UK parents' help‐seeking for child sleep: A qualitative investigation into parental preferences and reservations about resources

Abstract Child sleep is a common parental concern and there is an array of resources available to parents. However, an exploration of UK parents' help‐seeking behaviours around child sleep is lacking. This study sought to identify the resources parents use to seek information and help for child sleep, as well as to explore what factors parents prefer about certain sources and their reservations about using other resources. Parents of 6‐36 month old children residing in the United Kingdom (UK) completed an online questionnaire between October 2015 and October 2016 about their use, opinions and experiences regarding resources for child sleep. Quantitative data were descriptively analysed and thematic analysis was conducted on parents' open‐ended text responses. Participants were 266 UK parents (97% mothers). Parents' ages ranged from 21 to 45 years (M = 33.49 years, SD = 4.71) and all resided in the United Kingdom (UK). General Internet searches were the most commonly reported source used by 47% of parents with a range of other informal resources also frequently consulted. Health Visitors (HVs) were the most accessed healthcare professional reportedly consulted by 38% of parents. Seven themes represented parental preferences for their resource use. Most strongly endorsed included a desire for information from other parents, particularly those with practical experience and accessing information that aligned with their parenting values. Parents preferred sources that provided support and reassurance, as well as those that afforded parents the ability to select relevant elements from a range of information. Seven themes represented parents' reservations about resources. Most strongly endorsed were concerns about reliability, being judged and challenges associated with filtering vast amounts of information. Parents reported having reservations towards sources if they had a previous negative experience with the source. Possible implications of the findings and specific suggestions about how existing and future resources could be adapted to better meet parents' needs are highlighted.

Health Visitors (HVs) were the most accessed healthcare professional reportedly consulted by 38% of parents. Seven themes represented parental preferences for their resource use. Most strongly endorsed included a desire for information from other parents, particularly those with practical experience and accessing information that aligned with their parenting values. Parents preferred sources that provided support and reassurance, as well as those that afforded parents the ability to select relevant elements from a range of information. Seven themes represented parents' reservations about resources. Most strongly endorsed were concerns about reliability, being judged and challenges associated with filtering vast amounts of information. Parents reported having reservations towards sources if they had a previous negative experience with the source. Possible implications of the findings and specific suggestions about how existing and future resources could be adapted to better meet parents' needs are highlighted.

