Infant Sleep Behavior Practices and Knowledge of Fathers: An Exploratory and Descriptive Study

Abstract

Sudden unexpected infant death (SUID) is a term for any sudden death occurring under 1 year of age. SIDS (sudden infant death syndrome) is the sudden death of an infant that is unexplained after an investigation and often occurs during sleep or in the infant sleep area. In Indianapolis, 130 infants died in 2022 before their first birthday, and 17% were from SUIDs. Fathers’ understanding of infant safe-sleep knowledge and behaviors is mostly unknown. This study aims to describe fathers’ infant safe-sleep knowledge and behaviors. Study participants were recruited via promotional flyers from 2019 to 2024. Volunteers completed a survey on their infant safe-sleep knowledge and behaviors. Responses were entered via secure, web-based data-collection tool either directly by QR code accessible survey or manually by the research team. Frequency and comparative analyses were performed, and results described. Eighty-five fathers completed the survey. The lowest reported knowledge for safe-sleep practices was for breastfeeding, and wearable blankets being protective against SUID. A smaller percentage of fathers reported their baby never slept in the same bed as someone else and similarly reported never placing their baby to sleep in an adult bed. Fewer fathers correctly reported practicing room-sharing and pacifier usage. Interactive learning geared toward male caregivers on AAP recommendations for preventing sleep-related deaths is key. Focusing efforts with fathers on the risk of soft bedding, benefit of breastfeeding, pacifier usage, and room-sharing will be important to lowering SUID rates and helping men in their role as fathers

Introduction

In 2022, the infant mortality rate (IMR) for the United States increased for the first time in decades to a rate of 5.6 per 1000 live births (Ely & Driscoll, 2023). One major contributor to the IMR is sudden infant death syndrome (SIDS) which is part of sudden unexpected infant deaths (SUIDs). SUID is a broad term used to classify any sudden death occurring in infancy (less than 1 year of age). The cause of death may be diagnosed as suffocation, entrapment, cardiac arrhythmia, or sudden infant death syndrome (SIDS) (Moon et al., 2016). SIDS is the term used to describe the sudden death of a baby younger than 1 year of age that doesn’t have a known cause, even after a full investigation (Safe To Sleep, 2024). The CDC recommends placing infants in the supine sleep position, using a firm mattress in a crib, and keeping the sleeping area clear of toys, blankets, pillows, bumper pads, etc., to reduce the prevalence and risk of SUID (Sudden Unexpected Infant Death and Sudden Infant Death Syndrome, 2019).

In 2020, there were 3,356 cases of SUID in the United States (Sudden Unexpected Infant Death and Sudden Infant Death Syndrome, 2020). Annually, the U.S. has ~3,500 infant deaths due to SUID’s, which is the third leading cause of infant mortality in the U.S. (What Causes Infant Mortality?, 2021). Infant mortality data in Indianapolis is tracked by the Marion County Public Health Department (DR5598 MCPHD Epidemiology, 2023). In 2022, 130 infants died before their first birthday, giving Indianapolis an infant mortality rate of 10.7, almost double the rate of the U.S during that timeframe. Of those deaths 17% were due to SUID causes (DR5598 MCPHD Epidemiology, 2023).

Parental knowledge and behaviors in relation to infant sleep practices is important in how infants are positioned by parents and caregivers during sleep times and is crucial to decreasing SUID rates. However, the relationship between knowledge and behaviors is complex. For example, the Social Ecological Model (SEM) considers knowledge as influencing health related behaviors, in addition to intrapersonal, interpersonal, community, institutional factors and public policy (McLeroy et al., 1988; Nyambe et al., 2019). In this model knowledge influences behavior but predictors at the interpersonal level may influence them more heavily. Through SEM, knowledge is one influencing factor on actions and behaviors, but interpersonal, intrapersonal, and institutional influences can be more impactful depending on the situation (McLeroy et al., 1988). Fathers report multiple influences regarding infant safe sleep, as a barrier to practicing safe sleep (Hirsch et al., 2018). Challenges listed were parental disagreements, or incorrect advice from older family members. Older family members, in particular grandmothers and older female relatives, in African-Americans (Black) communities have great influence on how infants are put to sleep (Zoucha et al., 2016).

