Objective To investigate factors influencing African-American parents’ knowledge, attitudes and practice regarding infant sleep position and determine if these differ by socioeconomic status (SES).
Methods A cross-sectional sample of 412 parents with infants ≤6 months of age participated in a validated survey of knowledge, attitudes and practice.
Results There was no significant difference in attitudes or practice, and knowledge was similar regarding infant sleep position between African-American parents of higher and lower SES. The healthcare provider recommendation of exclusive supine sleep position use was associated with increased knowledge, overall decreased use of the side position (5.0% vs 16.8%, p<0.01) and increased occasional use of the supine position in the lower SES group (81.6% vs 68.6%, p=0.03). It was not associated with increased positive parental attitudes about the supine sleep position in either group. Neither a senior caregiver living in the home nor observation of hospital personnel placing infants in a non-supine position was associated with differences in sleep position practices in either group.
Conclusions Sleep position practices in African-American families do not differ by SES. Improved attitudes toward positioning and increased use of supine positioning may result if healthcare providers address common concerns and misconceptions about sleep position.
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The incidence of sudden infant death syndrome (SIDS) in the USA has declined by 50% since 1992 when the American Academy of Pediatrics (AAP) first recommended that infants be placed in a non-prone position for sleep.1 Despite the demonstrated success of the Back to Sleep campaign, African-American infants continue to be twice as likely to be placed prone for sleep2–12 and also twice as likely to die from SIDS as white infants.13 This racial disparity exists across all educational and income categories.2 ,6 ,14–16
Epidemiological studies have demonstrated the prone sleep position to be a major risk factor for SIDS. Studies have consistently demonstrated an increased rate of prone positioning in African-American infants2–12 and have also demonstrated a socioeconomic status (SES)-associated variability in SIDS and prone sleeping within the African-American community, with lower rates of both SIDS13 ,17 ,18 and prone positioning3 ,14 ,15 in families of higher SES.3 However, no studies have examined factors within the African-American community that may vary by SES. By examining within-group differences, it may be possible to move beyond comparative racial descriptions (ie, comparisons of white and African-American subjects) to identify potentially modifiable factors that might respond to culturally acceptable interventions within a disadvantaged group. Therefore, the primary aim of this study was to better understand factors contributing to the comparatively high incidence of prone sleep positioning in African-American infants and how these factors may vary by SES. We hypothesised that African-American parents of higher SES would have significantly more knowledge and more positive attitudes about the supine sleep position, and would be significantly more likely to use the supine sleep position for their infants than lower SES African-American parents. We also hypothesised that parental practice with regards to infant sleep position would be affected by healthcare provider recommendation, the presence of a senior caregiver in the home and observation of hospital personnel placing infants in the prone position.
We enrolled a cross-sectional sample of African-American parents with infants ≤6 months of age recruited from primary care paediatric clinics and private practices in Washington, DC and suburban Maryland. Parents who were over 18 years of age and a custodial parent of an infant ≤6 months old were eligible to participate if they self-identified as African-American and had parents born in the USA. This criterion was used to reduce cultural heterogeneity. An otherwise eligible parent was excluded if s/he was not a custodial parent of the infant, was unable to complete the survey in English, the infant had a chronic illness that would preclude use of the supine sleep position (eg, recent spinal surgery) or the infant was born at <36 weeks gestation (because these infants are frequently placed prone in the neonatal intensive care unit). This study was approved by the institutional review boards at Children's National Medical Center, Washington Hospital Center and Holy Cross Hospital.
We intentionally recruited parents of both lower and higher SES. SES was determined by parental educational attainment and eligibility for Medicaid and WIC (The Special Supplemental Nutrition Program for Women, Infants and Children), as previously described.19 The latter two were used as proxies for family income as they are easily verifiable and do not rely upon self-report; none of the higher SES families were eligible for WIC or Medicaid.
After written informed consent was obtained, qualified and interested parents participated in a 15 min, staff-administered survey that asked about their knowledge, attitudes and practices regarding infant care and sleep environment, and family demographics. This survey has been validated with parents in the target audience by the authors and has been used in previous studies.20 ,21
Optimal sample size was determined by assuming a 40% rate of prone positioning in the higher SES group and a 15% difference in prone positioning between lower and higher SES groups. On the basis of this assumption, an α value of 0.10 and a β level of 0.80, it was determined that a sample of size of 136 in each group was required. Parents were recruited for both groups until we had an adequate sample of both groups.
Descriptive statistics for the study group, including frequencies and percentages for categorical variables and means and SDs for continuous variables, were calculated. Because previous reports have cited these as being potentially related to the parental decision about sleep position, SES,13 healthcare provider recommendation of exclusive supine sleep position use,5 ,22 presence of a senior caregiver in the home14 ,21 and observation of the infant having been placed prone in the birth hospital14 were selected as potential predictor variables. Univariate and multivariate analyses, using the χ2 test, were used to assess whether sleep position was associated with the predictor variables. Test levels for significance were p values <0.05. All analyses were conducted with STATA/SE software V.9 (Stata, College Station, Texas, USA).
