Healthy Native Babies Project



Workbook and Toolkit 

Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)

NatioNal iNstitutes of HealtH 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
 


Healthy Native Babies Project Workgroup



Developed with the


Native American Management Services


under contract 3HHSN275200503412C



June 2010 
The information and materials created for the Healthy Native Babies Project were crafted with 

care and revised with the feedback of American Indian/Alaska Native (AI/AN) community 

members, who used the messages at numerous trainings held in U.S. Northern Tier 

communities. 

Just as 
one size fits all does not really apply to clothing, it does not apply to every AI/AN 

community that will use the Healthy Native Babies Project materials. While it is important to 

be consistent about the basic overall safe sleep messages, we encourage you to highlight 

those that best address and tailor those to best address the issues of greatest concern for your 

community. It is our sincere hope that your success will lead to a reduction in the disparate 

number of AI/AN babies dying of Sudden Unexpected Infant Death (SUID)/Sudden Infant Death 

Syndrome (SIDS). 

Healthy Native Babies Project Workgroup 
In memory of Carole Anne Heart 

Contents 

Chapter 1: Facts About Sudden Infant Death Syndrome (SIDS) 1



What is SIDS? 2



How many infants die of SIDS? 2



What causes SIDS? 6



What factors increase the risk for SIDS? 8



Chapter 2: Reducing the Risk 0f SIDS 15



Lowering the Risk of SIDS 16



Back Sleep Position 17



Sleep Surface and Sleep Environment 19



Sleep Location 21



Other Ways to Improve Infant Health and Possibly Reduce SIDS Risk 22



Make Time for Tummy Time! 26



Chapter 3: Strategies for Reaching Communities— 


Know Your Audiences 27
 


The Importance of SIDS Education 28



Who are the primary audiences? 28



A Critical Primary Audience: Child Care Providers 32



Who are the secondary audiences? 33



Critical Steps to Building a Positive Relationship Between 


Provider and Patient/Client 35



Outreach to Hard-to-Reach and Underserved Populations 38



Chapter 4: Strategies for Reaching Communities— 


Action Steps to Reduce the Risk of SIDS 45



SIDS Impacts the Entire Community 46
 


Health Education Approaches 47
 


The SOCO (Single Overriding Communications Objective) 51



Grassroots Organizing and Community Outreach 52 
 

Social Marketing 54



Forging Partnerships 55


Sample Outreach Activities 59
 


Chapter 5: Planning and Sustaining a Healthy Native Babies Project 61



A True Community Effort 62



Develop the Program Proposal or Plan 62



Sustainability Through Community-Based Program Development 62



Funding Applications 65



Implementation: Putting the Plan into Action 66



Evaluation 67
 


Acknowledgements 71



History of the Healthy Native Babies Project 74



Appendix 1: Abbreviations and Acronyms 78
 


Appendix 2: Ways to Reduce the Risk of SIDS 79



Appendix 3: Public Health Education Approaches— 


Selected Theories and Models 81



Appendix 4: Working with the Media and the Single Overriding 


Communications Objective (SOCO) 86



Appendix 5: Information Sources 91


Chapter 1: 

Facts About Sudden Infant 

Death Syndrome (SIDS) 

Objectives 

By the end of this chapter the learner will be able to: 

• Define SIDS. 

• Explain how many infants die of SIDS and recognize the

disproportionately higher SIDS rates among American

Indian/Alaska Native (AI/AN) infants. 

• Describe what is currently known about SIDS causes and risk

factors, especially risk factors common in AI/AN communities. 
 

2 

Chapter One 

What is SIDS? 

SIDS is the term used to describe the unexpected death of an infant younger than one year 

of age that remains unexplained after a thorough investigation. 

Each year in the United States, more than 4,500 infants die suddenly from no obvious 

cause. These deaths, called Sudden Unexpected Infant Death (SUID), occur suddenly and 

unexpectedly and the cause of death is not immediately obvious before an investigation. 

The SUID category includes both explained infant deaths, such as poisoning or car accident, 

and unexplained infant deaths. SIDS is listed as the cause of one-half of all deaths in the 

SUID category. SIDS is also the leading cause of all deaths among infants between one 

month and one year of age. 

A diagnosis of SIDS is made by collecting information, conducting scientific or forensic 

tests, and talking with parents, other caregivers, and health care providers. If, after this 

process is complete, there is still no identifiable cause of death, the infant’s death might be 

labeled as SIDS. 

SIDS is defined as: 

The sudden death of an infant younger than one year of age that 

remains unexplained after a thorough case investigation, including 

performance of a complete autopsy, examination of the death scene, 

and review of the clinical history.1 

The exact cause or causes of SIDS are not known. Based on scientific research, researchers 

now believe that babies who die of SIDS may be born especially vulnerable to both internal 

influences, such as brain abnormalities, and external influences, such as exposure to tobacco 

smoke in the environment. 

Even though there is no certain way to prevent SIDS or to predict which infants may die of 

SIDS, there are ways to reduce an infant’s risk for SIDS; these risk-reduction strategies are 

explained in the Chapter 2 of this Workbook. 

How many infants die of SIDS? 

The most current data from the Centers for Disease Control and Prevention (CDC) 

show that 2,323 infants died of SIDS in the United States in 2006. Although the overall 

SIDS rate in the United States has been steadily declining since the early 1990s, SIDS 

1

Willinger, M., James, L.S., & Catz, C. (1991). Defining sudden infant death syndrome (SIDS): Deliberation of an expert panel 

convened by the National Institute of Child Health and Human Development (NICHD). Pediatric Pathology, 11(5), 677-684. 

Visit Appendix 1 

for a list of 

abbreviations and 

acronyms and 

their explanations. 
 

rates remain high among certain groups, including 

American Indians/Alaska Natives (AI/ANs). Efforts to 

further reduce SIDS need to continue, especially within 

groups at higher risk. 

An Important Decline 

Between 1983 and 1992, the average number of 

SIDS deaths reported in the United States ranged 

from 5,000 to 6,000 each year. In 1992, the American 

Academy of Pediatrics (AAP) Task Force on Infant Sleep 

Position and SIDS (now called the AAP Task Force on 

SIDS, and called the AAP Task Force in this Workbook) 

recommended that all healthy babies younger than one 

year of age be placed to sleep on their backs or sides to 

reduce the risk of SIDS. This recommendation came 

after many international research studies reported that 

infants who slept on their stomachs had a significantly 

higher risk of dying from SIDS than those who slept on 

their sides or backs. 

In 1994, the Eunice Kennedy Shriver National Institute 

of Child Health and Human Development (NICHD) 

and a number of partners, including the AAP, the 

Maternal and Child Health Bureau of the Health 

Resources and Services Administration, the SIDS 

Alliance (now called First Candle/SIDS Alliance), 

and the Association of SIDS and Infant Mortality 

Programs, launched the Back to Sleep campaign to 

raise awareness among parents and caregivers about 

ways to reduce the risk of SIDS. The campaign’s top 

recommendation for reducing the risk of SIDS was to 

place healthy infants on their backs to sleep. 

In 1996, after more data were gathered about the 

dangers posed to infants who slept on their stomachs, 

the AAP Task Force recommended that all healthy 

babies be placed to sleep wholly on their backs, the 

position associated with the lowest SIDS risk. The 

AAP Task Force concluded that: 

> Stomach sleeping poses the highest risk of SIDS; 

> Side-lying position falls in between stomach and 

back sleeping in terms of risk; and 

> “Back is best” for reducing a baby’s risk of SIDS. 

SIDS is: 

• The leading cause of death for infants between 

one month and one year of age, 

with most deaths occurring between two 

months and four months of age (90 percent 

of SIDS deaths occur by six months of age 

• Least common during an infant
s first 

postnatal month, between one day and 

28 days after birth 

• A sudden and silent medical disorder that can 

happen to an infant who seems to be healthy 

• A death often associated with the sleep 

period and with little or no signs of suffering 

• Determined only after an autopsy, 

examination of the death scene, and a review 

of the infant
 s and family
 s clinical histories 

• A "diagnosis of exclusion," meaning the 

cause of death is labeled as SIDS only after 

ruling out other causes 

• Slightly more common among male 

infants and slightly more common during 

the winter months 

• A death which leaves unanswered questions 

and causes intense grief for parents, families, 

and communities 

SIDS is not: 

• Entirely preventable, but the risk can be reduced 

• The same as suffocation 

• Caused by vomiting and/or choking 

• Caused by diphtheria, pertussis, and tetanus 

(DPT) vaccine, or by other immunizations, 

shots, or vaccinations 

• Contagious or catchable 

• The result of child abuse or neglect 

• Caused directly by cribs 

• The cause of every unexpected infant death 
4 

Chapter One 

 

Figure 1. 

U.S. SIDS Rate and Sleep Position, 1988	2006 


 


 

 

 

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 20002001 20022003 2004 20052006 

100

50

SIDS Rate

(Per 1,000 Live Births) 

1.5
 

1
 

0.5

0.0

1.4 1.39

1.3 1.3

1.2 1.17

1.03

.87

.74 .72 .67 .62

.56 .57

.53

.77

.56 .54 .55

13 17

26.9 38.6 35.3

53.1 55.7

64.4 66.6

71.6 71.1 72.8 70.1 72.2 75.7

Percentage Back Sleeping 

Pre-AAP Recommendation Post-AAP Recommendation Back to Sleep Campaign 

0

Sources: SIDS rate source: National Center for Health Statistics, Centers for Disease Control and Prevention, Department

of Health and Human Services.27, 29 Sleep position data: Eunice Kennedy Shriver National Institute of Child Health and 

Human Development, National Infant Sleep Position Study.30, 31 

Data from 2004 indicate that the overall U.S. SIDS rate has declined by more than 

50 percent since the AAP Task Force’s initial recommendation in 1992. The SIDS rate 

among AI/ANs has also declined by about 50 percent since the 1990s. In addition, stomach 

and side sleeping decreased during the same period (see Figure 1). Many researchers, policy 

makers, and health care providers agree that declines 

in SIDS and stomach sleeping rates were assisted by 

public awareness campaigns, such as Back to Sleep. 

More Work to Do 

Despite the overall decline in U.S. SIDS rates, 

SIDS remains the leading cause of death among 

U.S. infants between one month and one year of 

age. SIDS is also the third leading cause of death 

overall among U.S. infants younger than one year 

of age. Even more troubling is the fact that SIDS 

rates remain high among certain ethnic/racial 

groups in the United States, including AI/ANs. 

The SIDS rate for AI/ANs is two to four times 

higher than the national average (see Figure 2). 

SIDS is the leading single cause of post-neonatal 

deaths (deaths that occur between 28 days and 

one year of age) for AI/AN infants. 

A further breakdown of the data shows some 

important trends in the SIDS rates for AI/ANs 

in Indian Health Service (IHS) Areas compared to 

Is the decline in SIDS deaths real? 

It is true that overall SIDS rates in the United States 

have declined, and that knowledge about SIDS has 

increased. But recent studies suggest that some 

deaths reported as SIDS would now be classified as 

“accidental suffocation or smothering” or from an 

“unknown or unspecified” cause. These data could 

mean that changes in reporting a cause of death 

may also play a slight role in the decrease reported 

since 1999. 

Differences in autopsy procedures, death-scene 

examination, review of family/medical history, 

and other information could lead to inaccurate 

diagnosis. These differences could impact the 

reliability of some SIDS statistics and have 

implications for the family. It is important, then, 

that all those involved with gathering and reporting 

such data follow standard procedures to ensure 

consistent and reliable collection of information. 
5 

Facts About Sudden Infant Death Syndrome (SIDS) 

urban Indians. (The Healthy Native Babies Project focuses on five IHS areas.) Figure 3 shows 

the SIDS rates for those who reside in these IHS areas compared to the overall rate for all 

IHS areas and compared to the SIDS rate for all races, for the period 2002 to 2004. Figure 4 

compares the SIDS rate for urban Indians in large metropolitan counties across the United 

States to the SIDS rate for all races in the same counties for the period 1997 to 2003. 

Figure 2. 

SIDS Deaths by Race/Ethnic Origin of the Mother, 2005 

Race Number Rate Per 1,000 Live Births 

All Races 2,234 0.54 

American Indian/Alaska Native 50 1.12 

African American 580 0.99 

White 1,264 0.55 

Hispanic277 0.28 

Asian/Pacific Islander 55 0.24 

Source: Matthews, T.J., Menacker, F., & MacDorman, M.F. (2008). Infant mortality statistics from the 2005 period linked

birth/infant death data set. National Vital Statistics Report, 52(2). 

Figure 3. 

AI/AN SIDS Rates for IHS Area Counties 

2002	2004* 


 


 

Aberdeen 

Alaska 

Bemidji 

Billings 

Portland 

All IHS Areas

U.S. All Races 

(Average) 

2.5

2.0

SIDS Rate

(Per 1,000 Live Births) 

1.5

1.0

0.5
 

0.0
 

IHS Areas 

*Source: National Center for Health Statistics, prepared by IHS Office of 

Program Statistics 

Figure 4. 

AI/AN SIDS Rates for Urban 

Indian Health Organization

Counties, 1997	2003* 


 


 


 

AI/AN 

All Races 

1.6

1.4

1.2

1.0

0.8

SIDS Rate

(Per 1,000 Live Births) 

0.6
 

0.4
 

0.2
 

0.0
6 

Chapter One 

The pie charts in Figure 5 compare the SIDS rate for each IHS Area with the rates of all 

other causes of death. It is important to note that each of the IHS Areas had a SIDS rate 

greater than the overall SIDS rate for AI/ANs and more than three times the SIDS rate for 

all races in the United States. 

Just as the work of the Back to Sleep campaign has been critical to increasing awareness about 

SIDS and to decreasing SIDS rates and risk factors, your work within AI/AN communities is 

critical to addressing and eliminating disparities in SIDS rates. Outreach and education can 

make a difference in saving infant lives—and your efforts within these communities and IHS 

Areas are critical to making that difference. 

Figure 5. 

SIDS Rates Versus All Other Causes of Death: IHS Areas 

87% 

13% 

89% 

11% 

84% 

16% 

SIDS Deaths 

All Other Deaths 

Aberdeen Alaska Bemidji 

86% 

14% 

91% 

9% 

85% 

15% 

Billings Portland Urban 

What causes SIDS? 

Researchers and health care providers don’t know exactly what causes SIDS, but there are 

many theories. 

More and more research evidence suggests that 

some infants who die of SIDS are born with brain 

abnormalities or defects. These abnormalities are typically 

found within a network of nerve cells that rely on the 

neurotransmitter serotonin. The cells are located in part 

What is a neurotransmitter? 

A neurotransmitter is a chemical that allows 

one nerve cell to send a nerve signal to another 

nerve cell(s). 
 

 

 

 

Facts About Sudden Infant Death Syndrome (SIDS) 

of the brain stem that probably controls 

breathing, heart rate, blood pressure, 

temperature, and waking from sleep. 

But scientists believe that brain defects 

alone may not be enough to cause a SIDS 

death. Evidence suggests that other events, 

such as not getting enough oxygen, getting 

too much carbon dioxide, overheating, or 

having an infection, must also occur for 

an infant to die from SIDS. Researchers 

use the Triple-Risk Theory to explain this 

concept. In this theory, all three factors 

have to be present for SIDS to occur. 

Having only one of these features may not 

be enough to cause death from SIDS, but 

when all three combine, the likelihood of 

SIDS is high (Figure 6 ). These factors are: 

> Vulnerable Infant. The infant has 
 

an unknown body defect or brain 
 

abnormality, which puts him or her 

in a weak position. The unknown 

problem could be a defect in the part 

of the brain (called the arcuate nucleus) that controls breathing and waking from sleep; 

or it could be a mutation or change in the infant’s genes that impacts how the body 

works. As a result, the infant might not be able to respond to different situations, such 

as when he or she isn’t getting enough oxygen or when he or she is taking in too much 

carbon dioxide. The vulnerable infant might not be able to awaken from sleep the way a 

normal infant does. Health care providers, parents, and families don’t know about these 

problems, so there is no way to know which infants are vulnerable. 

> Critical Developmental Period. During the first six months after birth, infants go 

through many quick phases of growth that can change the body’s ability to adjust or 

regulate itself—its temperature, breathing rate, heart rate, and sleeping and waking 

patterns. Some of these changes may make the infant’s body systems unstable. It is 

hard for health care providers to know when an infant’s internal system is unstable or 

how long it might be that way. It is impossible for parents and families to know when 

these critical periods are taking place. 

> Environmental Stress(es). All infants encounter stresses in their environments. These 

situations (sometimes called external or outside stressors) can include being placed to 

sleep on the stomach, tobacco smoke in the environment, overheating, and infections. 

Infants who have no problems like those explained above can usually correct or 

overcome such external stresses to survive and thrive. But, an infant who is vulnerable 

and whose body system is unstable because of a critical developmental period might 

not be able to overcome these stresses. 

7 

Outside Stressor(s) 

Vulnerable 

Infant 

Critical 

Developmental

Period 

SIDS

Figure 6. 

Triple-Risk Theory 

Adapted from Filiano & Kinney 1994.
Chapter One 

8 

According to the Triple-Risk Theory, all three situations must be present for SIDS to occur: 

1. First, the baby has an unknown or undetected problem or vulnerability. 

2. Then, as the infant goes through a critical developmental period, his or her body 

systems are unstable. 

3. Finally, the infant encounters one or more environmental stresses, but, because of 

the first two situations, he or she can’t overcome the stresses and dies from SIDS. 

For example, many babies experience low oxygen levels and high carbon dioxide levels 

when they have respiratory infections. Or they might re-breathe air they’ve already breathed 

out, which is high in carbon dioxide and low in oxygen, when this air becomes trapped 

in bedding while they sleep on their stomachs. Normally, infants sense these situations, 

and their brains make them wake up or change their heartbeats or breathing to get more 

oxygen. If the infant is vulnerable because of a brain defect, these protective triggers might 

be missing, so the child may die of SIDS. Such a scenario might explain why babies who 

sleep on their stomachs are at higher risk for SIDS. 

Removing one of these factors from the situation may tip the balance in favor of the baby’s 

survival. Because the first two factors—vulnerable infant and critical developmental period— 

either can’t be seen or are hard to pinpoint, the most effective way to improve an infant’s 

outcome is to remove or reduce environmental stresses. In the Triple-Risk Theory, all 

three factors must be present for SIDS to occur. If caregivers remove one of the factors—such 

as getting rid of an outside stressor by placing an infant to sleep on his or her back—they can 

significantly reduce the risk of SIDS. 

What factors increase the risk for SIDS? 

Currently, there is no known way to completely prevent SIDS, but there are ways to reduce 

the risk. Several factors present before the baby is born, at birth, and throughout the first year 

can impact SIDS risk. Many of these factors can be controlled or changed to reduce risk. 

Controllable risk factors, including those that might be more common in Native 

communities, that put infants at higher risk for SIDS are: 

> Overheating during sleep 

 Maternal alcohol use (during pregnancy and after the birth of the infant) 

> Commercial tobacco use (during pregnancy and in the baby’s living environment) 

> Bed sharing (especially when the adult has used alcohol or drugs or is tired) 

> Stomach sleeping during naps and at night 

> Soft sleeping surfaces and loose, fluffy bedding 

Let’s examine each of these risk factors in more detail. 

>

For resources 

and supporting 

information on 

SIDS and SIDS 

risk factors, see 

Appendix 5. 
 

Facts About Sudden Infant Death Syndrome (SIDS) 

9 

Overheating 

Studies show that an overheated baby is more likely to sleep 

too deeply and have a hard time waking up. This situation 

may play a role in SIDS. 

Babies should be warm during sleep, but not too warm. 

An overheated infant might sweat, have damp hair, and 

show flushed/red cheeks, heat rash, and/or rapid breathing. 

Overheating can result from the room temperature being too 

high, from the infant wearing too many layers of clothes or 

blankets, or from both situations. 

> Place the baby with feet at the end 

of the crib or sleep space. 

> Tuck the ends of the blanket under 

the mattress or pad. The blanket should 

come no higher than baby’s chest level 

to help ensure safety. 

> Make sure to keep the blanket away 

from the baby’s face. 

> Use only light sleep clothing—a diaper, 

onesie, t-shirt, or sleeper—under 

the blanket so that the baby sleeps 

comfortably and stays warm, but not 

too warm. 

What about swaddling? 

Swaddling is a common practice that

many believe helps a young infant feel

safer and more secure. If caregivers 

swaddle the baby, it is important to

consider what else the baby is wearing

and the temperature where the baby is 

sleeping. A swaddled baby probably does 

not need an additional blanket in his or 

her sleep space. After about two months 

of age, infants may be moving around 

Studies show that SIDS deaths seem to occur more often more in their sleep and will not need the 

during the winter months, when caregivers are more likely to 

overdress babies to keep them warm. As awareness about SIDS 

risk has increased, the rates of SIDS in winter and summer 

have evened out a bit. In the Aberdeen Area Infant Mortality Study, conducted among 

AI/AN families, researchers found that a baby’s SIDS risk was higher if he or she was wearing 

two or more layers of clothing. Other research showed that overheating might increase the 

risk of SIDS if the baby is already sick with a cold or infection, even though having a cold or 

infection by itself is not a risk factor for SIDS. 

Safe sleep recommendations suggest dressing baby in light sleep clothing, without 
 

a blanket, and keeping the room at a temperature that is comfortable for an adult. 
 

If parents and caregivers choose to use a blanket in the baby’s sleeping space, you can 

advise them to use the blanket safely (sometimes called the “feet to foot” method) in the 

following way: 

For resources 

on overheating

and SIDS, see

Appendix 5.

 
10 

Chapter One 

Maternal Alcohol Use 

Drinking Alcohol During Pregnancy 

During pregnancy, a baby eats and drinks everything that the mother eats or drinks, and 

alcohol is no exception. Using alcohol during pregnancy is known to cause both physical 

and mental problems, including permanent brain damage and developmental delays. 

The effect of alcohol depends on the mother’s and 

baby’s genes and on the amount of alcohol consumed. 

Based on research data, there is no safe level of alcohol 

consumption during pregnancy—this means that even 

one drink could be harmful and can increase a baby’s risk 

for lifelong problems. 

Maternal drinking during pregnancy increases an infant’s risk 

for SIDS once he or she is born. For instance, the Aberdeen 

Area Infant Mortality Study, which included participants 

from 10 Northern Plains Indian communities, found that: 

> Binge drinking (five or more drinks at one time) during 

the mother’s first three months of pregnancy increased 

the risk of SIDS to eight times that of infants whose 

mothers did not drink. 

> Any alcohol use three months before a woman 

got pregnant and during the first three months of 

pregnancy increased the risk of SIDS to six times that 

of infants whose mothers did not drink during the 

same time periods. 

One of the most serious problems caused by 

alcohol use during pregnancy is Fetal Alcohol 

Syndrome (FAS) a group of lifelong problems 

that can include: 

• Preterm birth (which also increases the 

risk for SIDS by itself) 

• Low birth weight (which also increases 

the risk for SIDS by itself) 

• Physical deformities 

• Hearing and vision problems 

• Growth deficits 

• Problems with motor skills 

• Learning difficulties and language 

problems 

• Hyperactivity 

• Attention, memory, and judgement 

problems 

Women who are planning to become pregnant or who are pregnant should not 

drink any alcohol. 

Drinking Alcohol After the Baby Is Born 

Drinking alcohol and then breastfeeding gives the baby a direct dose of alcohol through the 

breastmilk. This direct dose can lead to drowsiness, deeper sleep, weakness, and decreased 

growth. Babies and adults who have alcohol in their systems may be less able to wake 

up and respond to stressors in their environment. As a result, babies exposed to alcohol 

by breastfeeding might not be able to change their breathing to meet their body’s needs, 

especially if they are also overheated, or encounter other risks in the sleep environment. 

In general, a breastfeeding mother should not drink alcohol. 

If a mother decides to drink alcohol despite breastfeeding, you might want to suggest that 

she wait until after the alcohol has cleared her system before she feeds and cares for the baby. 

Depending on a mother’s weight and other factors, it can take as long as 18 hours after 

drinking for the alcohol to leave the mother’s body. You could also suggest that the mother 

For resources on 

maternal alcohol 

use and SIDS, see 

Appendix 5. 
Facts About Sudden Infant Death Syndrome (SIDS) 

11 

use a breast pump to express and store milk ahead of time, so that the baby can have stored 

alcohol-free milk until the mother’s body is free of alcohol. The safest option for the baby is 

for the mother not to drink at all while she is breastfeeding. Mothers and families should talk 

with a lactation consultant or other health care provider about concerns related to drinking 

alcohol and breastfeeding. 

Commercial Tobacco Use 

Smoking clearly impacts not only risk for SIDS, but also overall health of the mother and 

baby in the form of higher risk for other problems, including cancers and lung problems. 

Smoking During Pregnancy 

One of the most important things a mother-to-be can do for her baby is to not smoke 

cigarettes or use other commercial tobacco products during pregnancy. Infants of mothers 

who smoked during pregnancy are up to four times more likely to die of SIDS than children 

whose mothers did not smoke during pregnancy. 

