Baby Box: evaluation

3. Use of the box and its contents

Key findings

• Parents were very positive about the quality of the box and its contents – 97% rated it as ‘very’ or ‘fairly good’.
• While the research indicates that the contents are well used by families, there was some evidence that those who already had older children were less likely to use the full range of contents.
• The digital ear thermometer and bath and room thermometer were the items most likely to be rated by parents as among the most useful, and most likely to be seen by midwives, health visitors and family nurses as important to include.
• In comparison with the items parents feel are most useful, professionals (particularly midwives) appear to place relatively more importance on the box itself, as well as the blanket and guidance around safe sleeping.
• The items most commonly identified as ‘least useful’ by parents tended to be smaller, lower value items: the condoms (20%); the bath sponge (16%); the emery boards (16%) and the Royal Scottish National Orchestra App (16%).
• Items midwives and health visitors felt were least useful were somewhat different, and included: the reusable napppies voucher (31%); comforter toy (23%); nursing pads (21%); hooded bath towel (18%) and the leaflet on breastfeeding (17%).
• 39% of parents had used the box for sleeping, while 61% had not.
• Most parents (87%) already had another sleep space when they received their baby box. However, among the 13% who did not, 69% had used the baby box for their baby to sleep in.
• Younger parents and parents on lower incomes were less likely to have used the box as a sleep space.
• Parents’ reservations about using the box for sleeping included  perceptions (for example, feeling it was ‘wrong’ to put a baby in a box), and practical issues (for example, discomfort bending down to pick the baby up from a box on the floor).

In order for the Baby Box scheme to benefit families and to contribute to positive outcomes for parents and children, families need to understand how to use the box and its contents, and to actually be using them in practice. This chapter begins by summarising parent and professional accounts of families' use of the box and its contents, and which elements they consider most and least useful. It then looks at use of the box specifically, including why parents do and do not choose to use it for sleeping. The findings draw on both the surveys and qualitative research with parents and health professionals.

Outcomes

• Parents use and understand the box and contents
• Workforce understands contents and purpose of the box

Research Questions

• How are parents using the baby box (e.g. are they using it as sleeping space for their baby?)

Use and usefulness of the baby box and its contents^[17]

Parents were generally extremely positive about the box and its contents – the survey found that 97% felt it was 'very' (86%) or 'fairly' (11%) good quality. Findings from the qualitative research also indicated that the box and its contents were being well used by parents. Across the 36 in-depth interviews in the qualitative research, there was no item that was not used and considered useful by at least one parent.

In terms of general level of use of the contents, the qualitative interviews suggested that there are some differences between first time parents and those with older children. First-time parents often commented that they had used everything or nearly everything in the box, while parents with older children reported using fewer items:

"We used the towel, the bath towels, the sponges, we didn't use the bath thermometer. Purely I think if it was our first child, we would have used it, but we're used to bathing the wee boy so we kind of know what temperatures is good now."

Fife, 25-29, Income group 2, not first child

Health professionals reported observing the box and its contents being used by families – 47% of health professionals said they had seen parents using the box or its contents 'always or often' on their home visits, while a further 31% said they sometimes saw families using them. Just 20% said they rarely or never observed boxes being used. Midwives were more likely than health visitors and family nurses to say they saw families using the box or its contents always or often (61%, compared with 40% of health visitors). This may reflect the fact that midwives were more aware of the box and its contents (see Chapter 6) – health visitors may be less likely to recognise items being used as from the baby box. Alternatively, it may be that parents are more likely to show their midwives items from the box, since their midwife will have helped them register for it.

Which items were seen as most useful or important?

The parents' survey asked parents which five items from the box they had found most useful. The items most commonly chosen were: the digital ear thermometer (picked as one of the five most useful items by 71%) and bath and room thermometer (68%), followed by the baby wrap (42%), play mat (35%), travel changing mat (35%), the clothes in general (31%) and the box itself (27%). Similar items were discussed as being most useful in the qualitative research with parents, with thermometers and the wrap singled out as items that parents particularly valued (the perceived benefits of these items are discussed in more detail in the following chapter). Among parents who were using it as a main sleep space, the box itself was also singled out as particularly useful.

