1. Ohio department of Health – Infant safe sleep Campaign
Ohio Chapter, American Academy of Pediatrics Roundtable
Friday, April 4
Christy Beeghly, MPH,
ODH Violence and Injury Prevention Program Administrator

2. Ohio Injury Prevention Partnership (OIPP)
The Ohio Injury Prevention Partnership (OIPP) is a statewide group of professionals representing a broad range of agencies and organizations concerned with the prevention of injury.
Priorities for the OIPP include Prescription Drug Misuse, Falls Among Older Adults, and Child Injury.
The OIPP is coordinated by the Ohio Department of Health (ODH) with funds from the Centers for Disease Control and Prevention (CDC).
It advises and assists ODH and ODH’s Violence and Injury Prevention Program (VIPP) with establishing priorities and future program direction.
In keeping with its data driven approach, the OIPP has identified these 3 injury priority issues on which it is presently focusing its efforts - Prescription Drug Misuse, Falls Among Older Adults and Child Injury

3. Child Injury Action Group (CIAG)
The Child Injury Action Group was formed as an action group of the OIPP and developed its strategic plan
Child Injury Action Group Strategic Priorities:
Teen Driving
Child Passenger Safety Law Review/Revision
Sports-related Traumatic Brain Injury
Bicycle and Wheeled Sports Helmets
Infant Sleep-related Suffocation
The Child Injury Action Group was formed as an action group under the umbrella of the OIPP.
In 2010, the Child Injury Action Group began a year long, data driven, strategic planning process to identify it’s priorities and develop action plans to implement policy, systems and environmental change for each priority.
Infant Sleep–related suffocation was identified as a priority based on data from the Ohio Child Fatality Review. More than three Ohio infant deaths each week are sleep-related. If the sleep-related deaths were prevented, the Ohio infant mortality rate for 2010 would have been reduced from 7.7 to 6.6 deaths per live 1,000 births, according to the 2012 Ohio Child Fatality Review.

4. SUID rates per 100,000, OHio and U.S. 1999-2010*
Infant Sleep-related Deaths
Sleep-related Infant Death Rates have remained relatively
stable in the U.S during the past decade.
SUID rates per 100,000, OHio and U.S *
SUID – Sudden unexpected infant death – includes SIDS, ASSB and other/unspecified infant deaths
*Source: CDC WONDER

5. CIAG Infant Safe Sleep Subcommittee
The CIAG Goal: Reduce unintentional sleep-related deaths for infants aged <1 year from 38.0 per 100,000 by 10% by 2016.
The CIAG Infant Safe Sleep Subcommittee was formed and created action plans for the following objectives:
Promote and support parent education policies in birthing hospitals and licensed child care centers
Partner with baby product retailer to promote safe sleep to customers
Ensure that prenatal care providers and pediatric health care providers are promoting and distributing current safe sleep messages
Collaborate with other organizations to conduct a statewide safe sleep campaign
Enact a policy requiring all identified state agencies with a role in parent education, early intervention, or child care to follow and promote current safe sleep recommendations
The CIAG Infant Safe Sleep Subcommittee created objectives focused on ensuring the AAP guidelines were being promoted and followed in various settings including: hospitals, child care centers, baby product retailers, and state agencies.
Educating parents of newborns through a marketing campaign was a goal early on, but the committee realized they would need additional partners and funding to complete their objective.

