Piloting Eyes on the Baby : A Multiagency Training and Implementation Intervention Linking Sudden Unexpected Infant Death Prevention and Safeguarding

. We describe the coproduction, pilot implementation


Introduction
Sudden Unexpected Death in Infancy (SUDI) encompasses all cases in which there is death (or collapse leading to death) of an infant (up to 24 months of age), which would not have been reasonably expected to occur 24 hours previously and in whom no pre-existing medical cause of death is apparent [1].Sudden Infant Death Syndrome (SIDS) is the sudden unexpected death of an infant under 1 year of age, with onset of the fatal episode apparently occurring during sleep that remains unexplained after a thorough investigation, including performance of a complete autopsy and review of the circumstances of death and the clinical history [2].Successful SUDI/SIDS prevention has reduced unexpected infant deaths dramatically over the past 30 years by providing parents with infant sleep safety guidance [3].
In England, SUDI now clusters in the most vulnerable families for whom the universal provision of infant sleep safety guidance appears to be inefective.Te Child Safeguarding Practice Review Panel (2020) reported that "in spite of substantial reductions in the incidence of SUDI in the 1990s, at least 300 infants die suddenly and unexpectedly each year in England and Wales" [4].Te report summarised evidence from 40 infant death cases reported in 2018, highlighting that not only do these deaths now cluster among families in deprived socioeconomic circumstances, increasingly many of the families at risk for SUDI are also at risk for a host of other adverse outcomes, including child abuse and neglect.Te report noted that although universal SUDI prevention information is rigorously delivered by health professionals, many of the families most at-risk of SUDI are unwilling or unable to receive or act on this information, and that "something needs to change in the way we work with these most vulnerable families" to prevent avoidable SUDI [4].Likewise, the 2022 National Child Mortality Database (NCMD) report emphasised that 42% of unexplained deaths of infants occurred in the most socioeconomically deprived neighbourhoods [5].
Te Practice Review report authors recommended SUDI prevention should be understood as relationship-based safeguarding work to include partnership working within local areas for responding to issues of neglect, social and economic deprivation, domestic violence, parental mental health concerns, and substance misuse.Tis work, they noted, "needs to be embedded in multiagency working and not just seen as the responsibility of health professionals" [4].Local authorities and safeguarding partnerships were encouraged to implement targeted multiagency workforce (MAW) approaches for these families.Although MAW has been implemented for investigation of infant deaths in England since the Kennedy Report in 2004 [6], it has only recently been applied to SUDI prevention.Tere is currently no guidance for stakeholders wishing to implement multiagency SUDI prevention strategies, and the authors were unable to fnd examples of good practice in the academic literature.
MAW approaches have been used in other areas of public health and safeguarding where targeted interventions are needed for supporting at-risk or vulnerable individuals.
Examples include child safeguarding in the context of domestic violence [7,8], parental alcohol abuse [9], hoarding disorder [10], and juvenile suicide [11].Co-production has been a key feature of these interventions, which involves academic teams working in partnership with stakeholders and/or service users to design and evaluate research or intervention projects [12].Te Normalisation Process Teory (NPT) has been used to characterise and explain the mechanisms that promote and inhibit implementation and embedding of new health-related interventions by the workforce.NPT provides a framework to aid intervention development and implementation planning as well as evaluating and understanding the processes of implementation [13].Given the existing learning in this area, we chose to approach this multiagency project with an intention for stakeholder co-production using NPT as a guiding framework.
Tis project was instigated by the local Child Death Overview Panel (CDOP), who noted that SUDIs were consistently occurring among vulnerable families in County Durham.Two stakeholders who subsequently became members of the project Steering Committee approached the academic lead about undertaking this work.To inform our pilot programme, we frst systematically reviewed SUDI prevention policies issued by local authorities and NHS trusts across England.Tis explored and appraised the implementation of multiagency SUDI prevention in England to understand local variations and evaluate strengths and weaknesses.We found variable modes of SUDI prevention across England, with few policies explicitly mentioning a MAW approach, and considerable variation in the degree to which this was planned and executed.We concluded that guidance on implementing and evaluating MAW SUDI prevention was needed, and that all individuals who work with at-risk and vulnerable families should be trained to develop knowledge, skills, and confdence in removing barriers to safer infant sleep and thereby supporting SUDI prevention eforts [14].
We conducted a mapping exercise of universal and targeted SUDI prevention in County Durham in 2022.Stakeholder meetings with staf and service leads revealed that both midwifery and health visiting staf would beneft from up-to-date training on SUDI prevention, particularly for vulnerable families.Many staf lacked confdence in discussing the latest national guidance [15] or were unaware it had been updated.We therefore expanded the scope of our training to include health practitioners.
Te fnal aims of this project were to co-produce, pilot, and evaluate a multiagency workforce training and implementation programme for SUDI prevention among vulnerable families in County Durham, working with the local authority public health leads, family facing adult and child services, members of the local Child Death Overview Panel, key NHS staf, and third sector partners.