Further analysis of the survey findings indicates some variation in the items considered most useful by parental age, whether or not this was their first baby, and parental income. In particular:

• A higher proportion of parents aged over 30 chose the clothes and the box itself for sleeping as among the things they found most useful.^[18]
• First time parents were a little more likely than those with older children to feel the playmat and the travel changing mat were among the most useful items^[19]. Parents who already had children were a little more likely to choose the baby wrap^[20] and the clothes^[21] as among the most useful items.
• Parents on the highest incomes were more likely to mention the play mat^[22] and the travel change mat^[23] as among the most useful items. Those on lower incomes were more likely to mention the digital thermometer.^[24]

The professionals' survey included a similar question on which items were 'most important to include' in the box, indicating how health professionals prioritise the contents in terms of supporting families with new babies. The top two items mentioned by midwives, health visitors and family nurses echoed parents' views on the most useful items: the digital ear thermometer (66%) and the bath and room thermometer (57%). However, in comparison with parents' views of which items are most useful, professionals appear to place relatively more importance on the box itself (43%), as well as the blanket (39%) and guidance around using the box for safe sleeping (41%, Table 4.1). This may reflect the fact that, as discussed in Chapter 5, promoting safe sleeping was viewed as a core aim of the scheme by some health professionals.

Table 4.1: Parents and professionals views on which items are "most useful" or "most important to include" in the baby box

	Parents who picked item as top 5 "most useful"	Professionals who picked item as top 5 "most important"
Digital Ear thermometer	71%	66%
Bath and Room thermometer	68%	57%
Baby Wrap	42%	34%
Play mat	35%	28%
Travel Changing Mat	35%	15%
Clothes	31%	35%
The box itself	27%	43%
Leaflet on using the box for safe sleeping	1%	41%
Cellular blanket	18%	39%

Base: All parents (2,236) and all professionals (870)

Midwives were more likely than health visitors / family nurses to prioritise the inclusion of the box itself for sleeping (51%, compared with 39% of health visitors/family nurses); the cellular blanket (47%, compared with 35%); and the baby wrap (41%, compared with 30%). Meanwhile, health visitors/family nurses were more likely than midwives to choose the digital ear thermometer (71%, compared with 56%); the bath and room thermometer (63%, compared with 43% of midwives) and the playmat (36%, compared with 12% of midwives) as among the most important items to include.

Qualitative interviews with midwives and health visitors indicated that their views on what is most useful to include may be linked to the key topics these different professionals tend to focus on with families. For example, health visitors often singled out items they felt supported attachment (e.g. the playmat and wrap), which is a key theme for health visiting, while midwives mentioned the blanket and the box itself in the context of discussions about plans for how the baby will sleep immediately after they are born. Individual professionals' views on the most useful items also took into account their views of items that parents would not tend to buy themselves (e.g. the thermometers and wrap).

"If you haven't used or seen a sling before you are unlikely to shell out what, a minimum of £20 to £30 for a sling. I think it lets parents have a try with something that they wouldn't otherwise even consider."

Health Visitor

Which items were seen as least useful or important?

Fewer parents in the survey were able to identify five 'least useful' items than to identify items they had found 'most useful' – 24% said none of the items in the box (including the box itself) were 'least useful'. Similarly, in the qualitative interviews parents were often keen to emphasise that they had found everything, or almost everything useful.

The most commonly identified 'least useful' items in the parents' survey were typically the smaller, lower value items: the condoms (20%); the bath sponge (16%); the emery boards (16%); and the Royal Scottish National Orchestra (RSNO) App (16%). In addition, 14% mentioned the box itself and 9% said the clothes had been among the least useful items.

Qualitative interviews with parents highlighted reasons some parents might view the clothes (both in general and specific items of clothing) as less useful. This included parents with older children who felt they already had most of the clothes they needed already (in some cases, they had donated clothes from the box to charity), and other parents who simply viewed the clothes in the box less positively, preferring to buy their own. One view was that the clothes appeared "boyish" due to the choice of colours (although other parents praised the colours and patterns included). In terms of specific items of clothing that were viewed as less useful, the scratch-mittens were singled out in the qualitative intereviews, with parents commenting that their babies would not keep them on and that most baby-gros now have built-in scratch mittens.