Tobacco use during pregnancy can decrease the amount of oxygen the baby gets. This 

situation could decrease growth and function in the baby’s brain, nerves, and other organs 

as they develop. Tobacco use during the last half of pregnancy can cause changes in the 

baby’s brain that affect his or her ability to wake up and his or her ability to adjust breathing, 

heart rate, and control of movements. These changes could place the infant at higher risk 

for SIDS. In addition, pregnant women who smoke are at higher risk for pregnancy loss, 

preterm labor and birth, and having a low birth weight infant. 

Women should not smoke during pregnancy. 

Smoke in the Infant’s Living Environment 

Research estimates that commercial tobacco smoke includes more than 4,000 chemicals in 

addition to nicotine, the chemical most people know about. Scientists have identified more 

than 250 chemicals in tobacco smoke that are toxic (harmful or deadly). Tobacco use in the 

home or around the baby exposes the infant to second-hand nicotine and toxic chemicals. 

Infants whose caregivers smoke or who are exposed to second-hand smoke are at four times 

greater risk for SIDS than are infants whose caregivers do not smoke. In addition, infants 

who died of SIDS had higher nicotine concentrations in their lungs than infants who died 

from other known causes. 

A great deal of data indicates that infants who live in households where someone smokes 

are more likely to have respiratory infections, asthma (a serious breathing problem that 

can be life threatening), ear fluid problems, and more hospitalizations than those who live 

in smoke-free households. Second-hand smoke is especially hard on infants and children 

because their lungs and body systems for removing such toxins are still developing. 

A lesser-known result of smoking is that it reduces an adult’s ability to wake up. It also 

increases the risk of sleep apnea, a condition in which a person does not get enough air into 

the lungs during sleep. People with sleep apnea often snore loudly, pause in their breathing 

for several seconds, and then start normal breathing with a snort or choking sound. Sleep 

For resources on 

breastfeeding, 

see page 22. 

For resources on 

commercial tobacco 

use and SIDS, see 

Appendix 5. 
12 

Chapter One 

apnea is a known risk factor for cardiovascular disease (a group of problems related to the 

heart and blood vessels), but it also lowers the quality of sleep for those who have it. Lost or 

poor-quality sleep resulting from apnea can sometimes make it difficult for an adult to care 

for a baby during the night or to stay alert during the day. 

Parents should not smoke or allow others to smoke around the baby. 

Bed Sharing 

Even though bed sharing between an infant and an adult(s) is common, especially in certain 

cultures, the practice is hotly debated. On the one hand, research evidence shows that 

bed sharing can greatly increase the risk of SIDS, and that it is quite dangerous in certain 

situations. On the other hand, mothers and caregivers feel that bed sharing makes bonding 

and breastfeeding easier. 

The research evidence related to bed sharing and SIDS risk shows a clear increase in overall 

risk and a significant risk increase in specific situations. For instance, SIDS risk is significantly 

higher when an infant: 

> Shares a bed with other children; or 

> Is placed on a sofa to sleep; or 
 

> Sleeps in a bed with a mother who smokes cigarettes; or
 


> Sleeps in a bed with an adult who has been drinking alcohol; or 

> Is younger than 11 to 14 weeks of age; or 

> Sleeps in a bed with more than one bed sharer (more than one adult or sibling), 

especially if the infant is sleeping between two adults. 

Because of this evidence, the AAP Task Force recommends that babies be placed 

in a sleep area close to but separate from where others sleep. 

Some people suggest that bed sharing makes breastfeeding and bonding easier. Indeed, one 

study found that babies who bed share and breastfeed wake up more often, which may prevent 

the infant from going into the deep sleep 

linked to SIDS risk. However, the risks seem 

to outweigh any benefits that bed sharing may 

provide, especially in any of the situations listed 

above. Having baby’s sleep area in the same 

room as the parents, even right next to the bed 

in a bedside co-sleeper (a separate infant sleep 

area that attaches to an adult bed), as shown on 

left, or another safe sleep area, makes it easy to 

breastfeed and to touch the infant during the 

night while still reducing the SIDS risk. Studies 

have shown that room sharing with the parents 

decreases the risk of SIDS. 

For resources 
 

on bed sharing 

and SIDS, see 
 

Appendix 5. 
Facts About Sudden Infant Death Syndrome (SIDS) 

13 

Many people believe that bed sharing reduces SIDS risk because the adult or bed sharer will 

be able to hear any problems with the infant and to take action more quickly. However, there 

is no evidence to support this claim. If the bed-sharing situation is like any of those listed 

earlier, then the risk for SIDS is known to be greater. 

Chapter 2 of this Workbook explains more about bed sharing and SIDS risk. 

Stomach Sleeping 

Stomach sleeping carries between 1.7 times and 12.9 times the SIDS risk of back sleeping, 

depending on other factors. 

Exactly how stomach sleeping might lead to SIDS is not known. Studies suggest that 

stomach sleeping may increase SIDS risk through a variety of mechanisms. Stomach 

sleeping could: 

> Increase the likelihood of re-breathing exhaled breath, which is high in carbon dioxide 


and low in oxygen; 


> Block or obstruct in the upper airway; or 

> Get in the way of the body’s ability to cool itself, leading to overheating. 

When compared to infants placed on their backs to sleep, infants who sleep on their stomachs: 

> Are less reactive to noise; 

> Experience sudden drops in blood pressure and heart rate control; and 

> Experience less movement, difficulty waking up (sometimes called a high 
 

arousal threshold), and longer periods of deep sleep.
 


All of these characteristics may put an infant at higher risk of SIDS. 

The single most effective action that parents and caregivers can take to lower 


their baby’s SIDS risk is to place the baby on his or her back to sleep for naps 


and at night. 


Whatever the mechanism, evidence from numerous countries, including New Zealand, 

Sweden, and the United States, shows that placing babies on their backs to sleep results in a 

major decline in the SIDS rate compared to placing babies on their stomachs to sleep. The 

simple act of placing infants on their backs to sleep significantly lowers SIDS risk and can 

save infant lives. 
14 

Chapter One 

Soft Sleeping Surfaces and Loose, Fluffy Bedding 

Sleep surface and bedding are an important but often overlooked risk factor for SIDS. 

It makes sense that a soft sleep surface and loose bedding would be dangerous in terms of risk 

for SIDS or suffocation if an infant is placed on the stomach to sleep. Infants’ muscles are 

not well developed enough to move the face or nose/mouth if they become blocked in soft 

surfaces or by loose bedding. And, in fact, multiple studies have found the combination of 

stomach sleeping and soft sleep surfaces and/or loose bedding to be very hazardous. 

But research also shows that soft sleeping surfaces and loose, fluffy bedding are strong 

risk factors for SIDS even among babies placed on their backs to sleep. The same result 

was found for infants placed on their backs to sleep on adult beds. It is unclear what the 

mechanism might be or why the risk is higher on soft sleep surfaces; some theories suggest 

the baby’s airways are constricted if it lies “in” the surface rather than on top of the surface. 

Loose bedding, fluffy bedding, and other soft or stuffed objects in the sleep area can increase 

SIDS risk because they could end up covering the baby’s face and head. 

In the 1970s, the Consumer Product Safety Commission (CPSC) began setting safety 

standards for different crib features, such as minimizing the space between slats and ensuring 

that the mattress fits snugly into the crib frame. In 1998, the CPSC, in collaboration with 

the NICHD and AAP, issued a safety alert to tell parents and caregivers to place infants to 

sleep on a firm crib mattress and to remove all soft 

bedding from the crib. A few years later, the CPSC 

began setting standards for the firmness or softness 

of crib mattresses. Such “safety-approved” cribs are 

recommended to ensure a safe sleep environment. For 

more information on crib safety, visit the CPSC Web 

site at http://www.cpsc.gov/info/cribs/index.html. 

Parents and caregivers should avoid placing infants 

to sleep on any soft surfaces, including those not 

related to a crib, such as couches, armchairs, sofas, 

waterbeds, and adult mattresses (which are usually 

softer than crib mattresses). Placing baby to sleep 

on quilts, sheepskins, or pillows, even on top of a 

safety-approved crib mattress, also increases the risk 

for SIDS. 

Parents and caregivers should place their baby 

to sleep on a firm sleep surface, such as on a 

safety-approved crib mattress, covered by a 

fitted sheet and free of any soft toys or loose 

bedding. This is the safest sleep environment 

for baby. 
 

Chapter 2: 

Reducing the Risk of SIDS 

Objectives 

By the end of this chapter the learner will be able to: 

• Define actions that can reduce an infant
 s risk for SIDS, including 

those that address risk factors more common among AI/ANs. 

• Identify alternative sleep surfaces, including cradleboards. 

• Explain ways to lower SIDS risk associated with infant sleep location. 

• Describe situations that may improve infant outcomes and further

reduce the risk for SIDS. 

• Explain Tummy Time and why it is important for infant health. 
16 

Chapter Two 

 

 

 

 

 

 

 

Lowering the Risk of SIDS 

Even though SIDS is not completely preventable and there is no way of knowing which 

babies might die of SIDS, there are things parents and caregivers can do to reduce the risk of 

SIDS, including: 

Always place the baby on his or her back to sleep for naps and at night. The back 

sleep position is the safest, and every sleep time counts. 

Place the baby to sleep on a firm sleep surface, such as on a safety-approved* crib 

mattress, covered by a fitted sheet. Never place the baby to sleep on pillows, quilts, 

sheepskins, or other soft surfaces. 

Keep soft objects, toys, and loose bedding out of the baby’s sleep area. Don’t use 

pillows, blankets, quilts, sheepskins, or pillow-like crib bumpers in the baby’s sleep area, 

and keep all items away from the baby’s face. If you choose to use a blanket, place the 

baby with his or her feet at the end of the crib. The blanket should reach no higher than 

the baby’s chest. Tuck the ends of the blanket under the crib mattress to ensure safety 

(see page 9 for an example of “feet to foot”). 

Do not smoke during pregnancy and do not allow smoking around the baby. 

Don’t smoke before or after the birth of the baby, and don’t let others smoke around 

the baby. 

Do not drink alcohol during pregnancy or when breastfeeding. Alcohol use during 

pregnancy is a known cause of both physical and mental problems, including permanent 

brain damage, developmental delays, and increased risk of SIDS. Infants can also be 

exposed to alcohol through breastmilk, so women who are breastfeeding should not 

drink alcohol. 

Keep the baby’s sleep area close to but separate from where you and others sleep. 

The baby should not sleep in a bed or on a couch or armchair with adults or other 

children, but he or she can sleep in the same room as adults or other children. If you 

bring the baby into bed with you to breastfeed, put him or her back in a separate sleep 

area, such as a bassinet, crib, cradle, or bedside co-sleeper (an infant bed that attaches 

to an adult bed) when finished. 

Think about using a clean, dry pacifier when putting the baby to bed, but don’t 

force the baby to take it. If breastfeeding, wait until the baby is one month of age or is 

used to breastfeeding before trying a pacifier. 

Do not let the baby get overheated during sleep. Dress the baby in light sleep 

clothing only, and keep the room at a temperature that is comfortable for an adult. 

Appendix 2 of 

this Workbook 

includes a handout 

of these safe sleep 

recommendations 

that you can copy 

and give out 

during Healthy 

Native Baby 

Project gatherings 

and events. 

You can also use 

the Healthy Native 

Baby Project Toolkit 

Disk to create your 

own safe sleep 

materials, with 

language and 

images specific 

to your intended 

audience and 

IHS Area. 

* For information on crib safety, contact the Consumer Product Safety Commission at http://www.cpsc.gov or at 

1-800-638-2772, or talk to your health care provider. 
 

 

 

 

17 

Reducing the Risk of SIDS 

Avoid products that claim to reduce the risk of SIDS or to safely position 
 

the infant because most have not been tested for effectiveness or safety. Avoid 
 

products made of foam rubber or of visco-elastic polyurethane foam (also known 
 

as Memory FoamTM).
 


Do not use home monitors to reduce the risk of SIDS. If you have questions about 

using monitors for other conditions, talk to your health care provider. 
 


 

Reduce the chance that flat spots will develop on the baby’s head. Provide Tummy 
 

Time when the baby is awake and someone is watching; hold the baby upright when he 

or she is not sleeping; change the direction that the baby lies in the crib from one week 


to the next; and avoid too much time in car seats, carriers, and bouncy seats. (See the 
 

additional information about Tummy Time on page 25.)




 

Other things that improve infant outcomes and that may reduce SIDS risk include: 

breastfeeding; getting early and regular prenatal care and preconception care; and having 
 

Public Health Nurses visit the home.
 


The rest of this chapter describes some of these risk-reduction strategies in more detail and 

includes ways to address related issues more common in AI/AN communities. 

Back Sleep Position 

The single most effective action that parents and caregivers can take to lower 
 

their baby’s risk for SIDS is to always place the baby on his or her back to sleep 
 

for naps and at night. 
 

Researchers do not know exactly how back sleeping is protective, but studies from all over 

the world have shown that babies are safer sleeping on their backs. Researchers established 

the link between stomach sleeping and SIDS by observing dramatic decreases in SIDS rates 

in countries where public health campaigns to reduce stomach sleeping have been successful. 

In areas where stomach sleeping is rare (such as Hong Kong), SIDS rates are historically very 

low, which further strengthens the association. 

Every Sleep Time Counts 

Research shows that infants who are used to sleeping on their backs, but who are then placed 

to sleep on their stomachs or sides, are at greatly increased risk of SIDS—greater than the 

increased risk of infants who are always placed to sleep on their stomachs or sides. One study 

found that if an infant who was usually placed to sleep on his or her back was then placed 

to sleep on his or her stomach or side, his or her SIDS risk was seven to eight times greater 

than that of an infant always placed to sleep on the stomach or side. Make sure caregivers tell 

everyone who cares for baby to always place the baby to sleep on his or her back—for every 

sleep time. 
18 

Chapter Two 

How to Counter Fears of Choking 

Many parents and caregivers fear that babies placed on their backs to sleep are more likely to 

choke on spit up or vomit. Because of this fear, they might not place the baby on his or her 

back to sleep. It’s important to address this fear head on with the following fact: There is no 

evidence that choking is more common among healthy babies sleeping on their backs than among 

healthy babies sleeping on their stomachs. 

Cases of fatal choking are very rare, except when the infant had an underlying or associated 

medical condition. In most of the few reported cases of death due to choking, the infant’s 

sleep position at death, when known, was on the stomach. 

Babies might actually clear vomit and other secretions better when placed on their backs. 

The figures below show the location of the trachea and the esophagus in the back sleeping 

(Figure 7A) and stomach sleeping (Figure 7B) positions. When a baby is in the back sleeping 

position, the trachea (airway or windpipe) lies on top of the esophagus (gullet or tube to 

stomach). Anything thrown up or refluxed from the esophagus must work against gravity to 

reach the trachea. When a baby is in the stomach sleeping position, anything thrown up or 

refluxed will pool at the opening of the trachea, making it easier for the baby to choke. 

Figure 7. 

Orientation of the Trachea to the Esophagus 

 

Trachea 

Esophagus 

Figure 7A.

Upper-Respiratory Anatomy:

Baby in the Back Sleeping Position 

 

Esophagus 

Trachea 

Figure 7B.

Upper-Respiratory Anatomy:


Baby in the Stomach Sleeping Position
 

19 

Sleep Surface and Sleep Environment 

Caregivers can reduce SIDS risk by changing features of the infant’s sleep 

environment, such as using a firm sleep surface and removing soft, loose objects 

from the sleep area. 

Use a Firm Mattress or Sleep Surface 

SIDS risk is lower for infants who sleep on a firm surface, such as a safety-approved* crib 

mattress covered with a fitted sheet. Infants who sleep on soft surfaces, such as pillows, 

comforters, or quilts, are at higher risk for SIDS. Caregivers should never place the baby to 

sleep on pillows, quilts, sheepskins, or other soft surfaces. Similarly, they should not place 

infants to sleep on waterbeds, sofas, couches, armchairs, or soft mattresses that allow the 

baby’s head to sink in to the surface. 

Alternative Sleep Surfaces 

Even if families don’t have access to cribs or bassinets for their babies, alternative sleep 

surfaces (Figure 8) are readily available for little or no cost. For example, if put together well 

and not covered with thick blankets, sheepskins, or comforters, any of the following can 

provide firm sleep surfaces: 

> Sturdy, laundry-type basket with a smooth, 

firm bottom 

 Heavy, reinforced cardboard box or carton 

>

>

 Dresser, kitchen, or desk drawer 

> Metal or plastic basin with a flat bottom, such

as a washtub 

These sleep surfaces need little covering, such as a 

pad or a thin blanket that will not bunch up. For 

example, wrap a light blanket around a sturdy piece 

of cardboard and use strong tape or safety pins on the 

bottom to secure the blanket. That is all the covering 

needed for a firm sleep surface. 

One of the safest alternative sleep surfaces is the 

cradleboard. Native Americans may have originated 

the concept of Back to Sleep with the traditional use of the cradleboard. Although the specific 

design of a cradleboard differs from Tribe to Tribe, it is essentially a handmade, framed, 

flat basket where the baby spends much of his or her first year. The baby is placed on his 

or her back and swaddled into place in this safe and secure environment. Native teachings 

Figure 8. 

Alternative Sleep Surfaces 

Basket Box or Carton 

Drawer Washtub 

Reducing the Risk of SIDS 

*For information on crib safety, contact the Consumer Product Safety Commission at http://www.cpsc.gov or at 

1-800-638-2772, or talk to your health care provider. 

 

 

For resources on 

sleep environment 

and SIDS, see 

Appendix 5.
20 

Chapter Two 

say that cradleboards keep the baby safe in a distinct location, help with the child’s skeletal 

development, strengthen neck muscles, and provide an opportunity for the infant to be 

visually and emotionally stimulated by his or her environment and family. 

Because the rates of infant death and SIDS are high in 

many AI/AN communities, using cradleboards is a good 

way to keep babies safe. When swaddling a baby for 

the cradleboard, make sure the baby does not overheat. 

A light blanket may be all that is needed to keep the baby 

safe and comfortable. The photos above are examples of 

an infant ready for cooler or colder air temperatures. 

Many Tribes and urban Indian community centers offer 

classes on how to make and use cradleboards. Additional 

information and resources related to making and using 

cradleboards are provided in Chapter 3. 

Remove Soft Objects, Loose Bedding,

Toys, and Padded Bumpers from the

Sleep Environment 

Caregivers should remove pillows, blankets, quilts, 

comforters, sheepskins, and pillow-like crib bumpers 

from the baby’s sleep area. All items, including blankets, 

should be kept away from the baby’s face. 

The most current research shows that crib bumper 

pads or padded bassinets are dangerous and can cause 

death or injuries to babies. Before crib safety was 

regulated, the spacing between the slats of the crib sides 

posed a danger to babies. At the time, padded crib bumper pads protected the baby from 

these dangers. Now that crib construction is regulated and must conform to safety standards, 

the bumper pads are no longer needed and actually carry their own dangers. 

In a study published in the Journal of Pediatrics, researchers examined several databases 

maintained by the government’s CPSC. The databases tracked deaths and injuries related 

to cribs and bumper pads. Researchers found three types of deaths when bumper pads were 

Gifts That Can Increase Risk 

Giving gifts is a thoughtful and caring way to 

celebrate the birth of a baby. But some gifts 

can also increase the risk for SIDS. Caregivers 

should use good judgement when deciding 

whether or not to use a gift. Some items that 

increase SIDS risk include: very soft sheets, 

quilted crib sheets, plush or velour crib sheets, 

sateen crib sheets; infant pillows; crib wedges 

and sleep positioners; fleece infant wraps; plush 

sheet savers; and quilted mattress pads. To 

reduce the risk of SIDS, babies should always be 

placed to sleep on their backs on a firm surface, 

free of soft or loose items, for all sleep times. 

Instead of using a thick gift blanket with the 

baby, caregivers may want to hang the gift 

blanket on a wall as decoration, use it as a 

window covering in the baby
 s room, or use 

the blanket for adults or older children in a 

living area. This way, caregivers can show 

appreciation for the gift without increasing 

baby
 s SIDS risk. 
21 

Reducing the Risk of SIDS 

against bumper; suffocation from baby wedged between bumper and another object; and 

strangulation from bumper tie around baby’s neck. They also found several non-fatal injuries 

related to crib bumper pads. Because the bumpers prevent only minor injuries and can 

actually cause injury and death, the researchers concluded that bumper pads should not be 

used in infant cribs. 

Sleep Location 

The AAP Task Force recommends that infants be placed in a sleep area close to but 

separate from where others sleep. 

Placing a crib, bassinet, or cradleboard in the same 

room or sleep area as the parents allows the baby to 

be safely nearby and easy to reach for breastfeeding or 

other close contact. 

Another option is to use a co-sleeper or bedside 

sleeper (infant sleep area attached to an adult bed) to 

allow for close touch and easy access to the baby. 

Bed Sharing 

As explained in the previous chapter, bed sharing 

can increase the risk for SIDS, especially when the 

infant: shares a bed with other children; is placed on a sofa to sleep; sleeps in a bed with a 

mother who smokes cigarettes; sleeps in a bed with an adult who has been drinking alcohol; 

is younger than 11 weeks to 14 weeks of age; or sleeps in a bed with multiple bed sharers 

(more than one adult or sibling), especially if the infant is sleeping between two adults. 

When discussing bed sharing, keep in mind that the AAP recommends that a sleep area 

close to but separate from where others sleep is the safest sleep environment. Based on the 

evidence, bed sharing is always riskier than not bed sharing in terms of SIDS, accidental 

suffocation or smothering, and other accidental or unknown causes of injury and death. 

Caregivers must balance the dangers and benefits of bed sharing and take appropriate action 

to reduce the risk of SIDS and other causes of injury and death. You can help parents and 

caregivers create a safe sleep environment in the following ways: 

> Assess parents’ beliefs. 

> Determine what risk factors are present in the environment. 

> Provide education on known risk factors. 

> Show parents ways to make sleep environments safe. 

> Help parents reduce their baby’s risk through individualized counseling 
 

and demonstration.


22 

Chapter Two 

Parents should always be told about the dangers of bed sharing. If parents choose to 

bed share, make sure they follow other safe sleep practices to reduce the risk of SIDS. 

For instance: 

> Always place baby on his/her back to sleep (for naps and at night). 

> Never sleep with the baby on an armchair, couch, sofa, or waterbed. 

> Remove soft items (such as pillows, soft covers, toys, sheepskins, quilts, 
 

comforters, etc.) from the sleep area.
 


> Use only light sleep clothing on the baby. 

> Do not cover the baby with adult bedding. 

Some health care providers in AI/AN communities suggest that the following actions might 

reduce the risk of accidental suffocation. Remember, though, that the safest option for baby is a 

sleep area close to but separate from where others sleep. 

> Move the bed away from walls and other furniture so that the baby cannot become 
 

trapped between the mattress, bed frame/furniture, and the wall.
 


> Place the mattress low to or on the floor. 

> Place the baby in the area of the bed just above where an adult’s head is. 

> Do not allow siblings, other children, or pets in the bed. 

Other Ways to Improve Infant

Health and Possibly Reduce SIDS Risk 

In addition to the risk-reduction strategies explained earlier in this chapter, parents and 

caregivers can do other things to help improve their babies’ health that may also help protect 

against SIDS. Researchers are still gathering scientific evidence about these additional 

practices, but some findings show that babies benefit from these actions. 

Breastfeeding 

Breastfeeding, also called nursing, can be an easy and less expensive way for a mother to 

feed her child. 

According to the 2005 AAP Policy Statement on Breastfeeding, women who don’t have 

health problems should exclusively breastfeed their infants for at least the first six months 

of life. The AAP suggests that women try to breastfeed for the baby’s first 12 months of life 

because of the benefits to both mother and baby. Women can breastfeed after their baby is 

one-year old, if it is something that both mother and baby want to do. 

See the Healthy 

Actions for Native 

Babies Handout 

in the back 

inside pocket of 

the Workbook for 

more information. 

For resources on 

breastfeeding, 

see Appendix 5. 
23 

Reducing the Risk of SIDS 

Breastfeeding offers many benefits to the 

baby. For example: 

> Breastmilk provides the right balance 
 

of nutrients to help an infant grow 
 

into a strong and healthy toddler. 
 

> Breastfed infants are less likely to die 
 

during their first year and experience 
 

fewer illnesses than babies who are 
 

fed formula. 
 

> Some of the nutrients in breastmilk 
 

also protect an infant against some 
 

common childhood illnesses and 
 

infections, such as diarrhea, middle 
 

ear infections, and certain lung or 
 

respiratory infections.
 


> Some recent NICHD-supported 

research also suggests that breastmilk 

contains important building blocks for 

brain development and growth. Two specific building blocks, the fatty acids known as 

DHA and AA, may help increase infants’ cognitive skills. Many types of infant formulas 

available in the United States are fortified with DHA and AA. All formula available for 

preterm infants is fortified with these building blocks. 

Some studies also show that breastfeeding is associated with a lower risk of SIDS. 

