The Effect of Nursing Quality Improvement and Mobile Health Interventions on Infant Sleep Practices

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

Prevalence and Factors Associated With Safe Infant Sleep Practices

“…36 Several HRSAfunded initiatives 37,38 and the National Institutes of Health-funded Safe to Sleep campaign 7 include provider training modules that integrate effective behavior change methods, such as motivational interviewing. New mobile health message interventions, 39 clinical decision support tools, [40][41][42] and quality improvement initiatives, [43][44][45][46] including CDC-funded perinatal quality collaborative initiatives, 47 also show promise to improve safe sleep practices.…”

Development and Evaluation of Mobile Application for the Prevention of Musculoskeletal Risks in Nursing Work

“…19 The popularity of handheld devices, such as smartphones, with their portability, functionality and connectivity, have been gaining space and social and professional recognition in a number of areas, joining a variety of applications mainly in the area of health. [20][21][22][23][24] The International Labor Organization (ILO) 2 considers that the use of mHealth, encourages the exchange of knowledge and additional research for promotion at work, as well as the World Health Organization, who also encourages the investment of mobile applications for various purposes in areas such as monitoring, epidemiological surveillance, management, care promotion, prevention, and remote patient care, as it allows the individual to have greater participation in their care. 25 With increasing usage and different user profiles, it is important to ensure that applications address usability requirements.…”

Type I Error Control for Cluster Randomized Trials Under Varying Small Sample Structures

“…Second, a model with an added fixed effect for x ij , as in model (2). The doubled difference in maximized log-likelihood was compared to a χ 2 1 distribution since there was a one-parameter difference in model dimension.…”

“…When the response variable of interest is continuous, linear mixed models (LMMs), which require that observations are independent only after conditioning on cluster membership, are a common approach to the data analysis. CRTs are a widely used ex-perimental design (see for example [2][3][4]), and LMMs are an attractive option for data analysis. Some reasons for this attractiveness are that LMMs are robust to certain missing data mechanisms and can flexibly accommodate nested levels of clustering and/or varying cluster sizes [5].…”