Studies have explored the mother’s perspective, but few have explored infant safe-sleep knowledge and behaviors of fathers and male caregivers (Ramos et al., 2023). Those that have, report lack of knowledge as a barrier for male caregivers practicing infant safe sleep. One study found that many fathers did not understand the reasons behind the American Academy of Pediatrics (AAP) guidelines for safe sleep, which made it more difficult for the fathers to adhere to them (Parker et al., 2023). Lack of knowledge of infant physiology and the risk of co-sleeping has been described qualitatively, as well as conflicting influences providing incorrect information regarding infant safe sleep (Hirsch et al., 2018). While some fathers do have safe-sleep knowledge, they may not adhere to recommendations due to a lack of convenience or their personal beliefs (Hirsch et al., 2018). A recent study found that fathers had a lack of insight on behaviors relating to infant safe sleep and lack of knowledge on its importance and how to practice infant safe sleep (Parker et al., 2023). Fathers report suboptimal safe-sleep practices overall, which presents an opportunity to include fathers and male caregivers in infant safe-sleep promotion (Parker et al., 2023). There are many positive benefits from encouraging the involvement of fathers in parenting. Fathers’ involvement in parenting is associated with higher weight gain in preterm infants, improved breastfeeding rates, and higher academic achievement and receptive language skills (Tohotoa et al., 2009). However, lack of knowledge of breastfeeding can also cause men to feel inadequate (Sihota et al., 2019). Prior studies on fathers supporting breastfeeding has demonstrated the influence of knowledge about breastfeeding causing fathers to assist their partner’s initiation and duration of breastfeeding (Bugg et al., 2021; Furman et al., 2016). One study demonstrated that understanding of the benefits of breastfeeding, better equipped fathers to deal with barriers (Bugg et al., 2021). Paternal emotional and practical support have been shown to be positive factors in promoting successful breastfeeding (Tohotoa et al., 2009). We believe similar paternal support for infant safe-sleep practices in the home would help decrease SUID rates, and knowledge of the best infant safe-sleep practices will be key to adherence. A descriptive study of the understanding of infant sleep knowledge and behaviors of fathers and male caregivers is non-existent, and an exploratory study in a limited sample can further research in the field of paternal infant safe-sleep practices.

The purpose of our study was to assess fathers’ (defined as the infant’s male caregiver) knowledge and practice of infant safe sleep. Our study aims to: (a) describe fathers’ knowledge of safe-sleep practices; and (b) describe fathers’ behaviors (use of safe-sleep practices) when putting their infant to sleep themselves.

Methods

Setting and Participants

Recruitment for survey participants was performed through local child care centers, pediatric outpatient clinics, and newborn nurseries in the greater Indianapolis area. Our study was conducted during two time periods: first phase: 2019–2020 (July 2019–April 2020); second phase: 2021–2024 (January 2021–January 2024). Study participants represent a convenience sample. Eligible participants were male caregivers (which we define as “fathers”) of an infant 12 months of age or younger, able to read/speak English and at least 18 years of age. Caregivers of infants with a history of chronic illness that hindered them from being able to sleep prone (e.g., recent spine surgery), born at less than 26 weeks’ gestation age, or had a NICU hospitalization were excluded. Participants were recruited through two methods: (a) approached by trained research assistant at child care centers who provided materials that invited the male caregiver of an infant to participate, and (b) recruited through flyers posted/distributed in child care centers, clinics and newborn nurseries which contained QR codes that directed participants to the survey. Recruitment via flyer distribution was added due to social isolation restrictions at child care centers due to COVID pandemic restrictions, and the need to expand recruitment for a better representative sample size. On the survey, the father participants self-identified as male and as caregiver of an infant.