Some women, such as those with certain chronic health problems, including HIV, are 

advised not to breastfeed their infants. If your client has a health problem, suggest that she 

discuss breastfeeding with her health care provider. 

The decision whether or not to breastfeed is a private one that takes into account personal, 

family, professional, and economic issues. Every woman’s reasons for breastfeeding or bottle 

feeding are her own. You should always respect that decision. 

If a mother stops breastfeeding before the child is one-year old, or decides to bottle feed 

from the infant’s birth, then she should feed her infant iron-fortified commercially available 

formula. Health care providers advise women not to give their infants cow’s milk until the 

child is at least one-year old. 
24 

Chapter Two 

 

 

 

 

Resources Related to Breastfeeding 

There are many excellent programs ongoing around the country that promote and support 

breastfeeding. To obtain information, assistance, and/or resources related to breastfeeding or 

lactation support in your local area, contact one of the following resources: 

> Women, Infants, and Children (WIC) office: http://www.fns.usda.gov/wic/


Breastfeeding/breastfeedingmainpage.htm
 

> La Leche League International Group: http://www.lllusa.org/groups.php (to get 
 

information specific to your state)
 

> Local hospital obstetric unit 

> Pediatric clinics 

> Support programs, such as Healthy Families (http://www.healthyfamiliesamerica.org) 

Prenatal Care 

Prenatal care is the care woman gets before her baby is born. Getting early and regular 

prenatal care improves the health and outcomes of mothers and babies (see the Planning 

Pregnancy and Preconception Care sidebar on the next page). Prenatal care includes health 

care, along with education and counseling about how to handle different things related to 

pregnancy and parenting. 

Prenatal care is a primary way to help to identify and 

treat issues or concerns before they become fullblown health problems. Research also shows that 

not getting early or regular prenatal care is associated 

with SIDS. Health care providers encourage women 

to get early and regular prenatal care as yet another 

way to possibly lower SIDS risk. 

During prenatal care, a health care provider will 

talk with the woman about many issues, such as 

nutrition and physical activity, what usually happens 

during childbirth, and basic skills in infant care. 

Providers also watch the growth of the developing 

fetus as a way to detect and, if possible, treat 

problems that could lead to low birth weight, which 

is a risk factor for SIDS by itself. These providers 

also watch for signs of early labor as a way to prevent 

preterm birth, which is also a risk factor for SIDS 

by itself. 

Prenatal care also teaches pregnant women and their 

families some basics about caring for themselves and 
25 

Reducing the Risk of SIDS 

the baby. Providers discuss situations 

that increase the risk for SIDS, such 

as drinking alcohol, using tobacco, 

and unsafe sleep environments. 

Recent research suggests that some 

of the brain defects associated with 

SIDS may be influenced by or result 

from prenatal exposure to toxins, 

such as alcohol and tobacco. Getting 

early and regular prenatal care is a 

powerful way to improve an infant’s 

chances for a healthy life and to 

reduce the risk for SIDS. 

Public Health Nurse 

(PHN) Visits 

Results from the Aberdeen Area 

Infant Mortality Study, which 

involved AI/ANs from the Northern 

Plains, found that infants were 

less likely to die of SIDS if their 

mothers received visits from a PHN 

during pregnancy and after giving birth. A visit from a PHN reduced SIDS risk by one-fifth 

compared to babies who did not receive such attention. In light of these results, study leaders 

recommended “strengthening PHN programs” and community-based programs, such as 

Healthy Start, to provide the extra attention that AI/AN communities need to further reduce 

the risk for SIDS. 

PHNs provide many important services to families. Because the PHN comes into a family’s 

home, family members may be more comfortable interacting with the PHN and may be 

more likely to trust him or her than another type of provider, seen outside the home. 

During the visit, the PHN can: 

> Assess and provide guidance about the safety of the home environment. 

> Allow parents to ask questions and address concerns that they may have been shy 
 

about or forgotten to ask in an office, clinic, or hospital setting.



> Provide guidance about infant health and development. 

> Offer reality-based suggestions, interventions, and referrals as needed. 

You should suggest that families schedule regular visits from a PHN both during pregnancy 

and after the baby is born, if these visits are available in their area. 

Planning Pregnancy and Preconception Care 

Most health care providers suggest that women plan their

pregnancies as a way to improve their health and the health of

their babies. 

Many health care providers recommend that women see a health 

care provider for preconception care, care received before even 

trying to get pregnant. During this type of care, the patient and 

the health care provider can talk about things that can improve

not only the chances of getting pregnant, but also the likelihood

of healthy pregnancy. These things include:

• Avoiding alcohol, illicit drugs, and smoking 

• Getting recommended vaccinations/immunizations 

• Maintaining a healthy weight or, if needed, losing weight

• Improving nutrition, taking vitamins, and getting enough 

folic acid 

For more information, visit the NICHD Web site at 

http://www.nichd.nih.gov/health/topics/preconception_care.cfm. 

For resources on 

PHN visits and SIDS

risk, see Appendix 5. 
 

 

 

Make Time for Tummy Time! 

Encourage parents and caregivers to provide lots of 	Tummy Time,	 placing 

babies on their stomachs when they are awake and someone is watching them. 

Tummy Time is a necessary and very important part of a baby
 s healthy development of motor skill and brain 

functions. Among its many benefits, Tummy Time: 

• Reduces the risk of flat spots developing on the back of the baby’s head. Infants
 skulls are made up of several 

bones that are free-floating during the first few months of life so the brain can grow. Back sleeping may cause 

flat areas on the back of the infant
 s head. These flat areas are usually not dangerous and typically go away 

once the infant starts to sit up on his or her own. There is no evidence that this flattening is harmful or that it 

is associated with permanent problems with head shape. Tummy Time decreases the chance that such areas 

will form. Other ways to reduce the chance of flat spots include: 

• Changing the direction the baby
 s body is placed in the crib or bed 

(see Figure 9)
 Because babies naturally turn toward light or activity, 

changing how they lay in the crib can reduce the pressure on one 

specific area 

• Holding the baby upright
 sometimes called 
cuddle tim e

 when he or 

she is not sleeping 

• Limiting the amount of time spent in free-standing swings, bouncy 

chairs, car seats, and carriers 

• Promotes muscle and motor development. An infant lying on the stomach 

while awake and being watched is strengthening his or her neck and

 shoulder muscles. Strong neck and shoulder muscles can help babies reach 

motor development milestones. Tummy Time gets baby
 s body ready to sit up, slide on the belly, and crawl. 

As babies grow older and stronger, they actually need more Tummy Time to build enough 

strength to support their own bodies when they try standing and, later, walking. 

Advise parents and caregivers to let infants have two, three, or more short Tummy Time 

sessions throughout the day. After a diaper change or after the baby wakes up from 

a nap are ideal times for Tummy Time. Having a toy or toys in reach can help babies 

learn to play and interact with their surroundings. Having a parent, caregiver, or sibling 

nearby during Tummy Time is also a great way to bond with the baby. 

Some babies may not like the tummy position at first, but most take to it after just a 

few sessions. Make sure all family members know about the importance of Tummy 

Time, and suggest ways to make it a safe and fun part of the family
 s time together. 

After some practice, babies and families can enjoy all the benefits of Tummy Time. 

For more information on Tummy Time, visit the NICHD Web site at 

http://www.nichd.nih.gov/health/topics/Tummy_Time.cfm. 

Figure 9.
Chapter 3: 

Strategies for Reaching

Communities
 Know 

Your Audiences 

Objectives 

By the end of this chapter the learner will be able to: 

• Describe primary and secondary audiences for safe sleep messages

and suggest some options for where and when to reach out to them. 

• Understand the risks associated with unaccustomed sleep position

and its relationship to child care settings. 

• Describe essential behaviors for health and service providers to use

while interacting with AI/AN patients and clients. 

• Define hard-to-reach and underserved audiences and identify ways

to reach them. 

• Identify ways to reach out to families who have experienced loss of

a child from SIDS or another cause. 
28 

Chapter Three 

The Importance of SIDS Education 

Now that you know a little bit about SIDS, its common features, and ways to reduce the 

risk, let’s think about how to reach out to others with this information. To begin, who needs 

education about SIDS and SIDS risk-reduction strategies? 

The answer is: Everyone needs education about SIDS and SIDS risk reduction. 

Parents, grandparents, foster parents, family members, health care providers, day care/child 

care providers, emergency responders, and others of all ages need to know the risks for SIDS 

and the ways to reduce those risks. 

To be truly effective, everyone in the community and in a baby’s environment needs to know 

the ways of reducing SIDS risk and needs to practice the risk-reduction strategies consistently. 

Consistency—using these same practices time after time—can save infant lives. Remember 

that infants who are usually placed to sleep on their backs, but who are then placed to sleep 

on their stomachs—even for a single nap—are at greatly increased risk for SIDS. For this 

reason, consistency is critical—infants should be placed to sleep on their backs for every sleep 

time, for naps and at night. 

To be a good communicator, it is important to know your audiences, where you can reach 

them, and how you can reach them. The rest of this chapter helps to define the various 

audiences that you may need to reach, describes where you might be able to reach them, 

and suggests ways to reach out to them. 

Who are the primary audiences? 

Parents and Parents-to-Be 

Parents and parents-to-be are the first critical audience for SIDS education. Because they are 

the primary caregivers and decision makers for their infants, parents and parents-to-be need 

to learn about the risks for SIDS and about ways to reduce those risks. This education is a 

main step in any type of SIDS outreach. 

Sharing information about safe sleep guidelines can give parents effective tools for protecting 

their children, while also giving them the confidence to raise healthy children. An educated 

parent can also correct SIDS misinformation and counter SIDS myths, which may be 

common within the community. 

Where can you reach them? 

In addition to during regular health care visits, you can educate parents and parentsto-be during community gatherings, workshops, and health and wellness fairs. In 

these environments, they have the opportunity to ask questions about safe sleep 

recommendations so they can better understand SIDS and the research evidence that 

forms the basis of the recommendations. 

For resources 

on SIDS and 

reducing SIDS risk, 

see Appendix 5. 
Strategies for Reaching Communities
 Know Your Audiences 

 

Educational counseling can also include one-onone sessions with PHNs and outreach workers 

(such as social workers, community Elders, 

and health educators). Providers can tailor these 

sessions to meet the individual needs of parents 

and families. In addition, home-visiting providers 

have a unique opportunity to help parents assess 

risks in the infant’s sleep environment and to 

demonstrate safer sleep practices where the infant 

actually sleeps. 

Even though fear can be an effective way to get

attention at first, long-term use of fear is usually

not an effective way to change or maintain 

new and desirable behaviors. Similarly, using 

shame
 suggesting or implying that parents are 

irresponsible or that they 
don t care enough
 for 

the child because of their choices
 is also a poor 

way to motivate people to change their behaviors. 

Instead, put a positive focus on constructive 

actions that people can take to reduce the risk for

SIDS or to improve infant and family health. This

approach is not only more caring, but is also a

more effective way to create lasting change.

Parent-to-parent or peer support/activity groups 

also provide a good forum for education. These 

types of gatherings are especially useful for 

reaching teen and new parents, who often seek 

support from older, more experienced members 

of the community. By serving as a knowledgeable 

moderator during meetings of such groups, you 

can help the group members explore questions and concerns about SIDS risk reduction, safe 

infant care practices, and SIDS research. 

When can you reach them? 

During pregnancy and just after the infant is born are 

good times for educating parents about SIDS riskreduction strategies. For many women, pregnancy is a 

good time to think about and make healthy changes. 

Soon-to-be parents and new parents, especially, are 

highly motivated to do everything possible to ensure 

their infant’s health and happiness. A lot of times, 

though, they aren’t sure what the “right thing” is when 

it comes to reducing the risk for SIDS. They may also 

be getting mixed messages: their family may be telling 

them one thing about how and where babies should 

sleep; health care providers may be saying something 

else; and their friends may have different opinions. 

As a health educator working in any setting, you should keep in mind the importance of the 

following concepts: 

> Sharing critical and accurate information 

> Approaching parents and others with respect 

> Providing empowering messages about how to safely care for infants 

> Instilling confidence in parents’ ability to reduce the risk of SIDS and protect their children 

Parent and parent-to-be education is the key to solving the problem of SIDS. 

Use of Fear, 	Guilt Trips,	 or Shame

to Communicate Health Messages

29 
Chapter Three 

 

30 

Foster Parents and Foster Families 

Foster parents and families are an audience with some unique SIDS education needs for a 

number of reasons: 

> They probably did not have the chance to learn about SIDS during pregnancy and right 

after the baby’s birth. 

> Foster families with mostly older children are less likely to know current information 
 

about reducing SIDS risks. 
 

> In some cases, the factors or environments (such as problems with alcohol) that led to 
 

the child being placed in a foster home may be associated with increased SIDS risk. 
 

Where and when can you reach them? 

Those who are involved with placing children in foster care, such as maternal and child 

health service providers and social service and child protection providers, have an important 

opportunity to educate foster parents before or immediately after a child is placed in the 

foster home. In many cases, the required follow-up visits offer additional opportunities to 

assess the infant’s sleep environment and to recommend SIDS risk-reduction strategies for 

the foster home. 

This type of education and follow-up is critical for these particularly vulnerable infants. 

Foster families should be included as a regular audience for any community effort to reduce 

the risk for SIDS. 

The Community (Elders, Extended Family/Friends, and Youth) 

In the context of the importance that Native culture places on community, outreach 

materials and projects need to extend their messages to address the community as a whole. 

As part of your efforts in the Healthy Native Babies Project, 

you can offer to share the latest information and evidencebased strategies for reducing SIDS risk with Elders, extended 

families and friends, and youth in the community. 

In many AI/AN communities, Elders—particularly 

older women—are the opinion leaders about childrearing 

practices. As you begin your outreach efforts, remember 

the following: 

> Gather ideas and wisdom from the Elders. Because the 

Elders likely know the community better than anyone 

else, they can play a critical role in developing outreach 

strategies for the community, especially for those 

members who are hard to reach. 

> Present SIDS risk-reduction strategies to Elders in a 

way that does not confront or question their authority 

and knowledge. 
Strategies for Reaching Communities
 Know Your Audiences 

 

> Understand local history when planning activities. Some parents or community Elders 

may have been raised away from the community (in non-voluntary boarding school or 

foster family arrangements). As a result, they may lack context for current childrearing 

practices from their own childhoods. 

Where and when can you reach them? 

You can reach Elders and seniors through a variety of venues including: senior centers, 

congregate meal programs, nutrition centers, senior health fairs, senior housing, senior 

companion programs, Elder committees, and activity days. Many Tribes run U.S. 

Department of Health and Human Services (DHHS) Administration on Aging Title VI 

programs. Contact your local Title VI Director to discuss potential collaboration and 

outreach opportunities. To search for programs in your area, visit the Administration on 

Aging Web site for Native American Programs at: http://olderindians.org. 

Another unique aspect to doing outreach in AI/AN communities is the involvement of 

extended family and friends in various childrearing roles. For example: 

> The Native definition of “family” differs from that of most non-Natives. Within 

AI/AN communities, extended family and friends form unique family units that may 

differ from those common in non-Native communities. 

> Members of the family may play different roles in childrearing that don’t match 
 

up to the “normal” nuclear-family model. For many AI/AN communities, family 
 

responsibilities for childrearing include those 
 

traditional for the Tribe, rather than for 

an individual family. 

> Communities may also be a mix of traditional 
 

AI/AN families, which include extended family 
 

members, and nuclear families. 
 

Make sure your outreach efforts include the entire 

“family”—including family and friends. Don’t be 

judgmental about the specific form of the family. 

Keeping an open mind and an inclusive attitude about 

the variety of family structures, members, and roles 

your audience might have is also essential. 

Many AI/AN communities also have an active youth 

culture, which is often interested in activities that 

enable them to give something of themselves back to 

the community. While volunteerism and community 

service can help young people create their identities—a 

key developmental task for teens—such activities also 

provide an excellent forum for outreach about SIDS 

risk reduction. 

31 
Chapter Three 

32 

A Critical Primary Audience: Child Care Providers 

Did you know? 

• Two-thirds of infants younger than 12 months of age are in child care, defined as care from someone 

other than the infant
 s parent, at least some of the time. 

• About 20 percent of SIDS deaths in the United States occur in a child care setting, while the infant 

is under the care of someone other than the infant
 s parent. Many of these child care deaths are 

associated with the stomach sleep position, especially when the infant is unaccustomed to being 

placed to sleep in that position. 

• Infants who are usually placed to sleep on their backs, but who are then placed to sleep on their 

stomachs or sides
 like for a nap when being cared for by a babysitter
 are at extremely high risk 

for SIDS. In fact, the risk is 7 times to 8 times greater than for infants used to sleeping on their 

stomachs or sides. 

Infants who spend time in day care homes, child care 

centers, homes of friends or family members, or even 

their own homes under the care of family, friends, or 

babysitters can be at significantly higher risk for SIDS if 

their caregivers are not educated about risk-reduction 

strategies. Despite the decrease in overall SIDS rates, 

the proportion of SIDS deaths in child care settings has 

remained relatively constant since 1992. 

Many providers are simply not aware of the back 

sleeping or other safe sleep recommendations. Others 

rely on older information or are misinformed about 

SIDS risks. Research shows that educational programs 

are effective at increasing knowledge of safe sleep 

recommendations among child care providers. Such 

programs might already be in place in your area, through local or state health departments or through 

the boards that license or regulate child care providers. 

Take advantage of existing education programs and offer to share the latest research and safe sleep 

strategies with the program leaders or the provider audiences. If a program is not currently ongoing in 

your area, make sure to include this important audience in your Healthy Native Babies Project planning 

and outreach efforts. 

Tell anyone and everyone who cares for a child	parents, grandparents, foster 

parents, aunts, uncles, siblings, babysitters, child care providers	to place the baby 

on his or her back to sleep every time, for naps and at night. 
Strategies for Reaching Communities
 Know Your Audiences 

Where and when can you reach them? 

Babysitting classes, youth gatherings, or general health education classes are places where 

potential teen babysitter or sibling audiences can learn about reducing the risk of SIDS. 

Community center settings also provide opportunities to reach out to youth who may 

fall outside the potential babysitter or sibling audience. Empowered with risk-reduction 

knowledge, youth can become effective partners in your SIDS risk-reduction effort by 

spreading and practicing the strategies on their own. 

Who are the secondary audiences? 

The term “secondary audience” does not mean that groups are less important than the 

primary audiences described earlier. Instead, secondary audiences include people who do not 

directly provide care to children, but who interact in different settings with those who do 

provide direct care. Educating secondary audiences about ways to reduce the risk for SIDS is 

a good way to reach parents, grandparents, and other caregivers. These secondary audiences 

can help get your message deeper into the community, in less time. 

Health Care Providers (Doctors, Nurses, Dentists, and Others) 

Health care providers often have many opportunities to educate parents and families about 

SIDS risk and SIDS risk reduction. Providers are not just limited to doctors and nurses, but 

also include dentists and dental health providers, opticians/eye care providers, pharmacists, 

home health care workers, and others who may interact with families and with children. 

Identifying strategies to increase providers’ effectiveness as they educate, motivate, and 

support parents and caregivers in adopting SIDS risk-reducing practices is an important part 

of a successful Healthy Native Babies Project. 

Where and when can you reach them? 

Reach out to health care providers at different locations to ensure that they have the most 

accurate information about SIDS risk reduction. They can help spread safe sleep messages 

to their patients and clients in the following 

locations/situations: 

> In the hospital, clinic, or birthing 

center. The hospital setting immediately 

after the baby’s birth provides a perfect 

place to discuss SIDS risk reduction 

and to model safe sleep practices for 

parents and caregivers. Research shows 

that hospital nursery staff can have 

a significant impact on parent and 

caregiver behaviors after leaving the 

hospital. For example, in one 2002 

study, a 30-minute training session for 

nursery nurses increased understanding 

of their influence on families and 

33 
Chapter Three 

34 

helped the nurses to consciously and consistently place 

infants on their backs to sleep in the nursery. Families 

reported seeing the nurses place infants on their backs. 

More importantly, families continued to place their infants 

on the back to sleep at home.

> During the infant’s health care appointments, such as 

well-baby checkups. It doesn’t matter where these sessions 

take place—in a doctor’s office, in a clinic, in the baby’s 

home—these appointments provide a great opportunity to 

educate and continue educating parents and family about 

SIDS risk reduction. Doctors, nurses, physicians’ assistants, 

and other providers can explain and reinforce safe sleep 

messages during these visits.

> During other family health-related appointments. For 

example, a dentist may not give dental care for a child 

younger than one year of age, but he or she may spend time 

caring for the teeth of that child’s parents and grandparents. 

This set-aside time together provides a good opportunity 

for the dentist to discuss issues related to safe sleep 

environments and SIDS risk reduction. Pharmacists can 

also remind families about safe sleep messages when they 

pick up medicines or other items at the pharmacy or store. 

To make the most of every opportunity, make sure you reach out to all types of health care 

providers with important information about safe sleep strategies. Once these providers know 

the safe sleep strategies, they can help you get those messages out into the community and 

reinforce these teachings by talking about the issues consistently and during each encounter. 

Emergency Personnel, First Responders,


and Others Involved with the Death Scene 


Dealing with a sudden infant death presents both professional and personal challenges for 

first responders and for those who work in emergency medicine settings. A lot happens 

during this type of situation. While working to revive the infant, emergency medical staff 

might also have to console the parents, other caregivers, and family members. At the same 

time, these personnel might also be assessing and recording information about the death 

scene to assist with the investigation. 

Others—emergency room doctors and nurses, medical examiners, pathologists, and 

coroners—get involved later in the process to determine how the baby died. Funeral 

directors, clergy/spiritual leaders, PHNs, and grief or bereavement counselors may also 

play roles after the death of an infant. It is not surprising that, at times, dealing with and 

supporting parents and families who have just lost an infant can be overwhelming. 

The National Sudden and Unexpected Infant/Child Death and Pregnancy Loss Resource 

Center offers useful information for first responders, emergency personnel, coroners, funeral 

Universal Aspects of Care		

In most Indian health care settings 

(i.e., IHS, Tribal, or urban), health care 

and health education providers are a 

mixture of local AI/AN people and 

non-AI/AN providers with diverse ethnic 

and cultural backgrounds. 	 

There are aspects of the provider/ 

patient relationship that are universal 

in terms of the providers
 effective 

behaviors. In the mid-1990s, IHS 

conducted a broad-based consumer 

survey in which several common patient 

expectations were identified. Based on 

the survey, patients wanted to be: 

• Treated with respect and 

understanding; 

• Listened to/heard; and 

• Able to ask and be asked questions 

and have their questions answered. 
Strategies for Reaching Communities
 Know Your Audiences 

personnel, and others who may be involved with handling the death of an infant. Please 

visit http://www.sidscenter.org/AZtopics.html to find information for different audiences. 

All of these types of personnel can benefit from knowing the information about SIDS and 

SIDS risk presented in this Workbook. In addition, the Center also provides a fact sheet at 

http://www.sidscenter.org/documents/SIDRC/ProfessionalRole.pdf explaining the roles 

played by various professionals involved when a sudden infant death occurs, possible 

responses to grief, causes of sudden infant death, and some of the differences between 

SIDS and child abuse. 

Share these handouts and other information with the first responders and other emergency 

personnel in your community. You might also want to suggest that printed copies of these 

materials be stored in emergency vehicles. Be sure to include this important secondary 

audience in your SIDS risk-reduction outreach. 

Other Secondary Audiences 

Opportunities to spread safe sleep messages aren’t limited to situations related to health 

care or emergency health care. Any concentrated time with parents and families offers the 

chance to educate caregivers about SIDS and SIDS risk reduction. Hair dressers, barbers, 

manicurists, grocery store staff, general store staff, and others can all play important roles in 

spreading safe sleep messages and in reinforcing safe sleep practices. 

Think about where parents and caregivers in your community spend their time, and then 

reach out to the staff in those locations to help spread the safe sleep messages. 

Critical Steps to Building a Positive Relationship

Between Provider and Patient/Client 

In addition to the “Universal Aspects of Care” on the previous page, research from other 

settings has documented patient expectations that may help health care and other providers 

to connect with their patients and to start building a trusting relationship. Providers can 

adopt these steps as a standard of care when dealing with patients or clients: 

1. 	 Greet the patient or client by name. Greet your patients or clients respectfully 
 

with the most common local greeting phrases and using 
 

the patient’s name. 
 

2. Introduce yourself. It is important for providers to 

introduce themselves at the first visit or, if it has been a 

while since the patient has been seen, at follow-up visits. 

Providers should keep in mind that the amount of direct 

eye contact that is culturally appropriate to give and 
 

receive varies across AI/AN settings and sometimes by 

age and gender. 

Parents or caregivers who are dealing 

with an acute health problem for their 

child or themselves are not in the best 

state for receiving new information. 

Such times are probably not optimal for

addressing SIDS risk-reduction practices.

Providers should delay such outreach 
 

efforts until the immediate health 
 

problems are under control, unless the 

issue is directly related to SIDS risk. 