6. Partnerships CIAG ISS Committee Members
Safe sleep experts from across Ohio including LHDs, birthing and children’s hospitals, parent advocates, etc.
Internal ODH Partners
VIP Program
MCH Programs
Office of Public Affairs
Ohio Collaborative to Prevent Infant Mortality
SID Network of Ohio
Ohio Chapter, American Academy of Pediatrics
Cribs for Kids
Ohio Hospital Association
Ohio Children’s Trust Fund
Luckily, partners were available! The Infant Safe Sleep Committee was formed with safe sleep experts from across Ohio and they offered their expertise and support to the project.
The Ohio Children’s Trust Fund and Ohio Chapter AAP were early supporters of the project and began to collaborate to support the statewide marketing campaign. The ODH maternal child health community also requested funding for this issue from the state’s GRF.
With the reduction of infant mortality as a strategic priority for the Ohio Department of Health and a priority of the the State Health Improvement plan, the legislature was willing to create the infant vitality line which will funds infant mortality reduction initiatives, of which, the safe sleep marketing campaign is a part.

7. Marketing Campaign Development
Process
Began in early 2012 with regular planning and working meetings with CIAG ISS subcommittee members.
Review of data to determine most at risk populations
Development of marketing concepts
Focus group testing of marketing concepts with priority populations.
Once funding and support for a standardized statewide marketing campaign was widely established among our partners, the work began to develop the actual marketing campaign materials.
Understanding who was among our most at risk groups was the first order of business so ODH and partners reviewed available data on infant suffocations.
Next, we worked with the CIAG Infant safe sleep subcommittee experts to develop messaging and marketing concepts.
Finally, we secured a contractor to conduct focus groups around the state and used those results to hone the marketing campaign and address the issues parents felt were most unclear and important.

8. Campaign Development- Data Review
Overall sleep-related death rates have remained relatively stable but have not declined.
Ohio rates are higher than the U.S.
Black infants are at disparately high risk for suffocation.
Most suffocation deaths occur within the first 3 months.
More than 2 out of 3 infant suffocations are sleep-related (68%); while 28% are other/unspecified.
Urban areas, small towns and south eastern Ohio have higher SUID rates.
First, ODH and its partners reviewed available data sources including Ohio Vital statistics mortality data, Ohio Child Fatality Review and the Ohio Pregnancy Risk Assessment Monitoring System or PRAMS data.
Vital statistics data shows Black infants are at disparately high risk for suffocation. The Black rate is 165% higher than the white infant sleep suffocation/SUIDS rate. Males are at slightly higher risk than females with the distribution of deaths 59 percent male and 41 percent females.
Source: ODH, Office of Vital Statistics

9. Campaign Development- Data Review
Safe Sleep Behaviors Among Ohio Mother - PRAMS
Least likely to place their infants on their backs to sleep:*
Single
Less than 20 years old
Non-Hispanic black
Less than 12 years of education
Receiving Medicaid
To determine the current sleep practices and identify inconsistencies in use of appropriate sleep practice, we reviewed the Pregnancy Risk Assessment Monitoring System or PRAMS data.
Most (nearly ¾) of Ohio mothers put their infants on their backs to sleep. However, a significant proportion (more than 1 out of 4) do not.
The PRAMS data for back sleeping position was reviewed and this slide shows the specific maternal characteristics of those LEAST likely to place their infants to sleep in the back position.
*Source: Ohio Pregnancy Risk Assessment Monitoring System, Center for Public Health Statistics and Informatics, ODH 2010

10. Campaign Development- Data Review
Child Fatality Review Findings
Leading cause of infant mortality after prematurity
819 sleep-related infant deaths
56% were boys
38% were African American
88% were to infants younger than 6 months, again pointing to those first months as being the most important
The Child Fatality Review data provides insight into demographics specific risk factors. Again, African American babies are overrepresented. The majority of the deaths to these infants were placed on an unsafe sleep surface and were sharing the sleep surface with another person.

11. Campaign Development- Data Review
Child Fatality Review
Sleep Environments
Only 23% (192) occurred in a crib or bassinette
60% (494) occurred in unsafe places: adult beds, sofas, chairs
58% (473) were sharing a sleep surface with another person
ABCs of Safe Sleep Indicators
Of 819 sleep-related deaths, only 51 (6%) of reviews indicated the baby was placed Alone, On the Back, In a Crib or Bassinet
The Child Fatality Review data provides insight into demographics specific risk factors. Again, African American babies are overrepresented. The majority of the deaths to these infants were placed on an unsafe sleep surface and were sharing the sleep surface with another person.

