More than 3500 children die annually in the US from Sudden Unexplained Infant Death
(SUID) and sleep-related causes. Among the groups at highest risk for unsafe sleep
behaviors and sleep-related infant mortality are racial and ethnic minorities, young
mothers, and parents with substance use disorders. Safe sleep education is of great
importance for the local community as infant mortality rates are notably high in
Baltimore City. In 2017, Baltimore City's infant mortality rate was 1.3 times that of the
state of Maryland and 1.5 times greater than the U.S. average. Of these deaths, 16.3%
were related to sleep in Baltimore City compared to only 6.5% in the U.S. as a whole.
Although attempts at integrating safe sleep education into health care visits have been
met with varying success, the investigators have developed a theory- driven and
evidence-based safe sleep intervention that increased safe sleep knowledge and practices.

Given that rates of sleep-related deaths have plateaued in the past decade, new
prevention strategies are needed. For instance, strategic use of technology-based
approaches as well as targeted efforts in the pediatric emergency department (PED)
setting merit consideration for several reasons. First, smartphones and mobile
applications provide additional opportunities to disseminate health education to parents.
M-Health (mobile health) education apps have demonstrated the ability to deliver safety
education. However, the efficacy of mobile applications for increasing adherence to safe
sleep recommendations has not been tested. Second, there is a growing emphasis on the
need for prevention and health education in the emergency department. The emergency
department is also particularly well suited for the employment of technology-based
interventions, as clinicians have limited time to provide education while patients often
face long wait times. In the Johns Hopkins PED, previous research has demonstrated high
smartphone use, and acceptability of such interventions. Further, many SUID cases had in
emergency departments visits prior to death, which represents a missed opportunity to
intervene and educate families about safe sleep, making safe sleep education in the PED
imperative. Finally, many urban PEDs, serve a population at high risk for infant
mortality due to sociodemographic factors.

To address these gaps and needs, this study proposes to adapt the Safety in Seconds (SIS)
app to include safe sleep content and pilot test in the PED setting. The SIS app is a
theory-based, m-Health tool that has been previously tested in the PED in an NIH-funded
randomized trial that demonstrated its efficacy in improving appropriate car seat and
smoke alarm knowledge and use. This app provides computer-generated, tailored messages to
parents. There are three steps involved in the tool: (1) assessment; (2) data processing;
and (3) feedback. Parents complete an assessment in the app and the answers are processed
by a computer program to link each answer to specific theory-driven messages that are
responsive to parents' reported beliefs and practices. These messages are used to produce
a computer-generated, tailored report with persuasive and informative messages about
safety topics. Building on this SIS app with proven effectiveness, the goal of this
project is to incorporate evidence based, previously developed safe sleep education into
the app and encourage implementation of safe sleep practices among families presenting to
the PED.

Aim 1: Digitize existing educational content on infant safe sleep recommendations and
incorporate into the SIS app (following the previously utilized process for the current
app content on car seat safety and fire safety).

Aim 2: Pilot test the updated m-Health tool - SIS 2.0 - which incorporates new infant
safe sleep content (from Aim 1) with existing injury prevention content on child
passenger safety and fire safety. Feedback will be obtained from parents through
follow-up surveys and interviews. Hypothesis: use of the SIS app for provision of safe
sleep education will be effective in conveying this education.