35 
Chapter Three 

36 

3. Provide support and reassurance, and be responsive to patient/client anxiety. 

Many people seeking health care are experiencing physical pain and/or fear or anxiety 

about the future. A first critical step in reassuring the patient/client is to recognize 

these feelings and to know that he or she may display such feelings through verbal and 

non-verbal behaviors as the exam or meeting continues. Once a provider recognizes 

any anxiety or discomfort, he or she should attempt to put patients at ease by being 

attentive, being expressive through non-verbal means (such as not crossing the arms 

in front of the body, a pose that could signal one is closed and not listening), and by 

offering reassurance. 

4. Facilitate dialogue and collaboration. Critical to this process is asking carefully 

thought-out and non-judgmental questions in plain language, followed by attentive 

listening. At this stage of the encounter, providers should be assessing the best way to 

provide education and assistance. 

5. Respond to, teach, and negotiate desired behaviors. Based on information gathered 

during early steps of this process and on the clinical or other assessments made, the 

provider should attempt to clarify any risks or concerns and explain any options for 

care to the patient, parent, or family. It is important to avoid “talking down” to patients 

and to avoid the use of “jargon” words or concepts that may not be familiar to a nonprovider. The intent of this dialogue process is to: 

> Respectfully respond to the perspective of the patient/client; 

> Acknowledge and clarify an understanding of the problem as described, and identify 

how services can/may be combined with traditional medicine to address or alleviate 

the problem; and 

> Actively teach patients/clients, with the intent of informing and empowering them 

to assume appropriate responsibility for their own or their child’s health. Such 

teaching may require the provider to respectfully challenge assumptions, including 

some scientifically inaccurate ideas, that patients/clients may have about risks or 

solutions to health problems. For example, a family might be coping with pressure 

from the child’s grandmother to place the child to sleep on his or her stomach. 

Supplying the family with updated and accurate information will allow the new 

parents to come to their own decisions about safe child sleep position. 

6. Provide closure to the encounter by expressing a warm and encouraging goodbye. 

In addition to giving the patient/client encouragement, this last step offers final chance 

to ask and to answer any remaining questions. Simply moving on or ending the 

meeting, without an opportunity for closure, can leave patients emotionally uncertain 

of their situation or with important questions left unanswered. 

Research shows that eliminating any of these steps can have a measurable negative effect on 

patient/client satisfaction with the service(s). In some cases, skipping a step may also impact 

compliance with recommendations or treatments. Observations in many public and private 

health care settings (including IHS settings) have shown that many providers from various 
Strategies for Reaching Communities
 Know Your Audiences 

Figure 10. 

Stages of Behavior Change Theory 

Relapse 

Precontemplation 

Contemplation 

Decision/ 

Determination 

Action 

Maintenance 

health-related fields frequently miss one or more of these critical steps. Therefore, it is not 

an overstatement to suggest that following these steps can make a positive difference in the 

patient/client outcome(s). 

To further improve the relationship between providers and patients/clients, providers might 

want to integrate the “Stages of Change Theory” (Figure 10) and other recognized health 

education approaches into the basic steps listed previously. For instance, the Stages of 

Change Theory addresses behavior change as a process that occurs over time. Individuals, 

communities, agencies, etc., may be at different places in their motivation or willingness to 

change. Identifying where an audience member or group is on the change continuum (see 

Figure above) allows an educator to better adapt the message or intervention in a way that 

may more successfully produce behavior change. 

In the context of the Stages of Change Theory and other health education approaches, any 

risk-reduction effort for a selected community or specific audience requires a thorough 

evaluation of that audience’s current beliefs, practices, and fears to begin addressing these 

issues effectively. 

Appendix 3 provides short explanations of many common health education approaches. 

37 
Chapter Three 

 

 

38 

Outreach to Hard-to-Reach and Underserved Populations 

Trying to reach those who may have the greatest need for up-to-date health and prevention 

information can come with unexpected challenges. Hard-to-reach and underserved 

individuals are often the most stressed, the hardest to find, the least mobile (in terms of 

transportation), and the least able to follow through with health promotion and disease 

prevention activities. They are among the most vulnerable groups we attempt to serve. 

Several red flags might indicate that a family may need more individualized service or 

education messages: 

> Homelessness 

> Incarceration or problems with law enforcement system 

> Alcohol or substance use/abuse issues 

> Psychiatric conditions or depression 

> Learning disabilities or cognitive problems, such as FASD 

> Late prenatal care or no prenatal care 

> History of childhood abuse 

> Family violence 

> Involvement with child protective services or family services 

> History of SIDS or infant death in the family 

> Worrisome behaviors displayed/observed 

> Families for whom providers/visitors have a “hunch” that help is needed 

> Stating that their problems are significant 

> Saying that they need help 

In general, outreach to groups impacted by these types of issues and situations needs to be 

handled carefully and should respond to a person’s or family’s specific situation. 

One key element of outreach to hard-to-reach groups is going “where they are at,” meaning 

outreach staff may need to challenge their own comfort zones and immerse themselves in 

new and maybe uncomfortable situations. Before you or your colleagues set out to reach 

these populations, you may want to do the following: 

> Talk with others who already do outreach to these hard-to-reach groups to get ideas for 

your efforts. 

> Be compassionate. 

Visit Appendix 1 

for a list of 

abbreviations 

and acronyms and 

their explanations. 
> Be “real.” 

> Be willing to help the situation at hand. 

Another key element of this type of outreach is trying to understand the unique situations of 

these audiences. Listen to their stories, and keep in mind that there are basic human needs 

that, if not met, can get in the way of one’s ability to thrive. Individuals who have unmet 

survival or safety needs might find it difficult to really listen to prevention ideas. It may 

be hard for them to follow through on actions, especially if they don’t or can’t accomplish, 

understand, or value such actions. For many in these populations, survival and safety are 

the priorities—everything else takes second place. The outreach strategy for these audiences 

needs to include a message that makes sense from their perspectives and that relies on 

resources they have available to them. 

The table below lists organizations that assist and serve many hard-to-reach populations. 

Organizations that Serve Hard-to-Reach Populations 

Organization	 Address (Web or Mailing) Phone 

American Indian Community Center	 905 East 3rd Avenue 

Spokane, WA 99202 

(509) 535-0886 

Anishinabe Wakiagun
 American 

Indian Community Development 

Corporation 

http://www.aicdc-mn.org/node/23 (612) 871-2883 

Chief Seattle Club	 http://www.chiefseattleclub.org (202) 292-6214 

National Resource Center on 

Homelessness and Mental Illness 


(part of the U.S. federal govern­


ment s Substance Abuse and Men­


tal Health Resources Administration) 


http://www.nrchmi.samhsa.gov (800) 444-7415 


Native American Rehabilitation 

Association of the Northwest 

http://naranorthwest.org (503) 224-1044 

Peta Wakan Tipi http://petawakantipi.org (651) 646-8167 

Tahoma Indian Center http://www.ccsww.org/site/ 

PageServer?pagename= 

families_emergencyservices_ 

tahomaindiancenter 

(253) 593-2707 

United Indians of All Tribes 

Foundation 

http://unitedindians.org (206) 285-4425 

Strategies for Reaching Communities
 Know Your Audiences 

39 
Chapter Three 

 

40 

The next section describes some ways to reach out to those dealing with “red flag” issues. 

The Homeless 

Homelessness is one of several stressful life events than can lead to poor birth outcomes for 

AI/AN families. The statistics on this topic are cause for concern: 

> According to A Quiet Crisis: Federal Funding and Unmet Needs in Indian Country, 
 

a 2003 report released by the U.S. Commission on Civil Rights, approximately 
 

90,000 AI/AN families are homeless or under-housed. (The report is available at 
 

http://www.usccr.gov/pubs/na0703/na0731.pdf.) 
 

> Pregnancy Risk Assessment Monitoring System (PRAMS) data for Seattle, Washington, 

collected between 1999 and 2001, indicated 15 percent of new AI/AN mothers 

reported that they were homeless during the year before delivering their babies. (Public 

Health-Seattle & King County, Public Health Data Watch, Vol. 1, No. 1, Oct. 2004.) 

Several national and local organizations across the country serve this hard-to-reach 

population (see table on page 39). You should try to work with the staff of these 

organizations to provide information to these families. 

The Incarcerated 

Incarcerated women—those in jail, prisons, halfway houses, or probationary homes— 

represent an especially “hidden” population, which deserves access to information and 

education about SIDS risk reduction. Even though many of these women do not have 

children living with them in prison, some have infants living with or near them. Others, 

after release, may suddenly be the sole caregivers for one or more children. By providing 

risk-reduction messages and education to these women, you can empower them to care for 

themselves and for their babies and families. You can also reach out to the caregivers of the 

women’s children, such as foster parents, grandparents, and other family members, to help 

ensure consistency of care. 

Keep in mind the following as you conduct outreach with this population: 

> Rates of incarceration for indigenous people are usually higher than for other 
 

populations.



> Women of color, including AI/AN women, are generally over-represented in the 
 

prison population.



> Rates of domestic abuse and violence are often high among AI/AN women, 
 

and statistics show a close relationship between abuse and incarceration among 
 

AI/AN women.



> Many Native women are lumped into the “other” category, along with Native 
 

Hawaiians and Pacific Islanders, for state-level data about incarceration rates. This 
 

type of categorization could increase Native women’s feelings of being unimportant.
 

Strategies for Reaching Communities
 Know Your Audiences 

The table below lists resources related to working with those who are incarcerated. 

Resources Related to Working with Incarcerated Populations 

Organization Internet Address Phone/E-mail 

Critical Resistance http://www.criticalresistance.org (510) 444-0484 

Defending Justice: An Activist 

Resource Kit (From Political 

Research Associates) 

http://www.defendingjustice.org (617) 666-5300 

Incite! Women of Color Against 

Violence 

http://www.incite-national.org (484) 932-3166 

Partnership for Safety and Justice 

(Formerly the Western Prison Project) 

http://safetyandjustice.org/ 

programs/prison-program 

(503) 335-8449 

Individuals Impacted by Cognitive Problems and Fetal Alcohol

Spectrum Disorder (FASD) 

Because alcohol is a legal substance that is used widely in American culture, and because 

more than 45 percent of pregnancies in the United States are unintended, many women 

expose their fetuses to alcohol without knowing it and without meaning to do so. As 

explained in Chapter 1 of this Workbook, alcohol use during pregnancy is known to cause 

both physical and mental problems, including permanent brain damage and developmental 

delays. The true impact of alcohol exposure is often not known until a child develops 

behavioral problems or learning disabilities. Those exposed to high amounts of alcohol or 

exposed on a regular basis may have problems related to FASD, also known as Fetal Alcohol 

Syndrome (FAS). 

FASD is often considered a “hidden” problem because the brain is the organ most affected 

but you can’t “see” the problems, and because the symptoms might be subtle or hard to 

detect. Most people with FASD have normal intelligence, but they may miss social cues and 

signals that help others with social interactions. Many people impacted by FASD are also 

not diagnosed, or are not diagnosed in a way that supports them or helps them to interact 

with and understand the world around them. As a result, many people with FASD also have 

secondary problems, including (but not limited to): mental health issues, disrupted school 

experience, trouble with the law, time in jail or a treatment program, inappropriate sexual 

behavior, and alcohol or drug problems. 

41 
42 

Chapter Three 

 

FASD poses lifelong challenges and problems, but these can be reduced with individualized 

support and the right environment. These problems can be more troublesome in a family 

situation because more than one generation may be dealing with the challenges of FASD. 

In the context of SIDS education, you may need to adjust how you provide information 

to clients impacted by FASD. You may need to rely on “external brain strategies,” which 

allow individuals to use sensory and reminder devices and practices to accomplish daily tasks. 

For example: 

> Many clients with FASD may not be able to remember information from day to day. 

To educate persons with this problem, you may need to provide clearly written, stepby-step lists to help them remember risk-reduction tasks. Or, they may respond to more 

visual signals, such as a sheet showing safe sleep environments. 

> Demonstrating and modeling correct risk-reduction actions may also be useful for those 

with FASD. 

> Displaying visual reminders and step-by-step actions in very visible places within the 

home (such as on or near the baby’s sleep area) may also help remind caregivers of the 

steps they can take to reduce SIDS risk. 

> Reinforcing correct actions is also critical for outreach to these individuals. In some 

cases, this reinforcement and encouragement may need to come from someone close 

to the caregiver who can give advice and provide oversight. Someone in the baby’s 

environment can fill such a role. For instance, a PHN or other home visitor could 

regularly review the home safety situation and reinforce the risk-reduction messages by 

modeling the behaviors during scheduled visits. 

The table below includes resources related to working with this population. 

Resources Related to FASD and Individuals with FASD 

Organization Internet Address Phone/E-mail 

Bright Tomorrow FASD Support http://fasd.brighttomorrow.com (206) 424-4519 

FAS Community Resource Center http://www.come-over.to/FASCRC/ (520) 296-9172 

Fetal Alcohol Syndrome Consultation, 

Education, and Training Services, Inc. 

http://www.fascets.org wtemko@fascets.org 

FASD Center for Excellence (part 

of the U.S. federal government
 s 

Substance Abuse and Mental Health 

Resources Administration) 

http://www.fascenter.samhsa. 

gov 

1-866-STOPFAS 

(1-866-786-7327) 

National Organization on Fetal 

Alcohol Syndrome 

http://www.nofas.org (202) 785-4585 or



1-800-66-NOFAS


Strategies for Reaching Communities
 Know Your Audiences 

The Healthy Actions for Native Babies handout—in the folder at the back of this 

Workbook—is designed for use in teaching those with FASD or those with low reading 

abilities about safe sleep practices. You can use this handout as a starting point or as a main 

piece of your outreach in these populations. 

Families Who Have Experienced SIDS or Infant Death 

One of the most important things to remember when working with families familiar with 

loss from SIDS or infant death is that the families themselves are not to blame. The causes of 

SIDS remain unknown. Even though there are ways to reduce the risk, there is no definitive 

way to prevent SIDS from occurring. 

A SIDS death is a tragedy that often results in intense, personal grief for surviving 

family members and caregivers. Some parents describe the death of a child as the “most 

overwhelming emotional pain” they have ever experienced. The sudden, unexpected, 

and unexplainable nature of SIDS often adds to feelings of disbelief and shock. While 

going through this grief, many express doubts about their ability to get through and 

survive the pain; they may also question whether they will be able to find meaning in 

their lives again. 

Although the grief experience is different for each person, families will experience some 

common feelings and tasks as they move through grief to eventually accept this event. 

These include: 

> Denial 

> Anger 

> Bargaining 

> Depression 

> Acceptance 

Family members will move through these stages at very different rates. As family members 

deal with these emotions and stages, it is best to take your cues from them about how to 

provide support. Some parents may seem distant and cold. Others may express unpredictable 

and angry emotions. There is nothing you can say that will take their pain away, so it is often 

most helpful to listen and be present for them. Offering meals, child care, transportation, or 

help with other arrangements are also ways to provide support. 

Grief is a physical as well as an emotional experience. It is common for family members 

to sleep poorly, have bad dreams, feel a stomach ache or “heart ache,” or not want to be 

left alone in addition to their emotional ups and downs. Lack of concentration, loss of 

appetite, and being easily annoyed or angry at minor things or at people they are close to 

are also common. 

Children dealing with grief have unique needs depending on their ages and their ability to 

understand the situation. Some may feel guilty about negative feelings they may have had 

about the baby. Others may worry that they will also die. 

43 
Chapter Three 

44 

Within the context of SIDS, it is also important to realize that cultural norms may influence 

responses to and understanding of the death of an infant. For providers who do not share 

the same cultural or Tribal background as the families they are serving, it may be helpful to 

learn about the traditional beliefs and mourning practices among those families. You might 

want to talk with a local community member, Elder, or local Native health board to learn 

about community practices. For some families, traditional ceremonies or other traditional 

mourning practices may be an essential step in the grieving and healing process. For 

others, these traditions may be less important. The family may ask you to assist in making 

arrangements for these practices. Listening to and being respectful of the family’s beliefs 

and coping strategies is critically important to avoid causing emotional harm to an already 

grieving family. 

Keep in mind, too, that although reporting and thorough death scene investigations are 

critical to understanding SIDS, confidentiality is also a priority. This is especially true in 

small communities where many or most families are related or know each other in some 

way. Be respectful of people’s traditions, beliefs, and privacy. 

Resources for Dealing with Grief or the Loss of a Child 

> Association of SIDS and Infant Mortality Programs—at 

http://www.asip1.org/asippublications.html 

> Compassionate Friends—at http://www.compassionatefriends.org/Resources.aspx 

> Empty Cradle—at http://www.emptycradle.org/ 

> Fetal and Infant Mortality Review: A Guide for Home Interviewers—at 

http://www.acog.org/from_home/departments/NFIMRHomeInterviewers02.pdf 

> Georgia Sudden Infant Death Information, Support, and Referral Project—at 

http://sidsga.org/SitePages/Support.htm 

> Massachusetts Center for SIDS—at http://bmc.org/pediatrics-MA-SIDS/services.htm

> National Sudden and Unexpected Infant/Child Death and Pregnancy Loss Resource 

Center: Bereavement Resources—at http://www.sidscenter.org/bereavement/index.html 

> Northwest Infant Survival Alliance/SIDS Foundation of Washington—at 

http://www.nisa-sids.org/Bereavement.html 

> The Canadian Foundation for the Study of Infant Deaths—at 

http://www.sidscanada.org/bereave.html 
Chapter 4: 

Strategies for Reaching

Communities
 Action Steps 

to Reduce the Risk of SIDS 

Objectives 

By the end of this chapter the learner will be able to: 

• Identify recognized health education approaches (including

cultural competency and using Native languages). 

• Describe several strategies that can be used to encourage

behavior change. 

• List methods for community building and organizing. 

• Outline ways to network and get the message out about

safe sleep for infants. 

• Identify locally appropriate ways to raise awareness of SIDS

in AI/AN communities. 
Chapter Four 

46 

SIDS Impacts the Entire Community 

Reducing the risk for SIDS is not just a family matter—it takes action from the whole 

community to understand and practice ways to reduce SIDS risk. It is essential for 

health educators to work with community Elders, social workers, and other outreach and 

health care providers to carry out planned educational programs and activities, such as 

those described in Healthy Native Babies Project Workbook. This chapter describes some 

strategies that you can use in your community to raise awareness about this leading cause 

of infant death. 

Before beginning the educational efforts for this program, work with community leaders and 

other educators to create area-specific objectives for the region. This type of plan provides a 

“road map” for action, with clear guidance on how to conduct the program. Other planning 

considerations include: 

> Setting a date and securing a location for training to take place 

> Promoting the event through local newspapers, radio, TV, newsletters, posters, and 
 

billboards, and mailing invitations for the event to the intended audiences
 


> Preparing necessary handouts (and incentive items if available) prior to the event 

> Having the necessary equipment ready for use 

Finally, evaluating the effectiveness of the program by comparing the actual activities with 

the stated objectives is an important way to understand the impact of your efforts and to 

improve outcomes of future efforts. 

Outreach activities can include a wide range of educational methods and techniques. For instance, 

the most appropriate activities for one location might be presentations to small groups of people 

combined with events, which rely on 

social marketing and communication 

skills to change behavior. In this case, use 

of instructional equipment, handouts 

that can be easily copied, and media 

involvement are vital to ensuring that the 

safe sleep messages “go home” with the 

attendees. However, this approach may 

not work for a neighboring community. 

As you read through this chapter, 

consider the features and situations 

specific to your community or 

the communities in which you 

work. Think of ways to adapt this 

information to meet your audiences’ 

needs. Be creative and flexible—no 

two communities are the same. 
Strategies for Reaching Communities
 Action Steps to Reduce the Risk of SIDS 

Health Education Approaches 

Educating and motivating people in your community to follow SIDS risk-reduction 

practices and to encourage others to follow the practices takes more than simply providing 

information. How directly an educational effort actually leads to desired behavior changes 

depends on many factors related to the context of how, when, and where the message is 

delivered. It includes knowledge of the source of the information and that source’s credibility 

with those receiving information; preexisting knowledge, attitudes, and beliefs; as well as the 

audience’s state of mind at the time the message is received. 

Appendix 3 describes a few of the most recognized and effective health education approaches 

that educators often consider when developing strategies for health education projects. 

Several other considerations, essential for developing effective health education approaches 

for Native audiences, are outlined in this section: health literacy, cultural competence, and 

the use of traditional Native languages. 

Health Literacy 

According to the DHHS Healthy People 2010 report, the term “health literacy” is the degree to 

which individuals have the capacity to obtain, process, and understand basic health information 

and services needed to make appropriate health decisions. 

Even though the practice of individuals making health decisions is timeless, the discipline 

of health literacy is relatively new. The concept recognizes that people may have different 

capacities to understand health messages, and that such understanding is heavily influenced 

by the communication style, skills, attitudes, biases, and 

expectations of the doctors, nurses, educators, and others 

delivering the messages. In addition, health care systems and 

their efficiency, social and cultural factors, and community 

factors also impact health literacy. 

To be truly effective for all individuals—regardless of their 

race, ethnicity, culture, class, or age—health education must 

be geared to all levels of health literacy. 

Cultural Competence 

Cultural competence in health care is often described as a set of 

behaviors, attitudes, and policies that guide a program and its 

staff to work effectively in cross-cultural settings by integrating 

culture into the program and adapting service delivery so that it 
 

reflects an understanding of cultures. 

Culture includes patterns of thought, communication, 
 

language, beliefs, values, customs, rituals, expected behaviors, 
 

ways of interacting, and roles of relationships among racial, ethnic, and religious, spiritual, 
 

social, or other groups. For health care, cultural competency is most concerned with 
 

developing the capacity of the system or program to improve health and well-being by 
 

integrating the culture of the people served into the delivery of health care. 
 

Resources on Health Literacy

• Health Resources and Services

Administration: http://www.hrsa.gov/ 

healthliteracy 

• National Network of Libraries of 

Medicine: http://nnlm.gov/outreach/ 

consumer/hlthlit.html 

• NIH National Library of Medicine: 
 

http://www.nlm.nih.gov/medlineplus/



healthliteracy.html 
 

See Appendix 5 for additional health

literacy resources. 

47 
Chapter Four 

48 

 

 

Among non-Native providers, assuring cultural 

competence in providing care to Native groups 

remains a significant challenge, not only because 

non-Natives may be unfamiliar with the values and 

priorities of that community, but also because they 

tend to come and go with some frequency. If local 

health care programs are not already attempting 

to provide cultural competency training to health 

care and social service providers new to the culture, 

such instruction should be included (to at least 

some degree) as part of the implementation of the 

Healthy Native Babies Project. Even including basic 

instruction, such as the Critical Steps to Building a 

Positive Relationship Between Provider and Patient/Client outlined in Chapter 3, can have a 

lasting impact on provider-patient interactions. 

The Healthy Native Babies Project represents an effort to add AI/AN-specific cultural 

competence to recognized SIDS risk-reduction practices. Project materials and training 

encourage further development of community-specific cultural competence. Each 

outreach coordinator, health educator, and partner can choose the most appropriate 

outreach approach for his or her specific audience. Using the Toolkit Disk, you and your 

partners in this outreach can customize education materials with messages and images 

that are appropriate for your audience. 

Resources Related to Cultural Competence and Grief 

> Promoting Cultural Diversity and Cultural Competency Self-Assessment Checklist for 

Personnel Providing Services and Supports to Individuals and Families Affected by SIDS 

and Other Infant Death—at http://www11.georgetown.edu/research/gucchd/nccc/ 

documents/Checklist.SIDS-ID.pdf 

> Policy Brief: Cultural and Linguistic Competence in Family Supports—at 

http://www11.georgetown.edu/research/gucchd/nccc/documents/FamilySupports.pdf 

> Shafer, J. (1998). When an Infant Dies: Cross Cultural Expressions of Grief and 

Loss—at http://www.acog.org/departments/dept_notice.cfm?recno=10&bulletin=797. 

> Walker: Grieving in the Muskogee Creek Tribe—at http://www.ncbi.nlm.nih.gov/



pubmed/18693381 
 

> Hardy-Bougere: Cultural manifestations of grief and bereavement: A clinical 
 

perspective—at http://www.ncbi.nlm.nih.gov/pubmed/18649443 
 

> Clements: Cultural perspectives of death, grief, and bereavement—at 

http://www.ncbi.nlm.nih.gov/pubmed/12875179 

For additional 

resources 

on cultural 

competence, 

see Appendix 5. 
49 

Strategies for Reaching Communities
 Action Steps to Reduce the Risk of SIDS 

Using Local Traditional Languages 

There is a growing movement among AI/AN communities to reclaim traditional leadership 

and governance. Native academics and community leaders are stressing the need to preserve 

Native languages as a major component of this traditional leadership. 

To honor and support the Native language revitalization movement, you may want to 

include Native language tools in your outreach whenever possible. Many communities 

include Elders who speak English as a second language, but who speak their Native language 

most of the time. The use of traditional languages in health materials may not only spark the 

interest of learners or those slightly familiar with the language, but it may also be an easy way 

to involve language-knowledgeable Elders in your outreach. 

