Challenging Dogma - Fall 2009

Wednesday, December 16, 2009

The “Back to Sleep” Campaign and Its Failure in Narrowing the SIDS Rates Gap –Carrie Pierce

Sudden Infant Death Syndrome (SIDS) is the leading cause of death in healthy infants from one month old to one year of age; currently about 3000 deaths per year are caused by SIDS (1). It is defined as “the sudden death of an infant less than one year old that cannot be explained after a thorough investigation is conducted, including a complete autopsy, examination of the death scene, and review of the clinical history” (2). While the exact causes of SIDS are still unknown, many studies have linked various characteristics of a baby’s sleep environment to increased risk for SIDS; one of these characteristics is the baby’s sleep position (3).
During the 1970s, the most prevalent sleeping position for babies in the Netherlands changed from supine (back position) to prone (stomach position). Incidentally, the occurrence of SIDS in that country rose considerably afterward and research done over the next ten years linked sleeping position to SIDS. In addition, the credibility of the relation between prone sleep position and SIDS is strengthened by the observation that in countries where prone sleep positioning is rare, SIDS rates have been historically very low (3). Interventions and campaigns were launched around the globe in the early 90s in order to transmit the message that certain sleep positions were safer for babies (4,5).
In 1992, the American Academy of Pediatrics (AAP) published a statement recommending that healthy infants be laid down to sleep in a “nonprone” position – that is, either on their backs or on their sides – in order to reduce the risk of SIDS; the AAP later modified its statement in 1996, emphasizing that the supine position is preferred, although lateral position is an acceptable alternative. In 1994, the National Institute of Child Health and Human Development (NICHD) joined up with the AAP and various other SIDS awareness organizations to launch the Back to Sleep campaign in an attempt to disseminate the message previously issued by the AAP. The campaign focused on educating the public on a national level through a variety of brochures and posters targeted to parents and health care professionals. Campaign literature was sent to newborn nurseries across the country and made available to hospitals, health providers and health educators at no charge. In addition, the AAP and NICHD held press conferences, interviewed on television news shows, produced public service announcements for radio and television, and opened up a nationwide toll-free SIDS information hotline (6).
The campaign has been considered successful: studies found that after the initiation of the Back to Sleep campaign, the frequency of the supine sleeping position had increased and the overall rate of SIDS had decreased. Closer analysis of the SIDS statistics, however, showed a disturbing rate: overall, the occurrence of SIDS was two to three times higher in the black population than the U.S. population as a whole; similarly, prone sleeping was found to be twice as prevalent among black infants (7,3), even after the Back to Sleep campaign was under way (1). In 1996, 43% of African American infants still slept in the prone position, compared to 22% of white infants; the prevalence of back sleep positioning was 17% among African Americans and 37% among Caucasians. These discrepancies imply that the messages from the Back to Sleep campaign had not reached the black population to the extent that they had reached the white population (6,8).
In an attempt to reach the African American population that their campaign failed to impact previously, the NICHD collaborated with the National Black Child Development Institute and other historically black organizations to design a resource kit specifically focused on reducing SIDS among African Americans. The information kit, published in 2001, included modules for conducting community-based training sessions as well as literature – brochures, magnets, door hangers – that was to be distributed to their target audience (8). The most accessible campaign literature has been a brochure entitled “Babies Sleep Safest on their Backs”. This brochure features general SIDS information presented via statistics (“Facts about SIDS”) and a Frequently Asked Questions section and depicts black families smiling and placing their babies on their backs.
Although it is not clear why the SIDS rates differ so greatly between black and white infants, it can be argued that the Back to Sleep campaign has not succeeded in narrowing this disturbing disparity. This paper argues that Back to Sleep has failed as a campaign that properly targets African American parents and caregivers for three reasons. Section II outlines these three campaign flaws. Section III provides suggestions for how the campaign can be improved.