12. Campaign Concept Development
CIAG Committee members reviewed existing campaigns from national, state and local levels
Existing Campaigns:
National Back to Sleep change to Safe to Sleep released during process
ABCs approach – Alone. Back. Crib.
The data analysis helped refine the approach to the development of the marketing campaign. With the data supporting the cause, funding and support for a standardized statewide marketing campaign was widely established among our partners.
Work began to develop the actual campaign materials consisted of a review of existing infant safe sleep campaigns. At the time, there were two basic approaches to infant safe sleep campaigns – the ABCs in building block letters. There was also the “scary” approach to get the conversation started as I’m sure many have seen the City of Milwaukee ad with the baby in bed with the butcher knife.
The CIAG committee felt strongly that there ought to be a way to be thought provoking without comprising and using unsafe sleep images so the work began to take that direction. You’ll be able to see what the committee came up with in just a moment. While this is the shortest slide, this part of the process actually took the longest amount of time.

13. Campaign Concept Development
Existing Campaigns:
Scare tactic approaches
The data analysis helped refine the approach to the development of the marketing campaign. With the data supporting the cause, funding and support for a standardized statewide marketing campaign was widely established among our partners.
Work began to develop the actual campaign materials consisted of a review of existing infant safe sleep campaigns. At the time, there were two basic approaches to infant safe sleep campaigns – the ABCs in building block letters. There was also the “scary” approach to get the conversation started as I’m sure many have seen the City of Milwaukee ad with the baby in bed with the butcher knife.
The CIAG committee felt strongly that there ought to be a way to be thought provoking without comprising and using unsafe sleep images so the work began to take that direction. You’ll be able to see what the committee came up with in just a moment. While this is the shortest slide, this part of the process actually took the longest amount of time.

14. Campaign Development – Focus Groups
Purpose: Assess ISS knowledge, attitudes and beliefs:
Knowledge about infant sleep related suffocations.
Knowledge of the data
Attitudes of their own risk
Knowledge about safe sleep practices.
Where learned safe sleep practices and belief of sources.
Personal sleeping practices for infant(s).
Barriers to compliance (if not in compliance with ABC’s of safe sleep).
Assess reaction to the draft marketing concepts
As the CIAG committee worked to develop marketing concept drafts, ODH began work to secure a contractor to conduct focus groups around the state.
The goal of the focus groups was not only to obtain reactions to the marketing concepts to shape the campaign, but to truly understand parents views of safe sleep practices. As you can see, we asked not only what spoke to them for a marketing campaign, but what they knew about infant mortality, how they felt about the statistics, their current sleep practices with their infants, and the barriers to using the ABCs of safe sleep.

15. Campaign Development – Focus Groups
Demographic Breakdown
Location
Female, Caucasian, pregnant or parent of infant, less than 25 years of age, 12 or less than 12 years of education (2 Focus Groups)
Athens or Marietta
Female, Non-Hispanic Black, 12 or less than 12 years education, Medicaid Recipient, unmarried.
Cincinnati
Cleveland
Columbus
Male, primarily Non-Hispanic Black, urban residents, caregiver of infant.
Caucasian, college-educated, pregnant or parent of infant, primarily, married or unmarried, less than 45 years of age.
Female, primarily Non-Hispanic Black, other caregivers of young infants (i.e. grandparent, aunt, etc.).
Female, pregnant or parent of infant, Hispanic, 12 or less than 12 years education. (Spanish speaking)
12 focus groups took place around Ohio with the exact groups we identified by using the data mentioned earlier and their influencers – young african american fathers and “other” caregivers of young infants. Affectionately known as our grandma audience.
We also conducted focus groups with suburban, college-educated moms; young moms in southeastern Ohio; and Hispanic moms.