Existing programs and community Elders may be willing to mentor you and your colleagues 

in the use of the local language. Contact information for some traditional language 

organizations is included below. 

Resources Related to Traditional Languages 

Organization Internet Address Phone/E-mail 

Alaska Native Heritage Center http://www.alaskanative.net (907) 330-8000 

Alaska Native Language Center, 

University of Alaska, Fairbanks 

http://www.uaf.edu/anlc (907) 474-7874 

Anishinaabe Language Revitalization 

Program 

http://www.sagchip.org/language/ 

index.asp 

(989) 755-4026 

Bay Mills Indian Community College http://www.bmcc.org (800) 844-BMCC (2622) 

Native Shop: Native American Wom­ http://www.nativeshop.org (605) 487-7072 

en
 s Health Education Resource Center 

Indigenous Governance, University of 

Victoria, British Columbia, Canada 

http://www.web.uvic.ca/igov (250) 721-8098 

Indigenous Language Institute http://www.indigenous-language.org (505) 820-0311 

National Museum of the American 

Indian, Smithsonian Institution 

http://www.nmai.si.edu/education NMAI-education@si.edu 

Lannan Foundation http://www.lannan.org (505) 986-8160 

Native Languages of the Americas: 

Preserving and Promoting American 

Indian Languages 

http://www.native-languages.org redish@native-languages.org 

Little Traverse Bay Bands of Odawa 

Indians 

http://www.ltbbodawa-nsn.gov (888) 309-5822 or 

(231) 242-1400 

Continued on page 50 
50 

Chapter Four 

Resources Related to Traditional Languages (Continued)


Organization Internet Address Phone/E-mail 

Omaha Language Curriculum 

Development Project, 

University of Nebraska, Lincoln 

http://omahalanguage.unl.edu/ mawakuni-swetland2@ 

unlnotes.unl.edu 

Piegan Institute http://pieganinstitute.org (406) 338-3518 

Saginaw Chippewa Tribal College http://www.sagchip.edu (989) 775-4123 

Sault Tribe of Chippewa Indians http://www.saulttribe.com Cultural Program: 

(906) 632-7494 

Ojibwe Language Program: 

(906) 632-5200 

Waadookodaading http://www.waadookodaading.org (715) 634-2619 

Administration for Native 

Americans, Administration for 

Children and Families, DHHS 

http://www.acf.hhs.gov/programs/ 

ana/programs/Language.html 

1-877-922-9262 

In addition, the Native Healthy Babies Project Toolkit Disk allows you to incorporate Native 

phrases into your outreach materials. You can include one or more of the following phrases, 

translated in Native language, into your materials: 

> Children are sacred. 

> So that the People may live 

> Back to sleep is traditional. 

> Honor the past, learn for the future. 
Strategies for Reaching Communities
 Action Steps to Reduce the Risk of SIDS 

The SOCO (Single Overriding Communications Objective)

One critical aspect of health outreach, no matter what specific outreach method you use, 

is tailoring the message to make it accessible to the intended audience—that is, make the 

message one that your audience can understand and can take to heart. The SOCO is 

basically your main message—it is the main thing you want to get across. 

The process involves the following: 

1. 	 Develop a brief key message—this is your SOCO. 

2. 	 Outline three key facts about the topic that you want the audience to remember. 

3. 	 Identify your target audience—know specifically whom you want to reach with 
 

this message.



4. 	 State your main objective—the one thing your audience needs to take away from 
 

your encounter.
 


Appendix 4 of this Workbook includes resources related to SOCO. Keep in mind that your 

SOCO may be slightly different depending on your audience, the type of outreach, and the 

location of that outreach. You may want to go through the SOCO exercise not only for the 

overall project, but also for planning different pieces of your project to ensure your messages 

stay powerful and consistent. 

For more information on SOCO strategies, visit one of the following resources: 

Resources Related to SOCO 

> Get your message ready for prime time: Moving from data to action—at 

http://dhs.wisconsin.gov/dph_bfch/MCH/AnnualForum/Messaging/



MessageReadyforPrimeTime.pdf
 


> Planning Public Health Communications—at http://www.uic.edu/sph/dua/



Churchill/CommunicationsDUA3.htm
 


> Single Overriding Communications Objective Worksheet (Part of Forging Partnerships 
 

to Eliminate Tuberculosis Toolkit)—at http://www.cdc.gov/tb/publications/



guidestoolkits/forge/toolkitword.htm
 


> Tools for Behavior Change Communication—at http://www.infoforhealth.org/



inforeports/BCCtools/6.shtml
 


51 
Chapter Four 

52 

Grassroots Organizing and Community Outreach 

Community-based models focus on the idea that empowerment begins from within. 

In communities of underserved people—such as poor, indigenous, disenfranchised, or 

immigrant communities—it is important for individuals to build an awareness of themselves 

within a community context. Empowering 

them to set their own individual and collective 

goals, create plans, develop programs, provide 

leadership, establish community norms, and 

celebrate victories can make a big difference 

in the success of your outreach and in the 

outcomes of the community. Communities 

impacted by these types of issues are best suited 

to address them and to create the change they 

envision, but they need your guidance on how 

to achieve such tasks. 

Community organizing is a participatory 

process by which people organize themselves to 

take charge of their situation and work together 

for the common good. Through this process, 

community members move from a sense of 

powerlessness to powerfulness in their ability to 

become co-creators of public and community 

life. Grassroots organizing and networking 

are two key strategies within a broad range of 

community organizing methods. 

Among the many activities involved in grassroots organizing and networking are the following: 

> Identifying how issues impact communities though research and analysis 
 

(the Healthy Native Babies Project Workbook aims to assist you with this activity)
 


> Building a base of community supporters that will educate and mobilize other 
 

community members and allies



> Identifying the community’s vision for change through a process that is controlled 
 

by the community itself
 


> Setting a timeline and prioritizing the goals the community develops for creating change 

> Mapping out a plan that includes addressing internal and external obstacles, identifying 

resources needed to create the change the community desires, recruiting and mobilizing 

volunteers, and creating campaign messages 
Strategies for Reaching Communities
 Action Steps to Reduce the Risk of SIDS 

> Ensuring ongoing evaluation to assess what works and what doesn’t work so that 
 

plans can be revised to be more effective
 


> Having fun and celebrating successes 

The Native American Women’s Dialog on Infant Mortality (NAWDIM) offers 

information on organizing in Living like Neighbors: Supporting the Sovereignty and 

Treaty Rights of Indigenous Nations, by L. Henry-Tanner and C. Tanner. For more 

information, visit either http://www.westernstatescenter.org/resources/tribal.html or 

http://www.socialjusticefund.org/news/publications. 

In addition, a number of organizations may be able to assist you with community 

organizing. Some resources are listed below. 

Resources Related to Community Organizing 

Organization Internet Address Phone 

Center for Community Change http://www.communitychange.org (877) 777-1536 or 

(202) 339-9300 

Highlander Research and 

Education Center 

http://www.highlandercenter.org (865) 933-3443 

Inter-Tribal Council of Michigan, Inc. http://www.itcmi.org (906) 632-6896 

The California Partnership http://www.california-partnership.org (562) 862-2070 

Incite! Women of Color Against 

Violence 

http://www.incite-national.org/ 

index.php?s=37 

(484) 932-3166 

National Urban Indian Family 

Coalition 

http://www.nuifc.org (206) 829-2229 

Western States Center http://www.westernstatescenter.org (503) 228-8866 

53 
Chapter Four 

54 

Social Marketing 

Social marketing, specifically within the public health realm, is often described as using 

culturally tailored marketing and media methods to design, implement, and manage 

community-focused strategies for translating health findings into education and action 

programs. In most cases, social marketing is most effective when it is run in collaboration 

with health care and/or social service systems, which provide 

customers with access to essential services while reinforcing 

educational messages. 

Even though mass media (such as TV, radio, the Internet) is 

a critical tool for social marketing, many health-related massmedia projects have failed to show significant behavioral 

change. You can improve the effectiveness of your mass-media 

outreach using the following social marketing guidelines to 

craft your messages: 

> Define your intended audience(s) properly. 

> Create a culturally sensitive message. 

> Identify and counter resistance points to your 

message (see the sidebar for an example of how to 

counter misconceptions). 

> Present the message in clear, understandable language. 

Many successful media plans also include the following steps: 

> Select the appropriate media/venue for the audience or for the message. For example, 

it may be more effective to secure billboard space in the local community for your 

message, rather than to create TV ads to run on satellite stations. 

> Strive for the proper balance of media exposure or media mix to reach the intended 

audience. For example, use printed flyers, posters, and postcards to reach an audience 

that does not spend much time on the computer. 

Appendix 3 includes more information about social marketing. 

Appendix 4 includes information about working with the media. 

Countering Misconceptions 

This activity is critical for any outreach 

that tries to change behaviors. For 

example, one widely held misconception 

is that drinking beer during pregnancy 

is less harmful than drinking hard liquor 

during pregnancy. An appropriate 

message should explain that beer, 

hard liquor, wine, and malt liquor are 

all different forms of alcohol, but they 

are all still alcohol. Follow up with the 

message that there is no safe level of 

alcohol consumption during pregnancy, 

no matter what form that alcohol takes. 

 

 

 
Strategies for Reaching Communities
 Action Steps to Reduce the Risk of SIDS 

Forging Partnerships 

Your Healthy Native Babies Project will benefit from the knowledge, skills, and resources of 

other organizations and individuals. Forging partnerships is an important way to leverage or 

make the most of limited resources while spreading your message to a wider audience. As you 

plan and implement your Healthy Native Babies Project, consider contacting and partnering 

with the following types of groups. 

IHS EpiCenters and Health Boards 

The IHS established 11 Tribal epidemiology centers (EpiCenters) to assist the National IHS 

Epidemiology Program in improving the health of AI/ANs throughout the United States. 

These EpiCenters provide a variety of services and assistance, including data management 

and reporting, emergency response, surveillance, liaison between communities and providers, 

training, and consultations with clinicians. The table below provides contact information for 

these EpiCenters in the five IHS focus Areas for this Project. 

Resources for IHS EpiCenters 

Area		 Organization Internet Address Phone 

Aberdeen		 Northern Plains Tribal 

Epidemiology Center 

http://www.aatchb.org/ntpec (605) 721-1922 

Alaska Alaska Native Health Consortium, 

Alaska Native Epidemiology Center 

http://www.anthc.org/chs/ 

epicenter/ 

(907) 729-4567 

Billings Montana and Wyoming Tribal 

Leaders Council, Rocky Mountain 

Tribal Epidemiology Center 

http://www.rmtec.org (406) 252-2550 

Bemidji Great Lakes Inter-Tribal Council, 

Great Lakes EpiCenter 

http://www.glitc.org/epicenter/ 

index.html 

(715)588-3324 

Portland Northwest Portland Area Indian 

Health Board, EpiCenter 

http://www.npaihb.org/epicenter (503) 228-4185 

Urban Indian Health Institute 

(UIHI) 

http://www.uihi.org/category/ 

maternal-child-health/ 

(206) 812-3030 

In addition, the CDC, through its Tribal Consultation Advisory Committee, partners with 

several Regional Health Boards to address the health and other needs of AI/ANs both on 

Tribal lands and outside Tribal areas. Please visit http://www.cdc.gov/omhd/Populations/ 

AIAN/AIANHB.htm for a complete listing of the health boards and their contact information. 

55 
56 

Chapter Four 

Youth Involvement Organizations 

There are many youth involvement projects across the country, both reservation based 

and urban based. In addition, a number of projects are organized by youth, for youth, to 

foster healing and reconnect youth to traditional AI/AN values and culture. A few of these 

organizations are listed below. 

Resources for Youth Organizations 

Organization Internet Address 	 Phone 

Boys and Girls Clubs in Indian Country http://www.naclubs.org 	 1-866-NACLUBS 

or (301) 261-6925 

Lummi CEDAR (Community Health 

Elders, Education/Drug-free/Alcoholfree/Respect) Project 

http://www.cedar-project.org (360) 380-1464 

Sault Tribe of Chippewa Indians http://www.saulttribe.com/ 	 (906) 632-7494 

Elder Involvement Projects 

Elders are important community members with much knowledge and expertise that 

could benefit communities. Respectfully including Elders in programs that provide 

health education on SIDS risk reduction is a good way to teach communities about this 

important issue. Many local, regional, and national organizations work with AI/AN Elders. 

A comprehensive listing of Tribal entities with services for the elderly is maintained by the 

National Resource Center on Native American Aging at the University of North Dakota and 

is available at http://ruralhealth.und.edu/projects/nrcnaa/servicelocator.php. Additional 

resources are included below. 

Resources for Elder-Serving Organizations 

Area Organization 	 Internet Address Phone 

National National Indian Council on Aging http://www.nicoa.org/ (505) 292-2001 

National Resource Center on 

Native American Aging (NRCNAA), 

Center for Rural Health, University of North Dakota 

http://ruralhealth.und.edu/ 

projects/nrcnaa 

(800) 896-7628 

Aberdeen Oglala Sioux Tribe, Foster 

Grandparents 

(605) 867-5412 

Continued on page 57 
Strategies for Reaching Communities
 Action Steps to Reduce the Risk of SIDS 

Resources for Elder-Serving Organizations (Continued) 

Area Organization Internet Address Phone 

Aberdeen 

(Continued) 

Mandan, Hidatsa & Arikara Nation, Aging Services http://www.mhanation.com (701) 627-4547

Trenton Indian Service Area Senior Services http://www.ndhealth.gov/ 

localhd/TISA 

(701) 774-0303 

Flandreau Santee Sioux Tribe, 

Grace Moore Senior Citizens 

Center 

http://www.fsst.org/ 

Gracemooresenior_main.html 

(605) 997-2924 

Omaha Tribe of Nebraska, Senior 

Citizens Center 

(402) 837-5639 

Sac & Fox Tribe of the Mississippi 

Indians in Iowa, Meskwaki Senior 

Service Center 

http://www.meskwaki.org/ 

Seniors.html (Note: Must use uppercase 

’S’ in ’Seniors’ for the link to work)

(641) 484-3888 

57 

Alaska Southcentral Foundation Elders 

Program 

http://www.southcentral 

foundation.com/elder.ak 

(907) 729-6500 

Portland Portland Youth and Elders Council 

on Poverty Reduction, Native 

American Youth & Family Center 

http://www.nayapdx.org/ 

community-services/ 

portland-youth-and-elderscouncil.php 

(503) 288-8177 

Bemidji Native American Family Services 

(United Way of Bemidji Area) 

http://unitedwaybemidji.org/ (616) 458-4078 or 

(616) 457-6767 

Maternal and Child Health Agencies and Programs 

State and local maternal and child health agencies and programs help communities prevent 

infant mortality and focus on improving the health of mothers and children. Program 

activities can include improving access to prenatal and newborn care, conducting health 

education outreach, and supporting medical research that will improve outcomes for 

AI/AN families. 

The Maternal and Child Health Library offers many resources through its Web site at 

http://www.mchlibrary.info/KnowledgePaths/kp_infmort.html. 

You may also want to contact the Pregnancy Risk Assessment Monitoring System (PRAMS) 

project leaders in your state. PRAMS, a surveillance project supported by the CDC 

and state health departments, collects state-specific population-based data on maternal 

attitudes and experiences before and during pregnancy and shortly after the baby is born. 
58 

Chapter Four 

Some of the information collected by PRAMS is not available from other sources. These data 

can assist you in identifying groups of women and infants at high risk for SIDS and other 

health problems, in monitoring changes in health status, and in measuring progress toward 

goals and objectives. You can also partner with these projects to distribute information about 

SIDS risk reduction in the venues where PRAMS normally collects its data. Current PRAMS 

contacts are listed in the table below. 

Resources for Pregnancy Risk Assessment Monitoring System (PRAMS) 

State Contact Person Phone 	 Web Address 

Alaska Kathy Perham-Hester (907) 269-3447 	 http://www.epi.hss.state.ak.us/ 

mchepi/prams/default.stm 

Michigan Yasmina Bouraoui (517) 335-9398 http://www.cdc.gov/prams/states/ 

michigan.htm 

Nebraska Brenda Coufal 402) 471-9044 http://www.hhs.state.ne.us/prams 

South Dakota 

Tribal 

Jennifer Irving (605) 721-1922 

ext. 120 

http://www.cdc.gov/prams/States/ 

SouthDakota.htm 

Minnesota Barbara Forhnert (651) 201-5953 http://www.health.state.mn.us/ 

divs/cfh/prams/ 

Oregon Kenneth Rosenberg (971) 673-0237 http://oregon.gov/DHS/ph/pnh/ 

prams/index.shtml 

Washington PRAMS Coordinator (360) 236-3497		 http://www.doh.wa.gov/cfh/ 

PRAMS/default.htm 

Wisconsin Eleanor Cautley (608) 267-0334		 http://dhs.wisconsin.gov/births/ 

prams/index.htm 

Wyoming Angela Crotsenberg (307) 777-8787		 http://www.cdc.gov/prams/states/ 

wyoming.htm 

Note: Several Northern Tier States do not participate in PRAMS; they include: Idaho, Indiana, Iowa, Montana, and North Dakota. 

Hands-On Projects and Project Groups

(Cradleboard Classes, Native Art Classes, etc.) 

Organizing hands-on, culturally relevant projects creates opportunities for communities 

to talk about SIDS and SIDS risk reduction. These venues provide a more personal way to 

reach people and provide them with information and materials. These events, such as classes 

on making cradleboards, sessions on making other types of Native art, or classes on learning 

traditional Native languages, can bring people together to learn about SIDS risk-reduction 

strategies in their communities. You can also find ways to include Native Elders and youth 

in these activities. 
Strategies for Reaching Communities
 Action Steps to Reduce the Risk of SIDS 

Cradleboard Basics 

As discussed in earlier in this Workbook, Native Americans may have originated the concept 

of “back to sleep” with their longstanding historical use of the cradleboard. It is empowering 

for community members to remember that Native Americans have always had mechanisms 

for keeping babies safe. 

Many AI/ANs across the United States are reclaiming the tradition of using cradleboards. 

Organizing and hosting a community cradleboard-making class provides a great opportunity 

for community members to learn a craft, creates a traditional object that is safe for babies to 

sleep in, and encourages discussion about issues related to safe sleep environments. 

The Native American Women’s Dialog on Infant Mortality (NAWDIM) and SIDS 

Foundation of Washington provide cradleboard-making classes in the Puget Sound region. 

For more information on the classes or on how to start a class in your area, please contact 

the SIDS Foundation of Washington at (206) 548-9290, or at 4649 Sunnyside Avenue, N, 

Suite 348, Seattle, WA 98103. 

Make sure that you remind your community members not to use a cradleboard when an 

infant is a passenger in a car or other motor vehicle. For this situation, an infant car seat is 

the safest way to transport the baby and helps to ensure that he or she is protected in case 

of a motor vehicle crash. The National Highway Traffic Safety Administration Web site 

provides more information about infant car seats and safety; visit http://www.nhtsa.gov/ 

Safety/CPS. 

Sample Outreach Activities 

Conducting a Healthy Native Babies Project provides an important opportunity for you to 

make a difference in your community and to help protect the well-being of infants. 

The list below describes some possible activities and ideas for conducting your outreach to 

reduce the risk for SIDS in your community: 

> Distribute educational materials at meetings of local groups (such as faith 

organizations), in hospital and physicians’ waiting rooms, libraries, senior citizen 

centers, and at other locations throughout the community. Everyone needs to learn 

the SIDS risk-reduction strategies. Ask the staff at these locations if you can display 

copies of SIDS materials in a place where people can easily see them and pick them up. 

> Distribute information at local community events, such as fairs, block parties, cultural 

celebrations, pow-wows, sports tournaments, and other observances. 

> Partner with local hospitals and health centers so that they can give materials to parents 

and caregivers when their babies are released from the hospital, or when they come in 

for well-baby check ups. 

> Partner with local retailers who serve Native families to distribute information on a 
 

specific day of the week, such as Safe Sleep Saturday.



59 
Chapter Four 

 

60 

> Organize local “town hall” meetings or community forums to discuss the myths and 
 

facts associated with SIDS among AI/AN people and to describe how individuals and 
 

organizations in the community can work together to educate others about reducing 
 

SIDS risk. Promote the event using a postcard that you create using the Toolkit Disk 
 

in this packet.



> Contact the local health department or maternal and child health organizations that 

have SIDS programs in your community. Ask them if they provide information on 

SIDS and reducing SIDS risk to new or expectant parents. If they do, encourage them 

to continue their efforts. If they don’t, work with them to create and produce materials 

for their specific audiences, or give them the Back to Sleep campaign contact information 

so they can obtain their own materials and packet. 

> Write letters, send e-mails, or make telephone calls to local community leaders to tell 
 

them about the importance of reaching AI/AN families with SIDS risk-reduction 
 

strategies. Encourage them to get involved in your outreach and to support efforts to 
 

spread the message within the community. 
 

> Use a variety of materials and locations to reach out to families who have an infant 

younger than one year of age, anyone who is expecting a child, and everyone who may 

become a parent in the next few years. Let them know about your involvement in the 

Healthy Native Babies Project and explain the safe sleep messages. 

> Coordinate a workshop or presentation using the training materials provided in the 
 

Healthy Native Babies Project Facilitator Packet (call 1-800-370-2943 to obtain your 
 

packet). You can adapt these materials for workshops or brief presentations. 
 

> Consider contacting organizations in the community that have an interest in the safety 

and well-being of infants, and request a meeting with them to discuss educating their 

members about ways to reduce the risk of SIDS. You could even offer to work as a 

volunteer in return for the chance to spread safe sleep messages. Work together with 

agency leaders to decide how your skills and life experiences can best educate others in 

the AI/AN community about SIDS. 

> If your community has significant radio listenership, you may want to pursue a 
 

partnership with a local station to educate listeners about SIDS. Radio is often more 
 

accessible than TV in many communities and reaches harder-to-reach audiences 
 

better than other means. Simple interviews with community leaders, public service 
 

announcements (PSAs), and paid advertisements on radio can help spread safe 
 

sleep messages to a large audience quickly and easily. Appendix 4 includes more 
 

information about working with the media, including sample scripts for short radio 
 

PSAs. Keep in mind that radio can be more effective at getting your messages to 
 

hard-to-reach audiences, including those who have difficulty reading, are homeless, 
 

or are incarcerated. 
 

These are just a few ideas about how to get involved in educating the community about 

SIDS. Be creative, and remember that the most important thing is getting involved! 
Chapter 5: 

Planning and Sustaining a

Healthy Native Babies Project 

Objectives 

By the end of this chapter the learner will be able to: 

• Recognize strategies for achieving community input in project

development. 

• Identify information sources for developing a local or regional Healthy

Native Babies: Honoring the Past, Learning for the Future Project. 

• Describe approaches for securing project funding. 

• Explain project implementation, sustainability strategies, and

reporting requirements. 

• Understand the components and importance of a three-staged

approach to evaluation. 
Chapter Five 

62 

A True Community Effort 

The majority of successful projects in AI/AN communities are the result of communitybased efforts conducted by community champions and their partners. This success relies 

on recognizing community and partner expertise and emphasizing community input in 

all phases of the project. You can mobilize community partners and stakeholders at the 

beginning of the project to get buy-in from everyone involved. Then you and your partners 

can determine when and how to include groups and organizations from outside the 

community, based on the need for expertise not available locally. This chapter describes 

ways to plan a successful outreach project and put that plan into action. The chapter also 

outlines ways to evaluate and improve upon an outreach plan. 

Develop the Program Proposal or Plan 

Regardless of its specifics, every project will benefit from a defined project plan. Plans can 

vary in their level of detail, but most list out specific objectives/activities and identify the 

persons or groups responsible for each. The plan should also include a budget reflecting 

the contributions of each person, agency, and partner to the overall project. 

Most AI/AN populations recognize the circle as an important symbol in their cultures— 

the following model for program development is based on this understanding. In many 

communities, the Medicine Wheel represents the “seven directions”—the four directions/ 

points of the compass (N, E, S, W), Mother Earth, the Creator, and ourselves at the center. 

Within this context, everything is related so that when something happens in one of the 

directions, the balance of the rest of the wheel is affected. The Medicine Wheel is also the 

circle of life—life is cyclical, and the wheel’s quadrants represent the stages of life, from 

infancy to old age. 

Similarly, all of the various stages of program development are related—each activity is a part 

of a series of activities that lead to a well thought-out plan of action, as we read the circle 

clockwise. For this example, place SIDS at the center because it is the focus of the program 

being developed (Figure 11). 

Sustainability Through Community-Based

Program Development 

To be successful, community organizing efforts need to ensure that all stakeholders are 

invited to the initial meetings so that their buy-in occurs from the beginning, rather than 

after plans have already been made. As the organizer, you should make sure that partners 

from outside the community have credibility, respect, and experience working with Native 

communities. A good rule of thumb is to make sure that marketing for community activities 

always includes the 5 Ws: Who, What, When, Where, and Why. 
Planning and Sustaining a Healthy Native Babies Project 

63 

 

 

Figure 11. 

