Infant Sleep Positioning 1

Running head: INFANT SLEEP POSISTIONING EDUCATION AND COMPLIANCE

Does Infant Sleep Positioning Education

Increase Supine Sleep Care Giver Compliance?

Nicole Cook, Ashley Fryda, Nicole Hopper, Tyler Neff

Youngstown State University

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Introduction

Imagine putting a completely healthy baby to sleep and returning to find he or she

completely flaccid and unresponsive. Sudden Infant Death Syndrome (SIDS) is the sudden death

of a previously healthy infant under one year of age that remains unexplained after an autopsy,

an evaluation of the death scene, and a review of the infant’s medical history. According to

Moon and Oden, “ In the United States, approximately 20% of Sudden Infant Death Syndrome

(SIDS) deaths occur while the infant is in the care of a child care provider” (2003). Infant death

attributed to improper sleep positioning is an adverse event that can be avoided with proper

education of caregivers. However, many caregivers are receiving mixed information from health

care providers and written material. Until 2003, the U.S. Department of Health and Human

Services listed side placement for sleep even though this position was discovered to increase the

risk of SIDS (Raydo & Reu-Donlon, 2005). Researchers state that, “Additional research is

needed to determine effective methods of delivering targeted counseling and promoting safe

sleep practices among families” (Barnes-Josiah, Eurek, Huffman, Heusinkvelt, Severe-Oforah,

Schwalberg, 2008). The purpose of this study is to describe infant sleep positioning education

and caregiver compliance with supine sleep placement.

Review of Literature

Moon and Oden (2003) conducted a sixty minute educational in-service for child

care providers on the importance of the “back to sleep” infant sleep position. There were a total

of ninety-six child care providers that attended the in-service. The purpose of the study was to

provide information to child care providers on sudden infant death syndrome (SIDS), change

child care provider behaviors, and promote the development of written sleep position policies.
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The in-service was led by a trained health educator. The attendants were asked to

complete a survey before and after the in-service regarding the knowledge, beliefs, and practices

of the “back to sleep” method. Another survey was also sent to attendants six months following

the in-service. The purpose of the survey’s were to see what types of sleeping methods were

being utilized and taught to parents.

Results of the in-service showed that of the 96 attendants, child care providers that use

the supine position increased from 44.8% to 78.1%. A follow up survey showed that awareness

of the current recommendations of supine being the preferred sleep position increased from

47.9% to 78.1% and 67.7% of the centers still recognized the supine sleep position as the

recommended position six months following the in-service.

The study concluded that a targeted educational in-service for child care providers does

indeed play an important part in increasing the awareness and knowledge of sudden infant death

syndrome, and changed behaviors of child care providers regarding infant sleep positions, and

promoted the development of written sleep policies.

Price, Hillman, Gardner, Schenk and Warren (2008) conducted a nursing curriculum

based on the supine sleeping position of infants in Missouri hospitals. Before the training

session, nurses were required to take a pre-test measuring knowledge and current infant care

behavior regarding reducing the risk of SIDs. After the training session, nurses were asked to

complete a post-test evaluating intentions and knowledge regarding infant care positioning and

reduction of SIDS risk. A follow-up survey was also conducted 3-months later. Nurses who

participated in the training reported improvements in knowledge and supine sleep positioning

beliefs. Over 98% of nurses intended to place infants in the supine only sleep position following
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the training. The findings of this study determine that an educational intervention has a

significant effect of risk reduction adherence in a hospital setting.

            A random sample of 3,210 Nebraska women who gave birth in 2004 received a mailed

questionnaire regarding their receipt of a "This Side Up" t-shirt and SIDs risk reduction

materials. Half of the sample had received a t-shirt, and the other half received SIDs information.

The study revealed that receiving an infant t-shirt was not related to how mothers put their

infants to sleep. More research is needed on effective methods of promoting safe sleep practices

among families (Barnes-Josiah et al., 2007).

According to an integrative review article by Raydo and Reu-Donlon (2005), the

utilization of prone placement of infants for sleep has declined by more than 70 percent to less

than 20 percent after the 1992 release of the AAP’s guidelines. Despite the decline, numerous

parents are not receiving proper education related to infant positioning. Nurses are often the first

among the health care providers to educate postpartum woman about the “Back to Sleep”

guidelines and other SIDS prevention techniques. Hauck and colleagues studied 260 mothers that

lost a baby because of SIDS and only 46 percent reported being counseled about sleep positions

by a doctor or nurse after delivery (as cited in Raydo & Reu-Donlon, 2005). In some cases,

parents actually witness nurses placing infants in the prone position; therefore, they believe that

laying their infants on their stomachs is safe. Also, many parents believe that their babies will

choke if they lay on their backs. Educators must negate these concerns and reassure parents that

supine positioning is safe. To correct parental behaviors, ongoing reinforcement should be

implemented by providing them with oral teaching, written information, and role modeling

(Raydo & Reu-Donlon, 2005). This article provides excellent examples of studies that show

correlations between education and infant positioning, and the authors provide many
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suggestions; however, the researchers did not study the effectiveness of their suggestions for

educating caregivers.