| INTRODUC TI ON
Child sleep and child sleeplessness problems (CSPs) are common worries for parents (Mindell et al., 2015;Porter & Ispa, 2013;Trajanovska et al., 2010) affecting up to 25% of families (Sadeh et al., 2009;Wake et al., 2006). Whilst up-to-date United Kingdom (UK) prevalence data is lacking, just under half (46.3%) of 266 parents of infants and toddlers in a recent UK sample reported their child's sleep to be problematic to some extent (Cook, 2018). In many cases, these problems are persistent (Byars et al., 2012;Williamson et al., 2019). This is of note, given that CSPs can be associated with adverse outcomes for the functioning and well-being of both the child (Magee & Hale, 2012;Scher et al., 2010;Sivertsen et al., 2015;Spruyt et al., 2008) and family (Bayer et al., 2007;Martin et al., 2007). Parents appear particularly concerned with aspects of a child crying associated with sleep, naps, and night wakings (Simard & Pilon, 2021). There are multiple informal and formal healthcare resources available to parents that offer information, advice and/or help for child sleep.
Informal sources include other parents, friends, family members, general Internet searches or online forums, children and parenting groups and some books. Formal healthcare resources tend to include a range of healthcare professionals (HCPs), such as doctors, paediatricians, health visitors (HVs), midwives and practice nurses amongst others, as well as some printed literature and websites (Brady & Guerin, 2010;France et al., 2003;Henderson et al., 2013;Porter & Ispa, 2013;Simard & Pilon, 2021;Stremler et al., 2013;Tsai et al., 2014). HV is a term which, in the UK, represents a registered nurse or midwife who has undertaken additional training in community public health nursing; the focus of the role is to work with families with children up to 5 years of age.
There has been limited exploration of parents' help-seeking behaviours in relation to child sleep. From previous research, it appears there is geographic (and possible cross-cultural) variation in how and from where parents seek help for child sleep. For example, mothers in Taiwan, Canada and the United States of America, prefer to use informal sources (Johnson, 1991;Stremler et al., 2013;Tsai et al., 2014) whilst mothers from New Zealand and Australia prefer to seek help from formal healthcare resources (Henderson et al., 2013;Trajanovska et al., 2010). Canadian mothers have also reported being satisfied with formal healthcare professional consultations (Simard & Pilon, 2021). A UK-centric study of parents of 3-12 year old children suggests that what is important to parents is that information comes from those with relevant practical experience, with parents being accepting of this type of information coming from informal sources such as family and friends (Hatton & Gardani, 2018).
Given the differences in healthcare systems across countries, it is perhaps unsurprising that there is geographic variation, and it is unlikely results from different countries can be generalised.
Previous research has predominantly focused on parental use of formal healthcare resources (Blunden et al., 2004;Cook et al., 2020;Hsu et al., 2017;Morrell, 1999), yet parents may also use other resources and so this emphasis may underrepresent the proportion of parents who seek help and how they approach doing so. Only a few studies have explored help-seeking in a UK sample (Cook et al., 2020;Morrell, 1999). For example, Morrell (1999) explored advice seeking in mothers of 13-16 month olds. Findings suggested just over 40% of mothers who perceived their child had a CSP and/or mothers whose children met a research definition of a CSP had sought help or advice for child sleep. However, only help-seeking from formal healthcare resources, such as doctors or HVs, was explored and it remains unclear why some mothers who perceived their child to have a CSP had not sought professional help or if mothers had made use of sources other than HCPs. Recent studies have suggested that some parents have concerns about using HCPs for advice or support around child sleep due to a perceived lack of HCPs' knowledge or training (Cook et al., 2020;Hatton & Gardani, 2018 (Henderson et al., 2013) and information which is not aligned with preferred parenting style or beliefs (Tsai et al., 2014) have been found to negatively influence parental help-seeking for child sleep. In the UK, for most common CSPs, first-line treatments recommended by HCPs would be based  (Meltzer & Mindell, 2014;Mindell et al., 2006). However, not all parents may want or be capable of successfully implementing these types of sleep interventions (Blunden et al., 2011;Cook et al., 2020;Tse & Hall, 2008). Yet, it is uncertain what aspects of the sources themselves encourage or discourage parents from using certain resources for child sleep.
Therefore, even though a wide range of resources are available to parents for information, advice or help for their child's sleep little is known about what sources parents use and why. The current study sought to identify the resources parents use to seek information and help for child sleep, as well as to explore what factors parents prefer about certain sources and their reservations for using other resources. It is hoped these results could contribute to ensuring the provisions available for child sleep are informed by what parents want and would best meet their needs.

| Participants and recruitment
Details of the research project were displayed via an advert with an embedded online questionnaire link on (i) social media and (ii) online parenting websites alongside various national and local parenting groups. In addition, (iii) emails including the background to the study and the study advert were sent to parents of children in the study age range via the University's Babylab (active child research group within the University, which has an extensive database of parents in the local area who are interested in participating in child research) and (iv) Individuals/groups who had an interest in the research topic (primarily sleep consultants and experts) also disseminated an advert for the project. The final sample of parents completed the questionnaire between October 2015 and October 2016. Recruitment was from social media sites (Facebook, 58.6% and Twitter, 10.9%), 'other' (7.5%), word of mouth (7.1%), University Babylab (6.0%), parenting group (5.3%), and online advert (3.4%).
Participants were 266 UK parents (97% mothers) of 6-36 month olds. Parents' ages ranged from 21 to 45 years (M = 33.49 years, SD = 4.71, from age data given by 261 parents). This was a convenience sample, with participants completing the questionnaire via adverts disseminated online. To be eligible for the study parents needed to have a child aged 6-36 months, be living in the UK and have sufficient English language skills to understand and complete the online questionnaire.

| Parental help-seeking questionnaire development
As there was no existing tool to assess parental help-seeking behaviours for child sleep, a questionnaire was designed for this study.