Sustainability Model 

SIDS 

Implementation 

& Marketing 

Community 

Organizing 

Presentation Non-Community 
 

or Reporting Partnerships
 


Outcome of Information Summative Collection Evaluation 

Process of 
 

Formative Funding 
 Evaluation Application
 


The following types of information may also be useful for guiding, planning, and prioritizing 

community needs. 

> Primary data collection is the direct collection of data to identify gaps or disparities 
 

in health, resources, or outcomes by comparing the selected community with the state, 
 

other Tribes, or national populations. This type of data collection usually occurs in 
 

the form of surveys created from national question sets that allow comparisons once 
 

data collection is complete. By reviewing information and identifying any differences, 
 

communities can better prioritize needs and direct resources to address those needs. 
 

Generally, this information forms the basis for developing new programs, creating new 
 

facilities, and designing new services, but you can also use it to modify current projects 
 

or to address changing needs of the community. 
 

> Secondary data sources/analysis refers to the use of existing reports, records, or files 
 

to collect information needed to develop a project. Reports from previously conducted 
 

studies provide statistics and recommendations that help to narrow the focus of the 
 

project and define its priorities. Reports are usually based on community data, so an 
 

existing database may be available for you to use. Another source of information—
 


one that is often overlooked—is reviewing and analyzing medical records or service 
 

program files. You and your colleagues can use these types of resources to create your 
 

own “database” about the community. Program reports are also excellent resources for 
 

documenting history and for assessing the outreach experience of community members. 
 
Chapter Five 

 

 

 

64 

The majority of primary and secondary data sources include demographic information, such 

as age, gender, income, and education rates, specific to the population. This information 

is useful for identifying disparities and prioritizing issues for your effort. The primary 

resource for this information is your local EpiCenter. Each EpiCenter provides up-todate information, which can be targeted to the specific populations for your intended effort. 

Please visit page 54 for EpiCenter contact information. 

Other methods for collecting information are described below. Each method has its own 

strengths and weaknesses, but each offers a significant improvement over making decisions 

based on undocumented needs of the community. 

> The most commonly used method for collecting information is a survey. Surveys can 

provide accurate descriptions of people based either on a complete count of population 

or a representative sample of people from the selected community. Among the methods 

for collecting survey data are: 

> Self-administered questionnaires delivered/received by mail; 

> Self-administered questionnaires delivered/received at meetings or gatherings; 

> Face-to-face interviews; and 

> Telephone interviews. 

> A key informant approach relies on people who are most likely to be knowledgeable 

about the community as the primary source of information. This approach usually 

involves a questionnaire with broad open-ended questions and a very limited number of 

interviews. Key informants, commonly community leaders and people in key leadership 

positions, are selected because they likely know both the community and its Elders and 

can represent the needs of the population. 

> The use of focus groups involves gathering small groups (10 persons to 12 persons) of 

people to engage in a guided discussion or conversation. Presenting the group with a 

limited number of well thought-out and well-sequenced questions provides the focus. 

Focus groups can also validate data received through the needs assessment process and 

ensure that stakeholders have a voice in the process. 

> A community forum allows for broad participation in a single meeting, at which all 

interested parties are invited to attend and participate. A community forum can usually 

be conducted in the same manner as a focus group, but on a larger scale. 

Focus groups and community forums both provide an opportunity to learn more about other 

community projects and to build on or expand existing or established networks. This practice 

helps to reduce duplication and can make efforts more cost and time efficient. Partnering 

with other stakeholders also enables you to reach more people with less effort. 
65 

 

 

 

 

Planning and Sustaining a Healthy Native Babies Project 

In terms of focus groups and community forums, consider pursuing the following 

stakeholders to take part in your efforts: early childhood tracking programs, maternal 

and child health agencies and programs, IHS offices, Tribal health departments, PRAMS 

centers, and any other infant- or health-related organizations. 

Funding Applications 

Funding for programs or services is typically obtained through grants from private and/or 

public funding sources, which can include the federal government, state and local funding 

agencies, and private foundations. Each organization has its own format and forms for 

writing proposals, so following that specific format will increase your chances of getting 

funds. Whatever the format, there are five basic categories of information that you should 

be ready to provide: 

> Need or Background Information includes national statistics related to the topic that 

are then tailored to the region, state, and local community. At the community level, you 

may want to provide real-life examples (deleting names and any personally identifiable 

information) to illustrate the statistics you present. 

> Plan of Action or Intervention Information includes innovative approaches to 

addressing an issue and explains your proposed solution to the problem in the form 

of objectives and activities. This section is also a good place to mention the person(s) 

responsible and evaluation criteria for each of the objectives and activities. 

> The Timeline for the project should outline activities related to the project, from 

planning and pre-implementation, to project completion and post-completion 

evaluation. In some cases, the Plan of Action and the Timeline are combined to 

provide a thorough overall picture of the project. 

> Budget should correspond to proposed objectives and activities and should include 

information through to the completion of the proposed project. Such information 

would include: personnel, fringe benefits, consultants, travel, supplies, incentives, food, 

telephone costs, Internet costs, copying costs, postage, and indirect costs. Indirect costs 

are usually provided to the fiscal manager of your grant and cover administrative costs, 

office space rental, gas, heat, and electricity. 

> You should propose and select Personnel based on their abilities to do proposed 

tasks. Although you may have personal knowledge of their personnel’s expertise, be 

aware that credentials are important. Include resumes for all proposed personnel in 

your application. 

Appendix 5 includes 

many resources for 

the risk-reduction 

messages and other 

information in this 

Workbook. You may 

need to include 

this information in 

a formal proposal 

or plan to secure 

funding. 
Chapter Five 

66 

The links below provide application planning worksheets from several organizations and 

include examples and resources for the type of information funding agencies commonly seek 

in proposals. You can also use the Internet to search for other resources and examples. 

Resources Related to Funding Applications 

> Center for Community Vitality: http://www.ag.ndsu.nodak.edu/staffres/GrantDev/ 

checklist.htm (Note: Must use uppercase on “G” and “D” in “GrantDev” for link to work) 

> Michael and Susan Dell Foundation: http://www.msdf.org/Libraries/Documents/ 
 

Grant_Planning_Worksheet_2-7-2008.sflb.ashx
 


> Otto Bremer Foundation: http://www.ottobremer.org/guidelines.php 

> The Foundation Center: http://www.foundationcenter.org 

Implementation: Putting the Plan into Action 

Once you secure funding for your project, you need to go back to your project plan and 

define what needs to happen to put the plan into action. A well-written proposal spells out 

what is being done (objectives), by whom (personnel), and what specific actions are being 

taken (activities). 

Presentation, Reporting, and Dissemination 

Most funding agencies require you to submit reports and progress information throughout 

the funding cycle. Cycles vary, but most require reports at six and 12 months, with a final 

summary report due at the end of the funding period. Your funding agency may also require 

you to present update or overview information about your project to a board of directors 

or other governing body, so be sure to build the cost of these presentations into the budget 

for your project. At the community level, presentations may also be used to inform Tribal 

officials, partners, community members, and your intended audience. 

Sharing your project, project plan, and project progress with others can give them ideas on 

how to use your experiences as models for their own efforts, to make things better for Native 

and non-Native communities alike. 

Sustainability 

Sustainability—keeping the project up and running on schedule and on budget—requires 

a champion who can mobilize the community. The job requires special skills, knowledge, 

and experience. Some of the more common mistakes and barriers that may decrease 

sustainability include too little time for planning, overlap with another similar project, 

politics or organizational control (or lack of control), lack of trust, and lack of interest. 

In addition to your overall project plan, you may want to create a sustainability plan as a 

step-by-step way to guide ongoing management of the project. The process of creating a 
Planning and Sustaining a Healthy Native Babies Project 

67 

 

 

written sustainability plan can strengthen your partners’ buy-in and their understanding of 

what is needed to keep the program operating and improving. You can also use the plan to 

market the program to potential financial supporters. Four areas to consider for sustaining 

the project include: 

> Defining a vision 

> Building collaboration 

> Advocating for support 

> Finding funding 

For more information about sustainability for your project, visit the Afterschool Alliance at 

http://www.afterschoolalliance.org/documents/Toolbox/RoadtoSustainability.pdf. 

Evaluation 

Evaluation is an ongoing process used to develop, implement, and refine a project. 

Evaluation is an important way to determine what worked and what didn’t in your 

Healthy Native Babies Project. The process of evaluation usually focuses on: 

> Collecting information to assess needs; 

> Analyzing and interpreting the information to help refine objectives and activities; 

> Tracking activities, materials, and resources used in the project; and 

> Assessing how well the project achieved the overall goal. 

Several clear benefits of evaluation include: 

> Increased documentation of success and failure; 

> Better communication of goals and accomplishments; 

> More effective acquisition of funding and community leader support; and 

> Improved quality of services and achieved goals. 

Although research and program evaluation have much in common, the methods needed to 

assess a program’s effectiveness do not usually require a high level of statistical or scientific 

knowledge. Many of the most practical tools in evaluation require little more than simple 

logic and basic math skills, but be sure to use tools appropriate to the situation. One critical 

element for program evaluation is an objective viewpoint—that is, involving someone from 

outside the community or not associated or involved with the project to review outcomes 

without bias. 
Chapter Five 

 

68 

The following example illustrates a three-stage approach to evaluation. 

A Three-Stage Approach to Evaluation of a SIDS Risk-Reduction Proj

ect 

­

Stage 1: Needs Assessment and Project Design 

A needs assessment identifies the problem the program is designed to address in terms of its 

size and features: 

> How large is the problem? 

> How it is distributed in the community? 

> What factors are associated with or contributing to the problem? 

The EpiCenters for each IHS Area offer considerable data and other resources to help 

you define the size of the problem and its distribution in your Area. As reported earlier, 

national research studies have defined many of the features that contribute to SIDS risk in 

Native communities. 

Stage 2: Process Evaluation 

Process evaluation looks at how well the program was carried out or implemented. For 

outreach and public health staff who implement the Healthy Native Babies Project, process 

evaluation would focus on documenting the activities they completed, the types and number 

of resources they used, the objectives they achieved, the audience(s) they reached, and the 

specific educational approaches they used. 

Process evaluation provides the information needed to explain the activities, materials, and 

approaches used in the project to those outside the project. More importantly, it associates 

these components with actual results or outcomes in terms of reduced SIDS rates or reduced 

SIDS risk after a set amount of time. Knowing these relationships is essential to identifying 

“best practices” and sharing these approaches with other providers and AI/AN communities. 

In many cases, process evaluation contributes to broader knowledge that not only helps 

others, but also supports local quality improvement and improved outcomes. Efforts that 

were difficult or unsuccessful can provide as much useful information as those that are 
Planning and Sustaining a Healthy Native Babies Project 

successful. Seeking and using “lessons learned” is a valuable learning tool for SIDS-related 

efforts and other types of outreach and activities. 

Stage 3: Outcome Evaluation 

The ultimate goal or desired outcome of the Healthy Native Babies Project is a reduction in 

SIDS rates for AI/AN communities. To achieve this end, the Project activities aim to change 

behaviors to reduce the known risks for SIDS. The outcome evaluation of this project, then, 

measures and assesses the change in: 

> SIDS rates in the community over time; and 

> Knowledge and or behaviors relative to SIDS 
 

risk factors in the community.
 


You can adopt several sources of data or 

information about SIDS rates (described earlier in 

this Workbook) to determine actual or changes in 

SIDS rates as part of your evaluation. 

Measuring increases in the knowledge about SIDS 

risk factors or decreases in the actual risks (for 

example, more caregivers putting children to sleep 

on their backs) is often called an “impact measure” 

or “impact outcome.” Even though these types of 

outcomes are not the actual endpoint outcomes 

for a Healthy Native Babies Project, increased use 

of SIDS risk-reduction strategies and knowledge 

about SIDS risk are key impact measures for your 

project. They are likely to eventually reduce SIDS 

rates over time. 

For those working on outcome evaluation, a word 

of caution: Be patient. It may take several years for 

your Healthy Native Babies Project to show positive results, even when projects are well-run 

and effective. Literature also indicates that preventive strategies are critical, but that time is 

needed to actually see results. 

69 

Stay passionate about your work to improve the health of Native babies and communities,

and the results will follow. 
Chapter Five 

70 
Planning and Sustaining a Healthy Native Babies Project 

71 

71
72 

Acknowledgements 

This Workbook was developed by the Eunice Kennedy Shriver National Institute of Child 

Health and Human Development (NICHD) with Native American Management Services, 

Inc. (NAMS) under contract #HHSN275200503412C. 

Project Contributors 

The NICHD would like to thank the following individuals for their assistance in drafting 

and developing these materials. 

• Desiree Harris, Northern Cheyenne 

Tribal Health 

• Eric Bothwell, D.D.S., M.P.H., Ph.D., 

Performance Management Consultant 

• Geradine Simkins, R.N., C.N.M., 

M.S.N., Inter-Tribal Council of 

Michigan, Inc. 

• Leah Henry-Tanner, Seattle Children’s 

Hospital, Center for Children with 

Special Needs 

• Leander McDonald, Ph.D., 

Spirit Lake Nation 

• Lisa C. Neel, M.P.H., 

Public Health Consultant 

• Marilyn Pierce-Bulger, F.N.P., C.N.M., 

M.N., Pioneer Consulting 

• Christine Rinki, M.P.H., Northern 

Plains Tribal Epidemiology Center 

Healthy Native Babies Project Workgroup 

The NICHD would also like to acknowledge the members of the Workgroup who provided 

time, energy, and expertise to the project. 

• Ralph Forquera, M.P.H., Seattle Indian 

Health Board 

• Carole Anne Heart, Aberdeen Area 

Tribal Chairmen’s Health Board 

(AATCHB) 

• Diane Jeanotte, R.N., B.A.O., 

IHS Maternal and Child Health 

Program Officer 

• Elizabeth Kushman, Inter-Tribal 

Council of Michigan, Inc. 

• Allison J. La Pointe, M.P.H., Great 

Lakes EpiCenter 

• Jacqueline Left Hand Bull, AATCHB

• Lynn Lowry, P.H.N., Winnebago Tribe 

of Nebraska 

• Ted Mala, M.D., M.P.H., Alaska Native 

Medical Center, Tribal Relations and 

Traditional Healing, Southcentral 

Foundation 

• Mary McClain, R.N., M.S., 

Massachusetts SIDS Center, Boston 

Medical Center, and Aberdeen Area 

Perinatal and Infant Mortality Review 

• Kelly Murphy, Alaska Native Tribal 

Health Consortium 

• Alice Park, M.P.H., Urban Indian 

Health Institute 

• Leslie L. Randall, R.N., M.P.H., Nez 

Perce Tribal Member, University 

of North Carolina, and Northwest 

Portland Area Indian Health Board 

• Christine Rinki, M.P.H., South Dakota 

Tribal PRAMS, Northern Plains Tribal 

Epidemiology Center, and Aberdeen 

Area Tribal Chairmen’s Health Board 

• Judith Thierry, D.O., M.P.H., 

IHS, U.S. Department of Health 

and Human Services 
Acknowledgements 

AI/AN Families 

The NICHD and the Healthy Native Babies Project Workgroup would like to thank the 

AI/AN families for their openness and assistance in depicting the daily lives of AI/ANs 

throughout the United States. 

Photographers 

The NICHD and the Healthy Native Babies Project Workgroup would like to acknowledge 

the following photographers for their invaluable contributions to the project and materials. 

• Stephen Breshear • Kraig Haver

• Dennis Brusven • Al Kamuda

• Bob Charlo • Peter A. Taylor

Language Translations 

The NICHD and the Healthy Native Babies Project Workgroup would also like to thank the 

following individuals who contributed time and expertise in translating certain phrases and 

messages into Native languages for use in Healthy Native Babies Project materials. 

• Oscar Alexie • Moses Dirk • Ethel Parker, Elder

• Dora Ammann, Elder • Keri Edwards • Tachini Pete

• Mark AwakuniSwetland • Rita Hakala • Jonas Ramoth, Elder

• Reverend Everett

Harrison 

• Connie Rivard, Elder

• Janet Barr, Elder • Kenneth Ryan

• Alberta Grant Canby, 

Elder 

• LeeAnn Johnson • Emmaline Walker

• Favian Kennedy Sanchez, Elder 

• Clifford Canku • Jerome Kills Small • Alberta Stephan, Elder

• Sean Chandler • Verda King • Manfred J. Suina, Sr.

• April Laktonen 

Counceller • Rory Larson • Valerie Switzler

• Nora Dauenhauer • Tim McCleary

• Richard Dauenhauer • Vernetta Moberly • Jerry Yellowhawk

The phrases: 

• Children are sacred. • Back to sleep is traditional.

• So That the People May Live • Honor the past, learn for the future.

73 

• Malcolm Wolf
74 

History of the Healthy Native Babies Project 

The Eunice Kennedy Shriver National Institute of Child Health and Human Development 

(NICHD) has led the Back to Sleep campaign to raise awareness about ways to reduce the risk 

for SIDS since 1994. 

Since the campaign began, the overall SIDS rate in 

the United States has dropped by more than 

50 percent. Although the rate decline has occurred 

in all segments of the population, infants in certain 

groups, including the AI/AN communities, are still 

at disproportionally high risk for SIDS. AI/AN 

infants are nearly three times more likely to die of 

SIDS as white infants are. In addition, SIDS rates 

are particularly high in the five Northern Tier 

IHS Areas (Aberdeen, Alaska, Billings, Bemidji, 

and Portland). 

To address this alarming disparity, the NICHD 

supports efforts to improve the effectiveness and 

impact of the Back to Sleep campaign in AI/AN 

communities. During 2002 and 2003, the Institute 

and other partners convened workgroup meetings 

to develop an approach for assisting local programs with SIDS risk-reduction efforts in 

Northern Tier Native communities. 

The NICHD then assembled a smaller Workgroup, comprising stakeholders and previous 

workgroup members, to complete the following specific tasks: 

• Develop a method for collecting qualitative data from ten sites in the five Northern 

Tier IHS Areas. 

• Conduct focus groups with a defined primary audience in each of the five Northern 

Tier Areas to address risk factors for SIDS and potential approaches for reaching 

these audiences. 

• Develop a culturally tailored implementation approach for SIDS risk reduction based 

on the findings of the qualitative site work in collaboration with the feedback from 

the Workgroup. 
The NICHD and the Workgroup members used this information to develop and implement 

the innovative Healthy Native Babies Project. A team of experts—one from each of the five 

Northern Tier Regions—helped create this project, develop and evaluate the materials, 

and train outreach providers and provided technical support to those using the Healthy 

Native Babies Project materials. The NICHD consulted the Workgroup on all messages and 

products, including: 

• Healthy Native Babies Project Workbook and the Toolkit Disk to assist AI/AN 
 

programs in developing community-tailored SIDS risk-reduction educational 
 

messages and materials



• Resource lists, which include programs and research related to safe sleep education 

and activities 

History of the Healthy Native Babies Project 

• Toll-free phone number and technical assistance center (during the development phase)

• Resource stipends for 26 Tribes and organizations to develop outreach materials, 

including brochures, posters, printed onesies, flyers, printed bibs, postcards, and 

“Welcome Home” bags (filled with pamphlets, books, and other items) 

• Train-the-Trainer Sessions: 10 two-day sessions, held in 2006 and 2007, to explain 

culturally tailored SIDS risk-reduction messages to 232 attendees, who included Tribal 

members, community partners, health care providers, and other stakeholders 

After receiving positive feedback from the two-day training sessions and hearing about 

participant interest in additional training and resources, the NICHD and the Workgroup 

created a second-level training module/curriculum using existing materials and information. 

The result is the Healthy Native Babies Project Facilitator’s Packet, which includes facilitator 

guides for full-day and 90-minute training sessions, presentations, other materials, and a 

Resources Disk. The training sessions focus on helping health care providers, community 

members, and others in AI/AN communities to enhance their skills and expand the reach 

of the Healthy Native Babies Project. These sessions include hands-on activities, such as 

working through challenge risk-reduction scenarios, engaging in message-delivery role 

playing, and demonstrating safe sleep environments. They also aim to build participants’ 

confidence and overall knowledge. To order your Healthy Native Babies Project Facilitator’s 

Packet, call the NICHD Information Resource Center at 1-800-370-2943 or visit 

http://www.nichd.nih.gov/sids. 

75
76 

Appendix One: Abbreviations and Acronyms 
77 

Appendix 2: Ways to Reduce the Risk of SIDS 

77
78 

Appendix 1: Abbreviations and Acronyms 

As you read through this Workbook, you will notice many abbreviations and acronyms. 

These items, and their full explanations, appear below. 

AAP American Academy of Pediatrics 

AI/AN American Indian/Alaska Native 

CDC Centers for Disease Control and Prevention 

CPSC Consumer Product Safety Commission 

DHHS U.S. Department of Health and Human Services 

DPT Diphtheria, Pertussis, and Tetanus 

EpiCenter IHS Tribal Epidemiology Center 

FAS Fetal Alcohol Syndrome 

FASD Fetal Alcohol Spectrum Disorder 

IHS Indian Health Service 

NICHD Eunice Kennedy Shriver National Institute of Child 

Health and Human Development 

NIH National Institutes of Health 

PHN Public Health Nurse 

PRAMS Pregnancy Risk Assessment Monitoring System 

PSA Public Service Announcement 

SIDS Sudden Infant Death Syndrome 

SUID Sudden Unexplained Infant Death 

WIC Special Supplemental Nutrition Program for Women, 

Infants, and Children 

Appendix One: Abbreviations and Acronyms 
 

 

 

 

 

 

 

79 

Appendix 2: Ways to Reduce the Risk of SIDS 

Appendix 2: Ways to Reduce the Risk of SIDS 

Even though SIDS is not completely preventable and there is no way of knowing which 

babies might die from SIDS, there are some things that caregivers can do to reduce the risk 

of SIDS. 

> Always place the baby on his or her back to sleep for naps and at night. The back 


sleep position is the safest, and every sleep time counts. 


> Place the baby to sleep on a firm sleep surface, such as on a safety-approved* crib 


mattress, covered by a fitted sheet. Never place the baby to sleep on pillows, quilts, 


sheepskins, or other soft surfaces. 


> Keep soft objects, toys, and loose bedding out of the baby’s sleep area. 

> Don’t use pillows, blankets, quilts, sheepskins, or pillow-like crib bumpers in the 


baby’s sleep area, and keep all items away from the baby’s face. 


> If you choose to use a blanket, place the baby with his or her feet at the end of the 


crib (sometimes called the “feet-to-foot” method). The blanket should reach no 


higher than the baby’s chest. Tuck the ends of the blanket under the crib mattress 


to ensure safety. 


> Do not smoke during pregnancy and do not allow smoking around the baby. Don’t 


smoke before or after the birth of the baby, and don’t let others smoke around the baby. 


> Do not drink alcohol during pregnancy or when breastfeeding. Alcohol use 


during pregnancy is a known cause of both physical and mental problems, including 


permanent brain damage, developmental delays, and increased risk of SIDS. Infants can 


also be exposed to alcohol through breastmilk, so women who are breastfeeding should 


not drink alcohol. 


> Keep the baby’s sleep area close to but separate from where you and others sleep. 

The baby should not sleep in a bed or on a couch or armchair with adults or other 


children, but he or she can sleep in the same room as adults or other children. If you 


bring the baby into bed with you to breastfeed, put him or her back in a separate sleep 


area, such as a bassinet, crib, cradle, a bedside co-sleeper (an infant bed that attaches to 


an adult bed), or other safe sleep location when finished. 


> Think about using a clean, dry pacifier when putting the baby to bed, but don’t 


force the baby to take it. If it falls out while the baby is sleeping, you don’t need to force 


it back in the baby’s mouth. If breastfeeding, wait until the baby is one month old or is 


used to breastfeeding before trying a pacifier. 


*For information on crib safety, contact the Consumer Product Safety Commission at http://www.cpsc.gov or at 

1-800-638-2772, or talk to your health care provider. 
 

 

 

 

 

 

 

 

 

 

 

 

80 

Appendix 2: Ways to Reduce the Risk of SIDS 

> Do not let the baby get overheated during sleep. Dress the baby in light sleep 

clothing and keep the room at a temperature that is comfortable for an adult. 

> Avoid products that claim to reduce the risk of SIDS or to safely position 

the infant because most have not been tested for effectiveness or safety. Avoid 

products made of foam rubber or of visco-elastic polyurethane foam (also known 

as Memory FoamTM). 

> Do not use home monitors to reduce the risk of SIDS. If you have questions 

about using monitors for other conditions, talk to your health care provider. 

> Reduce the chance that flat spots will develop on the baby’s head. 

> Provide Tummy Time when the baby is awake and someone is watching; 

> Hold the baby upright when he or she is not sleeping; 

> Change the direction that the baby lies in the crib from one week to the next 

(that is, baby’s feet face one end of the crib for a week, then face the opposite end 

of the crib the next week); and 

> Avoid too much time in car seats, carriers, and bouncy seats. 

> Other things that improve infant outcomes and that may reduce SIDS 

risk include: 

> Breastfeeding; 

> Getting early and regular prenatal care and preconception care; and 

> Having Public Health Nurses visit the home. 

