc Med.2003; 157
:33
–39
[Abstract/Free Full Text] - Unger B, Kemp JS, Wilkins D, et al. Racial disparity and modifiable risk factors among infants dying suddenly and unexpectedly. Pediatrics.2003; 111(2) . Available at: www.pediatrics.org/cgi/content/full/111/2/e127
- Scragg R, Mitchell EA, Taylor BJ, et al. Bed sharing, smoking, and alcohol in the sudden infant death syndrome. New Zealand Cot Death Study Group. BMJ.1993; 307 :1312 –1318
- Fleming PJ, Blair PS, Bacon C, et al. Environment of infants during sleep and risk of the sudden infant death syndrome: results of 1993–5 case-control study for confidential inquiry into stillbirths and deaths in infancy.
BMJ.1996; 313
:191
–195
[Abstract/Free Full Text] - Mitchell EA, Tuohy PG, Brunt JM, et al. Risk factors for sudden infant death syndrome following the prevention campaign in New Zealand: a prospective study.
Pediatrics.1997; 100
:835
–840
[Abstract/Free Full Text] - Task Force on Infant Positioning and SIDS. Does bed sharing affect the risk of SIDS?
Pediatrics.1997; 100
:272
[Abstract/Free Full Text] - Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Changing concepts of sudden infant death syndrome: implications for infant sleeping environment and sleep position.
Pediatrics.2000; 105
:650
–656
[Abstract/Free Full Text]
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