"Okay in theory": a qualitative study of safer sleep advice in families with infants at risk and families reporting risky sleep practices.

Background: Safer sleep messages have reduced the rates of sudden unexpected deaths in infancy by 90% in England since 1990. However, deaths continue, mainly in deprived families or where unsafe sleep practices remain common. Understanding the factors influencing these decisions can help further reduce these deaths. This study explores what influences infant sleep-related care practices among caregivers of at-risk infants and those who report non-adherence to safer sleep advice.

Methods: A previously collected survey of infant care practices allowed the identification of 'high scorers' based on a calculated risk score determined by background characteristics and those reporting risky behaviours as 'risky sleepers'. Semistructured telephone/online interviews took place from August to December 2022. Reflexive thematic analysis identified key themes.

Results: Twenty-nine interviews were conducted with 28 families, with 14 'high scorers' and 15 'risky sleepers'. The key themes were trustworthy sources, interpretation of risk and desperate times call for desperate measures. Caregivers of high-risk infants generally understood and followed safer sleep guidance but described rare occasions of compromised safety, usually due to routine disruptions. Those engaging in risky sleep practices cited factors such as sleep deprivation, past experiences, self-identity and personal interpretations of safer sleep advice as influential.

Conclusions: Safer sleep messages are reaching families, but targeted support is needed to prevent rare but fatal incidents. Health professionals should consistently discuss co-sleeping using improved communication strategies to enhance trust. Co-created, accessible and bitesize resources should support parents in problem-solving and planning for safer sleep during disruption to routines.