Materials and Methods
We used an academic-stakeholder co-production approach to design and implement the programme [12]  A list of potential job roles to be included was compiled and organised into three core strands refecting specifc training needs and modes of implementation (Table 2).

Phase 1b: Engaging and Supporting the Multiagency Workforce.
Training content was co-produced via iterative development of training presentations.Training videos were then recorded by the project team and uploaded to a customised online learning platform together with links to preand post-training surveys, post-training quizzes, resource links, and a completion certifcate.Strand 1 training consisted of one 50 minute video-talk while Strand 2 and 3 training consisted of three 30 minute video-talks.Staf groups were invited to register for online individual or group training via their managers and team leaders.Where possible staf were assigned protected time to complete the training and discuss implementation within their teams.A dedicated website served as a portal to access the sign-up process for training, the online training platform, and the resources available and created for this project to support the MAW in implementing SUDI prevention, a list of which is shown in Table 3.
We used the NPT principles to foster engagement and encourage embedding of SUDI prevention into everyday work [16].NPT is an action theory that supports the analysis of what people do to change their existing practice rather than focusing on their attitudes or what they believe.NPT principles encourage cognitive participation and coherence by supporting the development of communities of practice and encourage refexive monitoring and supporting individual and collective sense-making [16] (Figure 1).
To support the development of a community of practice we ofered online drop-in SUDI discussion forums every 6-8 weeks; the sessions were intended for staf to ask questions or discuss situations they had encountered.For the duration of the project the project team mobilised volunteer SUDI Champions to support their teams by raising awareness of SUDI prevention and the Eyes on the Baby training and connecting their colleagues with the SUDI forums and resources.We sent monthly Eyes on the Baby newsletters to all trainees containing short articles exploring SUDI risks and various MAW job-roles such as the role of drugs and alcohol in SUDI and the links between domestic abuse and SUDI.

Phase 2:
Evaluation.Immediately before and after training staf completed two short surveys (Phase 2a), and in the following months were invited to complete two longer surveys about implementing SUDI prevention in practice (Phase 2b) (four surveys in total).Te short pretraining survey (T1) assessed SUDI knowledge and confdence prior to training, and a post-training survey (T2) captured trainees' feedback, knowledge, and confdence after completing the course.Te two identical follow-up surveys (F1 and F2) based on the NoMAD (NPT) implementation survey [17], spaced 4-8 weeks apart, assessed how SUDI prevention activities were embedded in workplaces over time.Training uptake and completion rate data were collected and summarised.All evaluation survey data were recorded anonymously.Outcomes were summarised descriptively, and pre-post knowledge and confdence ratings were compared using chi-square tests.

Health & Social Care in the Community
To capture the views of those staf members and strategic leaders most closely engaged in the project, we conducted semi-structured interviews with four of fourteen SUDI champions (LC) and eight of the nine non-academic members of the Steering Committee (HB) during April and May 2023 (Phase 2c).Consent was sought verbally and in writing, all interviews were conducted online; recorded and transcribed using anonymous identifers, and focussed (as relevant) on previous SUDI prevention experience of the interviewees, how they had supported SUDI prevention in their roles throughout the project, challenges encountered, strengths and weaknesses of the programme, and views on the future of local and national MAW SUDI prevention.Interviews lasted between 30 and 90 minutes.Interviewers (LC and HB) used descriptive themes to summarise the observations and experiences of the interviewees, crosschecking one another's transcripts and summaries [18].

