Caregiver voices and choices for infant sleep interventions across five countries: The OPTIONS study

Caregivers of infants aged 6-18 months with problematic sleep often seek assistance to improve their child's sleep through behavioural sleep interventions (BSI). BSI approaches can vary considerably in the level of assistance caregivers offer to infants and in parental acceptability. BSI do not always align with caregiver preferences, which may not be considered by healthcare providers, reducing caregiver agency and risking disengagement. This study firstly explored caregiver experiences when receiving support for BSI from healthcare providers, and their sense of agency associated with the healthcare interaction. Secondly, it assessed acceptability of a proposed "Informed Choice" model of BSI delivery where caregivers are provided with information about multiple evidence-based options, asked their preference and encouraged to choose. Lastly, it investigated whether caregiver perspectives of healthcare interactions around infant sleep and acceptability of the "Informed Choice" model varied across five countries.

Between February and May 2023, the OPTIONS study for caregivers of babies (Offering ParenTs Intervention OptioNs for baby's Sleep), a non-experimental cross-sectional study, recruited adult (18+) caregivers of infants aged 6-18 months to complete an anonymous online survey in 5 countries - Australia, Canada, Türkiye, United Kingdon (UK), and United States (US). Data collected included demographics and family factors, along with experiences of support for managing infant sleep. The Caregiver Family Empowerment Scale (FES) and an additional adapted empowerment subscale explored caregiver sense of agency. The Theoretical Framework of Acceptability (TFA) Generic Questionnaire measured acceptability of the "Informed Choice" model of BSI delivery. Differences between countries were explored with Kruskal Wallis H test and post hoc analysis and an additional binary regression.

Respondents (n = 983) were from Australia (22%), Canada (13%), Türkiye (38%), UK (13%), and US (14%). In this study, 38-56% caregivers reported receiving no support for infant sleep. For those who did received support this waslargely sought from non-professionals, sourcing information online or through family or friends, with only 37 - 51% receiving advice from a health care professional. The majority (60% - 88%) from each participating country reported that they would prefer to be offered multiple BSI options. However, across all countries, of those that had sought support, less than 50% reported being offered multiple options. In terms of agency, post-healthcare provider consultation most caregivers believed their child's sleep would improve (65%), that they were able to advocate for their child (63%) and they had techniques to improve their child's sleep (54%). Acceptability of the "Informed Choice" model of BSI delivery was uniformly high. Participants from Australia, Canada and the US reported significantly higher mean acceptability scores compared to those from Türkiye, while those from Australia and Canada reported significantly higher scores than the UK. The UK and Türkiye were not significantly different. Reasons for these differences are discussed.

The "Informed Choice" model of BSI delivery is acceptable to caregivers across five countries. This model of care differs from the current parental perception of standard care offered by healthcare professionals and could arguably increase caregiver agency and empowerment to select a BSI which is aligned with their preference. Cultural differences must be understood and considered. Parent empowerment and intervention alignment could in turn increase, the likelihood that parents will implement BSI, increase adherence to their chosen protocol, and reduce problematic infant sleep and its negative impact for infants and their families.