As with the most useful items, there was some variation in perceptions of the least useful items by parental age, whether this was their first child, and by parental income. In particular, the parent survey found that:

• The bath sponge and emery boards were both more likely to be picked as amongst the least useful items by older parents than by younger parents.^[25] Younger parents were more likely to say that 'nothing' in the box had been 'least useful' (32% of 16-24 year-olds, compared with 22% of parents aged 35 or older).
• Parents with other children were more likely to say the books were among the least useful items (6% compared with 2% of first-time parents) perhaps because they already have books from their older children.
• Condoms were less likely to be seen as among the least useful items by parents on very low incomes (18% of those with household incomes under £15,599) than by parents on higher incomes (24-25% of those on £26,000 or more a year felt the condoms were among the least useful items). Those on lower incomes were also more likely to say that 'nothing' in the box had been 'least useful'.

The items professionals felt were least important to include were somewhat different from those parents found least useful. The most commonly mentioned 'least important' items were: the reusable nappies voucher (31%); the comforter toy (23%); the nursing pads (21%); the hooded bath towel (18%); and the leaflet on breast feeding (17%). Twenty per cent said none of the items in the box were less important to include.

Qualitative interviews with health professionals did not provide a clear answer as to why some of these items might have been more likely to be viewed as less useful (as with parents, individual health professionals' views of the most and least useful items varied considerably). However, overall the items singled out as less useful tended to reflect either the items individual professionals had seen being used the least, or inexpensive items (like nursing pads) that they felt parents could more easily afford themselves. The finding that 17% felt the leaflet on breastfeeding was among the least important items may reflect a view, raised in the qualitative interviews with health professionals, that parents are already given numerous leaflets and can feel overwhelmed by the volume of information they receive. Finally, although they were often cited as among the most useful items, it is worth noting that occasional issues with the functioning of the thermometers were mentioned. This appeared to be something that had been raised with professionals by a small minority of parents in each case

Question for consideration: How should any future changes to the contents of the box take into account which items are considered most and least useful or important by parents and health professionals?

Use of the box itself

The baby box itself is designed to be used as a safe sleep space for young babies (up to the stage they can sit or kneel up, roll over, or pull themselves up). It comes with a mattress and fitted sheet that fits in the box and a leaflet and diagrams on the underside of the lid explaining how to use the box safely for sleeping. NHS advice also states that 'whatever space you choose, a baby should be given a clear, flat, safe sleep space in the same room as you and should be placed on their back for every sleep'^[26].

Just over a third (39%) of parents who responded to the survey had used the box for their baby to sleep in, while 61% had not. Older parents were more likely to say they had used the box for sleeping (46% of those aged 35 or older, compared with 30% of parents aged 16-24). Parents with the lowest household incomes (under £15,599/year) were least likely to say they had used the box for sleeping (32% of those with incomes under £15,599 had used it for sleeping, compared with 38% to 45% of those on higher incomes).^[27]

This difference in whether parents had used the box for sleeping by income did not appear to reflect differences in whether or not families already had a sleep space before receiving the baby box – the vast majority of parents across all income groups said they already had somewhere for their baby to sleep in the first three months (87%, a figure that did not vary significantly by income).

Reasons for not using the box for sleep

Qualitative interviews with parents explored the reasons why some parents choose not to use the box for sleeping. A key reason parents gave was that they already had an alternative sleep space (including bedside cribs, Moses baskets, cots or sling), or that they were co-sleeping. It should be noted that the NHS explicitly advises against sleeping with a baby on a sofa or armchair, and against sharing a bed with a baby if anyone in the bed smokes, has consumed alcohol or drugs, or the baby was born prematurely or with low birthweight.^[28] As noted above, the survey confirmed that in a majority (87%) of cases parents had already bought a sleep space by the time they received their baby box. Among the 13% who did not have another sleep space when their baby box arrived, 69% had used the baby box for their baby to sleep in, compared with 34% of those who already had an alternative sleep space.

Parents who had other sleep spaces discussed a number of perceived advantages of those options over the baby box. For example, those with bed-side cribs liked the fact this enabled them to be closer to their baby in the night, which helped with feeding, while those with Moses baskets felt they seemed "comfy" in comparison with the baby box.