Results
Te intervention process and uptake outcomes are shown using the TiDier checklist in Figure 2.

Training Uptake (Phase 1).
A wide range of staf (n � 993) encompassing 47 job roles registered themselves or were registered by a manager or team leader for Eyes on the Baby training.Details of the job roles, the corresponding training strand, and job category for each role are shown in Table 4. Job categories were devised by the project team to facilitate analysis and were informed by the job-clusters identifed in the initial policy review [14].
Figure 3 shows that 397 staf in County Durham completed the Eyes on the Baby training between October 2022 and March 2023, the largest group belonging to Strand 2 (staf in roles that involve contact with vulnerable families on a regular basis).Of the 993 registered staf members 57% (n � 570) logged on to the training platform at least once, and 70% (n � 397) of these completed the training (gaining 80% on each quiz).Although staf assigned to Strand 1 was the fewest, they had the greatest percentage uptake with 69% (74/107) of registered staf completing the training.Te overall largest group of MAW staf to register (n � 481) and complete the training (n � 256, 53%) was Strand 2, while health practitioners in Strand 3 were the least likely to complete the training (67/405, 17%).59 individuals took part in the online SUDI forums (11 Strand 1, 34 Strand 2, and 14 Strand 3).
For Strands 1 and 2 sign-up by a Team Leader was the most successful recruitment method in terms of number of registrations and completions.However, self-sign-up was the most successful recruitment methods for Strand 3 staf completing the training.Although a large proportion of Strand 3 staf was registered by senior managers there were few completions (3.9%).All staf were encouraged to complete the training within a month of registering: average completion-time was 20 days with no strand taking more than 30 days on average.

Doing SUDI Prevention (Phase 2b
). Tough SUDI prevention was new to most of the Strand 1 workforce, 75% of respondents to the post-training survey (T2, n � 101) could see the value of engaging with Eyes on the Baby programme and believed that taking part in SUDI prevention was a legitimate part of their role.Domestic abuse team members were particularly positive about this.Likewise, most Strand 2 respondents (n � 51) felt SUDI prevention was part of their work (65%), while 87% saw the value of SUDI prevention training and believed SUDI     Health & Social Care in the Community  4).Te follow-up survey was issued twice, 1 month apart.F1 was completed by 40 staf, F2 by 61.As the survey was anonymous we cannot know how many, if any, staf completed it twice, however due to the small number of survey completers we combine them in Figure 4.At completion of F1 approximately one month after training, Strand 1 participants 38% (3/8) were unsure about how the training would afect the nature of their work.By the time of F2 80% (8/10) of respondents indicated they now understood how SUDI prevention afected the nature of their work.Across all NPT statements relating to coherence and cognitive participation, Strand 1 responses improved over time as they became more familiar with their role in SUDI prevention (Figure 5).In Strand 2 both negative and positive changes in responses were observed between F1 (18 responses) and F2 (39 responses), while for Strand 3 the response proportions remained the same (often they were at 100% for F1, 14 responses) or increased for F2 (12 responses) (Figure 5).

Embedding Implementation: Collective Action and
Refexive Monitoring.MAW staf groups experienced different training and implementation trajectories through the project with some completing training early in the project with longer to embed SUDI prevention in their daily activities than those who were trained later.A pooled analysis of survey results at F1 and F2 includes staf at diferent stages in their implementation journey, so to examine the efect of time-since-training, we extracted the data from two large groups of early and late adopters to compare their outcomes post hoc.Children's Services staf completed the training at the beginning of the 6 month training phase (early adopters), while Drug and Alcohol Support Staf completed it almost 6 months later at the end of the training phase (late adopters).
A comparison of follow-up survey responses between these early and late adopters indicated a positive trend over time for 3 out of 4 of the statements relating to collective action, and all the statements relating to refexive monitoring.For example, 66% (12/18) of respondents within Drug and Alcohol support services agreed with the statement "I can easily integrate SUDI prevention into my existing work," compared with 93% (13/14) among early adopters within Children's Services team who had been working on implementation for a longer period.