II. A Critique of the Back to Sleep Campaign
This section argues that the Back to Sleep campaign is flawed for three reasons. First, the campaign fails to take into consideration that a parent’s decision to place an infant in a certain sleep position may be greatly influenced by the opinions of the people around him or her; second, the campaign does not present the SIDS prevention mechanisms in a way that is relatable to parents’ main concerns and desires; third, the campaign reinforces skepticism and distrust toward the medical establishment and therefore toward the AAP’s own message.
A. The Back to Sleep Campaign Disregards Social Influence
Before the AAP issued its statement in 1992, doctors had been advising parents and caregivers to place their babies to sleep on their stomachs in order to prevent them from asphyxiating or choking on their vomit (9). Therefore, the social norm before the initiation of the Back to Sleep campaign was to place a baby in the prone position. This new recommendation - to place the baby on his or her back – drastically contradicted what the mother had been told by her own mother. Mothers may learn about back sleeping from the health career professionals in the hospital or through the Back to Sleep campaign brochures, but after a week or so at home (and often influenced by older relatives), many make the decision to place their babies on their stomachs (10). Because the Back to Sleep message is mostly transmitted to mothers through hospitals and health care providers either at the time of delivery or shortly thereafter at a doctor’s appointment, there is a large chance that the campaign’s message will not reach older caregivers and family members (10). By providing information to only parents, the Back to Sleep campaign mistakenly assumes that information given to one individual (out of potentially several who might be affecting the sleep position decision) is enough to change behavior. The majority of these families who place their baby prone do so because they receive a recommendation from another family member, usually a grandmother whose own children were raised as prone sleepers (11,20).
The contradicting messages between the AAP and members within a mother’s social network are further complicated when the Theory of Reasoned Action is applied to the equation. Introduced in 1975 by Martin Fishbein, this theory posits that a person’s behavior depends on his or her attitude toward that behavior and whether or not his or her peers or social network would approve of the behavior, given that the opinion of these peers are important to the individual in question (12). Had the NICHD considered the implications of the Theory of Reasoned Action for its Back to Sleep campaign, it may have predicted that a mother would probably not place her baby in the “supine position” if an older, more experienced family member told her otherwise. Moreover, young parents may feel particularly inexperienced and vulnerable and may be likely to turn to their own parents for help (22). A grandmother would know the infant personally and would be able to give more contextualized advice than a doctor would (10).
B. The Back to Sleep Campaign Fails to Transmit Relatable Messages to the Target Audience
The second flaw in the Back to Sleep campaign is that it fails to transmit its SIDS messages in a way that the target audience finds relatable (10). Rather, the SIDS messages in the “Babies Sleep Safest on Their Backs” brochure are not meaningful or pertinent to the campaign’s target audience and they do not reflect the most relevant and cherished qualities of daily experiences, information and support for childcare (10). Black parents are, of course, concerned about protecting their infants, but generally their concerns involve dangers that they understand, such as choking, suffocation and falling. SIDS, on the other hand, is regarded as something that occurs randomly and hypothetically, and is therefore not among the immediate concerns for many parents (10).
Part of this is due to our general lack of knowledge about SIDS; we have yet to know what causes it and therefore we have yet to fully understand it. Without any proven hypothesis of its etiology, SIDS seems abstract and distant. The Back to Sleep campaign literature only perpetuates this ambiguity by emphasizing how little is known about SIDS and causes it. This vagueness unfortunately has weakened the campaign’s prevention messages: by not framing SIDS or supine sleeping correctly, the brochure virtually has allowed parents to challenge the messages or easily dismiss them, particularly if they directly contradict their current practices (10).
Additionally, the Back to Sleep messages are in complete contrast to parents’ general values when it comes to caring for their child. Parents and caregivers want what works for their baby specifically, while the Back to Sleep message is generalized for all babies (10). Parents and caregivers are focused on immediate concerns, while the campaign is focused on something that cannot be predicted. Most importantly, parents and caregivers honor common sense and personal parenting experiences that have been passed down from older generations (21). The campaign’s message dictates rules and regulations that are much stricter and impersonal (10).