Procedure

A self-administered survey was developed to measure participants self-reported knowledge and behaviors about infant safe-sleep position, location, and environment. The survey contained questions to measure knowledge of infant safe-sleep recommendations, adapted from questions in the Cribs for Kids Safe Sleep Ambassador Survey, and self-reported infant sleep behaviors were assessed with questions adapted from the Assessment of Safe Sleep: Validation of the Parent Newborn Sleep Safety Survey (Whiteside-Mansell et al., 2017). The adapted behavior survey was previously validated in only mothers (Whiteside-Mansell et al., 2017). Survey responses were collected in REDCap, a secure, web-based data-collection tool, on a university designated computer. Participants were compensated during the first phase with a safe-sleep kit provided to the family (total value: $40), and during the second phase, families received an emailed gift card for participating (total value: $40). The study was funded by the Indiana University School of Medicine Program to Launch Underrepresented in Medicine toward Success (PLUS) program funding from 2020 to 2023. The study was determined to be exempt from human subjects review by the Indiana University Institutional Review Board.

Independent Variables

Demographic characteristics were collected and included an “other” or “prefer not to answer” option. Self-reported age (years), sex (male, female), race (American Indian/Alaska Native, Asian, Black/African American, Native Hawaiian/Pacific Islander, White), ethnicity (Hispanic/Latino, not Hispanic/Latino), level of education (high school or less, some college, college, graduate or professional), marital status (single, married, unmarried couple), and cohabitation (yes or no) status were collected. Race and ethnicity categories were chosen based on Indianapolis Census Reporter information (Census Profile, n.d.) (See Supplementary Material for the full survey).

Outcome Variables

The primary outcomes assessed included 10 measures of parental knowledge and 15 measures of infant sleep behaviors. The survey contained a total of 38 questions with a mixture of multiple choice, Likert-type scale, true-false, and demographic questions (See Supplementary Material).

Data Analysis

A total of 86 fathers participated in the survey; one father was excluded from the study because there were no responses to the knowledge or behavior items on his submitted survey. Survey responses were de-identified for analysis. Correct responses for each knowledge and behavior question were based on AAP recommendations for best practices for infant safe sleep as well as validated answers from the Cribs for Kids Safe Sleep Ambassador Survey and the Assessment of Safe Sleep: Validation of the Parent Newborn Sleep Safety Survey (Moon et al., 2016, 2022; Whiteside-Mansell et al., 2017). The correct response was assigned a score of “1”, and all other responses in the survey were scored “0.” Descriptive analyses were performed on demographic characteristics of fathers in the study. Analysis was conducted to look for differences in the samples collected during two different time points of the study, and no differences were observed.

Scores were tabulated by summing the individual items for the knowledge and behavior scale, respectively, and reported as an average total score for the study population (Tables 2 and 3). For each survey question, we summed the total correctly chosen response for each question, then converted to a percentile by dividing by the number of the scale items and multiplying by 100. Besides general descriptive statistics, analyses were performed to determine if there were significant associations between demographic characteristics and knowledge and behavior scores, using ANOVA models. Multivariable analyses were also performed using factorial ANOVA models, using those variables that were significant in the bivariable models at p < .05 and removing those that were collinear, keeping the variable with the higher R² value. Cronbach alpha statistics were generated to look at internal consistency of the scales. All analytic assumptions were verified. Analyses were performed using SAS v9.4 (SAS Institute, Cary, NC).

Table 2.

Percentage Correct Safe-Sleep Knowledge Questions (Range 0–10 for Total).