| Analysis method and presentation
Quantitative (multiple choice) data is descriptively presented. This analysis method was chosen due to its theoretical flexibility, which was appropriate for the exploratory nature of the study.
Analysis was conducted from an inductive perspective where participants' words formed the foundation from which themes were generated. To ensure the credibility of the analysis process two supervisors (LW and JA) and a qualitative researcher (KH) not involved in the project were extensively involved in the reviewing, discussion and refinement of codes and themes (independently reviewing over 10% each of the total data set). Themes are presented concurrently with descriptions of how each theme was conceptualised by the researchers alongside supporting quotations from participants. In a small number of places, obvious typographic or grammatical errors in quotations were corrected for presentation.

| Procedure
Ethical approval was issued by the University's Research Ethics Committee (study number 150932). The questionnaire was accessed via an anonymous weblink, which was included in the adverts that were distributed by various means (as reported in the recruitment section). When a participant clicked on the weblink they were initially presented with the information sheet, on the same page participants also provided informed consent by ticking a box. Participants were then able to access the questionnaire (hosted by Qualtrics). Participants were able to cease completing the ques-

| Participant characteristics
Full sample demographics are reported elsewhere (Cook et al., 2020).
In summary, over three-quarters of the sample self-identified as being white British (87.2%, based on 262 reported ethnicities) and well-educated with 76.3% (based on 259 reported education levels) reporting that they held either a university degree or had completed further postgraduate education. Most of the sample (79.7%, based on 265 reported occupations) was employed and 19.5% reported being full-time parents.
Responses came from many of the UK counties (n = 48).
Inclusion criteria stated that children had to be aged 6-36 months; the children had a mean age of 19.41 months (SD = 9.26).

| Parents' use of resources
A considerable proportion of parents (n = 179, 67.3%) reported having sought advice, information, or help for their child's sleep at some point. The proportion of parents who reported having used individual source types for the sample as a whole and in age bandings are displayed in Figure 2. Across the whole sample and all age groups, general Internet searches were the most common source

F I G U R E 1 An illustration of survey content and flow
Help-seeking -Section A: Sources and behaviours Help-seeking -Section B: Motivations for not seeking help (only shown if parent reports not having sought advice information of help for child sleep in section A) Help-seeking -Section C: Gaps between available and desired sources and reservations for main source types Child sleep (8 items) Knowledge about child sleep (19 items)

Demographics (16 items)
Help-seeking (min 13 items) of information, reportedly having been used by 47% of the whole sample. Health Visitors (HVs) were the most commonly used formal healthcare resource, reportedly having been used by 38% of the whole sample. Other parents, books, and trusted parenting or health websites were also commonly reported used resources. Identifying the type of information desired before seeking advice may be specific to parents who adopt gentle or attachment style parenting as, conversely, parents did not commonly report actively seeking behaviourally based methods. Much of the advice and/or treatment methods that would be provided to parents from HCPs, whose advice is based on the strongest evidence base, would be behaviourally based in nature. This type of approach, even though evidence-based, may contradict and therefore be unacceptable to those with, some specific beliefs about approaches to parenting.

Theme C. Support and re-assurance
In many cases, it was not just the content of the information that was key for parents but also, and in some cases most importantly, the broader support, reassurance, and the 'human ele- The source or its content was in line with the parent's desired parenting style or approach to parenting. This included actively using or avoiding sources due to its inclusion or avoidance of certain approaches.
'They provide support and advice that is child centred and avoids any "sleep training" methods' (Mum,34,of  Also of importance was that parents perceived that the source, individual or information could be trusted: 'The crucial thing here is that I trust these people' (Mum,

25, of girl 9 months).
Other parents were perceived to have the best understanding of the realistic challenges associated with child sleep, and so could understand and support those experiencing similar challenges. Notably, many parents felt that this type of support and reassurance was lacking from HCPs.

Theme D. Having access to a broad range of information and the ability to select what is relevant
Whilst some parents showed a preference for accessing particular resources, as described above in Theme B, many indicated it was preferable to have the ability to access a broad range of sources, principally as it allowed them to explore a variety of options and ideas: What was key to many parents was being able to review a range of resources and select only the aspects of information or advice that they felt would be useful to them. This information-seeking approach enabled parents to acknowledge the individuality of their child, their parenting style and their circumstances.
3.3.2 | What were parents′ general reservations or barriers to using resources?
The reservations parents held or factors that they perceived to act as barriers when consulting resources for child sleep were also identified. As with their preferences, their reservations also cut across specific types of resources (Table 2).