Rasinski, Kuby, Bzdusek, Silvestri, and Weese-Mayer (2003) designed a quasi-

experimental study in Chicago, Illinois to delineate compliance with SIDS risk reduction

behaviors after an educational session. Mothers living in Black urban areas were the targeted

sample, and each participant completed a survey before and after a SIDS Risk Reduction

Education Program. According to the results, 480 mothers participated in the first survey while

472 participated in the second. The findings revealed that there was a 50 percent decrease in the

incidence of placing infants in adult beds, or sofas, or cots among whites studied. Additionally,

blacks that placed infants in adult beds, or sofas, or cots decreased from 42 to 35 percent.

Unfortunately, the number of blacks that placed pillows in the sleep area increased from 12 to 18

percent. This study shows a clear relationship between education and changing infant positioning

to meet current standards for SIDS risk reduction. Also, the population that was selected is prone

to receiving a lack of information. On the other hand, the study population included discrete

neighborhoods that were not the poorest in Chicago. Likewise, participants could have altered

their answers to fit socially acceptable behaviors, and they represented an above average

maternal age. Ultimately, the researchers believe that there would be an increase in supine infant

positioning if all the mothers could continuously see the benefits of using the supine position and

participate in specific educational programs provided by nurses and doctors (Rasinski et al.,

2003).

Since the initiation of the nationwide Back-to-Sleep Campaign in 1994, the rate of

SIDS cases has been reduced by nearly forty-percent; however, African American infants are

still twice as likely to die of SIDS compared to Caucasian and Latino infants. A group of
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physicians out of Yale University School of Medicine conducted a qualitative research study

examining actual and potential barriers that influence infant supine sleep position compliance in

African American urban caregivers. Colson and colleagues (2005) interviewed 49 caregivers in

the Boston-New Haven areas and discovered four themes that repeatedly influenced infant sleep

position. The four significant contributing factors were safety, advice, comfort, and knowledge.

The research group concluded that the data collected could be used to develop educational

models aimed at increasing knowledge about the risk of SIDS and improving compliance in the

APA’s recommendation to place all infants in the supine sleep position (Colson et al, 2005).

Methodology

As a group, we will conduct a quasi-experimental study. This study will examine the

cause and effect relationships between education and caregiver compliance in regards to supine

sleep position. Quasi-experimental research is a type of quantitative design that has a moderate

degree of control by the researcher and uses various methods of measurement and manipulation

in order to achieve a desirable environment to carry out the procedure.

A target area that we thought would most likely represent the population as a whole will

be chosen. There is an increased incidence of SIDS in inner-city, minority residents. Cleveland,

Ohio has a large and diverse population and seems an appropriate place to conduct our research

study according to size and location. An educational program will be conducted at various

municipal buildings throughout the city. Many people are intimidated in hospital settings;

therefore, municipal buildings would be a desirable alternative to the traditional hospital setting

and provide a non-threatening environment for participants.

In order to make the public aware of their opportunity to participate in the research study

and educational intervention the researchers will pass out flyers at the local grocery stores and
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discount chains. They will also post flyers at local daycare facilities and community centers.

Nurses in the Labor and Delivery Units at the local hospitals will be encouraged to participate in

the educational program as well as be asked to include a flyer in discharge packets sent home

with each new mother. Anyone that is interested in participating will be encouraged to call a

toll-free number and speak with a representative from the research team who will answer

preliminary questions.

Each participant must meet study criteria. Participants will be required to be actively

participating in the care of an infant between the ages of zero and six months. Participants must

be at least eighteen years of age, a US resident, and whose primary language is English. All

participants will be required to sign a waiver releasing our research team from any legal/medical

indiscretions. Because of limited resources and availability, the sample size will be limited to

120 subjects. Participants that do not meet one or more of the described criteria will be excluded

from the research study.

Because of the nature of the research study, this study qualified for exception of review

by the IRB. The research study posed no apparent risk to the research subjects who participated.

Because the study will be conducted in an educational environment and involve normal

educational practices it does not require the comprehensive review that other studies might

necessitate. The researchers will provide educational information that is readily available and

evidence-based.