Parents also discussed a number of reservations about using the baby box for sleeping. These included both psychological and practical barriers, including:

• Feeling uncomfortable with the idea of their baby sleeping in a box in principle: one view (expressed particularly among parents on lower incomes) was that putting a baby in a cardboard box simply felt "wrong" to them or was something they just would not consider. This view was echoed by midwives and health visitors, who observed that the idea of a baby sleeping in a box appeared stigmatising for some, and that younger parents and those on low incomes appeared to be particularly likely to be resistant to this idea:

"I haven't had any clients use the Box for sleeping. I have said maybe during the day you can use it in the lounge, that would maybe be a nice way to use it. But … my clients [say] … 'There is no way I'll put my baby in the box.'"

Family Nurse

• The fact the box needs to be used flat on the floor, which led to concerns that:
  • the baby would be more vulnerable to pets or young siblings, or to parents stepping out of bed in the night (similar barriers were also raised in interviews with midwives and health visitors)
  • their baby might get cold in the box as a result of being on the floor
  • it was less convenient than other options (especially a bedside crib) for night-time feeding
  • parents would be uncomfortable picking the baby out of the box, particularly if they were recovering from a Caesarean section, or had back, pelvic or other issues.

"Another thing that contributed to me not putting him in the box to sleep when I think back…I've recently had a flair up with my pelvis so when I was 22 weeks pregnant my pelvis went and I was on crutches so … after having him I couldn't get down to the floor to put him in or pick him up again."

Highland, 30-34, Income group 2, not first child

• A separate issue relating to the positioning of the box was that it is not meant to be slanted or propped up (the guidance provided with the box notes that boxes should not be 'propped up') – something that parents who had babies with colic or acid reflux wanted to be able to do. It should be noted that the NHS advises that babies should always be placed flat on their back for safe sleeping, and advises against raising the head of a cot or Moses basket even if the baby has colic or acid reflux.^[29]
• Reservations relating to the structure of the box included:
  • The fact that the box was not transparent and had high sides, which meant parents felt they could not see their baby as easily as in other sleep spaces
  • A perception that the box's cardboard composition meant it was not easily wiped down or cleaned
  • A view that the box did not look "comfortable"
  • A belief that the box was not easily transportable because it was too big to fit in the car, or was bulky to carry. It was noted that other sleep spaces could be collapsed in transit.

The leaflet included with the box states that parents should "Only use the mattress provided with the box". However, in a small number of cases, while the box itself was not used for sleeping, parents reported using the mattress that came in the box, either using it on the floor (without the box) for their baby to sleep on during the day or (more exceptionally) putting it in a Moses basket. As noted above, this is explicitly advised against – the labelling on the baby box mattress has been amended to make it even clearer that it should not be used with any other sleep space).

Where the box was not used for sleeping, it was primarily used for storage, either for toys or other items for the baby and in the longer term as a memory box. Other uses included a play space (and in one case a "ball pit") and a space for taking photos of their baby. Parents with older children mentioned that siblings had enjoyed colouring in the box.

Question for consideration: Some of the reasons for not wanting to use the box for sleep relate to practices that are explicitly advised against by the NHS for young babies – for example, sleeping them in ‘padded’ spaces, or tilting their sleep spaces. The findings suggest that not all parents are aware of this advice.

How can safe sleeping practices best be communicated to new parents to increase awareness – including through the box and other avenues?

Reasons for using the box for sleep

Parents who did use the box for their baby to sleep in split into those who had used it as a secondary sleep space (for example, for daytime naps, or when visiting grandparents), and those who used the box as a main night-time sleep space.

Those who had used the box as their baby's main night-time sleep space felt that the box was as good as other options in terms of quality and comfort. They were generally motivated to use the box for sleep either because their baby had issues with other options – for example, they thought their baby was allergic to the wicker of their moses basket, or that they were not settling in their crib – or simply because it had been provided and they thought they would try it.

For parents who used the box as a 'secondary' sleep space, having the box as an additional sleeping option was seen as useful in: helping to differentiate night and day-time sleeping; making it easier to spend more time at grandparents' homes; and being able to see their baby during day-time naps without having to carry a Moses basket up and down stairs – especially for those with back problems or who had had a C-section, for whom transporting a sleep space would be painful.^[30]

"The advantages were having a second thing that I didn't have to carry up and down. I knew she was safe in it, yes."

Lothian, 30-34, Income group 3, not first child