Theme A. Parental concerns about reliability
Parents held concerns about the reliability of the information. One mother highlighted a broad range of concerns about the reliability of information: 'Interpretation. Relevance. Fact versus fiction. Old wives' tales' (Mum, 40, of boy 24 months).
Although this concern was particularly pertinent in relation to online sources, some parents highlighted that they discriminated between online sources based on their perceived reliability as making use of resources that they perceived to be based on reliable information allayed concerns: 'I generally prefer to take advice from trusted websites such as the NCT [National Childbirth Trust]  However, it was clear that many parents were aware of and concerned about how reliable the information was and that the desire for well-evidenced information motivated some parents to make use of professional healthcare resources.

Theme B. Judgemental
There was an overarching fear for parents of being judged by people who were involved in delivering advice or support across the range of resources. Parents were most concerned about judgement from HCPs, other parents, or family members. One mother reported that interactions with HCPs: '…results in a lot of parents lying to health professionals because they feel like they are being judged' (Mum, 29, of boy 25 months).
Due to societal expectations and social pressures, child sleep was reported as a topic which could generate competition between parents:

'[I] don't listen to friends with similar aged children as it's a lot of competition about whose baby sleeps better'
(Mum, 26, of boy 12 months).
This reservation was most strongly reported in relation to family and friends, but also for online forum-style sources.
Parents held concerns about potential negative emotional or relationship consequences of using certain sources for information or advice. This was particularly pertinent for relationships with those close to them: It is clear that any negative experience could have a profound impact on how useful resources were perceived to be and how likely parents were to make use of them in the future.

Theme D. Hard to filter information
This theme, predominantly but not exclusively highlighted in relation to online resources, was the challenge of finding, obtaining or filtering information: For some, the sheer volume of information was overwhelming to understand and synthesise: 'I was becoming low and anxious with all the conflicting advice online and from books' (Mum, 36 of girl 17 months).
It is interesting that the volume of information available or the number of 'hits' resulting from a general Internet search was, as previously discussed, viewed as beneficial by some parents, for offering a range of information and options but also disliked and found to be overwhelming by others. their reliability, particularly for online resources (Porter & Ispa, 2013;Scullard et al., 2010) and (b) concerns about being judged (Hatton & Gardani, 2018). Additional novel findings were that (c) previous use (their own or others') of resources with a non-favourable outcome was influential and (d) the volume of available information about child sleep felt overwhelming.