16. Marketing Campaign Development – Concepts
So, what did we find out? This slide speaks to the issue discussed earlier- how do we reach moms without using the shock factor? What do moms really want/need to see to pay attention to these ads and in turn to safe sleep practices?
These are two of the concepts developed that the focus groups reviewed – a version of the “Scary ads” and one using safe sleep imagery.
The rumpled bed ad was the least favorite of the focus group participants and This Side Up ad was most preferred by participants.

17. Marketing Campaign Development – Concepts
These concepts were also presented to the focus groups. As you can see – we tailored messages to the grandma audience as well. The one of the left was an attempt to be shocking because the audience could be unsure of if the baby was alive or not. It ended up being viewed as confusing by focus group participants.

18. Marketing Campaign Development – Concepts
The Baby Proofing Begins here ads were also viewed as confusing because it was unclear what the ask was of the focus group participants. They assumed we were referring to baby proofing the house, rather than the crib.
We tailored messages to the father audiences as well. A key finding from the focus groups was there was no difference in perception of ads and ABCs between race, gender, age – Matrix analysis of the practices found that there reasons and rational for their safe sleep practices were basically the same. Allowing us to utilize one ad for the statewide campaign. However, the materials will be made available to safe sleep practitioners should they wish to use them.

19. Marketing Campaign Development – Concepts
The final variation of the concepts are on this slide. The Seriously baby was an attempt to convey the serious nature of why babies need to sleep alone. This version ended up being viewed as unclear and the need to view a safe sleep environment was once again reiterated. Some mothers also felt the baby was talking back to them which was interesting.
The baby proofing concept coupled with a safe sleep environment did nothing to influence parents to baby proof the crib, they still though of other areas in the house that needed to be baby proofed.

20. Campaign – Focus Group Key Findings
Knowledge of ISS:
Most had heard most or all ISS recommendations at some point but not as the “ABC’s of safe sleep”.
Less than 30% of participants reported putting their infants to sleep per all the ABCs.

21. Campaign – Focus Group Key Findings
Barriers to ABCs:
Choking Concerns - Skeptical of back sleeping being safest
Warmth/Comfort - Bare Crib is “sterile” – needed a full- body sleep sack as bare arms/legs made baby appear cold
Safety/Bonding – Babies are safest with mom and bumper pads are important b/c they “protect baby”
Don’t tell me what to do!
Parents want the why of ABCs
More than finding out how to grab the attention of our most at risk audience, the focus groups revealed the actual barriers to the ABCs of safe sleep. The ABCs are widely used to promote safe sleep practices, but our focus group participants let us know exactly why they weren’t following the ABCs if they were aware of them.
Barriers to ABCs:
Choking – parents are extremely skeptical about the back position being the safest, even relating that they put their baby to sleep however they feel baby will be most comfortable, despite physician’s advice. Messaging with a QR code link to the Cribs for Kids animation of a baby lying on their stomach spitting up is being developed. Safe sleep practitioners relate this is the only choking education piece that seems to change a parent’s mind
Warmth/Comfort – the bare crib was viewed as sterile and uncomfortable feeling, ads with bare legs and arms made parents uncomfortable, they wanted to start throwing blankets on the baby, parents reported turning their baby onto their stomach if they were observed not sleeping soundly so messaging about arousal is being developed
Safety/Bonding – bumper pads are viewed as a safety feature because of – why sell them if they’re not safe? babies are safer and sleep better when they’re in bed with their parent so messaging about sharing the room not the bed is being developed
Don’t tell me what to do – parents wanted the why of ABCs, don’t just tell them what to do, tell them why…
For example, Share the Room. Not the Bed. should be followed with 62% of sleep-related deaths happened on adult beds, chairs or couches. This tells parents why the baby should be alone.

