An inner-city school-based program to promote early awareness of risk factors for sudden infant death syndrome
Article Outline
Abstract
Adolescent, nonwhite women with less than high school education have infants at higher risk for Sudden Infant Death Syndrome (SIDS) but face barriers to risk reduction education. We implemented a novel school-based health education program (grades 4 to 12) and found an association between exposure and awareness of risk factors.
Keywords: Sudden Infant Death Syndrome (SIDS) , Adolescent smoking , Black infant mortality , SIDS risk reduction , Health disparities
SIDS rates have declined 54% to 0.56 deaths per 1000 live births in 2001 [1] from 1.2 deaths per 1000 live births in 1992 [2], paralleling decreases in nonsupine infant sleep and maternal prenatal smoking, two major risk factors [3], [4]. Yet, SIDS remains the leading cause of postneonatal infant mortality, disproportionately for infants of nonwhite mothers who are younger (< 20 years) and less educated (< 12th grade) [4]. And the racial disparity is growing [1], [2].
A higher prevalence of nonsupine sleep in black infants is thought to contribute to racial disparity [3], [5] and may be associated with problems in the availability, accuracy, source, and methodologies of risk-reduction education [3], [6]. However, even with effective interventions, barriers exist. Prematurity, more prevalent in Blacks [7], and less prenatal care limit access to prenatal education. Grandparents assisting young mothers have even less access to risk-reduction information [8].
Low smoking rates among black students [9] and adult black females [10] might suggest that this health risk is not relevant. However, in the 1990s, the prevalence of tobacco use rose by 80% in black adolescents, compared with 28% in white adolescents [11]. For black female students, this trend continued throughout the decade [12]. Moreover, black male adults, a potential source of passive exposure, have one of the highest smoking rates [11]. Finally, the physiological impact of nicotine tends to be greater among blacks [13], and a larger proportion of black infants sleep in adult beds [5], exacerbating the hazards of parental smoking.
In light of these risks and barriers, we piloted a new venue for reaching the highest risk groups, a school-based health education program. We hypothesized that such a program would be associated with higher knowledge levels.
Methods
An interactive, culturally and developmentally sensitive health education program conducted through school, community, and classroom activities addressed health risks of smoke exposure and nonsupine infant sleep. The inner-city students (80% black, 20% Latino) were in a New Jersey county with the highest rate of postneonatal infant mortality. We compared anonymous assessments of students (grades 4 through 12) exposed to the program (n = 452; 33% of the student body) with those from a cross-section of students from the same grades and schools taken before its onset (n = 358; 26% of students).
Baseline knowledge was assessed from April to December of 1999, school and community activities initiated in 2000, and classroom interventions held from January to May 2001. Outcome evaluations were obtained 2 to 3 weeks after the classroom intervention.
Students were also compared with a convenience cohort of 65 baseline parents who attended orientations held before the program’s onset and completed anonymous assessments. The Institutional Review Board of Saint Peter’s University Hospital approved this study as meeting the standards for exempt status.
Classroom activities included designing posters and completing exercises to resist pressure to smoke [14]. Families participated in community fairs, bilingual presentations, and student poster contests. Culturally relevant teaching tools included African-American and Latino dolls and puppets and a coloring and activity book with racially diverse characters. The SIDS Center of New Jersey operates under a grant from the New Jersey Department of Health and Senior Services with an educational mandate to promote healthy outcomes.
Students indicated if smoking was unhealthy or increased the risk of heart disease, stroke and/or cancer, if smoke exposure of a baby or a woman who was going to have a baby elevated the risk of SIDS, and if back, side, or stomach sleep had the lowest risk. No demographic data was obtained.
Owing to design constraints, students’ baseline and posteducation evaluations were not matched for a repeated measures analysis. For each query, answer status (risk identified vs. not identified) by group (pre-education parent, pre-education student, and posteducation student) was analyzed by the Pearson Chi-square test. The alpha level was 0.05.