Between April 2006 and May 2010, a total of 412 parents participated in the survey; 264 were of lower SES and 148 were of higher SES. Mean parental age was 26.8 years (range 18–48), mean infant age was 9 weeks and median infant age was 7 weeks (IQR 4–12 weeks). The mean, median and IQR for infant age were similar between the higher and lower SES groups. Table 1 summarises the characteristics of the study participants. Higher SES parents were older (p<0.01), more likely to be married (p<0.01) and more likely to have a college or postgraduate degree (p<0.01). Overall, 62.9%, 8.5% and 9.5% of parents exclusively used the supine, side and prone positions for infant sleep, respectively; the remaining 19.1% did not place their infant consistently in one position. There was no significant difference between African-American parents of higher SES and lower SES in the use of the supine, side and prone positions, both exclusively and occasionally. Additionally, there were no differences in the use of any sleep positions, both exclusively and occasionally, when African-American parents with a college degree were compared with those who had a high school diploma or who did not complete high school.
Potential differences between the two groups in knowledge and attitudes about SIDS and infant sleep position were assessed (table 2). Parents with higher SES were significantly more likely to report that they knew what SIDS was (94.6% vs 86.0%, p=0.01). However, there was no significant difference between higher and lower SES groups in identifying the supine sleep position as the recommended sleep position for infants (83.1% vs 79.5%, p=0.38), in the belief that prone sleeping definitely or possibly places babies at an increased risk of dying from SIDS (61.2% vs 60.6%, p=0.86), or in identifying that the supine sleep position is the best way, in the parent's own opinion, to place a baby to sleep (62.8% to 54.2%, p=0.09).
The impact of an exclusive supine sleep position recommendation from a healthcare provider was assessed. Compared to those who had not, parents who had received an exclusive supine sleep position recommendation were more likely to demonstrate increased knowledge; they were more likely to state that they knew what SIDS was, believe that the prone sleep position increases the risk of SIDS and identify the supine sleep position as the position recommended by the AAP (table 3). However, an exclusive supine recommendation from a healthcare provider was not associated with increased positive parental attitudes about the supine sleep position. There was no overall difference in the identification of supine, side or prone sleep position by parents as the position they believed to be best, regardless of healthcare provider recommendation. Within the lower SES group, parents who had received an exclusive supine sleep recommendation were significantly more likely than those who had not to identify the prone position as the infant sleep position that they believed to be best (11.4% vs 1.4%, p=0.01). Paradoxically, healthcare provider recommendation was associated with differences in parental practice. Lower SES parents who had received an exclusive supine sleep position recommendation from a healthcare provider were less likely to use the side sleep position for their infant, both exclusively (4.9% vs 20.0%, p<0.01) and occasionally (19.5% vs 32.9%, p=0.02), and more likely to use the supine sleep position occasionally (81.6% vs 68.6%, p=0.03) than parents who had not (table 4). If they received an exclusive supine recommendation from a healthcare provider, African-American parents were less likely to use the side sleep position for their infant, both exclusively (5.0% vs 16.8%, p<0.01) and occasionally (19.7% vs 31.0%, p=0.02), and there was a general trend, although not statistically significant, towards increased use of the supine sleep position, both exclusively and occasionally. However, healthcare provider recommendation was not associated with any difference in infant sleep position in higher SES families, and no difference was found in any group in the rates of prone sleeping based on healthcare provider recommendation. Finally, neither the presence of a senior caregiver in the home (table 5) nor parents having observed their infants being placed prone while in the hospital (table 6) had a statistically significant association with sleep position among either SES group or African-American families as a whole.
In contrast to earlier studies3 ,14 ,15 that have suggested an SES-associated variability in sleep position within the African-American community, we did not find any difference in the rates of supine, side or prone sleep position use between African-American parents of higher and lower SES. This was observed despite significant differences between the two groups in parental age, educational level and marital status, factors which previously have been associated with increased rates of prone sleeping.3 ,8 ,15 ,23 ,24
It is unclear why our results are different from those of previous studies. However, our findings were confirmed in that there was no difference in sleep position use between African-American parents with a college degree and those with a high school diploma or who did not graduate from high school. It is possible that the similar, relatively high, knowledge levels regarding recommended sleep practices between the two SES groups account for the lack of difference observed in sleep position practice. However, it should be noted that, despite approximately 80% of all parents stating that the supine position was recommended, only approximately 60% of parents believed that the prone position increased SIDS risk or had the opinion that the supine position was the best sleep position for the infant. This suggests that improved knowledge about infant sleep position recommendations does not translate to increased positive attitudes about the supine sleep position. Previous studies have found that parents and other caregivers have misgivings about the supine position for infants, primarily due to concern that there is a higher likelihood of aspiration when supine25–29 and the perception that the infant does not sleep as well when supine.10 ,21 ,29–34 Recently, there has been a plateau in the use of supine positioning among all racial/ethnic groups in the USA,35 and this may be because parents perceive the benefits of not using the supine position as outweighing the risk of SIDS.