		Dad (n = 85)
Total score	N/A	8.9 ± 1.6
Survey question	Correct Response (1 point)	Percent surveyed who selected the correct answer
To keep baby warm at night the safer option to a blanket is:	“Wearable blanket”	80.0%
All of the following are risk factors for infant safe-sleep-related deaths, except:	“Breastfeeding”	80.0%
Room-sharing means:	“When a baby sleeps in the same room as his/her parents”	83.5%
Where is the safest place for a baby to sleep?	“Crib”	96.5%
Which position is safest for a baby to sleep in?	“Back”	94.1%
The place where a baby sleeps should always be:	“Firm”	90.6%
Which item can be in the crib with the baby?	“Pacifier”	88.2%
Babies should sleep alone in a safety approved environment with a tight fitted sheet for up to 1 year of age (True or False)	“True”	92.9%
Babies sleep safest on their back. They should not sleep on their side or stomach (True or False)	“True”	92.9%
Nothing and no one should be in the baby’s sleep area/crib (True or False)	“True”	92.9%

Table 3.

% Correct Safe-Sleep Behavior Questions (Range 0–15 for Total).

		Dad (n = 85)
Total score	N/A	11.9 ± 2.2
Survey question	Correct response (1 point)	Percent surveyed who selected correct behavior
How often do you put your baby down to sleep on his/her back?	“Every time”	85.9%
Is the mattress in the crib firm?	“Yes”	94.1%
At night, the baby sleeps in the same room as you or another adult?	“Yes”	52.9%
How often do you and your baby sleep in the same bed?	“Never”	71.8%
How often does your baby sleep in the same bed with someone else?	“Never”	80.0%
How often do you put your baby down to sleep in an adult bed?	“Never”	71.8%
Where do you put your baby down to sleep the most?	“Crib/Pack n’ Play/Cribette”	97.7%
When your baby is sleeping how often is there a pillow in the crib for him/her to rest their head on?	“Never”	90.6%
When your baby is sleeping how often is there a bumper pad around the edge of the crib?	“Never”	83.5%
How often is there a cushion, pillow, heavy blanket, or sheepskin, on top of the mattress but underneath the baby?	“Never”	88.2%
How often is there a stuffed animal in the crib with your baby?	“Never”	88.2%
When your baby is sleeping how often does the crib have a mattress in it-one that fills up the whole bottom of the crib and doesn’t leave any space between the mattress and the edges of the crib?	“Every time”	92.9%
How often do you use a wedge or something else to hold the baby in particular position while s/he sleeps, or to keep him/her from rolling?	“Never”	87.1%
How often is there a heavy blanket, comforter, or bedspread in the crib with your baby?	“Never”	89.4%
How often do you give your baby a pacifier when you put him/her down for sleep?	“Every time”	17.7%

Results

Most participants in the study self-identified as White, Non-Hispanic, and college educated (See Table 1). Fewer fathers in the study self-identified as Black compared to Indianapolis demographics (22.6% vs. 28%, respectively) (Census Profile, n.d.). The percentage who self-identified as Hispanic was also lower than for Indianapolis (7% vs. 12%, respectively). Our study population was more educated (with bachelor degree or higher) when compared to Indianapolis (54% vs. 36%) and was more likely to be married (72% vs. 45%) (Census Profile, n.d.).

Table 1.

Demographics.

Sociodemographic feature
Dads (n = 85)
Age (years)	32.7 ± 8.1
Race
Black	23.8%
White	70.0%
Other	6.3%
Hispanic ethnicity	7.6%
Education
≤High school	27.4%
Some college	17.9%
College	29.8%
Grad/Prof	25.0%
Marital status
Single	15.9%
Married	74.4%
Unmarried couple	9.8%
Cohabitation
Yes	85.7%
No	14.3%

Note. Frequencies may not add to 85 due to missing data.

Knowledge for safe-sleep practices was lowest for two items: breastfeeding is not a risk factor for infant sleep-related deaths (80%, Table 2), and a wearable blanket is the safest option to keep baby warm at night (80%, Table 2). Among the participating fathers, 83.5% chose the correct definition of room-sharing (Table 2), and 96.5% chose the correct answer for the safest place for a baby to sleep. Correct selections to the remaining knowledge items ranged from 88% to 96%. Internal consistency among knowledge scores among the two separate data-collection points was high, with a Cronbach alpha score of .966.

