Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Monday, December 10, 2007

The Failure Of The Back-to-Sleep Campaign: A Stagnant and Inappropriate Approach Leaves African American Infants At Risk for SIDS - Erica Tobey

Sudden Infant Death Syndrome (SIDS) is defined as “the sudden death of an infant under 1 year of age, which remains unexplained after thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history”(1). The mechanism of SIDS is not fully understood, although a number of risk factors and means of reducing SIDS risk have been identified (1). In the early 1990s, a growing body of international research evidence pointed to the prone (stomach) sleep position for infant sleep as conferring increased risk for SIDS death (2). In 1992, the American Academy of Pediatrics (AAP) issued a Policy Statement naming non-prone sleep positions (side and supine) as the safest positions for infant sleep (2). As further research emerged, the AAP amended its recommendations to include the exclusive use of the supine position for infant sleep in 2000 (3). In 2005, a report identified additional risk factors for SIDS in the infant sleep environment including bedsharing and the use of soft bedding and advocated their elimination to ensure the safest infant sleep environment possible (1).

Based heavily on the Health Belief Model and implemented through a Social Marketing Campaign, the Back to Sleep campaign aims to provide child caregivers with the information necessary to reduce the risk of SIDS are much as possible for American infants. The campaign was launched in 1994 to widely disseminate the message that prone sleeping was unsafe for infants to physicians, nurses and parents and has evolved as the AAP recommendations have shifted (1,4-7). The Back to Sleep campaign spread its message through a multi-pronged social marketing campaign. The message was spread through television, radio and print public service announcements, print advertising, informational brochures and posters, educational videos, and intense media outreach and coverage (4-7). Since the campaign’s inception, 80 million brochures and other materials have been publicly distributed and are currently available through the National Institute of Child Health and Human Development’s website (4,7). These materials are still widely distributed to requesting physicians, hospital nurseries and other health professionals. In the 13 years since the programs inception, the Campaign has partnered with Pampers and Gerber to further distribute the Back to Sleep message (5, 8, 9). In addition to the message that infants are safest when sleeping in the supine position, the Campaign also stresses nine additional steps parents and caregivers should take to reduce the risk of SIDS including using an approved sleep surface and avoiding bedsharing (10).

In the years since the AAP first discouraged prone sleeping and the Back to Sleep Campaign was launched, the overall rates of SIDS deaths in the United States have shown remarkable reductions of approximately 50% (11). At the same time, the overall rates of prone sleeping have decreased by 58% while the rates of supine sleeping have increased by 63% (12). These data suggest that the Back to Sleep message has been widely disseminated and accepted and that a direct reduction in the number of infants dying of SIDS has resulted. In fact, the Back to Sleep Campaign has been widely touted as an incredible success of Public Health interventions to directly result in behavioral changes that have greatly improved the health of the public. These data mask the overall racial disparity in SIDS deaths between African American and white infants.

In 2001, African American infants had an increased risk of death from SIDS 80% greater than their white counterparts (13). In 2006, 21.9% of African American mothers reported use of the prone position for infant sleep, compared to 12% of white mothers (12). These statistics do not reflect an entirely successful intervention in the African American community despite attempts to address these disparities. Targeting of the African American community through culturally specific educational materials has been misguided and inadequate and has left this high risk group at increased risk. The Back to Sleep campaign fails African American infants because of its strict adherence to a social marketing approach based on the Health Belief Model, its failure to consider economic and cultural barriers to adopting the supine sleep position in African American communities, and a disregard for the role of self-efficacy in the adoption of safe sleeping practices for African American infants.

The Back to Sleep campaign and the Health Belief Model

The failure of the Back to Sleep campaign to broadly influence infant sleep choices in African American populations is a direct result of its basis on the Health Belief Model (HBM). The HBM aims to change individual’s health behaviors by appealing to their rational natures. It presumes that healthy behaviors are adopted when an individual’s perceived susceptibility and severity of a health outcome are weighed against the perceived benefits of and barriers to adopting the healthy behavior (14-16). The Back to Sleep campaign assumes that all caregivers will understand the susceptibility of their infant to SIDS, will recognize the severity of sudden and unexplained infant death, and will adopt the supine position for infant sleep, along with the other safe sleep recommendations, because the benefits are great and the barriers to adoption are minimal. From the campaign’s perspective, the Back to Sleep message itself provides the information needed to undertake this cost-benefit analysis and may also act as a triggering event which the HBM postulates may be necessary to instigate behavior change (17). The decision making process as presented by the HBM is not always an accurate reflection of reality; simply being exposed to the Back to Sleep message does not unilaterally translate into supine sleep position adoption. Caregivers may underestimate their infant’s susceptibility to SIDS or the barriers to adopting safe sleep practices may be insurmountable. Even in instances of targeted educational interventions, where parents and other caregivers are exposed to the Back to Sleep message, the rates of supine sleep position choice are not 100% after intervention, and caregivers often change infant sleep position as infants age (18-22). This indicates a health behavior choice pathway that differs from that proposed by the HBM. If the HBM were universally true, once caregivers adopted the supine sleep position, the cost-benefit analysis of behavior adoption would have determined the superiority of supine positioning and a rational individual would not change sleep position. Since this is not the case, the Back to Sleep campaign should consider other methods for changing sleep position behavior.