Finally, the Back to Sleep campaign devalues personal knowledge and disregards the role that individual and shared experiences play in caring for a child (10). In doing so, parents may feel that their own knowledge and power as parents have been disregarded by the campaign and therefore may feel threatened by it and choose to ignore it (13).
C. The Back to Sleep Campaign Reinforces Distrust
The third problem with the Back to Sleep campaign is that it targets the African American population so much that it backfires, reinforcing distrust towards the messenger. The “Babies Sleep Safer on Their Backs” pamphlet offers a brief list of statistical facts about SIDS and the frequency of its occurrence. The most striking of these facts is the statement that “African American babies are 2 times more likely to die of SIDS than white babies” (14). Respondents from a focus group conducted in New York City by the Bureau of Maternal, Infant and Reproductive Health stated that they felt singled out by this statement and had interpreted it to mean that researchers had been able to “figure out why white babies are dying but not [why] African American babies [are dying]” (10). By choosing to include this alienating statistic in the brochure without any context or indication as to why SIDS might be occurring at a higher rate among black infants, the NICHD indirectly implies that an African American baby is more susceptible to SIDS just by being born (8). The inclusion of this statistic in this brochure further dissuaded the target audience from taking any of the campaign’s messages seriously (10).
The “racialized” reproachful statistics in the brochure also caused parents to feel that their child-raising methods and habits were being scrutinized and studied and the “book learning”, “formal” instructional presentation of the information led them to feel resentful and defensive (10). When these sentiments combine with the campaign’s unclear messages that contradict common sense and beliefs, parents’ skepticism and distrust toward the source of the information – i.e. the medical establishment – is reinforced (8). Therefore, the “Babies Sleep Safest on their Back” brochure was seen as “yet another example of the medical establishment scrutinizing their community, disregarding their own knowledge or ability, and telling them what to do” (10). The danger here is that a parent’s inability to accept the campaign’s message due to feelings of distrust and resentment leaves him or her with no other choice but to seek out information elsewhere – possibly from family members and friends who may contradict the campaign’s message.
The confusing and critical statistics, the formal language, and the messages that contradict what they have learned from others encourages the target audience to find the brochure’s messages incredible and untrustworthy, reinforcing a distrust of the medical establishment from where the message came (8). By inappropriately over-targeting the African American population, the Back to Sleep campaign unintentionally places blame on the population that it had intended to engage and include in its campaign (10).
III. Proposed Alternatives and Suggestions for the Back to Sleep Campaign
A. The Proposed Intervention
The African American population was not adequately reached by the Back to Sleep campaign, which relied on brochures and media to convey its message. An improved intervention would have to go beyond standard modes of communication and engage the parents and caregivers directly. A study conducted on the effectiveness of delivering a 15-minute educational session to small groups of black parents resulted in a roughly 30% increase in supine sleeping position and an overall increase in awareness about SIDS and the Back to Sleep recommendations (15). This study collaborated with a publicly funded program – in this case, the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) – in order to target a population that was at higher risk than others. WIC is a federally funded program that provides food assistance and nutrition education to pregnant women and their children who are considered at risk for nutritional deficiency because of socioeconomic status. The WIC site involved in the study’s intervention was situated in Washington, D.C. and served predominantly African Americans. The intervention formed part of a program that focused on educating pregnant and lactating women on nutrition and infant safety; the Back to Sleep topics including sleep position, bed sharing and smoke avoidance were incorporated into this information session. Completion of the session was necessary in order to receive food vouchers from WIC (15).
The NICHD could make significant improvements on the Back to Sleep campaign with the addition of a program similar to the one described above: an informal information session for small groups (3-10 people) of new and expectant parents that focuses on the importance of safe sleep position and changing parent behavior. The session would be led by trained health educators who would incorporate the ideas of the Back to Sleep campaign into the discussion; it might also be helpful to include a discussion portion where parents could ask the health educator and each other for advice and tips.