22. Campaign – Focus Group Key Findings
Current Practice of Parents
Experience Counts
First-hand experience
“Bed Sharing Can be Done Safely”
“Baby is Safer with Me”
Trust Pediatrician vs. Mother’s instinct
Grandparents don’t bed share
No difference in perception safe sleep beliefs across SES, gender, race or generational divide
When asking about the current sleep practices of their infants and how they receive information some key findings include:
Experience Counts- Mothers with more than one child who participated were unlikely to consider changing their sleep practices when given information about safe sleep. If this was their first child or the child was young (between 3 – 4 months old) they were more willing to change. Also, parents who knew someone who had experienced a sleep related or SIDS tragedy were likely to practice all the ABCs. This prompted the development of personal stories for both the ads and website.
Bed Sharing – Mothers felt there was a way to safely sleep with their infant on the same surface and that if a mother suffocated her child that drugs or alcohol was likely involved. Bed sharing was mentioned and practiced by at least three participants in every focus group. Parents feel their child is safer sleeping with them and this was most prevalent among African American fathers. Moms and dad both believe they would never sleep soundly enough to accidentally roll over on the baby. Grandparents report never sleeping with the baby in their bed.
Mother’s Instinct – mothers generally trusted their pediatrician’s advice, but felt they relied mostly on their instincts and didn’t hesitate to go against the recommendations if they felt it was in their infant’s best interest.
No difference in perception of ads and ABCs between race, gender, age – Matrix analysis of the practices found that there reasons and rational for their safe sleep practices were basically the same.

23. Campaign – Focus Group Key Findings
Feedback on Ad Concepts
Statistics Speak! “3 babies per week….”
Model Safe Environments – Show me a warm looking baby in a safe crib
Ohio Department of Health logo
The review of the ad concepts brought about several themes from focus group participants.
Statistics Speak! – Parents felt the statistic originally included in the majority of the ad concepts “In Ohio, three healthy babies die each week while sleeping. was confusing and didn’t differentiate between sleep-related deaths and SIDS. They wanted more information on how, where and why those babies died. Another version was much more appealing to focus group participants “Every week in Ohio, 3 babies die in unsafe sleep environments.”
Model Safe Environments – Ads that showed the entire safe sleep environment with the baby in the crib looking warm were most preferred.
Ohio Department of Health logo – the ads with the ODH logo and website were preferred by participants. The ODH logo gave participants assurance that the information was correct.

24. Fighting barriers… Main Image
Builds on onesie that started so many conversations
Focus groups liked the simple message which interested them in the rest of the ad
Meet the barrier-fighting babies – This is the base image for the campaign. Participants loved the bright, eye-catching color in the orange ad. So the bright color scheme was continued in the various versions.
The statistic the focus group participants most identified with was added to the top of the ad. The committee had previously avoided coupling the statistic about the number of deaths with safe sleep imagery for fear the audience would think the baby in the crib was deceased, but the focus group participants assured us they felt the baby was just sleeping.

25. Fighting barriers… Barrier: Bed Sharing I My Crib
2 out of 3 babies who died while sleeping were sharing an adult bed, couch or chair – I have to sleep alone in my crib
The pink baby is fighting the bed sharing barrier. Language is on some versions that clarifies why baby needs to sleep alone in her crib.

26. This Side Up…
The This Side Up ad provides the perfect way to fight the barriers to the ABCs of safe sleep. Ads have been modified to help fight the barriers to the ABCs. This ad was also modified to make the ABCs language more clear and to add a sleep sack to make the baby look warm to parents.
Balancing the need to be eye catching and succinct yet informative has been difficult, but the language is being reviewed at this time to help overcome the barriers to the ABCs including choking, bed sharing and the warmth/comfort/safety issues.

27. Fighting barriers… Barrier: Choking Breathe Easy
Babies who sleep on their backs are less likely to choke than those who sleep on their stomachs!
The green baby boy is fighting the choking barrier as most parent people their baby will choke if he spits up while on his back. Language is added to support the idea that baby is less likely to choke on their back.