| DISCUSS ION
The high proportion of parents who reported having sought information or advice for their child's sleep emphasises the importance of the topic (Porter & Ispa, 2013;Trajanovska et al., 2010). Sleep problems in infants and toddlers are common but highly amenable to intervention (Mindell et al., 2006). However, to be appropriately There is a clear challenge in synthesising the sometimescontradictory issues raised by parents when it appears there is variation in what parents want. For example, many parents reported preferring resources of an informal nature, with some even avoiding formal healthcare resources, even though parental concerns about reliability were widespread and many parents noted that discriminating between vast amounts of conflicting information was problematic. In addition, there was a desire for diverse material but also content which met specific parenting values.
Whilst these tensions may appear contradictory, perhaps they reflect different stages or approaches to help-seeking at different time points. A new sleep intervention developed in the UK for parents of infants has acknowledged the need for broader parenting approaches to be incorporated into child sleep resources (Ball et al., 2020). The key implication of the current findings is that there is a need to fully integrate what parents do and do not want from child sleep resources and address some of the clear tensions identified in the current study in the future development of resources.
General Internet searches were the most used resource by parents and this reflects the trend of parents' increasing use of online resources to seek information about child sleep (Allen & Rainie, 2002;Khoo et al., 2008). Online delivery has been shown to be successful for the delivery of interventions for paediatric sleep (Mindell et al., 2011a;Mindell et al., 2011b) and recent evidence suggests that parents regularly use websites which they perceive to be reliable for child sleep (Simard & Pilon, 2021 (Mindell et al., 2021). However, although there is evidence of the efficacy of this type of content (Leichman et al., 2020), a formal evaluation of the effectiveness of these websites has not been established.
Parents clearly want evidence from people that they trust and whom they believe will offer them realistic advice and broader emotional support. Whilst many parents appeared to have faith in the reliability of National Health Service (NHS) resources and healthcare services there remained limitations to these, most notably that they are not perceived as providing a broad range of options for parents to review before making their own personal decisions (due to being mandated to provide only evidence-based information). Therefore, perhaps the most appropriate and realistic solution would be a This approach may also help engage parents with the material offered via formal sources (Hatton & Gardani, 2018). Another practical approach could be joint future resource production with parents, healthcare professionals and sleep 'experts' collaborating (as highlighted by Hatton & Gardani, 2018). Working collectively has a range of practical benefits (Hickey et al., 2018) and may help to identify the most viable solutions to address the parental preferences and reservations highlighted. Parents and experts have successfully collaborated to identify research questions around key parenting topics, such as feeding (Collins et al., 2020) and to develop an information booklet-based sleep intervention aimed at parents of infants (Ball et al., 2020). Successful co-production of an online sleep resource has been achieved for parents of children with epilepsy where several novel amendments (addressing issues such as those reported in the current paper) were made to traditional behavioural sleep intervention delivery to ensure alignment with parental requirements (Wiggs et al., 2021).
These findings need to be considered in the context of some limitations. This was an undefined internet sample which, even though a broad spectrum of parental opinions and experiences were included, is unlikely to be representative of the general population of the UK and may be subject to selection bias due to the nature of data collection. For example, it is clear the current sample comprised participants of above-average education levels and SES. In addition, there is a lack of ethnic diversity and the current sample does not reflect the general UK population family composition. Future, studies in more diverse populations are needed to further understand cultural and geographic influences on parental help-seeking behaviours. Nevertheless, a strength is that the current study provides a broad spectrum of parental opinions and experiences and included a thematic analysis of a relatively large sample size of parents.
Responders were mainly mothers and so it is possible that fathers or other caregivers may seek help for child sleep in different ways and this requires further exploration.
In addition, as the current data reflect parental beliefs and experiences in 2015-2016, it is possible that since then, and post Covid-19, parents' use and experiences of resources may differ. However, recent work suggests that existing resources are still not meeting parents' needs (Rhodes et al., 2020;Vazquez-Vazquez et al., 2021) and that many parents in need of support with child sleep are still not seeking help (Newton et al., 2021). Therefore, there remains a need to understand parents' opinions and experiences of support and resource use in order to understand factors which promote and inhibit parental help-seeking behaviour and that is provided by the current work.
Finally, questions were developed specifically for use in this study and it is possible that these did not adequately encapsulate all aspects of parents' help-seeking behaviours. Further exploration using different methods, such as interviews, could be further enlightening.

| CON CLUS ION
Current results extended the existing literature by identifying sources used by parents to seek help for infant and toddler sleep, including exploring factors that UK parents preferred and those which created reservations about using sources. Parents made use of a wide range of resources and many of these were commonly informal in nature, with HVs being the only HCP widely used. Parents wanted a range of easily accessible, evidence-based information provided by someone with relevant experience who offered support and reassurance. They also wanted the freedom to make an informed decision and select only what was deemed to be in-line with their desired approach to parenting and suitable for their individual circumstances. Many parents did not feel that existing resources adequately met their needs. Future development of resources (materials and services) could helpfully be informed by incorporating parents' views.

AUTH O R CO NTR I B UTI O N
All authors contributed to the conception, design, analysis, and interpretation of data as well as drafting and critically revising the manuscript for important intellectual content. GC was also responsible for data collection.

ACK N OWLED G EM ENTS
The authors would like to thank all participating families for their time and involvement. Thanks also to Dr Kimberley Harcourt who contributed to the thematic analysis process.

CO N FLI C T O F I NTE R E S T
The authors declare no commercial or financial conflicts of interest.

Ethical approval was obtained through Oxford Brookes University
Research Ethics Committee (study number 150932).

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.