Participants will be given a consent form to sign stating that their names will remain

confidential and be presented with all of the risks and benefits of taking part in the study. The

consent form will also explain the procedure, state the time commitment (30 minutes), state that
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participation in the study is voluntary and they may with draw at any time they wish (Burns &

Grove, 2007)

                         After signing consent, participants will take part in a 30 minute community education

program, developed by Eunice Kennedy Shriver of the National Institute of Child Health and

Human Development, NIH, DHHS. The program, Reducing the Risk of Sudden Infant Death

Syndrome, discusses what is known about SIDs, how to reduce the risk of SIDs, and resources

that are available for the family and community. Participants will receive a 12 page hand out and

will be shown a video. The handout will discuss what the “Back to Sleep” campaign is and that

the goal of the campaign is to promote back sleeping as the safest sleep position for infants under

1 year of age. The handout will then outline what SIDs is, myths and facts, and how to reduce a

baby’s risk. Topics included in reducing a baby’s risk are: placing the baby on his or her back to

sleep at nighttime and naptime, using a firm mattress, such as in a safety-approved crib,

removing all fluffy and loose bedding from the sleep area, making sure the baby’s head and face

stay uncovered during sleep and not letting the baby get too warm during sleep. The participants

will then be shown the video on reducing risk.

To measure the level of the caregivers’ knowledge regarding infant sleep positioning and

current recommendations, pre and post educational surveys were developed. The survey

measures the educational program’s ability to increase caregiver compliance with SIDS risk

reduction behaviors. Like the survey used by Moon and Oden in their study about the effects of

education on child care providers, the survey evaluates the caregivers’ knowledge, beliefs, and

practices related to infant sleeping (2003). The survey covers demographic data like age, gender,

and ethnicity of the caregiver and infant. Additionally, questions include topics like infant sleep
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locations, items placed in the sleep locations, cigarette smoke exposure, sleep positions, and

reasons for choosing certain positions. Lastly, the survey contains two final questions that ask the

subject if he or she believes that the stomach position increases the risk for SIDS and his or her

knowledge about current AAP infant recommendations regarding safe infant sleeping. The

survey contains both closed and open ended questions ranging from multiple choice to extended

answers. The results from the pre and post educational surveys are intended to show an increase

in compliance with the supine sleep position after the educational course. To determine long

term compliance, a follow-up phone interview will be conducted six months after the educational

service. The interviewer will ask the subjects the same questions that are presented on the pre

and post survey, and the information will be collected for analysis.

In addition, the measurement device must consistently assess caregivers’ compliance

with supine positioning. The survey contains questions used by Rasinski, Kuby, Bzdusek,

Silvestri, and Weese-Mayer to explore the SIDS risk reduction practices of mothers in black

urban communities before and after an educational session (2003). Rasinski et al states that the

survey is “Consistent with questions used by Willinger et al in the National Infant Sleep Position

Study (NISP) and by Brenner et al, the questions referred to the mother’s usual behavior (p.

348). The NISP used the same survey from 1992 to 2008 to study infant care practices and to

examine the spread of information about AAP recommendations (Rasinski et al). Since the use

of this survey has been repeated many times, the validity of the tool has been established.

Additionally, Rasinski et al received approval for their survey from the Social Sciences

Institutional Review Board at the University of Chicago. Basically, the survey is able to

appropriately determine caregiver compliance. However, reliability coefficients could not be

located for the surveys. In order to ascertain reliability of the instrument, Cronbach’s alpha
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testing will be performed. Furthermore, limitations with the surveys include: the absence of the

caregiver with the six month follow up survey, subjects answers may be based on what they

believe is acceptable, and the reception of a survey that is incomplete.

The data retrieved from the surveys will be entered into a secure computer with the

assistance of an organizational computer program. The computer program will be used to store,

retrieve, catalog, and sort the data gathered from the subjects' pre and post education surveys.

Additionally, the information gathered from the six-month follow up interview will be included

in the data set. To reduce error, a systematic approach will be used to enter the data into the

program (Burns & Grove, 2007). First, the responses to the survey before the educational

program will be entered in the SPSS database. Then, the answers to the survey after the

educational program will be added. Finally, the responses from the six-month follow up

interviews will be inserted. Next, the data will be cleaned. Every datum on a printout of the

information will be cross-checked with the original datum to ensure accuracy and all errors will

be corrected (Burns & Grove). Surveys that contain missing data will have to be either be

excluded or determined to have enough information to be used in statistical analyses. The

researcher will determine whether or not there is enough data present on the survey to accept it

for further study. Missing information may be obtained from the individual subject through

telephone contact.

Once the data has been entered and organized appropriately, it will be analyzed. First, the

information will be examined descriptively through exploratory analysis. An ungrouped

frequency distribution will be used to organize subjects' age, gender, race, and other

demographical data (sample size n=120). Also, the subjects' responses to questions regarding

infant sleep positions and safety will be included. Three tables will be formed to include the pre
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and post educational survey along with the results from the six-month follow up interviews.