To learn more about SIDS or to order risk-reduction education materials, contact the 

Back to Sleep campaign at: 

Phone: 1-800-505-CRIB (2742) 

TTY: 1-888-320-6942 

Fax: 1-866-760-5947 

Mail: 31 Center Drive, Building 31, Room 2A32, Bethesda, MD 20892 

E-mail: NICHDInformationResourceCenter@mail.nih.gov 

(Use subject line: BACK TO SLEEP ORDER) 

Internet: http://www.nichd.nih.gov/SIDS 
Appendix 3: Public Health Education Approaches
 Selected Theories and Models 

Appendix 3: Public Health Education

Approaches	Selected Theories and Models 

Adapted from National Cancer Institute, NIH, DHHS. (2005). Theory at a Glance: A Guide 

for Health Promotion Practice, Second Edition (NIH Publication No. 05-3896). Washington, 

DC: Government Printing Office. Available at https://cissecure.nci.nih.gov/ncipubs/detail. 

aspx?prodid=T052. 

A theory is general principle that is developed to explain, organize, or predict observations 

about the world. A model is an illustration or diagram of the concepts in a theory. 

Generally, health behavior theories are principles that explain why individuals or groups 

behave the way they do, and explain how behaviors that may put health at risk can be 

changed. Communication is the act of passing information from one person to another. 

Communication theories explain whether the intended recipient of the information actually 

receives, understands, or acts upon the information that was sent. 

Many of the approaches to SIDS risk reduction described in this Workbook focus on 

individual or family behavior change, such as smoking or infant sleep practices. Additionally, 

this Workbook presents approaches to communicating new concepts to individuals and 

communities using a variety of media. Understanding health behavior and communication 

theories is particularly useful because human behavior is very complex, and changing health 

behavior can be extremely challenging. Service providers and program planners can use this 

section to learn why certain strategies are or are not successful in achieving behavior change 

in a program, or to develop new approaches to reduce risky behavior. 

Health Belief Model (HBM) 

The HBM was originally designed to explain why people did not participate in programs 

to prevent or detect diseases. The core components of HBM include: 

> Perceived susceptibility—the subjective perception of risk of developing a particular 
 

health condition



> Perceived severity—feelings about the seriousness of the consequences of developing 
 

a specific health problem
 


> Perceived benefits—beliefs about the effectiveness of various actions that might 


reduce susceptibility and severity (taken together, perceived susceptibility and severity 


are labeled “threat”) 


> Perceived barriers—potential negative aspects of taking specific actions 

> Cues to action—bodily or environmental events that trigger action 

More recently, the HBM has been amended to include the notion of self-efficacy as another 

predictor of health behaviors, especially more complex behaviors in which lifestyle changes 

must be maintained over time. A wide variety of demographic, social, psychological, and 

structural variables may also impact people’s perceptions and, indirectly, their health-related 

81 
82 

Appendix 3: Public Health Education Approaches
 Selected Theories and Models 

behaviors. Some of the more important variables include educational attainment, age, 

gender, socioeconomic status, and prior knowledge. 

Further Reading 

Janz, N.K., & Becker, M.H. (1984). The health belief model: A decade later. Health 

Education Quarterly, 11, 1-47. 

Strecher, V.J., & Rosenstock, I.M. (1997). “The health belief model.” In K. Glanz, F.M. 

Lewis, & B.K. Rimer (Eds.), Health Behavior and Health Education: Theory, Research, and 

Practice (Second Edition). San Francisco, CA: Jossey-Bass. 

Stages of Change 

The stages of change are sometimes referred to as the transtheoretical model. The central 

concept of the stages of change is that individual behavior change is an ongoing process, 

not a single event. Individuals are at varying levels of motivation or readiness to make a 

change in health risk behavior. By knowing an individual’s current stage, you can help 

set realistic program goals. You can also tailor messages, strategies, and programs to the 

appropriate stage. 

Five distinct stages are identified in the stages-of-change construct: 

> Precontemplation—Individual is not yet ready for change, often not informed or 

under informed about the behavior, or unsuccessfully attempted change before and 

is now demoralized. Individuals at this stage often avoid thinking or talking about the 

risk behavior. 

> Contemplation—Individual is thinking about changing health risk behavior sometime 

in the future, but is weighing the pros and cons. Often this individual is ambivalent 

and may get “stuck” thinking about making change. 

> Preparation—Individual is ready to make change in the very near future and has likely 

prepared to make change by having a plan of action and getting assistance by joining a 

program, buying a self-help book, or talking to a service provider. 

> Action—Individual has taken concrete steps and has actually changed the identified 

health risk behavior. At this stage, close attention to relapse prevention is critical. 

> Maintenance—Individual has sustained the behavior change and is working to avoid 

relapse. These individuals typically have more confidence in their ability to maintain 

behavior change than those in the action stage. 

Individuals who are at different points in the process of change benefit from different 

interventions that are matched to their stage at that time. An individual who has not ever 

thought about making a behavior change requires a different approach than an individual 

who has decided to make a change. This model is particularly useful in individual 

interventions. By knowing an individual’s current stage, providers can help set realistic goals 

and tailor messages, strategies, and approaches to the appropriate stage. In addition, this 
Appendix 3: Public Health Education Approaches
 Selected Theories and Models 

process is circular: while an individual may have made a behavior change, the change may 

not be consistently applied or they may “regress” to an earlier stage and progress through the 

remaining steps again. 

Further Reading 

Prochaska, J.O., & Velicer, W.F. (1997). The transtheoretical model of health behavior 

change. American Journal of Health Promotion, 12(1), 38-48. 

Behavioral Intentions 

Studies of behavioral intentions suggest that the likelihood of adopting a desired behavior 

by an individual is best predicted by their intention to take that action. Intention, in turn, 

is influenced by their attitudes toward that behavior, their perceptions of the benefits of the 

behavior, and what they think their peers think about the behavior. Research by Fishbein and 

Ajzen supports the idea that individuals’ and society’s perceived attitudes are an important 

precursor to action. Therefore, in order to change a behavior, an individual’s attitudes and 

perceptions of benefits must first be changed. 

Further Reading 

Fishbein, M., & Ajzen, I. (1975). Belief, Attitude, Intention and Behavior: An Introduction to 

Theory and Research. Reading, MA: Addison-Wesley. 

Communications for Persuasion 

William McGuire has described the steps an individual must be persuaded to pass through to 

assimilate a desired behavior. These steps are: 

> Exposure to the message 

> Attention to the message 

> Interest in or personal relevance of the message 

> Understanding of the message 

> Personalizing the behavior to fit one’s life 

> Accepting the change 

> Remembering the message and continuing to agree with it 

> Being able to think of it 

> Making decisions based on bringing the message to mind 

> Behaving as decided 

> Receiving positive reinforcement for behavior 

> Accepting the behavior into one’s life 

These steps highlight the importance of planning a health education or social marketing 

campaign that considers all the factors in persuading an individual to adopt a new behavior. 

83 
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Appendix 3: Public Health Education Approaches
 Selected Theories and Models 

This includes plans to ensure that a message is both received and absorbed. The steps draw 

attention to the need to stage a campaign over time in order to address the needs of the 

audience as they progress towards behavior change. 

Further Reading 

McGuire, W.J. (1984). Public communication as a strategy for inducing health-promoting 

behavioral change. Preventive Medicine, 13(3), 299-313. 

Social Marketing 

Social marketing has been defined as “the application of commercial marketing technologies 

to the analysis, planning, execution, and evaluation of programs designed to influence the 

voluntary behavior of target audiences in order to improve their personal welfare and that of 

their society” (Andreason, 1995). 

This definition encompasses several key aspects of the social marketing approach; it is seen as: 

> A focus on benefiting individuals and society; not a focus on profit and organizational 

benefits typical of commercial marketing practices 

> A focus on changing behavior, not awareness or attitude change 

> An approach that recognizes the target audience’s primary role in the process 

Social marketing practices are based on commercial marketing practices that make the 

consumer the central focus for planning and conducting a program. Lessons learned 

from social marketing stress the importance of understanding the intended audiences and 

designing strategies based on their wants and needs rather than what good health practice 

directs that they should do. 

Further Reading 

Andreason, A. (1995). Marketing Social Change: Changing Behavior to Promote Health, Social 

Development, and the Environment. San Francisco, CA: Jossey-Bass. 

Kotler, P., & Roberto, E.L. (1989). Social Marketing: Strategies for Changing Public Behavior. 

New York, NY: Free Press. 

Lefebvre, R.C., & Rochlin, L. (1997). “Social marketing.” In K. Glanz, F.M. Lewis, & B.K. 

Rimer (Eds.), Health Behavior and Health Education: Theory, Research, and Practice (Second 

Edition). San Francisco, CA: Jossey-Bass. 
 

Appendix 3: Public Health Education Approaches
 Selected Theories and Models 

Diffusion of Innovations Theory 

Diffusion of innovations theory addresses how new ideas, products, and social practices 

spread within a society or from one society to another. The challenge of diffusion requires 

approaches that differ from those focused solely on individuals or small groups. It involves 

paying attention to the innovation (a new idea, product, practice, or technology) as well 

as to communication channels and social systems (networks with members, norms, and 

social structures). 

A focus on the characteristics of innovations can improve the chances that they will be 

adopted and hence diffused. It also has implications for how an innovation is positioned to 

maximize its appeal. Some of the most important characteristics of innovations are their: 

> Relative advantage—is it better than what was there before? 

> Compatibility—fit with intended audience. 

> Complexity—ease of use. 

> Trialability—can it be tried out first? 

> Observability—visibility of results. 

Communication channels are another important component of diffusion of innovations 

theory. Diffusion theories view communication as a two-way process rather than one 

of merely “persuading” an intended audience to take action. The two-step flow of 

communication—in which opinion leaders mediate the impact of mass media—emphasizes 

the value of social networks (or interpersonal channels) over and above mass media for 

adoption decisions. 

Further Reading 

Green, L.W., Gottlieb, N.H., & Parcel, G.S. (1987). “Diffusion theory extended and 

applied.” In W.B. Ward (Ed.), Advances in Health Education and Promotion. Greenwich, CT: 

JAI Press. 

Rogers, E.M. (1983). Diffusion of Innovations (Third edition). New York, NY: Free Press. 

85 
86 

Appendix 4: Working with the Media and the Single Overriding Communications Objective (SOCO) 

Appendix 4: Working with the Media and the Single

Overriding Communications Objective (SOCO) 

The following section describes some ways to work with and contact the media, including 

newspapers, radio stations, Web sites, and other outlets. Think about using one or more of 

the following samples when conducting your Healthy Native Babies Project outreach. Please 

note that brackets [ ] surround information that you or your organization contact will need 

to provide. 

Sample Placement Request for Item in Newspaper/Newsletter,

Magazine, etc. 

Dear [Name of Copy Editor]: 

[Name of Your Organization] Spearheads Local Outreach Effort To Reduce Risk for 

Sudden Infant Death Syndrome (SIDS) in [Local Community Name] 

[Name of Your Organization] recently kicked off a community education campaign 

to help parents and other caregivers reduce the high incidence of death from Sudden 

Infant Death Syndrome (SIDS) among American Indian and Alaska Native babies. 

Please review the attached document, a [Public Service Announcement, News Release, 
 

Flyer, etc.], for distribution or publication in the [Name of Publication, Newspaper, 
 

Newsletter, etc.].
 


I am requesting that you air or print this item from [Specific Time Period Dates, Number 
 

of Days/Weeks, etc.].
 


If you have any questions, you can reach me at [Contact Phone Number].
 


Thank you,
 


[Full Name of Contact]
 


[Title or Position]
 


[Name of Organization]
 

Appendix 4: Working with the Media and the Single Overriding Communications Objective (SOCO) 

Sample News/Media Release for Use in Newspaper,

Newsletter, Magazine, etc. 

For Immediate Release: [DATE] 

Contact: [Name of Person within Your Organization Available to Answer Questions] 

Phone: [Contact Phone Number] 

[Name of your organization] Spearheads Local Outreach Effort to Reduce Risk for 

Sudden Infant Death Syndrome (SIDS) in [Local Community Name] 

[Name of Your Organization] recently kicked off a community education campaign 

to help parents and other caregivers reduce the high incidence of death from Sudden Infant 

Death Syndrome (SIDS) among American Indian and Alaska Native (AI/AN) babies. 

Although the SIDS rate has declined in recent years, AI/AN babies are still nearly 3 times 

more likely to die of SIDS than white babies are. 

Overall, SIDS is the leading cause of death in all infants younger than 1 year of age, and 

most SIDS deaths occur between the ages of 2 and 4 months. Research has shown that 

placing babies to sleep on their backs dramatically reduces the incidence of SIDS. 

“SIDS is a community problem. We must come together to help educate the entire 

community about ways to reduce the risk for SIDS,” said [Name of Spokesperson] 

of [Your Organization Name]. “This campaign is designed to bring together parents, 

grandparents, caregivers—everyone who is concerned about infant health—to learn how 

to keep our babies safe and healthy.” 

Activities led by [Your Organization Name] are part of the Healthy Native Babies Project 

within the national Back to Sleep campaign, led by the Eunice Kennedy Shriver National 

Institute of Child Health and Human Development (part of the National Institutes of 

Health), the Maternal and Child Health Bureau (within the Health Resources and Services 

Administration), the American Academy of Pediatrics, the SIDS Alliance/First Candle, and 

Association of SIDS and Infant Mortality Programs. 

Representatives of organizations interested in joining this community-based effort are 

encouraged to contact [Contact Name] at [Phone Number]. 

87 
88 

Appendix 4: Working with the Media and the Single Overriding Communications Objective (SOCO) 

Sample Scripts for Radio


Public Service Announcements (PSAs) 
 

About Back Sleeping 

:30-SECOND RADIO PSA



Narrator: Did you know that the safest way for babies to sleep is on their backs? 
 

This position gives the best protection against SIDS—Sudden Infant Death Syndrome—
 


sometimes called “crib death.” American Indian and Alaska Native babies are 2 to 4 
 

times more likely to die of SIDS than other American babies. Protect our future 
 

generations! Remember, babies sleep safest on their backs. To learn more about SIDS, 
 

call 1-800-505-CRIB. That’s 1-800-505-2742. A public service of this station and the 
 

[Your Organization Name].
 


About Dressing Babies for Sleep 

:15-SECOND RADIO PSA 

Narrator: Dress babies in light sleep clothes to reduce the risk for SIDS—Sudden 

Infant Death Syndrome. Protect our future generations! To learn more about SIDS, call 

1-800-505-CRIB. A public service of this station and the [Your Organization Name]. 

About Preventing Baby from Getting Overheated (Very Important in

Winter Months) 

:30-SECOND RADIO PSA 

Narrator: As you bundle up this winter, remember that you can reduce the chance your 

baby will die of SIDS—Sudden Infant Death Syndrome—by dressing your baby in light 

sleep clothes and keeping the room at a temperature comfortable for an adult. Your baby 

is too warm if you notice sweating, flushed cheeks, heat rash, or rapid breathing. Protect 

our future generations! To learn more about SIDS, call 1-800-505-CRIB. That’s 

1-800-505-2742. A public service of this station and the [Your Organization Name]. 
Appendix 4: Working with the Media and the Single Overriding Communications Objective (SOCO) 

About Drinking During Pregnancy or While Breastfeeding 

:30-SECOND RADIO PSA 

Narrator: Remember that drinking alcohol when pregnant or breastfeeding can harm babies 

and increases the risk for SIDS—Sudden Infant Death Syndrome. If you are pregnant or 

breastfeeding, keep your baby safe by not drinking alcohol. Protect our future generations! 

To learn more about SIDS, call 1-800-505-CRIB. That’s 1-800-505-2742. A public service 

of this station and the [Your Organization Name]. 

About SIDS Awareness 

:15-SECOND RADIO PSA 

Narrator: Help protect babies in [Community Name] from Sudden Infant Death 

Syndrome—SIDS—sometimes called “crib death.” Always place babies to sleep on their 

backs, for naps and at night. Protect our future generations! To learn more about SIDS, 

call 1-800-505-CRIB. A public service of this station and the [Your Organization Name]. 

About Smoking Commercial Tobacco 

:15-SECOND RADIO PSA 

Narrator: Help reduce the risk for SIDS—Sudden Infant Death Syndrome—by not smoking 

during pregnancy or around your baby. Don’t let others smoke around your baby, anywhere 

in the house or in the car. Protect our future generations! To learn more about SIDS, call 

1-800-505-CRIB. A public service of this station and the [Your Organization Name]. 

About Smoking Commercial Tobacco 

:30-SECOND RADIO PSA 

Narrator: Smoking during pregnancy can cause long-term health problems and increases the 

chance that your baby will die of SIDS—Sudden Infant Death Syndrome. Give your baby 

a smoke-free environment before and after birth. Don’t smoke while you are pregnant. And 

don’t smoke or allow others to smoke around your baby, anywhere in the house, or in the car. 

Protect our future generations! To learn more about SIDS, call 1-800-505-CRIB. A public 

service of this station and the [Your Organization Name]. 

89 
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Appendix 4: Working with the Media and the Single Overriding Communications Objective (SOCO) 

Single Overriding Communications Objective (SOCO)

Work Sheet* 

Key Message: 

In one brief paragraph, please state the key point or objective in doing the interview. This 

statement should reflect what you would like to see as the lead paragraph in a newspaper 

story or broadcast news report. 

Key Facts: 

What are the three facts or statistics you would like the public to remember as a result of 

reading or hearing about this story? 

1. 

2. 

3. 

Target Audience: 

Who is the main audience or population segment you would like this message to reach? 

Primary: 

Secondary: 

Interview Objective: 

What is the one message the audience needs to take away from this report/interview? 

Primary Media Contact: 

Who in your office/organization will serve as the primary point of contact for the media? 

Name:
 


Phone:
 


Date and time available:
 


*Developed by Robert J. Howard, former assistant to the director, National Center for Infectious Diseases, CDC 
Appendix 5: Information Sources 

Appendix 5: Information Sources 

This appendix includes source information for most of the scientific and evidence-based 

references that support the information provided in this Workbook. It is not intended to be 

an exhaustive list of references/resources related to SIDS or other topics, but is intended as a 

starting point for individuals’ own research. 

General Information about SIDS, SIDS Risk Factors, and Health.................. 92



Pregnancy-Related Factors.............................................................................. 93



Overheating ................................................................................................... 93



Maternal Alcohol Use..................................................................................... 94



Commercial Tobacco Use............................................................................... 95



Safe Sleep Environments, Sleep Locations, and Sleep Surfaces........................ 95



Breastfeeding.................................................................................................. 96



Pacifiers.......................................................................................................... 97



Public Health Nurse (PHN) Visits ................................................................. 98



Bed Sharing/Co-Sleeping ............................................................................... 98



Strategies for Reaching Communities............................................................. 99



Action Steps to Reduce SIDS Risk in Communities.....................................100



Planning and Sustaining a Healthy Native Babies Project ...............................101



91 
 

 

 

 

 

 

 

 

 

92 

Appendix 5: Information Sources 

General Information about SIDS, SIDS Risk Factors, and Health

> Eunice Kennedy Shriver National Institute of Child Health Development (NICHD), 

part of the National Institutes of Health (NIH) within the U.S. Department of Health 

and Human Services (DHHS), provides overall leadership and maintenance of the 

national Back to Sleep campaign. For more information, visit the NICHD Web site at: 

> Back to Sleep Web site: http://www.nichd.nih.gov/sids/ 

> Back to Sleep publications and materials: 

http://www.nichd.nih.gov/publications/pubskey.cfm?from=sids 

> A to Z Health and Human Development Topic—Sudden Infant Death Syndrome 

(SIDS): http://www.nichd.nih.gov/health/topics/Sudden_Infant_Death_ 

Syndrome.cfm 

> A to Z Health and Human Development Topic—Tummy Time: 

http://www.nichd.nih.gov/health/topics/Tummy_Time.cfm 

> NICHD News Releases about SIDS: http://www.nichd.nih.gov/news/releases/ 

news.cfm, select keyword “Sudden Infant Death Syndrome (SIDS)” and year “All” 

> American Academy of Pediatrics (AAP) Web site has numerous articles on SIDS 
 

research and policy statements. AAP Web site: http://www.aap.org
 

> AAP Task Force on Reducing Sudden Infant Death Syndrome. (2005). The 

changing concept of Sudden Infant Death Syndrome: Diagnostic coding shifts, 

controversies regarding the sleep environment, and new variable to consider in 

reducing risk. Pediatrics, Nov;116(5), 1245-1255. Available through the AAP 

Web site at http://pediatrics.aappublications.org/cgi/content/full/116/5/1245. 

> The Centers for Disease Control and Prevention (CDC) provides information 
 

about SIDS, Sudden Unexplained Infant Death (SUID), and related topics at 
 

http://www.cdc.gov/SIDS/index.htm. 
 

> First Candle/SIDS Alliance Web site provides access to research studies for parents 
 

and professionals on current trends and advancements in the area of SIDS: 
 

http://www.sidsalliance.org. 
 

> Health Resources and Services Administration, also a sponsor of the Back to Sleep 

campaign, supports the National Sudden and Unexplained Infant/Child Death and 

Pregnancy Loss Resource Center; visit http://www.sidscenter.org for more information. 

> Indian Health Service (IHS) has numerous documents on SIDS reduction and prevention; 

visit http://www.ihs.gov/ and search for “SIDS” in the “Search IHS.gov” area. 

> National Indian Health Board advocates on behalf of all Tribal governments and 
 

AI/ANs in their efforts to provide quality health care; the Board, in partnership 
 

with the CJ Foundation and the DHHS, distributes Face Up to Wake UpTM; visit 
 

http://www.nihb.org/docs/res_kit_aian_sids.pdf for more information.
 
 

 

Appendix 5: Information Sources 

> National Sudden and Unexplained Infant/Child Death and Pregnancy Loss Resource 


Center: http://www.sidscenter.org 


> Paterson, D.S., Trachtenberg, F.L., Thompson, E.G., Belliveau, R.A., Beggs, A.H., 
 

Darnall, R., Chadwick, A.E., Krous, H.F., & Kinney, H.C. (2006). Multiple 
 

serotonergic brainstem abnormalities in sudden infant death syndrome. Journal of 
 

the American Medical Association, Nov1;296(17), 2124-2132. Abstract available at 
 

http://www.ncbi.nlm.nih.gov/pubmed/17077377. 
 

> SIDS Resources has a Web site that includes a variety of resources for new parents: 
 

http://www.sidsresources.org/newparents/parentsabout.shtml.



> Thach, B. (2008). Tragic and sudden death: Potential and proven mechanisms 


causing sudden infant death syndrome. European Molecular Biology Organization 


(EMBO) Reports, 9(2), 114-118. Abstract available at http://www.ncbi.nlm.nih.gov/ 


pubmed/18246101. 


> U.S. National Center for Health Statistics (NCHS) provides U.S. health statistics on 


numerous topics, including infant mortality and SIDS; visit http://www.cdc.gov/nchs/ 


fastats/infant_health.htm for more information. 


> Urban Indian Health Institute (UIHI), established in July 2000 as a division with 


the Seattle Indian Health Board, is a community health center focusing on urban 


AI/ANs. The UIHI provides centralized nationwide management of health surveillance, 


research, and policy considerations regarding the health status disparities affecting 


AI/ANs; visit http://www.uihi.org/ for more information. 


Pregnancy-Related Factors

> Alexander, G.R., & Kotelchuck, M. (2001). Assessing the role and effectiveness 

of prenatal care: History, challenges, and directions for the future. Public Health 

Reports, Jul-Aug;116(4), 306-316. Abstract available at http://www.ncbi.nlm.nih.gov/ 

pubmed/12037259. 

> NICHD A to Z Health and Human Development Topic—Pregnancy: 

http://www.nichd.nih.gov/health/topics/pregnancy.cfm 

Overheating

> Iyasu, S., Randall, L.L., Welty, T.K., Hsia, J., Kinney, H.C., Mandell, F., McClain, M., 

Randall, B., Habbe, D., Wilson, H., & Willinger, M. (2002). Risk factors for sudden 

infant death syndrome among Northern Plains Indians. Journal of the American Medical 

Association, Dec4;288(21), 2717-2723. Abstract available at http://www.ncbi.nlm.nih. 

gov/pubmed/12460095. 

> NICHD, NIH, DHHS. (2006). Safe Sleep for Your Baby: What does a safe sleep 
 

environment look like? Available at http://www.nichd.nih.gov/publications/pubs/



upload/Safe_Sleep_2009_Eng.pdf. 
 

93 
 

94 

Appendix 5: Information Sources 

> Randall, L.L., Welty, T.K., Willinger, M., Iyasu, S.I., & the Aberdeen Area Infant 

Mortality Study Steering Committee. Mi in a kin towani ewaktonji kte ni, I will never 

forget my child. A report prepared for the Aberdeen Area Chairman’s Health Board. 

June 30, 1998. 

Maternal Alcohol Use 

> Randall, L.L., Welty, T.K., Willinger, M., Iyasu, S.I., & the Aberdeen Area Infant 

Mortality Study Steering Committee. Mi in a kin towani ewaktonji kte ni, I will never 

forget my child. A report prepared for the Aberdeen Area Chairman’s Health Board. 