B. Support for the Proposed Intervention
1. Involve Influential Social Networks
One of the major flaws of the Back to Sleep campaign is that it violates the Theory of Reasoned Action by ignoring the possibility that parents may receive advice from family members and friends that clashes directly with the campaign’s message. The campaign goes on the assumption that parents will be more likely to trust the NICHD instead of a family member who is an experienced parent. Therefore, the message needs to be either delivered to parents by someone they can trust or delivered to families and friends – members of the same social network – at the same time. The proposed information sessions would be required for parents to attend and would be open to additional family members or friends who would be caring for the baby. By receiving the information at the same time as other new parents in an informal, open discussion, new parents might feel more comfortable with and open to the information being distributed. By attending an information session and taking matters into her own hands, a young mother might very well feel empowered to use the advice from the health educator and feel comfortable in her decision to place her infant in the safe sleep positioning, rather than heed contradicting advice from a family member or friend.
Another way to target social networks at the same time is to expand the program to various places in the community where networks naturally form. A SIDS Risk Reduction Education Program based in Chicago found that expanding their program – which was similar to the one proposed in this paper – was highly successful. The program was held in church sessions, neighborhood health fairs; health clinics, and schools that focused on pregnant and parenting teens (16). This could be an effective way to address groups simultaneously – for example, family members who attend church together; neighbors; and friends who attend the same school. Conducting the information sessions in these locations also provides for a stronger intervention because the learning happens in a trusted community and results in a more intensive intervention than the Back to Sleep campaign (16).
Finally, as experienced caregivers, older family members feel that they have valuable knowledge to share and many take pride in being a resource to their family and to the community. An information session open to all family members would prevent older caregivers from feeling excluded from caring for an infant. If an older caregiver were going to a session, younger parents might be encouraged to attend as well (10).
2. Reframe Supine Sleeping to Address Parental Concerns
The proposed intervention would use research from focus groups to figure out what parents have expressed as their top concerns for the baby (its safety and comfort) and present supine sleep positioning in a way that correlates with these concerns. For instance, there is a greater risk for asphyxiation when a baby is sleeping prone on a soft surface as a result of rebreathing exhaled gases trapped in bedding (1). Babies placed in the prone position also have reduced ability to lose heat, making them susceptible to hyperthermia (1). Studies have also shown that infants placed in the supine position for sleep have significantly less visits to the doctor for ear infections than infants who sleep in the prone position and that supine sleepers are less likely to have fever, stuffy nose or trouble sleeping (17). While these mechanisms have not proven to be direct causes of SIDS, all are proven to be associated risks with SIDS and all require supine sleep position (17). If parents become familiar with the supine sleeping position as a means to prevent dangers that they are familiar with, they may be more likely to avoid the prone sleep position.
3. Deflect Reactance
The proposed intervention would be conducted in a way that would ensure a non-judgmental, non-blaming and familiar environment for the target audience. According to experiments done on reactance, people feel less threatened by messages coming from similar communicators than messages from dissimilar communicators; the similarity therefore increases the likelihood for compliance (18). New parents would receive a more relevant intervention from an African American local health educator in a community setting, rather than reading a generalized, impersonal brochure in a hospital waiting room. Therefore, parents may be more likely to comply with the AAP recommendations when part of an intervention like the one proposed above.
Another benefit to the proposed intervention is the interactive quality of the information sessions. This would enable participants to be more involved in the learning process and therefore become more accustomed to being in control and making responsible childcare decisions. Participants would also have the opportunity to ask the health educator and each other questions, whereas the Back to Sleep brochures left parents confused and going to other sources for advice. The proposed intervention will embrace the factors from the Psychological Reactance Theory that suggest using similarity to reduce resistance by fostering positive interpretations of the communicator’s actions (18).
IV. Conclusion
While the Back to Sleep campaign has succeeded in reducing the overall SIDS rate greatly since its initiation, the rates of SIDS in the United States still exceed those reported in other countries and the gap between the prevalence of prone sleeping and SIDS among black and white populations continues to be exceptionally alarming (11).