The Back to Sleep campaign fails to incorporate the concept of modeling as a means of influencing health behaviors because of its basis on the Health Belief Model. The importance of modeling is emphasized by Social Learning Theory which incorporates the concept of Observational Learning or learning how to behave by observing the behaviors of others (23). This concept of observational learning is a powerful tool in behavior change, and modeling of healthy behaviors may be a key component of an interventions success (23, 24). With regards to infant sleep position choice, modeling has been shown to have a substantial impact on healthy sleep position adoption (18). When safe infant sleep practices were adopted for all infants in an inner-city nursery, 33% more parents reporting using the supine position for sleep (18). Furthermore, when parents did not observe supine sleep in the nursery, they were less likely to choose the supine sleep position at home, and those observing the prone sleep position overwhelmingly reported intention to use this position (25, 26). Research shows that African American mothers receive recommendations for supine sleep less frequently than their white counterparts and do not always observe the supine position in nurseries (25, 27). Given the importance of modeling in behavior change, and the disproportionate modeling of safe sleep practices to African American caregivers, the Back to Sleep campaign fails to reach these at risk caregivers when it fails to incorporate modeling into its interventions.

Economic Barriers to Safe Sleep Recommendations

The Back to Sleep campaign also fails to recognize the economic and social barriers to adopting safe infant sleep positions and environments for many African American mothers and infants. Obtaining the correct equipment to establish the sleep environment advocated by the Back to Sleep campaign can be very expensive for families of low Socio-Economic Status (SES). Non-Hispanic whites, for whom the Back to Sleep message has been most effective in changing infant sleep position choices, experience poverty far less frequently than African Americans. In 2006, 3 times as many African Americans were living in poverty as Non-Hispanic whites (28). Additionally, the average monthly program participation rates for public assistance were 3.5 times higher for African Americans compared to whites (29). These data make clear that the economic realities of most Non-Hispanic white mothers do not mirror those of African American mothers. The Back to Sleep campaign’s failure to recognize the social and economic differences of target populations receiving the campaigns’ message, and to address those differences in meaningful ways, have contributed to the campaigns failure for African American infants.

Preparing an infant sleep area that meets Back to Sleep guidelines requires procuring a number of costly items, such as a crib and firm mattress (30). In November 2007, the average cost of equipment meeting Back to Sleep guidelines was $192 (31, 32). This represents nearly 75% of the monthly income of an African American woman receiving government benefits, without consideration for housing, food, utilities or other expenses (29). Unsafe sleep practices such as bed sharing with other children, bed sharing with mothers or sleeping on non-approved surfaces such as couches may result out of financial necessity. The lack of availability of a safe crib lead to increased bed sharing in a study of low SES African American mothers and infants (33). When safe cribs were provided for families lacking access, these cribs were used for infant sleep suggesting that when economic barriers to adopting the Back to Sleep message are removed, mothers who would not otherwise be able to comply can and will adopt safe infant sleep practices (33).

In the late 1990s, the Back to Sleep campaign partnered with Gerber and Pampers to bring the message of safe infant sleep directly into the homes of infants with these popular products (8, 9). Both Gerber and Pampers offer brand name products at prices that exceed those of their generic counterparts (34, 35). For a woman of low SES, many of whom are African American, trying to save money by comparison shopping for the least expensive baby food and disposable diapers available is a logical step. Indeed, spending patterns relate to poverty status with the poor spending less on food at home than those categorized as not poor (36). By failing to partner with consumer product companies that span the price gamut, caregivers of low SES are far more likely to miss out on receiving the Back to Sleep message.

African American children and infants are disproportionately underexposed to the Back to Sleep message because of economic factors in childcare settings. When SIDS death rates in childcare settings were found to far exceed expected rates, the Back to Sleep campaign implemented a targeted intervention to change sleep practices through education in licensed childcare centers and SIDS rates decreased (37, 38). While this targeted intervention effectively brought the message of safe infant sleep practices to the child care community, African American infants were again at higher risk because of financial factors. U.S. Census data indicate that African American children received care in arrangements other than parental care or center-based care 3.8% more frequently than Non-Hispanic Whites in 2005 (39). Often families of low SES utilize unlicensed or relative care out of financial necessity and these arrangements are not reached by increased Back to Sleep efforts in childcare settings (38).