28. Fighting barriers… Barrier: Warmth/Comfort/Bonding/Bumpers
Safe and Sound
This crib may look empty, but I’m warm and safe here.
The blue baby boy is trying to fight many barriers including: warmth, comfort, bonding and bumper safety.

29. The babies …
This is a sample of how the babies will typically appear on the sides of buses, billboards, movie theater screens, etc. There isn’t the ability to add the explanatory language you see in the following slide.

30. The babies …
This is a sample of the poster that will be available for order for our partners. It includes the additional explanatory language – the “why” of the ABCs. This will be used in formats where the public will have the opportunity to stop and read so for waiting room poster, brochures, etc.

32. Marketing Campaign Launch
Goal: Educate the target population (mothers 16-45, fathers and grandparents in high-rate infant mortality areas of Ohio i.e. Cleveland, Columbus, Cincinnati, Dayton, Youngstown, Akron, Toledo and SE Ohio)
Mediums –
Television Ads
Interior Transit Ads
Bus wraps
Movie Theaters Ads
Web banner ads
Billboards
Radio Ads
In summary, the marketing campaign actually began running April 1 on the mediums and cities listed on the slide. A more formal launch is being planned to coincide with what our partners are doing.

33. Timing and Marketing Strategy
Now! Through June 30, 2015
Cable PSA’s began airing 4/1
ODH planning a press release 4/8-4/15 to officially launch the campaign.
Saturation through multi-media layering; multiple flights

34. Marketing Campaign Launch
Supporting Projects
Development of website for parents/caregivers (still under development)
Printing/Distribution of brochures, posters, etc.
Expansion/Support of Cribs for Kids in Ohio
Customized Survival Kits (~>3,800 over 2 years) with Ohio marketing materials, Charlie’s Kids books, sleep sacks, fitted crib sheets, pack n plays
CFK sites supported in 9 OEI cities
The CIAG is working on other projects to support the marketing campaign, website and educational materials, also getting resources out into the community by expanding the Cribs for Kids program in Ohio.

35. Partner Projects Ohio AAP Hospitalist & Primary Care QI Projects
Ohio Hospital Association Kits
ODH Safe Sleep Policy and video training
Senator Jones’ SIDS Awareness bill
We’ve also worked closely with these partners to support their projects and ensure there is a coordinated statewide message and approach to promoting safe sleep in Ohio.
Christy – background info on the Ohio AAP projects –
Primary Care QI Project – Ohio AAP has developed an injury prevention quality improvement program that offers Ohio pediatricians a tool to discuss pertinent injury risks children one year of age and younger face at the time of their pediatric office visit
Hospitalist Project – This is a project we are starting focusing on safe sleep in children’s hospitals. What we will be trying to do is teach physicians, nurses and other multi-disciplinary staff) to model safe sleep in the hospital setting, because this has been proven to lead to better sleep practices in the home; an audit form will be used to gauge the initial sleep practices at the hospital and changes over the course of the project. We also hope to incorporate some aspects of parental education and maybe even product distribution (sleep sacks, magnets, etc.). Once we implement this in the children’s hospitals it could be applied outside them as well; I know eventually we want to get the importance of safe sleep modeling into the birthing centers. This is the area we Ohio AAP is looking for the most assistance in right now, including funding and planning.

36. Future ciag projects
Safe Sleep Awards for health care providers, retailers, state agency, etc.
Development of model policies for hospitals and other needed materials based on outcome of SB 276
Development of toolkits for reaching out to pediatricians, OB/GYNs, birthing educators, etc.
Once the marketing campaign is complete, the CIAG committee plans to focus on some other projects to support and promote infant safe sleep here in Ohio including: safe sleep awards, development of model policies and toolkits for working with hospitals and health care professionals.

37. Contact Information
Christy Beeghly, MPH
614/