Results
Of the 358 baseline and 452 posteducation students, 147 (41%) and 167 (37%), respectively, were from high school.
Table 1 and Figure 1 compare baseline students, posteducation students, and baseline parents. Posteducation students were most likely to code smoking as a risk for heart disease (p < .001) and stroke (p < .01), identify infant but not prenatal smoke exposure as a risk for SIDS (p < .01), and identify supine sleep as carrying the lowest SIDS risk. Preference for supine infant sleep by posteducation compared with baseline students occurred in all grades (4th: 62% vs. 15%; 5th: 81% vs. 25%; 6th 74% vs. 38%; 7th: 63% vs. 9%; 8th and 9th: 93% vs. 23%; 10th to 12th: 78% vs. 25%), p < .001.
Table 1. Baseline student, baseline parent and education group student ability to identify risks associated with smoking
| Rating smoking as a risk for: | Baseline Student (%) | Baseline parent (%) | Education Group Student (%) | X2 (df = 2) | p Value |
|---|---|---|---|---|---|
| Health | 343/358 (96) | 62/65(95) | 427/447(96) | 0.05 | |
| Heart disease | 218/354(62) | 41/65(63) | 331/450(74) | 13.78 | <0.001 |
| Cancer | 328/354(93) | 65/65(100) | 407/450(90) | 7.38 | <0.05 |
| Stroke | 201/354(57) | 40/65(62) | 308/450(68) | 11.67 | <0.01 |
| SIDS⁎ when exposed in pregnancy | 213/353(60) | 33/63(52) | 271/443(62) | 1.79 | |
| SIDS⁎ when exposed in infancy | 177/355(50) | 25/63(40) | 265/437(61) | 11.73 | <0.01 |
⁎ Sudden Infant Death Syndrome. |
Fig. 1.
Optimal infant sleep position selected by baseline students and parents and postintervention students to reduce the risk of SIDS.
To determine if passage of time, independent of intervention, was associated with a knowledge increment, we compared baseline evaluations from a group of 8th and 9th grade students assessed 8 months apart. No differences were noted in knowledge of supine placement (p = .69) or infant smoke exposure (p = .57).
Discussion
Students receiving a school-based health education program demonstrated more awareness of health risks related to SIDS compared with a cross-section of students from the same grades and schools evaluated before the program’s onset. They also exceeded SIDS knowledge of baseline parents. To the best of our knowledge, this is the first study of a school-based SIDS risk-reduction program.
Methodological limitations precluded a randomized controlled trial or within-student linkage of baseline and posteducation evaluations. Moreover, although both student groups came from the same population, lack of demographic data reduced our ability to control for potentially confounding variables. However, given the consistency of responses across grades, we hypothesize that potential age-related confounders, such as exposure to infants, did not play a key role. Nor did we determine if knowledge would endure or result in behavioral changes. With the time gap between measures, we were also concerned that intervening factors might have contributed to the outcome but found no spontaneous increments in baseline knowledge measured months apart.
In contrast to SIDS-related risks, there was a high level of baseline knowledge of the association between smoking and cancer, a probable result of the effectiveness of previous campaigns. School-based interventions for SIDS risk reduction may therefore be a promising solution to existing barriers and the evident lack of information in the emerging generation and worth further study.
Acknowledgment
This project was supported in part by a grant from the CJ Foundation for SIDS. We thank Cande Ananth, Ph.D., and Sandra England, Ph.D. at UMDNJ-Robert Wood Johnson Medical School for reviewing this manuscript.
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The SIDS Center of New Jersey is based at Robert Wood Johnson Medical School, New Brunswick, NJ and Hackensack University Medical Center, Hackensack, NJ.
PII: S1054-139X(04)00449-5
doi:10.1016/j.jadohealth.2004.12.002
© 2005 Society for Adolescent Medicine. Published by Elsevier Inc. All rights reserved.
