Oakland County is located in Southeastern Michigan, just north of Detroit, and consists of 910 square miles. The Oakland County Health Division (OCHD) serves the county population of 1.2 million.
Infant mortality prevention is a major public health focus for OCHD. For every 1,000 live births, more than five infants die before reaching their first birthday. Although Oakland County’s overall infant mortality rate has steadily decreased over time, disparities continue to exist between various racial and ethnic groups, particularly between African-Americans and Caucasians.
Over the last two decades, a national focus on proper infant sleep environment and position has helped lead to a reclassification of deaths once attributable to Sudden Infant Death Syndrome (SIDS). These preventable deaths are more appropriately attributed to accidental strangulation/suffocation in/on the sleep surface. A sleep-related death is the death of an infant, birth to one year of age, where elements of an unsafe sleeping environment were present regardless of medical examiner cause and manner of death. This encompasses infant deaths classified as “sudden infant death syndrome,” “suffocation” and “undetermined,” where upon death scene investigation the infant was found to be in a potentially unsafe sleep environment. An unsafe sleep environment includes soft bedding or articles in the crib or bed; an infant sleeping in an adult bed; other sleep surfaces such as a couch or chair, an infant sleeping with another adult or child, and an infant sleeping in a non-supine position. The rise in deaths attributed to accidental strangulation/suffocation in the sleep environment has demonstrated the need to spread prevention messages about unsafe sleep environments to parents, caregivers, medical personnel, and the community at large.
OCHD recognized the potential of connecting with numerous and varied community partners to help reach out to targeted areas of the community. To facilitate this, OCHD developed a train-the-trainer program to give caregivers the tools and education necessary to multiply prevention efforts, promote safer infant sleeping practices in the community, and prevent suffocation.
The goals of the Safe Sleep Train-the-Trainer program are:
Increase community partner knowledge on proper safe sleep practices.
Provide the tools and create the ability for community partners to increase knowledge on proper safe sleep practices themselves.
The objectives of the Safe Sleep Train-the-Trainer program are:
All participants will describe plans for using information provided in their packets to educate clients.
Participants will indicate when and where they would conduct trainings.
Nursing faculty will incorporate education into course content.
Twenty OCHD Public Health Nurses volunteered to be safe sleep training presenters. A two-hour orientation session for staff included training on the Safe Sleep PowerPoint and procedures. A letter from the Manager/Health Officer was sent to community partners as an invitation to host train-the-trainer sessions and a safe sleep display.
OCHD staff trainers provided a two-hour training to community organizations who were identified as key partners to educate clients about safe sleep. Each organization was given a packet to facilitate individual client teaching or classroom-style training. The packet contained print and electronic copies of the presentation, free educational materials from Tomorrow’s Child (a Michigan non-profit organization with the mission to prevent unsafe sleep-related deaths), a materials order form, OCHD handouts, Safe Sleep DVDs, a training evaluation form, pre and posttests, and a flyer to advertise training sessions. Participant organizations were also provided a full size Pack ‘N Play (portable crib) and lifelike doll with a poster for permanent display in a high-traffic area.
Participants described plans for using information provided in their packet to educate clients, family and friends. Respondents intended to use the Pack ‘N Play display as a conversation starter. Plans also included referring clients to the websites provided in the presentation and the OCHD Nurse on Call Public Information Hotline.
Participants planned to educate clients in multiple environments including home visits, hospital stays, birth classes, and breastfeeding education sessions. Other plans involved adding the Safe Sleep DVD to a patient education library and using it as part of an educational DVD series.
A unique partnership involved relationships developed between OCHD and nursing instructors at Oakland University, Rochester College, University of Michigan, and Wayne State University who incorporated our train-the-trainer program into their curriculum. OCHD staff trained nursing students using the Safe Sleep presentation. As an assignment, students were provided with a list of 500+ child care facilities in Oakland County to provide presentations to staff and parents. The assignments entailed students identifying community partners, leading train-the-trainer sessions, and distributing educational materials. Instructors plan to include this assignment in their syllabus for future semesters.
