1. Results Introduction Aims & Hypotheses Methodology Discussion
Parents’ Health Literacy and Reactions to the
American Academy of Pediatrics’ Safe Sleep Guidelines
Lizbeth Lopez, Jillian Austin MS, BCBA, Jennifer Doering, RN, PhD,
& W. Hobart Davies Ph.D.
Results
Figure 1 shows that the great majority of parents agree with and were aware of each of the AAP guidelines. However, a number of participants were less aware and reported less agreement with some of the recommendations. The top three recommendations that parents reported lower levels of agreement awareness were “ Offer Pacifier” (75%/67%) and “Room-Sharing” (77%/72%), “No Wedge Positioner”(76%/82%), respectively.
Figure 2 shows that most participants reported almost always following the AAP guidelines. However, the top three guidelines parents reported never following were “Offer Pacifier” (17%), “Room Sharing” (11%), and “No Bed-Sharing” (8%).
Figure 3 shows that most participants reported the AAP guidelines were absolutely essential. Though, the top three guidelines in which participants reported lower importance were “Firm Surface” (24%), “Room-Sharing” (24%), and “Offer Pacifier” (20%).
Figure 4 shows the qualitative responses to reasons why parents disagreed with the recommendations.
Figure 5 shows the qualitative responses to reasons why parents reported not following the AAP guidelines.
A series of linear regressions were calculated to predict compliance based on importance, agreement, awareness, and health literacy skills.
Significant regression equations were found for each of these factors indicating that importance, agreement, awareness, and health literacy all are significant predictors of compliance of the AAP guidelines.
Introduction
1Centers for Disease Control and Prevention. (2010). Parents and caregivers. Retrieved from
2Eunice Kennedy Shriver National Institute of Child Health and Human Development. (2015). Retrieved from
3Gaydos, L. M., Blake, S. C., Gazmararian, J. A., Woodruff, W., Thompson, W. W., & Dalmida, S. G. (2015). Revisiting safe sleep recommendations for African-American infants: Why current counseling is insufficient. Maternal and child health journal, 19(3), 496.
4Haun, J., Luther, S., Dodd, V., & Donaldson, P. (2012). Measurement variation across health literacy assessments: Implications for assessment selection in research and practice. Journal of Health Communication, 17,
Annually about 3,500 infants die suddenly and unexpectedly.1 Of these deaths, unsafe sleep is responsible for 64% of infant deaths, making it one of the leading causes of death among infants.2
The AAP has developed recommendations for parents to address the various factors that contribute to an unsafe sleep environment.
Unsafe sleep is a preventable form of infant death2 and could benefit from targeted interventions.
There are a number of parent beliefs that could contribute to noncompliance with recommendations. It is unclear if parents disagree with the recommendations, if they are unaware of the recommendations, if they simply are simply unimportant to them, or if they do not understand them.
Health literacy refers to a patient’s capacity to understand health-related information3. It could impact parents’ understanding of, and compliance with, the safe sleep guidelines.
Aims & Hypotheses
This study aims to better understand why parents may not be following the AAP’s safe sleep guidelines in order to inform interventions to reduce sleep-related infant death.
It is hypothesized that there will be variable rates of agreement and compliance with the individual guidelines; parents will perceive some guidelines as more important than others; and health literacy will be a significant predictor of parental behavior.
Methodology
Participants
122 parents participated (75% Female, 32.9 M age, 14.6 Years Educated, 2.2 M Number of Children, 78% White).
Procedure
Parents were recruited by students in a psychology course.
Using SurveyMonkey.com, participants completed a demographic questionnaire and reviewed and responded to a list of the AAP’s safe sleep guidelines having to do with sleep position and environment (Table 1).
Participants were asked about their awareness of (Yes/No), agreement with (Yes/No), importance of (5-point Likert scale from 1, not at all to 5, absolutely essential), and compliance with (4-point Likert scale from 1, never to 4, almost always) the recommendations.
The qualitative questions asked were: “Please explain your reasons for any items that you disagree with” and “If there were recommendations that you WERE aware of but DID NOT follow, why was that?”
The Brief Health Literacy Scale is a instrument which measures health literacy using four items.4 Responses, on a 5-point Likert scale, were summed to create a total score. Low scores suggest low health literacy levels, meaning they have a difficult time interpreting health information. High scores suggest adequate health literacy levels, meaning they do not have a difficult time interpreting health information.
Discussion
In the present sample, parents had adequate health literacy and were largely aware of, agreed with, complied with the AAP recommendations and rated them as important; however, these fluctuated depending on the specific recommendations.
The qualitative responses offer some insight as to why parents disagreed with, and did not comply with, certain recommendations. Based on these responses it is possible parents do not understand the rationale behind the recommendations, even if they understand what the recommendation means.
According to participant responses on reasons for noncompliance, it seems as if parents are not following the AAP recommendations based on personal beliefs. This suggests that parents may not value the source of the recommendations.
Of note, each variable predicted whether a parent was likely to comply with the recommendation, suggesting many potential avenues for intervention (e.g., increase awareness of the recommendations or increase health literacy). Future research should assess whether a targeted intervention improves compliance.  
One of the limitations of the present study was that some of the questions (compliance and awareness) were retrospective in nature and required parents to recall information. Future research should focus on current parents of infants.
Table 1. American Academy of Pediatrics Safe Sleep Guidelines
Place your baby on his or her back for every sleep time.
Place your child to sleep on a firm sleep surface.
Place your baby to sleep on a flat sleep surface. Car seats and other sitting devices are not recommended for routine sleep.
Keep soft objects or loose bedding out of the crib or sleep area. This includes pillows, blankets, and bumper pads
The baby should sleep in the same room as parents, but not the same bed (room-sharing without bed-sharing).
The infant should not sleep in the same bed with caregiver or older children (no bed-sharing).
Offer a pacifier at nap and bed time.
Wedges and positioners should not be used.
Avoid overheating the infant or covering the infants head.
References
1Centers for Disease Control and Prevention. (2010). Parents and caregivers. Retrieved from
2Eunice Kennedy Shriver National Institute of Child Health and Human Development. (2015). Retrieved from
3Gaydos, L. M., Blake, S. C., Gazmararian, J. A., Woodruff, W., Thompson, W. W., & Dalmida, S. G. (2015). Revisiting safe sleep recommendations for African-American infants: Why current counseling is insufficient. Maternal and child health journal, 19(3), 496.
4Haun, J., Luther, S., Dodd, V., & Donaldson, P. (2012). Measurement variation across health literacy assessments: Implications for assessment selection in research and practice. Journal of Health Communication, 17,
Contact Jillian Austin at for more information.