Qualitative Results (Phase 2c
).Four of the fourteen SUDI Champions volunteered to be interviewed.Tey had supported their colleagues in similar ways such as promoting the training, making resources available, sharing updates, sourcing relevant information, and adding SUDI prevention to meeting agendas.Te role was seen positively and not considered to afect workload.Champions noted that the resources provided could be distributed without redesign staf as it could be ftted into a busy schedule."I think if they're regularly informed and updated on things, it will refresh their memory because sometimes they don't have any unborns or babies on their caseload, so then they may forget slightly."

Steering Committee Member Interviews. All Steering
Committee Members agreed to be interviewed and 8/9 was available to take part.Prior to joining the Eyes on the Baby project SUDI prevention was not a workplace priority for the local authority strategic managers, while it was a moderate priority for members with NHS roles and a high priority for those directly involved with child deaths; it was lower on the   Health & Social Care in the Community agenda and considered primarily the domain of health professionals by those running family-facing council services.Tose in health-facing roles felt well informed about the inequalities apparent in sudden infant deaths, however local authority strategic leads and managers had been on a steep learning trajectory with one commenting: "Tis [project] has been quite an eye-opener for me-interesting and informative-as historically I have not had a lot to do with it [SUDI prevention] at all." Local authority and NHS managers found their involvement to be transformative-exposing them to new ways of implementing SUDI prevention and sharpening their knowledge of infant sleep risks and vulnerable families.Tey felt their staf, in both health care and social care roles, had gained renewed confdence and were better equipped to have conversations about SUDI prevention because of their involvement.One stakeholder commented: "Te staf absolutely accept that it's everybody's responsibility . . .and they can see that where we have a lot of interactions with families, especially prebirth or in those frst few weeks and months, they defnitely think it's their responsibility to have those conversations." Interviewees' refections on the practicalities of implementing the MAW approach to SUDI prevention are described below around co-production and collaboration, initiating and sustaining change, staf responses to MAW, barriers to participation, and fostering future innovation.

Co-Production and Collaboration.
A universal sentiment expressed by interviewees was the importance of the diversity of roles and experience refected in the membership of the Steering Committee.Tis was felt to be one of the key foundations for a successful MAW project-that the stakeholders involved in driving the project worked closely with the diverse staf groups who would be recipients of the training and become engaged in SUDI prevention.Tere was enthusiasm at the outset to cast the MAW net widely and give everyone the opportunity to fnd a role for themselves in this work.Tis "wide net" was part of the initial brief from the local CDOP who initiated this project, to consider who were the most vulnerable families in this area, and to think about who worked with those families most closely.
Interview participants appreciated the opportunity presented by their involvement in the project to forge links across services that "didn't exist in County Durham beforehand," while the broad reach of SUDI prevention as being "everybody's business" resonated in key partner agencies.One stakeholder who had had been involved in the early initiation of this work refected upon engagement with academia as part of the co-production approach noting: "It's taken the project somewhere we hadn't expected it to go to when the initial conversations were happening in CDOP, and I see that as a very strong positive really."Working in collaboration with academics was a novelty for many members of the steering committee, an experience that they found to be "useful" and "enjoyable" and would like to do again.