OCHD serves the entire county, which is home to 1.2 million people and located just north of Detroit, Michigan. It is a geographically large county of 910 square miles and contains urban, suburban and rural areas. Vital statistics data show Oakland County had 13,346 births in 2012 (most recent data available). Commonly, safe sleep messaging tactics have focused only on utilizing healthcare providers that interact with the family of the newborn or attempt to passively educate the primary care givers through media such as billboards, flyers or press releases. These strategies risk that safe sleep messaging is disregarded due to multiple messages about the care of a newborn or the lack of time and energy of the care givers to educate themselves. Active, less passive, interaction addressing specific issues about safe sleep is necessary to convey and instill accurate knowledge to community partners and give them the confidence to teach or reinforce messages with the families they interact with on a regular basis. However, there are many other community resources and secondary caregivers that interact with families during the first year of an infant’s life, when safe sleep is of the greatest concern. These groups can help to introduce or reinforce proper safe sleep messaging with primary care givers and others in the community.
The simple “Back to Sleep” mass messaging has been effective, but other longer and more complicated safe sleep messaging that teaches the importance of having the infant sleep alone, in their own crib and without other plush items is less succinct and can be more difficult to convey. Experience has also shown the importance of actively reaching out to other less frequent direct care givers (e.g. grandparents or baby sitters) with proper safe sleep education.
OCHD utilized its relationships with numerous and varied community partners to access targeted areas of the community. The collaboration involved in this training is an impressive demonstration of a local public health agency addressing a long standing community need and engaging a broad and comprehensive array of community partners to assist with reaching the population. Specific achievements include:
Over 20 OCHD staff provided 69 safe sleep trainings to 1,346 community partners and 426 nursing students, resulting in a total of 1,772 additional safe sleep trainers in the community over 18 months.
Community partners and nursing students provided trainings to another 900 caregivers of infants.
Community partners and nursing students continue to educate caregivers of infants, as training materials can be used repeatedly.
Permanent safe sleep displays are present to educate clients in 49 locations around Oakland County.
Best Start for Babies-Oakland (BSB-O) is the Community Advisory Coalition for infant mortality reduction in Oakland County. Convened by the OCHD, BSB-O members meet every other month to learn about the issues contributing to infant mortality in Oakland County, brainstorm strategies, and hear updates about community resources. Members of this community advisory group represent a wide variety of human service organizations, parents, health care providers, and faith-based organizations, all with the objective of working together to decrease the rate of infant mortality in Oakland County. For the past two years, this group has focused on getting out the safe sleep message in the community and increasing breastfeeding rates.
Activities of the BSB-O members include:
Using the safe sleep training presentation developed in 2013 that adheres to the American Academy of Pediatrics 2011 Guidelines (outline, presentation, Pack ‘N Play display, video, brochures, handouts).
Training interested community partners in safe sleep strategies (WIC staff, Human Service Agencies in the County, Michigan Department of Human Services staff, birthing hospital staff, senior centers, middle school students as potential babysitters, preschool staff, school of nursing students, etc.). Most recently, training targets inpatient hospital staff, fire department staff, kinship caregivers, community church groups, and community health fairs.
Translating the PowerPoint presentation and handouts into Spanish and Arabic to reflect the two main non-English speaking communities in Oakland County.
Offering training and materials to local birthing hospitals to assist them with client teaching of safe sleep strategies.
Providing materials for community partners to hold classroom-style training or one-on-one teaching to clients.
Offering Pack ‘N Plays, if appropriate, at sites to be used for future training events and to display as a model safe sleep environment.
Providing individual client teaching to all pregnant women during OCHD Public Health Nurses (PHN) home visits.
Distributing brochures, handouts and DVDs reinforcing the safe sleep message, including the materials available through Tomorrow’s Child at no charge.
Giving Pack ‘N Plays to clients who meet pre-determined criteria for being at-risk of infant death using unsafe sleep strategies (and have no other access to obtaining a crib).
Training clients that receive a Pack ‘N Play on safe sleep strategies and signing commitment form to follow safe sleep strategies with their baby.
Distributing infant size onesies to individual clients during the home visit that have safe sleep guidelines screen-printed on them to reinforce verbal teaching.
Community partners who participated in the train-the-trainer program were given a survey following completion of the two-hour training session.
Participants were asked to rate the relevance of this training to their work using a Likert scale of 1 to 5, with 1 “not at all relevant” and 5 “extremely relevant.” During the last two review periods the mean score has been 4.37 and 4.21.