Of the predictor variables examined, only healthcare provider recommendation of exclusive supine sleep position use was associated with differences in sleep position. Lower SES parents who received an exclusive supine recommendation were more likely to occasionally use the supine position and less likely to use the side position, either occasionally or exclusively. Receiving an exclusive supine recommendation from a healthcare provider was not associated with a difference in prone positioning. This suggests that, among lower SES parents, a supine recommendation may convince the parent who might otherwise use the side position to change to the supine position. However, the parents of infants at highest risk of SIDS, those who use the prone sleep position, may be less open to influence by their paediatrician.
We found that, while an exclusive supine sleep recommendation by healthcare providers was associated with generally higher knowledge about SIDS and recommended sleep position, it was not associated with increased parental identification of the supine sleep position as best. In fact, within the lower SES group, parents who received an exclusive supine recommendation were more likely to identify prone position as the one that they believed to be best. This suggests that the current strategy of providing a brochure or just stating the supine recommendation is not sufficient to influence parental attitudes and practices regarding prone positioning. Healthcare providers need to be aware of the common concerns and misperceptions, particularly about aspiration and infant comfort,10 ,21 ,25–34 that impact on parental decisions about how they place their infant for sleep so that these concerns and misperceptions can be addressed.
Parents may also seek input about infant sleep position from multiple sources, including senior caregivers and hospital personnel. Although our study demonstrated that neither the presence of a senior caregiver living in the home nor observation of hospital personnel placing infants in a non-supine position was associated with differences in sleep position practices, studies have demonstrated that consistent messaging about infant sleep position is associated with improved adherence36 and that inconsistent messages may result in the parent deciding that sleep position is not very important.19
This study has the limitations inherent in parental reporting. The surveys were administered by research staff who were not healthcare providers. Nonetheless, we acknowledge that some parents may not have been entirely forthcoming in their responses. Parents may have been reluctant to admit to prone positioning, thus leading us to underestimate the incidence of prone sleeping. Furthermore, while our study population included parents representing the spectrum of sleep position practices, it was limited to African-American parents in the Washington DC area. Therefore, these results may not be generalisable to other groups or localities. However, the rates that we report are similar to those from national surveys on infant sleep positioning.35 In addition, since the percentage of parents reporting using the prone position was lower than what we had estimated in our sample size calculations, some of the analyses may have been underpowered. Our analyses of the presence of senior caregivers in the home and observation of the use of prone positioning in the hospital, as well as our subgroup analyses, may also have been underpowered as at least one group in these analyses did not reach the 136 calculated as necessary to detect a 15% difference in sleep position use. In particular, the lack of an association between parental observation of hospital personnel placing infants in a non-supine position and sleep position practices found in our study may have been due to the relatively low number of parents having observed hospital personnel placing infants in a non-supine position, likely due to our exclusion of infants born at <36 weeks gestational age.
Sleep position practices among African-American parents do not differ by SES. Only healthcare provider recommendation of exclusive supine sleep position use was associated with differences in sleep position practices, with a lower rate of side sleep position use by African-American parents as a whole and an increased rate of occasional supine sleep position use among lower SES parents. Neither the presence of a senior caregiver living in the home nor observation of hospital personnel placing infants in a non-supine position was associated with differences in sleep position practices. While an exclusive supine sleep recommendation from a healthcare provider was associated with increased knowledge levels, it was not associated with increased positive parental attitudes about the supine sleep position. Thus, it appears that there are significant limitations on the effects of healthcare provider advice on sleep practices and attitudes toward positioning. Improved attitudes toward positioning and increased use of supine positioning may result if healthcare providers address common concerns and misconceptions about sleep position.
What is already known on this topic
There is a black–white racial disparity in sudden infant death syndrome across all economic and educational levels. African-Americans have the higher SIDS rate.
African-Americans are twice as likely to place their infants in the prone position for sleep.
What this study adds
There is no difference in infant sleep position practice by socio-economic status in African-Americans.
Healthcare provider recommendation of exclusive supine sleep position use is associated with lower risk infant sleep position practice by lower socio-economic status African-Americans.
We would like to thank Rosalind Oden, Brandi Joyner and Taiwo Ajao for data collection and management.
Contributors DR cleaned and analysed the data, and drafted and revised the paper. RM initiated the project, designed data collection tools, implemented the study, monitored data collection for the entire study, wrote the statistical analysis plan and revised the draft paper. RM had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. She is the guarantor.
Funding We received funding for this project from NIH grants K24RR23681-01A1 and MD000165-03 and AHRQ grant 1RO3HS016892-01A1. The funding was used for design and conduct of the study; collection, management, analysis and interpretation of the data; and manuscript preparation.
Competing interest None.
Ethics approval This study was approved by the institutional review boards at Children's National Medical Center, Medstar and Holy Cross Hospital.
Provenance and peer review Not commissioned; externally peer reviewed.
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