Infant safe-sleep practices that had the lowest number of fathers reporting the correct behavior pertained to infants in adult beds. Fewer fathers selected the correct safe behavior response for risk of their baby sleeping in the same bed as themselves or someone else (71.8% and 80%, Table 3). In addition, fewer fathers chose the correct response for how often they placed their baby to sleep in an adult bed (71.8%, Table 3). Only 52.9% of surveyed fathers placed their baby down to sleep in the same room as an adult (Table 3). Use of a pacifier during infant sleep was correctly reported by only 17% of fathers reporting that they gave their infant a pacifier every sleep time. Internal consistency among behavior scores among the two separate data collection points was high, with a Cronbach alpha score of 0.974.

On bivariate analyses, race, marital status, and cohabitation were significantly associated with infant safe-sleep knowledge. Being married or cohabitating with a partner was significantly associated with higher infant safe-sleep knowledge for fathers. The father’s race correlated with their knowledge scores, with White men surveyed having a significantly higher knowledge score than Black men (9.41 vs. 7.95) (Table 4). The association of race with knowledge score remained significant when controlling for marital status; however, marital status’ association was attenuated when including both in the model (Table 5).

Table 4.

Bivariate Associations of Covariates on Male Knowledge Results.

Variable	Knowledge score	p-value
Education
HS or less	8.52 (0.34)	.1688
Some college	8.47 (0.42)	No significant pairwise associations
College	9.08 (0.33)
Graduate degree+	9.48 (0.36)
Marital status
Single	8.15 (0.44)	.0040
Married	9.23 (0.20)	Pairwise: single vs. married p = .0284
Unmarried couple	7.50 (0.56)	Pairwise: married vs. unmarried p = .0046*
Cohabitation
Yes	9.06 (0.20)	.0148
No	7.73 (0.49)	Pairwise: yes vs. no p = .0148*
Race
Black	7.95 (0.35)	<.0001
White	9.41 (0.20)	Pairwise: Black vs White, p = .0005*
Other	7.00 (0.68)	Pairwise: White vs other, p = .0110*
Ethnicity
Hispanic	8.00 (0.68)	.1599
Non-Hispanic	9.00 (0.19)	No significant pairwise associations

Note. Values are means (standard errors) with p-values from ANOVA models; pairwise p-values are given unadjusted, but with an * to indicate they are still significant with a Bonferroni correction.

Table 5.

Multivariable Associations of Covariates on Male Knowledge Results.

Variable	Knowledge score	p-value
Marital Status
Single	7.95 (0.49)	.3040
Married	8.31 (0.33)
Unmarried couple	7.39 (0.53)
Race
Black	7.59 (0.37)	.0017
White	9.05 (0.32)	Pairwise: Black vs White p = .0027*
Other	7.01 (0.67)	Pairwise: White vs other p = .0071*

Note. Values are means (standard errors) with p-values from factorial (no interactions) ANOVA models; pairwise p-values are given unadjusted, but with an * to indicate they are still significant with a Bonferroni correction.

Bivariate analysis of the infant safe-sleep behaviors of fathers, race, marital status, and cohabitation were significantly associated with the behavior scores. Marriage or cohabitating with a partner was significantly associated with higher score for fathers’ infant safe-sleep behaviors. The father’s race was associated with behavior scores, with White men surveyed having a significantly higher behavior scores than Black men (12.32 vs. 11.11) (Table 6). The association of race with behavior became non-significant when accounting for marital status (Table 7). Marital status was significantly associated with the behavior score, while effects of race was lessened when including both in the model (Table 7).

Table 6.

Bivariate Associations of Covariates on Male Behavior Results.