To reduce the racial disparity, all families must be counseled and empowered to choose the safest sleep position for their infants. To best target previously overlooked populations that have fallen in the gap between mortality rates across racial groups, collaboration with other publicly funded programs may be necessary in order to provide the most effective intervention (19).

1. Hauck F. Sleep environment and the risk of sudden infant death syndrome
in an urban population: The Chicago Infant Mortality Study. Pediatrics 2003; 111:1207-1214.
2. Center for Disease Control and Prevention. Sudden infant death
syndrome: United States, 1983 to 1994. Morbidity and Mortality Weekly Report 1996; 45(40):859-863.
3. American Academy of Pediatrics 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(3):650-656.
4. American Academy of Pediatrics Task Force on Infant Sleeping Position
and SIDS. Infant sleep position and SIDS in the United States: joint commentary from the American Academy of Pediatrics and selected agencies of the federal government. Pediatrics 1994; 93:820.
5. American Academy of Pediatrics Task Force on Infant Positioning and
SIDS. Positioning and SIDS. Pediatrics 1992; 89:1120-1126.
6. Malloy MH. Effectively delivering the message on infant sleep position.
JAMA 1998; 280(4):373-374.
7. Moon RY. Nighttime child care: inadequate sudden infant death syndrome
risk factor knowledge, practice and policies. Pediatrics; 111(4):795-799.
8. Hackett M. ‘Babies sleep safest on their backs’: race, resistance, and the
consequences of cultural competency. Submission for American Sociological Association Annual Meeting 2006. [Unpublished].
9. Malloy MH. Trends in postneonatal aspiration deaths and reclassification
of sudden infant death syndrome: impact of the Back to Sleep program. Pediatrics 2002; 109:661-665.
10. Bureau of Maternal, Infant, and Reproductive Health. Beliefs and
Practices regarding sudden infant death syndrome: risk reduction among African American mothers, fathers, and caregivers in New York City. Summary of SIDS Focus Groups 2004.
11. Gibson E. Infant sleep position practices two years into the Back to Sleep
campaign. Clinical Pediatrics 2000; 39(5):285-289.
12. Edberg M. Individual health behavior theories (pp.129-143). In: Edberg M,
ed. Essentials of Heath Behavior. Sudbury, MA: Jones and Bartlett Publishers, 2007.
13. Thomas L. A critical feminist perspective of the Health Belief Model:
implications for nursing theory, research, practice and education. Journal of Professional Nursing 1995; 11(4):246-252.
14. National Institute of Child Health and Human Development. Babies sleep
safest on their backs. National Institute of Child Health and Human Development, 2002.
15. Moon RY. Back to Sleep: an educational intervention with women, infants,
and children program clients. Pediatrics 2004; 113:542-547.
16. Rasinski KA. Effect of a sudden infant death syndrome risk reduction
Education program on risk factor compliance and information sources in primarily black urban communities. Pediatrics 2003; 111(4):e347-e354.
17. Daley KC. Update on sudden infant death syndrome. Current Opinion in
Pediatrics 2004; 16:227-232.
18. Silvia PJ. Deflecting reactance: the role of similarity in increasing
compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27(3):277-284.
19. Pickett KE. Widening social inequalities in risk for sudden infant death
syndrome. American Journal of Public Health 2005; 95(11):1976-1981.
20. Brenner RA. Prevalence and predictors of the prone sleep position among
inner-city infants. JAMA 1998; 280(4):341-346.
21. Hauck F. The contribution of prone sleeping position to the racial disparity
in sudden infant death syndrome: the Chicago Infant Mortality Study. Pediatrics 2002; 110(4):772-780.
22. Willinger M. Factors associated with caregivers’ choice of infant sleep
position, 1994-1998: the National Infant Sleep Position Study. JAMA
2000; 283(16):2135-2142)



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