Initiating and Sustaining Change.
Stakeholders refected during interviews on the changes we were asking staf to make in their work roles, and what would be needed to ensure these changes became embedded in everyday working practices.Some local authority services had made substantial progress on this by the time of these interviews, and the importance of engaging the right people early was clearly recognised."Like most change management, it's getting those early adopters and early implementers and engaging with senior managers."Within family social care and family centres interviewees reported clear examples of engagement, as both prebirth and post-birth services and early help teams had stepped quickly into the early adoption and implementation space, using the opportunity presented by the training to review all their intervention packages with targeted groups of families."It's really early in terms of showing that longer term impact, but we can see the conversations have changed in relation to this.We are not thinking about an add on or saying we need to think about it.We are doing it.It's already more entwined, I think."3.2.4.Responses of Staf to MAW.Some family services and social care staf were surprised by the inclusion of members of the workforce whose role did not involve ofering direct family support (e.g.housing ofcers, domestic abuse teams, paramedics)."I think they [members of my team] were quite shocked that the training was gonna be that far reaching, but I think they could see clearly why that was really important to do." Te uptake of Strand 1 training by paramedics, housing ofcers and others indicated to the stakeholders that there was defnite value in involving these groups of staf in SUDI prevention work, and they could see tangible evidence of an investment from partner agencies and the wider workforce."Te world is becoming a bit more open to the fact that we cannot leave this all to health-they don't have enough contact with the most vulnerable families-or even any families-it is becoming a bit easier to get the idea of MAW into people's minds." As previously noted, some staf completed the training individually as and when they had the time, while others were allocated protected time during group sessions.Interviewees recognised that ofering a range of delivery approaches meant staf who had autonomy over their workday could ft the training in around other commitments, while others beneftted from scheduled group training sessions that they were expected to attend."Feedback within my area of the service was that people felt that it defnitely worked better during the training as a group.I saw that obviously when [project team member] came to my centre "cause that sparked quite a lot of conversation afterwards within that group of professionals."3.2.5.Barriers to Participation.Interviewees refected on the barriers they had encountered in engaging staf groups such as police and GPs that they had initially anticipated would see the value of a MAW approach to SUDI prevention.Staf turnover came up in several interviews, both in reference to Health & Social Care in the Community key leaders who had supported the project, and in terms of keeping SUDI prevention on the agenda in services with heavy staf workloads and high turnover."People sometimes have not got head space, and when they think of training, they think 'Oh God, I have not got time for any of that'."Tis was a particular issue in primary care, with both health visitors and GPs feeling overstretched and lacking capacity to engage in SUDI prevention training, despite potential for these roles to have a real impact.It was recognised by many of the interviewees that more time was needed to embed this approach within teams in County Durham than the project funding allowed.Ongoing evaluation was felt to be needed past the end of the project to capture evidence of change in a range of settings and that SUDI prevention may drop of the MAW radar without enthusiastic and committed leadership from the local authority.On a regional or national scale several participants articulated the need to spread the word about MAW SUDI prevention, and to make Eyes on the Baby available to other local authorities or to scale it up as a national programme."I defnitely think it's a national thing.It's not something that's isolated to Durham in relation to this study, is it? . ... It's wherever there's clusters of deprivation you've got this issue.And that is across the board."

Discussion
Since the recommendation of the Child Safeguarding Practice Review Panel report [4] that SUDI prevention among vulnerable families be brought under the multiagency safeguarding umbrella, only a handful of local authorities have attempted to implement a comprehensive MAW approach for SUDI prevention [14].None have publicly documented and evaluated the process of implementation to date; this report therefore documents how the Eyes on the Baby project team co-produced, piloted, and undertook an initial evaluation of a MAW training and implementation programme in County Durham and shares the learning from this process.
To focus as many eyes on vulnerable babies as possible, we collaboratively and deliberately produced SUDI prevention training and implementation tools for a wide range of multiagency staf.Tese were designed to help staf to ofer resources, discussion, and support around SUDI prevention to vulnerable families, over and above the universal education provided by midwives and health visitors.Staf in family-facing services (Strand 2) enthusiastically embraced the opportunity for training and to implement this into practice.Interviews with SUDI champions and strategic leaders emphasised a picture of commitment, collective working, and enthusiasm for SUDI prevention work among staf, although a poor response to the follow-up evaluation surveys makes it difcult to assess how far this extended.
For staf with ad-hoc contact with vulnerable families (Strand 1), implementing SUDI prevention was a new ask, although some had familiarity with MAW from previous initiatives.While some key teams did not engage in this project (notably police due to the short timescales required by the project funding which could not be accommodated in the police training cycle) others such as Housing seized the opportunity.Despite some staf being dubious about their potential to impact SUDI, the majority of respondents to the follow-up evaluation showed commitment and engagement and evaluated their involvement positively, although the number of Strand 1 staf responding to the evaluation was disappointing.Future iterations of this or similar projects will engage stakeholders from this strand of the workforce on the Steering Committee from the outset to facilitate buyin to all project components.
Despite large numbers of health practitioners (Strand 3) being signed up for the training programme by strategic managers, only a small proportion took up the ofer due to high workloads and staf shortages.Tose health practitioners who engaged with the evaluation embraced MAW SUDI prevention.In future iterations of the project, it will be important to ensure better communications with midwives, health visitors, and other health practitioners via their service leads to facilitate training and evaluation uptake.
Strengths of this project included the graded training programme which enabled us to engage a wide range of multiagency staf with SUDI prevention information tailored to their job role, and the use of NPT to capture how the implementation process unfolded over time for staf, allowing us to identify what successful implementation looked like, and how it was produced.Te three formal propositions of NPT are that: people to be continuously invested in the intervention [19].
MAW staf in all three training strands who responded to the implementation surveys showed an understanding of the role we were asking them to perform (coherence) and of thinking about the value of SUDI prevention (refexive monitoring), while only the staf groups that completed the training early and were able to fully embed SUDI prevention in their work showed evidence of enacting SUDI prevention (collective action) and developing a SUDI community of practice (cognitive participation).Tis highlights a key limitation of this project in the short time period available for late adopters to implement the training and embed SUDI prevention in their work before receiving the follow-up evaluation surveys.For some teams, these follow-up surveys came too soon after training and were not spaced sufciently far apart, illustrated by the low completion rates of the training evaluation and follow-up surveys.We are also unable to report on whether individuals completed one or both follow-up surveys due to anonymous completion.

