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Original Investigation
July 25, 2017

The Effect of Nursing Quality Improvement and Mobile Health Interventions on Infant Sleep PracticesA Randomized Clinical Trial

Author Affiliations
  • 1Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville
  • 2Department of Family Medicine, School of Medicine, University of Virginia, Charlottesville
  • 3Department of Pediatrics, Yale University, New Haven, Connecticut
  • 4Slone Epidemiology Center, Boston University, Boston, Massachusetts
  • 5Department of Biostatistics, School of Public Health, Boston University, Boston, Massachusetts
  • 6Department of Family, Community, and Mental Health Systems, School of Nursing, University of Virginia, Charlottesville
JAMA. 2017;318(4):351-359. doi:10.1001/jama.2017.8982
Key Points

Question  Will 2 separate, complementary interventions (nursing quality improvement intervention and mobile health intervention) promote safe infant sleep practices?

Findings  In a 4-group cluster randomized clinical trial with 1263 families, mothers who received a mobile health intervention with regular text or email messages and videos reported statistically significantly higher rates of placing their infants supine to sleep compared with mothers who received control interventions (adjusted prevalence, 89.1% vs 80.2%, respectively), room sharing without bed sharing (82.8% vs 70.4%), no soft bedding use (79.4% vs 67.6%), and any pacifier use (68.5% vs 59.8%). A nursing quality improvement intervention did not influence infant safe sleep practices.

Meaning  A mobile health intervention improved adherence with infant safe sleep practices. Whether widespread use of this type of intervention is feasible and reduces sudden and unexpected infant death rates remains to be studied.

Abstract

Importance  Inadequate adherence to recommendations known to reduce the risk of sudden unexpected infant death has contributed to a slowing in the decline of these deaths.

Objective  To assess the effectiveness of 2 interventions separately and combined to promote infant safe sleep practices compared with control interventions.

Design, Setting, and Participants  Four-group cluster randomized clinical trial of mothers of healthy term newborns who were recruited between March 2015 and May 2016 at 16 US hospitals with more than 100 births annually. Data collection ended in October 2016.

Interventions  All participants were beneficiaries of a nursing quality improvement campaign in infant safe sleep practices (intervention) or breastfeeding (control), and then received a 60-day mobile health program, in which mothers received frequent emails or text messages containing short videos with educational content about infant safe sleep practices (intervention) or breastfeeding (control) and queries about infant care practices.

Main Outcomes and Measures  The primary outcome was maternal self-reported adherence to 4 infant safe sleep practices of sleep position (supine), sleep location (room sharing without bed sharing), soft bedding use (none), and pacifier use (any); data were collected by maternal survey when the infant was aged 60 to 240 days.

Results  Of the 1600 mothers who were randomized to 1 of 4 groups (400 per group), 1263 completed the survey (78.9%). The mean (SD) maternal age was 28.1 years (5.8 years) and 32.8% of respondents were non-Hispanic white, 32.3% Hispanic, 27.2% non-Hispanic black, and 7.7% other race/ethnicity. The mean (SD) infant age was 11.2 weeks (4.4 weeks) and 51.2% were female. In the adjusted analyses, mothers receiving the safe sleep mobile health intervention had higher prevalence of placing their infants supine compared with mothers receiving the control mobile health intervention (89.1% vs 80.2%, respectively; adjusted risk difference, 8.9% [95% CI, 5.3%-11.7%]), room sharing without bed sharing (82.8% vs 70.4%; adjusted risk difference, 12.4% [95% CI, 9.3%-15.1%]), no soft bedding use (79.4% vs 67.6%; adjusted risk difference, 11.8% [95% CI, 8.1%-15.2%]), and any pacifier use (68.5% vs 59.8%; adjusted risk difference, 8.7% [95% CI, 3.9%-13.1%]). The independent effect of the nursing quality improvement intervention was not significant for all outcomes. Interactions between the 2 interventions were only significant for the supine sleep position.

Conclusions and Relevance  Among mothers of healthy term newborns, a mobile health intervention, but not a nursing quality improvement intervention, improved adherence to infant safe sleep practices compared with control interventions. Whether widespread implementation is feasible or if it reduces sudden and unexpected infant death rates remains to be studied.

Trial Registration  clinicaltrials.gov Identifier: NCT01713868

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