Self Efficacy and the Back to Sleep Campaign

Self-efficacy is the belief a person has that they can execute a certain activity and is an vital determinant of health behavior change (15, 23). The Back to Sleep campaign has not considered the self-efficacy of African American providers in adopting healthy infant sleep positions. The Back to Sleep messages is no longer as simple as putting infants in the supine position for sleep. Campaign materials present 7 recommendations for healthy infant sleep in addition to 7 components of a healthy infant sleep environment and there is great emphasis that all requirements be met for all infant sleep episodes in order to reduce the risk of SIDS (30, 40). Evidence shows that stressful events in the postpartum period can diminish a mothers’ belief in her efficacy to care for her infant and that low SES African American mothers encounter a number of stressors which negatively impact their children’s health (41, 42). New mothers in high risk groups with many additional stressors may find the 14 overall campaign recommendations for every sleep daunting and have little self confidence that they can achieve them. If a new mother does not believe that she can meet all recommendations for each sleep episode, she may not use the supine sleep position at all, because she feels she is destined to fail providing an adequately safe environment. By inundating mothers with a multitude of recommendations for safe infant sleep, the message of supine sleep as the key risk reducer for SIDS is lost and the Back to Sleep campaign fails to affect sleep position choice in these populations.

In addition to unwieldy recommendations, the Back to Sleep campaign also uses an “all or nothing” approach that can reduce the self-efficacy of mothers and caregivers. The campaign pamphlet specifically targeted at African American outreach reads, “Always put your baby on his or her Back to Sleep, even for naps. Make sure everyone who cares for your baby knows to place your baby on his or her back to sleep and about the dangers of soft bedding” (40). There is also great emphasis placed on the fact that “every sleep time counts” (40). In reality, mothers cannot guarantee that their infant will be placed in a safe sleep position every time they are put down for sleep, particularly when other caregivers are involved. By insisting that in order to make their babies safe mothers must perform an impossible task, the self-efficacy of those mothers is reduced and they will be less able and willing to subscribe to healthy sleep practices (23).

Research indicates that, even when mothers begin using the supine position for sleep, they do not necessarily use it throughout the highest risk antenatal periods and often cite infant comfort and better sleeping in the prone position as their motivation for change (19, 21, 22). For these caregivers, factors associated with infant care are clearly to blame. For parents, infancy can be a time of very low self-efficacy for following the Back to Sleep recommendations, because of their demanding nature. This is particularly true for low SES African American mothers for whom chronic stressors, such as residence in unsafe neighborhoods, can lead to negative health behaviors (42). During infancy, maternal self efficacy is the single most important determinant of parenting behavior (43). When placed into stressful situations, those with a low level of self-efficacy abandon healthy behaviors more readily (41). For low SES African American mothers, the combination of chronic stressors brought on by poverty and the stringent requirements of the Back to Sleep campaign diminishes their self-efficacy and leads to unsafe infant sleep positions after initially using a safe position, or not attempting the safe sleep recommendations at all.

The Back to Sleep campaign fails to recognize that feelings of powerlessness in controlling health behaviors may keep African American mothers from adhering to the campaigns messages for safe infant sleep. The locus of control theory is derived from Social Learning theory and refers to an individuals belief that they have control over their life events or if these events are beyond their control (44). Research indicates that individuals of lower SES tend to feel like they have less control over their health compared to higher SES individuals (45, 46). African American mothers are thus more likely to feel powerless over their own health behaviors and those relating to their children. For these women, the messages of the Back to Sleep campaign may further isolate rather than empower. The voice of the campaign is overwhelmingly paternalistic and authoritative. It requires women who may feel they have no control over their lives to control every aspect of their infants sleep environment. For women that feel powerless, the campaigns’ messages further undermine their self-efficacy and do not empower them to adopt healthy sleep behaviors.

A Path for the Future

It is clear from the marked reduction in overall SIDS rates since the inception of the Back to Sleep campaign that the campaign messages for safe infant sleep practices and positioning are truly making a difference. The unfortunate shortcomings of the campaign for African American infants, however, can no longer be ignored. Improvements to the Back to Sleep campaign need not be complicated or impossible to implement, they simply need to incorporate health behavior change models that move beyond the Health Belief Model, recognize and find ways around economic barriers to adopting the campaigns messages, and preserve African American mothers self-efficacy and empower them to change. Interventions that incorporate modeling in the nurseries of hospitals serving predominantly low SES African American populations will address the persistence of prone sleeping from a new angle. A program which assists low SES mothers with the means to purchase all of the equipment necessary for a safe sleep environment will also serve this end, as will partnering with product manufacturers that low SES mothers are more likely to encounter on a regular basis. Finally, the Back to Sleep message must be streamlined into small, concrete steps for mothers at high risk for low self-efficacy because of poverty and other chronic life stressors. By focusing the message to these women on using the supine position for every sleep, the greatest risk factor for SIDS will be addressed and these mothers will gain the self-efficacy to work towards attaining the other suggestions of the campaign, motivated by their own success.


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  • At December 11, 2007 at 9:38 AM , Anonymous Meg Gavaghan said...

    Great paper, Erica! I thought your evidence to support the expense of creating an appropriate sleep environment for infants was especially important in your arguments. -- Meg

  • At December 12, 2012 at 2:49 AM , Anonymous Anonymous said...

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