. Conclusion
As a co-produced research project, Eyes on the Baby secured buy-in from a wide range of professionals in social care, health care, safeguarding, and academia who worked together to devise a tailored SUDI programme that suited the needs of the local context.Steering Committee members enthusiastically engaged in the project, using their status and connections to promote Eyes on the Baby to their colleagues and staf and setting expectations that the MAW over whom they had infuence would engage with training and implementation.Te use of NPT allowed us to track and understand the initial stages of the implementation process, although poor engagement with follow-up surveys limits the outcomes.Further work is also needed to fully embed MAW for SUDI prevention in County Durham and establish sustainability.Tis work is now being taken forward by the Durham Safeguarding Children Partnership to ensure ongoing training provision and evaluation, and the Eyes on the Baby project continues to be developed and refned in collaboration with additional local authorities in north-east England.

Figure 5 :
Figure 5: Change in follow-up survey responses between frst and second timepoints.

3. 2 . 6 .
Future Commitment and Spreading Innovation.All stakeholders interviewed expressed their commitment to the future of MAW SUDI prevention, either locally in County Durham or by spreading the information about this approach regionally or nationally."My colleagues elsewhere [. ..] have been very interested, particularly about the multiagency aspect of it.Tey're the ones that have directly approached me to talk about it."At a local level, stakeholders were keen to see Eyes on the Baby continue past the end of the funded-pilot phase, with the training made available to the MAW via the Durham Safeguarding Children Partnership training website, overseen by the multiagency workforce development and learning group and implemented by the DSCP Learning Development Ofcer.Some interviewees felt Eyes on the Baby should become a mandatory course for all members of the workforce who might have contact with families with babies as part of their annual safeguarding training to ensure SUDI prevention was on everyone's radar.
(a) Interventions become normalized and embedded as people do the work (both individually and collectively) to enact them.(b) Tis work is done through four mechanisms (coherence; cognitive participation; collective action; 12 Health & Social Care in the Community refexive monitoring) which promote or inhibit implementation.(c) Ongoing implementation and integration require which we called Eyes on the Baby.Details of the stakeholders who 2 Health & Social Care in the Community formed the Steering Committee and co-production group are shown in Table 1.Te study was approved by the Durham County Council Research Ethics Board and Durham University's Research Ethics Committee.In designing the Eyes on the Baby programme our objectives were as follows:

Table 1 :
Nonacademic steering committee members.Denotes co-investigator, the academic lead was PI and Steering Committee Chair). *

Table 3 :
Resources available to multiagency workforce.

Table 4 :
Job roles in County Durham included in MAW for SUDI prevention.
CoherenceI can see the potential value of the SUDI prevention training for my work I value the efect that the Eyes on the Baby training has had on my work I believe that participating in SUDI prevention is a legitimate part of my role I am open to working with other services in new ways to prevent SUDI I will continue to support SUDI preventionThere are key people in my workplace who drive SUDI prevention forward and get colleagues involved My contribution to SUDI prevention in County Durham is important