June 30, 1998. 

> Evanson, D., & Matthews, D., for the Office of Fetal Alcohol Syndrome, State of 

Alaska. (1998). The Developing Baby. Retrieved from http://www.hss.state.ak.us/fas/ 

info/developingBaby.htm. 

> Iyasu, S., Randall, L.L., Welty, T.K., Hsia, J., Kinney, H.C., Mandell, F., McClain, M., 

Randall, B., Habbe, D., Wilson, H., & Willinger, M. (2002). Risk factors for sudden 

infant death syndrome among Northern Plains Indians. Journal of the American Medical 

Association, Dec4;288(21), 2717-2723. Abstract available at http://www.ncbi.nlm.nih. 

gov/pubmed/12460095. 

> La Leche League International. (2008). What about drinking alcohol and breastfeeding? 

Retrieved from http://www.lalecheleague.org/FAQ/alcohol.html. 

> Office of Fetal Alcohol Syndrome, State of Alaska. (2002). Do Children Outgrow FASD? 

Retrieved from http://www.hss.state.ak.us/fas/info/faqs_outgrowFAS.htm. 

> Randall, L.L., Krogh, C., Welty, T.K., Iyasu, S.I., & Willinger, M. (2001). The 

Aberdeen Indian Health Service infant mortality study: Design, methodology, and 

implementation. American Indian Alaska Native Mental Health Research: A Journal of 

the National Center, 10(1),1-20. Abstract available at http://www.ncbi.nlm.nih.gov/ 

pubmed/11484150. 

> Riley, E.P., & McGee, C.L. (2005). Fetal Alcohol Spectrum Disorders: An overview 

with emphasis on changes in brain and behavior. Experimental Biology and Medicine 

(Maywood), Jun;230(6), 357-365. Abstract available at http://www.ncbi.nlm.nih.gov/ 

pubmed/15956765. 

> Schulte, P. (1995). Minimizing alcohol exposure of the breastfeeding infant. Journal of 

Human Lactation, Dec;11(4), 317-319. Abstract available at http://www.ncbi.nlm.nih. 

gov/pubmed/8634109. 

> Wattendorf, D.J., & Muenke, M. (2005). Fetal Alcohol Spectrum Disorders. 
 

American Family Physician, 72, 279-282, 285; retrieved from http://www.aafp.org/


afp/20050715/279.html. 
 
 

 

 

 

Appendix 5: Information Sources 

Commercial Tobacco Use 

> Anderson, M.A., Johnson, D.C., & Batal, H.A. (2005). Sudden infant death 

syndrome and prenatal maternal smoking: Rising attributed risk in the Back to Sleep 

era. BMC Medicine, Jan;3, 4. Abstract available at http://www.ncbi.nlm.nih.gov/ 

pubmed/15644131. 

> CDC, DHHS. (2006). Babies whose mothers smoke before and after birth are three to four 

times more likely to die from SIDS. Retrieved from http://www.cdc.gov/tobacco/sgr/ 

sgr_2004/consumerpiece/page5.htm. 

> Health Effects of Second Hand Smoke Exposure: Childhood Illnesses & Diseases, Ontario 

Campaign for Action on Tobacco; retrieved from http://www.ocat.org/healtheffects/ 

childhood.html. 

> Project Cork aims to assemble and disseminate current, authoritative information on 

substance use and abuse for clinicians, health care providers, human service personnel, 

and policy makers. For more information, visit http://www.projectcork.org. 

> Maternal smoking during pregnancy remains the most important modifiable risk 

factor for SIDS; retrieved from http://www.projectcork.org/bibliographies/data/ 

Bibliography_Pregnancy.html. 

> American Lung Association; retrieved from Healthy Air, at http://www.lungusa.org/ 

healthy-air. 

> Stop Smoking, Stop SIDS; retrieved from http://www.sidsma.org/professionals/



StopSmoking.html. 
 

> Wisborg, K., Kesmodel, U., Henriksen, T.B., Olsen, S.F., & Secher, N.J. (2000). 
 

A prospective study of smoking during pregnancy and SIDS. Archives of Disease in 
 

Childhood, Sep;83, 203-206. Abstract available at http://www.ncbi.nlm.nih.gov/



pubmed/10952633. 
 

Safe Sleep Environments, Sleep Locations, and Sleep Surfaces

> AAP Task Force on Reducing Sudden Infant Death Syndrome. (2005). The changing 

concept of Sudden Infant Death Syndrome: Diagnostic coding shifts, controversies 

regarding the sleep environment, and new variable to consider in reducing risk. 

Pediatrics, Nov;116(5), 1245-1255. Available through the AAP Web site at 

http://pediatrics.aappublications.org/cgi/content/full/116/5/1245. 

> Healthy Child Care America, SIDS Information; available at 

http://www.healthychildcare.org/sids.html. 

> Moon, R.Y., Kotch, L., & Aird, L. (2006). State child care regulations regarding infant 

sleep environment since the Healthy Child Care America-Back to Sleep Campaign. 

Pediatrics, Jul;118(1), 73-83. Abstract available at http://www.ncbi.nlm.nih.gov/ 

pubmed/16818551. 

95 
 

96 

Appendix 5: Information Sources 

> Morgan, K.H., Groer, M.W., & Smith, L.J. (2006). The controversy about what 
 

constitutes safe and nurturant infant sleep environments. Journal of Obstetric, 
 

Gynecological, and Neonatal Nursing, Nov-Dec;35(6), 684-691. Abstract available at 
 

http://www.ncbi.nlm.nih.gov/pubmed/17105632. 
 

> NICHD, NIH, DHHS. (2006). Safe Sleep for Your Baby: What does a safe sleep 
 

environment look like? Available at http://www.nichd.nih.gov/publications/pubs/


upload/Safe_Sleep_2009_Eng.pdf.


> Paluszynska, D.A., Harris, K.A., & Thach, B.T. (2004). Influence of sleep position 
 

experience on ability of prone-sleeping infants to escape from asphyxiating 
 

microenvironments by changing head position. Pediatrics, Dec;114(6), 1634-1639. 
 

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15574627. 
 

> Thach, B.T., Rutherford, G.W. Jr., & Harris, K. (2007). Deaths and injuries attributed 

to infant crib bumper pads. Journal of Pediatrics, Sep;151(3), 271-274, 274.e1-3. 

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17719936. 

Breastfeeding

> Alm, B., Wennergren, G., Norvenius, S.G., Skjaerven, R., Lagercrantz, H., 

Helweg-Larsen, K., Irgens, L.M. (2002). Breastfeeding and the sudden infant death 

syndrome in Scandinavia, 1992-95. Archives of Diseases in Childhood, Jun;86(6), 

400-402. Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12023166. 

> American Academy of Breastfeeding Medicine is a worldwide organization of 
 

physicians dedicated to the promotion, protection, and support of breastfeeding 
 

and human lactation. The Academy recognizes the benefits of breastfeeding at 
 

http://www.bfmed.org/media/files/documents/pdf/press releases/strong evidence 

base for benefits of breastfeeding (3-19-09).pdf and through its Web site at 

http://www.bfmed.org. 

> Chen, A., & Rogan, W.J. (2004) Breastfeeding and the risk of post-neonatal 
 

death in the United States. Pediatrics, May;113(5), e435-e439. Abstract available 
 

at http://www.ncbi.nlm.nih.gov/pubmed/15121986. 
 

> La Leche League International: Resources: http://www.llli.org/resources.html 

> McVea, K.L., Turner, P.D., & Peppler, D.K. (2000). The role of breastfeeding in 
 

sudden infant death syndrome. Journal of Human Lactation, Feb;16(1), 13-20. 
 

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11138219. 
 

> Mosko, S., Richard, C., & McKenna, J. (1997). Infant arousals during mother-infant 

bed sharing: Implications for infant sleep and sudden infant death syndrome research. 

Pediatrics, Nov;100(5), 841-849. Abstract available at http://www.ncbi.nlm.nih.gov/ 

pubmed/9346985. 

> NICHD A to Z Health and Human Development Topic—Breastfeeding: 

http://www.nichd.nih.gov/health/topics/Breastfeeding.cfm 
 

 

 

 

 

> The AAP provides numerous resources and information related to breastfeeding at 

http://www.aap.org/healthtopics/breastfeeding.cfm, including the AAP Policy on 

Breastfeeding and the Use of Human Milk, at http://www.aap.org/breastfeeding/ 

PolicyOnBreastfeedingAndUseOfHumanMilk.html. 

> The Office of Women’s Health, DHHS, maintains a Web site about breastfeeding at 

http://www.4woman.gov/breastfeeding/index.cfm?page=227. 

Pacifiers 

> American Academy on Pediatric Dentistry (AAPD) is a national membership 

organization representing the specialty of pediatric dentistry and including more 

than 7,000 pediatric dentists. Web site: http://www.aapd.org. 

> AAPD Council on Clinical Affairs. (2008-2009). Policy on Oral Habits. Pediatric 

Dentistry, 30(7 Suppl), 51-52. Full text available at: http://www.aapd.org/media/ 

Policies_Guidelines/P_OralHabits.pdf. 

> AAPD Parent Resource Center: Thumb, Finger, and Pacifier Habits, available at 

http://www.aapd.org/publications/brochures/tfphabits.asp. 

> AAPD Council on Clinical Affairs, 2008-2009, Clinical Guidelines on Infant 

Oral Health Care. Full text available at: http://www.aapd.org/media/Policies_ 

Guidelines/G_InfantOralHealthCare.pdf. 

> AAP Task Force on Reducing Sudden Infant Death Syndrome. (2005). The changing 

concept of Sudden Infant Death Syndrome: Diagnostic coding shifts, controversies 

regarding the sleep environment, and new variable to consider in reducing risk. 

Pediatrics, Nov;116(5), 1245-1255. Available through the AAP Web site at http:// 

pediatrics.aappublications.org/cgi/content/full/116/5/1245. 

> Franco, P., Scaillet, S., Wermenbol, V., Valente, F., Groswasser, J., & Kahn, A. 

(2000). The influence of a pacifier on infants’ arousals from sleep. Journal of 

Pediatrics, Jun;136(6), 775-779. Abstract available at http://www.ncbi.nlm.nih.gov/ 

pubmed/10839876. 

> Hauck, F.R., Omojokun, O.O., & Siadaty, M.S. (2005). Do pacifiers reduce the risk 

of sudden infant death syndrome? A meta-analysis. Pediatrics, Nov;116(5), e716-723. 

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16216900. 

> Hauck, R. (2006). Pacifiers and sudden infant death syndrome: What should 
 

we recommend? Pediatrics, May;117(5), 1811-1812. Abstract available at 
 

http://www.ncbi.nlm.nih.gov/pubmed/16651341. 
 

> Heinig, M.J., & Banuelos, J. (2006). American Academy of Pediatrics Task Force on 

Sudden Infant Death Syndrome (SIDS) statement on SIDS reduction: Friend or foe 

of breastfeeding? Journal of Human Lactation, Feb;22(1), 7-10. Abstract available at 

http://www.ncbi.nlm.nih.gov/pubmed/16467282. 

Appendix 5: Information Sources 

97 
98 

Appendix 5: Information Sources 

> Howard, C.R., Howard, F.M., Lanphear, B., Eberly, S., Debliecki, E.A., Oakes, D., & 

Lawrence, R.A. (2003). Randomized clinical trial of pacifier use and bottle-feeding or 

cup feeding and their effect on breastfeeding. Pediatrics, Mar;111(3), 511-518. Abstract 

available at http://www.ncbi.nlm.nih.gov/pubmed/12612229. 

> Kahn, A., Sawaguchi, T., Sawaguchi, A., Groswasser, J., Franco, P., Scaillet, S., 

Kelmanson, I., & Dan, B. (2002). Sudden infant deaths: From epidemiology to 

physiology. Forensic Science International, Sep14;130(Suppl), S8-S20. Abstract available 

at http://www.ncbi.nlm.nih.gov/pubmed/12350296. 

> Li, D.K., Willinger, M., Petitti, D.B., Odouli, R., Liu, L., & Hoffman, H.J. (2006). 

Use of a dummy (pacifier) during sleep and risk of sudden infant death syndrome 

(SIDS): Population based case-control study. British Medical Journal, Jan7;332(7532), 

18-22. Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16339767. 

> Schubiger, G., Schwarz, U., & Tönz, O. (1997). UNICEF/WHO Baby-Friendly 

Hospital Initiative: Does the use of bottles and pacifiers in the neonatal nursery 

prevent successful breastfeeding? Neonatal Study Group. European Journal of 

Pediatrics, Nov;156(11), 874-877. Abstract available at http://www.ncbi.nlm.nih.gov/ 

pubmed/9392404. 

Public Health Nurse (PHN) Visits

> Randall, L.L., Welty, T.K., Willinger, M., Iyasu, S.I., & the Aberdeen Area Infant 

Mortality Study Steering Committee. Mi in a kin towani ewaktonji kte ni, I will never 

forget my child. A report prepared for the Aberdeen Area Chairman’s Health Board. 

June 30, 1998. 

> Iyasu, S., Randall, L.L., Welty, T.K., Hsia, J., Kinney, H.C., Mandell, F., McClain, M., 

Randall, B., Habbe, D., Wilson, H., & Willinger, M. (2002). Risk factors for sudden 

infant death syndrome among Northern Plains Indians. Journal of the American Medical 

Association, Dec4;288(21), 2717-2723. Abstract available at http://www.ncbi.nlm.nih. 

gov/pubmed/12460095. 

> Randall, L.L., Krogh, C., Welty, T.K., Iyasu, S.I., & Willinger, M. (2001). The 

Aberdeen Indian Health Service Infant Mortality Study: Design, methodology, and 

implementation. American Indian Alaska Native Mental Health Research: A Journal of 

the National Center, 10(1), 1-20. Abstract available at http://www.ncbi.nlm.nih.gov/ 

pubmed/11484150. 

Bed Sharing/Co-Sleeping

> AAP Task Force on Reducing Sudden Infant Death Syndrome. (2005). The changing 

concept of Sudden Infant Death Syndrome: Diagnostic coding shifts, controversies 

regarding the sleep environment, and new variable to consider in reducing risk. 

Pediatrics, Nov;116(5), 1245-1255. Available through the AAP Web site at 

http://pediatrics.aappublications.org/cgi/content/full/116/5/1245. 
 

 

 

 

 

Appendix 5: Information Sources 

> Baddock, S.A., Galland, B.C., Bolton, D.P., Williams, S.M., & Taylor, B.J. (2006). 


Differences in infant and parent behaviors during routine bed sharing compared with 


cot sleeping in the home setting. Pediatrics, May;117(5), 1599-1607. Abstract available 


at http://www.ncbi.nlm.nih.gov/pubmed/16651313. 


> La Leche League International 

> Fisher, V. (2001). Issues Surrounding Cosleeping and SIDS Risk. From 


NEW BEGINNINGS, 18(5), 175. Summarized at http://www.llli.org/NB/ 


NBSepOct01p175.html. 


> Sears, W. (1999). Nighttime Parenting and Sudden Infant Death Syndrome. From 


NEW BEGINNINGS, 16(3), 68-70. Summarized at http://www.llli.org/NB/ 


NBMayJun99p68.html. 


> McKenna, J.J. (1993). Rethinking “healthy” infant sleep. From Breastfeeding 


Abstracts, Feb;12(3). Summarized at http://www.llli.org/ba/Feb93.html. 


> McKenna, J.J., & McDade, T. (2005). Why babies should never sleep alone: A review 


of the co-sleeping controversy in relation to SIDS, bedsharing, and breastfeeding. 


Pediatric Respiratory Reviews, Jun;6(2), 134-152. Abstract available at http://www.ncbi. 


nlm.nih.gov/pubmed/15911459. 


> Ostfeld, B.M., Perl, H., Esposito, L., Hempstead, K., Hinnen, R., Sandler, A., Pearson, 


P.G., & Hegyi, T. (2006). Sleep environment, positional, lifestyle, and demographic 


characteristics associated with bed sharing in sudden infant death syndrome cases: A 


population-based study. Pediatrics, Nov;118(5), 2051-2059. Abstract available at 


http://www.ncbi.nlm.nih.gov/pubmed/17079578. 


Strategies for Reaching Communities

> Bereavement resources: Please see the Resources for Dealing with Grief or the Loss of a 

Child information on page 44 of this Workbook. 

> LaDue, R.A. (2002). A Practical Native American Guide for Professionals Working with 


Children, Adolescents, and Adults with Fetal Alcohol Syndrome and Fetal Alcohol Spectrum 


Disorder. Washington, DC: Government Printing Office. (Supported by a grant from 


the Indian Health Service administered through the Northwest Portland Area Indian 


Health Board.); available at: 


> http://www.ihs.gov/MedicalPrograms/Behavioral/download/



PracticalGuide2FAS.pdf,



> http://www.ihs.gov/generalweb/whatsnew/announce/fas.asp. 

99 
 

 

100 

Appendix 5: Information Sources 

> Malbin, D. (2002). Trying Differently Rather Than Harder (2nd Edition). Portland, OR: 

Tectrice, Inc. Available for order at http://www.fascets.org/market_place.html. 

> McClain, M., Arnold, J., Longchamp, E., & Shaefer, J. (2004). Bereavement 
 

Counseling for Sudden Infant Death Syndrome (SIDS) and Infant Mortality: Core 
 

Competencies for the Health Care Professional. McLean, VA: Association of SIDS and 
 

Infant Mortality Programs. 
 

> National Cancer Institute, NIH, DHHS. (2004). Making Health Communications 

Programs Work: A Planner’s Guide (NIH Publication No. 04-5145). Washington, DC: 

Government Printing Office. Available at https://cissecure.nci.nih.gov/ncipubs/detail. 

aspx?prodid=T068. 

> Pierce-Bulger, M., & Nighswander, T. (2001). Nutaqsiivik: An approach to reducing 

infant mortality using quality improvement principles. Quality Management in 

Health Care, Spring;9(3), 40-46. Abstract available at http://www.ncbi.nlm.nih.gov/ 

pubmed/11372502. 

> State of Alaska, Behavioral Health, Office of Fetal Alcohol Syndrome: 

http://www.hss.state.ak.us/fas/ 

> Wattendorf, D.J., & Muenke, M. (2005). Fetal Alcohol Spectrum Disorders. 
 

American Family Physician, 72, 279-282, 285; retrieved from http://www.aafp.org/


afp/20050715/279.html.


Action Steps to Reduce SIDS Risk in Communities

> Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of how people 

change: Applications to addictive behaviors. American Psychologist, 47(9), 1102-1114. 

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1329589. 

> Institute of Medicine, within the National Academy of Sciences, offers information 

health literacy through its Web site at http://www.iom.edu/Activities/PublicHealth/ 

HealthLiteracy.aspx. 

> Motivational Interviewing, part of the National Registry of Evidence-Based Programs 

and Practices, http://www.motivationalinterview.org/ 

> National Center for Cultural Competence at Georgetown University has an entire 
 

portfolio of information on cultural competence at http://www11.georgetown.edu/


research/gucchd/nccc/. 
 

> Turning Point, a former initiative of the Robert Wood Johnson Foundation and the 

W.K. Kellogg Foundation, sought to transform and strengthen the public health 

system in the United States by making it more community-based and collaborative. 

Information on social marketing and public health that resulted from this initiative is 

available at http://www.turningpointprogram.org/Pages/socialmkt.html. 
 

 

 

Appendix 5: Information Sources 

Planning and Sustaining a Healthy Native Babies Project 

> Catalog of Federal Domestic Assistance (CFDA) is a database of all federal 

programs available to state and local governments; federally recognized Indian 

Tribal governments; territories (and possessions) of the United States; domestic public, 

quasi-public, and private for-profit and non-profit organizations and institutions; 

specialized groups; and individuals. Visit the CFDA Web site at http://www.cfda.gov/. 

> Pew Charitable Trusts is a non-profit organization that aims to: improve public 
 

policy by studying and promoting policy solutions for various domestic and 
 

international problems; inform the public through impartial, fact-based polling and 
 

other research-based tools; and stimulate civic life by encouraging and supporting 
 

organizations and institutions that enhance well-being. For more information, visit 
 

the Pew Web site at http://www.pewtrusts.org/. 
 

> Robert Wood Johnson Foundation supports and conducts efforts to improve the health 
 

and health care of all Americans. The Foundation’s goal is to help Americans lead 
 

healthier lives and get the care they need. The Foundation also provides grant support 
 

to eligible organizations. For more information, visit the Foundation Web site at 
 

http://www.rwjf.org/. 
 

> W.K. Kellogg Foundation aims to help create conditions in communities for children 
 

and families to be successful by helping children to learn, develop, and stay healthy, 
 

and by strengthening families within the context of communities and places. The 
 

Foundation provides investments in and grant support for eligible organizations. For 
 

more information, visit the Foundation Web site at http://www.wkkf.org/. 
 

In addition to the resources listed above, the following resources, provided in Chapter 5, are 

also useful for sustaining an outreach project: 

> Afterschool Alliance: Road to Sustainability 

http://www.afterschoolalliance.org/documents/Toolbox/RoadtoSustainability.pdf 

> Center for Community Vitality 

http://www.ag.ndsu.nodak.edu/staffres/GrantDev/checklist.htm 

(Note: Must use uppercase on “G” and “D” in “GrantDev” for link to work) 

> Michael and Susan Dell Foundation 

http://www.msdf.org/Libraries/Documents/Grant_Planning_Worksheet_2-7-2008. 

sflb.ashx 

> Otto Bremer Foundation 

http://www.ottobremer.org/guidelines.php 

> The Foundation Center 

http://www.foundationcenter.org 

101 
102 

Appendix 5: Information Sources 
Healthy Actions for Native Babies

Use this handout to help educate those within American Indian/Alaska Native 

communities who might have cognitive problems, such as Fetal Alcohol Syndrome 

(FAS), Fetal Alcohol Spectrum Disorder (FASD), and traumatic brain injury, or who 

might not read well. 

The risk-reduction actions described here mirror those provided in Appendix 2 of 

the Healthy Native Babies Project Workbook.

How can I protect my baby before it is born?

> Don’t smoke during your pregnancy.

>

>

>

 Don’t drink while you are pregnant or breastfeeding.

 Get early and regular prenatal care.

 Have a Public Health Nurse visit your home.

How can I protect my baby in my home?

 Don’t smoke around the baby.

 Don’t let others smoke around the baby.

Don’t drink alcohol when caring for your baby 

or when breastfeeding the baby.

 Have a Public Health Nurse visit your home.

What else can I do to help my baby?

>

>

>

>

>

>

>

>

>

>

>

 Reduce the chance that flat spots will develop on 

the baby’s head. 

 

 

 

 

Provide Tummy Time when the baby is awake 

and someone is watching.

Hold the baby upright when he or she is 

not sleeping.

Change the direction that the baby faces in 

the crib from one week to the next (that 

is, baby’s feet face one end of the crib for a 

week, then face the opposite end of the crib 

the next week).

Avoid too much time in car seats, carriers, 

and bouncy seats. 

 Breastfeed your baby.

 Take your baby to health care appointments (sometimes called 

“well baby checkups”) on a regular basis, as recommended.

Crib Head Crib Head

 
How should my baby sleep?

> Place baby on its back to sleep for every sleep time, 

for naps and at night.

> 

>

>

Place baby on a firm surface for sleeping, such 

as a safety-approved crib or alternative sleep 

surface, such as a basket, box or carton, drawer, 

or wash tub.

Don’t leave soft things, blankets, toys, pillows, 

padded bumpers, or quilts in the baby’s sleep area.

Keep all items away from baby’s face.

Basket Box or Carton

Drawer Wash Tub

>

>

>

>

 Don’t let baby get too warm during sleep.

 Dress baby in light sleep clothing, such as a sleeper (sleep suit 

with sleeves and feet “built in”) or onesie (one piece sleep suit).

 Don’t use a blanket.

 Keep the temperature comfortable for you and it will also be 

fine for baby.

> Give the baby a pacifier to suck on while he or she is 

falling asleep.

> 

>

>

Don’t force the baby to take the pacifier.

It is OK if the pacifier falls out while the baby is sleeping—

You don’t need to put it back in baby’s mouth.

Wait until baby is used to breastfeeding before using 

a pacifier.

Where should my baby sleep?

> Make a separate place for your baby to sleep that is 

close to you and in the same room. This is the safest 

place for baby to sleep.

> Don’t sleep with baby on a couch, armchair, sofa, or 

waterbed. The baby could suffocate if it gets trapped 

in these surfaces or between your body and the surfaces.

> Don’t let siblings, pets, or other children sleep in 

bed with the baby. The baby could suffocate if a 

person or animal rolls over on top of it.

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 Place baby in area of bed where an adult isn’t 

sleeping, or in the area just above where adult head is.

 Keep baby away from adult bedding.

 Move bed away from walls and other furniture so 

baby can’t fall and get trapped between the bed and 

another surface.

 Place mattress low to or on the floor, away from walls, 

so the baby can’t fall or get trapped between the bed 

and the wall.