Variable	Knowledge score	p-value
Education
HS or less	11.35 (0.46)	.3537
Some college	12.67 (0.57)	No significant pairwise associations
College	11.88 (0.44)
Graduate degree+	12.05 (0.48)
Marital status
Single	11.77 (0.57)	.0005
Married	12.31 (0.26)	Pairwise: single vs. unmarried p = .0057*
Unmarried couple	9.13 (0.73)	Pairwise: married vs. unmarried p = .0001*
Cohabitation
Yes	12.20 (0.27)	.0232
No	10.55 (0.66)	Pairwise: yes vs. no p = .0232
Race
Black	11.11 (0.50)	.0181
White	12.32 (0.29)	Pairwise: Black vs. White p = .0384
Other	10.00 (0.97)	Pairwise: White vs. other p = .0249
Ethnicity
Hispanic	11.67 (0.92)	.8156
Non-Hispanic	11.89 (0.26)	No significant pairwise associations

Note. Values are means (standard errors) with p-values from ANOVA models; pairwise p-values are given unadjusted, but with an * to indicate they are still significant with a Bonferroni correction.

Table 7.

Multivariable Associations of Covariates on Male Behavior Results.

Variable	Knowledge score	p-value
Marital Status
Single	11.79 (0.69)	.0084
Married	11.60 (0.46)	Pairwise: single vs. unmarried p = .0072*
Unmarried couple	9.05 (0.74)	Pairwise: married vs. unmarried p = .0035*
Race
Black	10.58 (0.52)	.1590
White	11.66 (0.45)	No significant pairwise associations
Other	10.20 (0.94)

Note. Values are means (standard errors) with p-values from factorial (no interactions) ANOVA models; pairwise p-values are given unadjusted, but awith an * to indicate they are still significant with a Bonferroni correction.

Discussion

Men value their parenting role and need information and knowledge to help them along their fatherhood journey (Tohotoa et al., 2009). Fathers have previously relayed hearing prior safe-sleep messages, and knew certain messaging aspects regarding position, location, and dress (Hirsch et al., 2018). They also reported knowledge lacking in appropriate sleep environment and risk of co-sleeping. Fathers’ involvement in caregiving lead to improved infant and maternal sleep 6 months post-partum (Moon et al., 2022). Understanding paternal practice and knowledge of infant safe sleep may inform targeted safe-sleep interventions for male caregivers.

In our surveyed population, fewer fathers correctly chose the benefits of room-sharing and pacifier usage to decrease SUID. Fewer than 1 out of 20 (17.7%) correctly reported that infants should use a pacifier at every sleep time. The knowledge of the benefit of pacifier usage for safe-sleep practice among fathers has not been reported elsewhere. Pacifier usage at any sleep time including nap or bedtime is recommended by the AAP to reduce risks of SIDS (Moon et al., 2022). One study reported paternal caregivers’ lack of usage of other protective measures against SIDS, including pacifiers (Hirsch et al., 2018). Like our population, their participants were male caregivers. However, they did not report pacifier usage separately. Thus, opportunities exist for structuring messaging and education with fathers and male caregivers about the benefits of pacifiers to lower SIDS.

Men reported unsafe sleep behaviors in the practice of room-sharing. In our study of fathers, room-sharing behavior (52.9%) was reported at a much lower percentage than knowledge of what room-sharing means (83.5%). Although not described previously in men, the practice of room-sharing has been reported in mothers, where 57% of mothers reported the practice (Hirai et al., 2019). Messaging and education around the concept of room-sharing for all who take care of infants will help reduce SUID.

Fewer fathers selected breastfeeding as being protective against SUID. Breastfeeding is associated with a reduced risk of SIDS, and feeding of human milk is recommended by the AAP to combat infant sleep-related deaths (Moon et al., 2022). Fathers play an important role in supporting their partners with breastfeeding and significantly influence breastfeeding rates and success (Mahesh et al., 2018; Tohotoa et al., 2009). With support from fathers leading to better breastfeeding rates and duration, the additional knowledge of breastfeeding reducing risk of SIDS could have an additional impact. Designing outreach programming, and messaging for fathers around the benefits of breastfeeding will be vital in helping lower SIDS rates.