In the same review periods 97.3% and 96.4% of participants reported that the training improved their understanding of safe sleep practices. All participants who reported that the training did not improve their understanding stated they had previous training on this topic.
More than 98% of respondents reported feeling prepared to train clients using the provided materials.
Participants were also asked to describe their plans for using information provided in their packet to educate clients. All participants responded with intentions to provide individual education or group presentations, use the Pack N’ Play display as a conversation starter, and/or refer clients to the websites provided in the presentation and OCHD Nurse on Call Public Information Hotline. As a result of the safe sleep train-the-trainer program, respondents indicated that it’s especially important to emphasize the dangers of overheating, co-sleeping, and entrapment, and confirm that babies with reflux need to and can safely sleep on their backs.
Community partners administered pre- and post-tests to all clients trained through individual client teaching or classroom-style training. The questions focused on teaching points with the highest priority as identified by the community partners. The pre- and post-tests consisted of nine true/false questions covering multiple sleeping arrangements for infants.
The question that has had the highest percent increase in knowledge among clients for both review periods has been “I can cover baby’s carrier with a blanket when it’s cold outside.”
While the questions with the highest pre-test scores for both review periods have been “Everyone should follow safe sleep guidelines-parents, grandparents, aunts, uncles, and babysitters.” and “Baby can sleep in bed with me. I will wake up if something is wrong.”
All respondents scored higher than 95% on all post-test questions in both review periods except for in the first review period “If baby falls asleep in a car seat or carrier, don’t wake him up. It’s ok to sleep there for a little while.” and in the second review period “Baby could suffocate with someone watching.”
Results of the pre- and post-tests are being used to guide future training sessions for subsequent staff and community partners. In the first 18 months, the Safe Sleep Train-the-Trainer program provided education to 1,346 community partners, 426 nursing students and another 900 infant caregivers, with more than a 20% increase of knowledge among all trained. This program has become self-sufficient, with community partners continuing to provide education to clients and integrating the most helpful prevention messages into their daily activities. The scope of this effort was possible due to the collaboration between OCHD and community partners that had a multiplying effect. Therefore, knowledge about and adoption of safe sleep practices will continue to grow in Oakland County, with the ultimate goal of decreasing the number of infant deaths due to accidental strangulation or positional asphyxia.
The cost of the program has been minimal given the educational impact in the community. Annual costs have been:
Educational Supplies including onesies with safe sleep messaging, Pack ‘N Plays displays and safe sleep DVDs has been approximately $9,000.
Printing is $2,500.
Staff and fringe benefit costs is $15,000 including a staff Health Educator developing and implementing the Safe Sleep project and staff Public Health Nurses preparing and giving presentation to community partners and nursing students.
The Safe Sleep Train-the-Trainer Program filled a specific gap in service to Oakland County residents, training staff at numerous Oakland County partner organizations to provide safe sleep education to their clients. Previous to this effort, there had not been a comprehensive effort to promote consistent, reliable information about safe sleep practices across the county. This program also relied on cooperation and coordination between Oakland County departments and nongovernmental organizations.
The Safe Sleep Train-the-Trainer program had measurable results, with a 28% increase in knowledge of safe sleep practices among the caregivers trained. Finally, the program is innovative in that it used a train-the-trainer approach, which ensures program sustainability and self-sufficiency. Oakland County organizations that participated in the train-the-trainer program will be able to continue educating caregivers about safe sleep without having to rely on Oakland County Health Division for funding or support. OCHD developed a relationship with nursing instructors at Oakland University, Rochester College, University of Michigan and Wayne State University who incorporated our train-the-trainer program into their curriculum. OCHD staff trained nursing students to use the Safe Sleep PowerPoint presentation. Students identified community partners, led train-the-trainer sessions, and distributed educational materials as part of a class assignment. Instructors made copies of educational materials for students to distribute, students signed up to check out the display from the instructor to bring to their site and then returned it for the next group to use. Instructors plan to include this assignment in their syllabus for future semesters. The OCHD Safe Sleep Train-the-Trainer program is a commendable effort due to the gaps in services it filled, the measureable results that it produced, and the innovative technique that it utilized.