After, the mean, median, and mode will be identified to delineate the demographic data, answers

to each survey, and the six-month follow up consultation. Then, the variance and standard

deviation will be calculated to determine that average deviation from the mean. We can use this

information to identify the different age, races, or genders that may have a more positive or

negative result from the SIDS risk reduction educational session. Furthermore, a cumulative

distribution table will be created to reveal the caregivers' knowledge and behavior before and

after the informative program, and their reason for choosing certain infant sleep positions.

Once the normal curve of scores is studied, the decision to utilize parametric or non-

parametric tests will be made. If the results are distribution free and the parameters of the

population are unknown, a Kruskal-Wallis one-way analysis of variance for ordinal data will be

performed. The dependent variable, level of compliance with supine positioning, will be

measured at the ordinal level through the percentage of subjects reporting that they place infants

on their backs for sleep. The analysis will show the differences among the subjects responses

before, immediately after, and six-months past the educational program.

Another non-parametric test, the Chi-square test, can be performed to reveal differences

among the survey responses (Burns & Grove, 2007). The dependent variable, compliance with

supine positioning, will be measured at the nominal level. Frequencies of compliance before,

after, and six months past the informational program will be compared with the frequencies that

would be expected if the data categories were independent of each other. The resulting statistic

will be compared to values in the Chi-square statistical table to see if the value is equal or

greater, which will reveal significant differences between SIDS risk reduction education and

compliance with placing infants on their backs for sleep.

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On the other hand, the distribution of the variable in the population may be known and

the information may be normally distributed. In this case, a parametric test would be utilized

(Burns & Grove, 2007). To meet the criteria for the study, a one way analysis of variance will be

used as an inferential statistical test to infer differences among the subjects' survey responses and

examine causality. The dependent variable, compliance, will be measured at the interval level.

The difference between the averages of subjects' compliance between before, after, and six-

months past the SIDS risk reduction education will be computed. In addition, within-group and

between-group variance will be determined to find the total variance. Next, the significance of

the F statistic will be explored. A significant difference between pre, post, and the six month

follow up survey responses will exist if the F statistic is equal or greater than the table value. If a

significant difference exists, it can be inferred that the educational program caused a change in

subjects' compliance with supine infant sleep positioning.

In order to protect the rights of the subjects participating in our study, upon entering each

subject will be assigned a number. Names will not be released to anyone outside of the study.

When conducting a research study it is crucial to protect the subjects’ rights to self

determination, privacy, anonymity, fair treatment, and lastly the protection from discomfort and

harm.

The subjects’ rights to self determination will be protected by informing all participants

about the study, offering an option of participating or not, and finally allowing any of the

subjects to withdraw from the study at any time without consequence. In order to ensure that the

subject’s right to privacy is protected, each subject will be referred to by a number rather than by

names. Because HIPAA also plays an important role in privacy, all of the subject’s protected

health information (PHI) will be saved to an electronic scan disk that will only be accessible to
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the researchers conducting the study. After completion of the study, the disk that contains all of

the subject’s protected health information will be disposed of properly. Prior to participation, all

subjects will be required to sign a confidentiality form stating that no information will be

disclosed to individuals outside of the study and all participants remain unknown. By doing this,

the rights’ of all subjects regarding anonymity and confidentiality will indeed also be protected.

With regards to the Institutional Review Board (IRB), because the study that we will be

performing poses no apparent risks or harm to any of our subjects, we are exempt from review.

Risks and Benefits

In any research study, there are always risks and benefits that are present. Because our

study is geared toward promoting better compliance of parents regarding sleeping positions of

infants, there are no risks to either the child or parent while participating. However, there are a

variety of benefits from participating in this study. After completion of this study, participants

will have a better understanding of the risk factors that are tied to Sudden Infant Death Syndrome

(SIDS). Participants will also be more knowledgeable concerning the importance of safe

sleeping methods with newborns. By the end of the study, it is a goal that participants will be

more compliant with the correct sleeping methods that are meant to be implemented with

newborns. Although, there are many benefits to the participants from this study, the society as a

whole can benefit from this study as well. By making people aware of the importance of safe

sleeping methods of newborns, the incidence of Sudden Infant Death Syndrome (SIDS) will

hopefully continue to decline in time.

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Works Cited

Barnes-Josiah, D. L. (2007). Effect of "This Side Up" T-Shirts on Infant Sleep Position. Matern

Child Health , 45-48.

Eve R. Colson, M. (2001). Posistion for Newborn Sleep: Associations with Parents' Perceptions

of Their Nursery Experience. BIRTH , 249-253.

Miller, L. (2008). How Does Cot Death Prevention Advice Influence Parents' Behavior? Child:

Care, Health, and Development , 613-618.

Price, S. K., Hillman, L., Gardner, P., Schenk, K., & Warren, C. (2008). Changing Hospital

Newborn Nursery Practice: Results From a Statewide "Back to Sleep" Nurses Training

Program. Matern Child Health , 363-371.