Our sample of fathers reported not placing their infant to sleep on soft bedding or with soft items in the sleep space 83%–89% of the time. This was much higher than reported paternal behaviors from a previous study of 32% using approved sleep surface and 44% using no soft bedding (Parker et al., 2023). However, one out of six to nine babies are still placed at risk. Thus, continual work to improve fathers’ understandings around soft bedding is crucial to combat SUIDs.

Race was significantly related to both behavior and knowledge scores. Men who identified as White had higher scores than those who identified as Black even after controlling for cohabitation status. We hypothesize that kin support contributes to the influence of race on knowledge score. Kin support in families varies, and is more prevalent in Black households and includes help with child care, including advice for sleep positioning (Howard et al., 2022). In addition, intergenerational exchange of childrearing practices is common, with a stronger influence in Black communities (Van Ijzendoorn, 1992). It’s been reported in African American (Black) communities a sense of respect afforded older women and grandmothers in the family and community regarding care for children. However those study participants admitted being unsure or confused about correct sleep practices (Zoucha et al., 2016). Understanding this dynamic and the role familial and social networks play in how an infant sleeps will be important in improving safe-sleep practices among all fathers, especially those in at risk communities.

Marriage and cohabitation have a correlation with infant safe-sleep behavior and knowledge of fathers and male caregivers. Of interest, on covariate analyses race is significant for knowledge scores after controlling for marital status while the opposite is true for behavior—race is no longer significant, and marital status remains significant. Mothers represent most parents in infant safe-sleep studies and are the main recipient of safe-sleep knowledge and information sharing from health care providers. We hypothesize that fathers who are married will most likely practice the behaviors of the mother and are more likely to receive safe-sleep messaging from the mother than those fathers who are not living with the mother. This has been reported in the literature on the sharing of information with fathers around breastfeeding, that is, information is more likely to come from partners than from health care workers (Sihota et al., 2019). The correlation of marital status influencing infant safe-sleep behaviors may be due to a similar mechanism. Marital and cohabitation status is a significant influential factor for infant safe-sleep behaviors and examining the source of information on infant safe-sleep practices that fathers receive is important in intervention strategies and design.

There are several limitations to our study. Our population represents a convenience sample and may not be typical of the greater population of fathers. Responses to the survey were self-reported and can be influenced by recall bias and social desirability bias. We were unable to assess how much space restraints can influence sleep arrangements, and understanding this dynamic would be important to intervention strategies addressing resource allocations in communities. Another limitation is that the adapted behavior survey was validated in only mothers (Whiteside-Mansell et al., 2017), and the correlation with males may not be fully transferable. We also acknowledge not being able to assess understanding of definitions of concepts such as “bed-sharing” and “room-sharing,” so the notion of room-sharing may not have been as intuitive to some survey respondents and may have contributed to our survey results. We were also not able to assess the source, if any, of safe-sleep knowledge of the fathers. Understanding the source of safe-sleep knowledge is an important concept, especially with interpersonal factors (e.g., impact of people a person lives with) being influential on behaviors from the SEM framework (Nyambe et al., 2019).

Conclusions

Studies have demonstrated fathers and male caregivers want messaging that is factual, brief and serious around infant safe-sleep strategies (Hirsch et al., 2018). Tailoring educational interventions can improve infant safe-sleep rates (Moon et al., 2017). The information from our sample of fathers can be used to tailor messaging and focused interventions that provide the basis for educational engagement with fathers and male caregivers. Infant safe-sleep messaging for fathers and male caregivers should emphasize the importance of avoidance of soft bedding and other items in the babies sleep area, as well as the risk reduction for SUIDs that room-sharing offers. Messaging to fathers on benefits of breastfeeding and pacifier usage will be important, as well as information on introducing pacifier use with breastfeeding. The messaging will need to be culturally sensitive, especially when used in communities that identify as Black.