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Intervention to Improve First-Time Fathers' Transition to Fatherhood for Mental Health and Well-Being

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Testing the feasibility and acceptability of an intervention to improve first-time fathers’ transition to fatherhood focusing on the role of mental health and wellbeing
 
PART A

  1. Background

1.1 Introduction
During the last decade there has been an increased policy emphasis on improving mental health and wellbeing among the general population in England (DH, 2011). Mental health has been highlighted as a priority by the European health and social agenda (European Commission, 2008) and internationally, by the World Health Organisation (WHO 2005). Mental health problems represent the largest single cause of disability in the UK, with the cost to economy estimated at £105 billion a year (Mental Health Taskforce, 2016). Moreover, the cost of treating mental illness is likely to double over the next 20 years (Trautmann et al, 2016; DH, 2011).  As well as resource implications, mental health has profound effects on an individual’s quality of life, and physical and social well-being (WHO, 2003). There are also wider social impacts, which includes loss of productivity, reduced levels of education and increased rates of crime (DH, 2011). This, therefore is a major public health issue.
The focus on mental health and wellbeing particularly during the transition to parenthood is attracting more attention, especially as new parenthood brings about a number of changes and challenges for both the mother and father, but also because it is a time when parents are more likely to be in contact with relevant healthcare professionals and services. It can be a stressful time, with new adjustments to lifestyles and routines, which can significantly impact on the mental wellbeing of both parents (Asenhed et al, 2014; Genesoni and Tallandini, 2009; Deave et al, 2008). A report from the London School of Economics concluded that perinatal mental health problems carried a total economic and social long-term cost to society of about £8.1 billion for each one-year cohort of births in the UK (Bauer et al, 2014). This report however was based on costs relating to maternal perinatal mental health, and included estimates for adverse effects on the child as well as the mother, but not the father (Bauer et al, 2014). Similarly, the majority of research into perinatal mental health to date has tended to focus on women. The UK National Institute for Health and Care Excellence guidelines on antenatal and postnatal mental health (NICE, 2014) recommend routine assessment of mothers, but did not include any reference or recommendations for fathers. As a result maternal mental health needs during this period are more widely recognised by health professionals and support for mothers has improved. However, men’s mental health during their transition to fatherhood remains comparatively poorly understood and under-researched, with many new fathers’ needs often unmet (Paulson & Bazemore, 2010).
1.2 Significance of the study
The limited research into men’s mental health during their transition to fatherhood has mainly focused on anxiety and depression during their partners’ pregnancy and one year following birth. In a recent systematic review of forty-three papers, Leach et al (2016) reported a prevalence rate for any anxiety disorder in men ranged between 4.1% – 16.0% during their partner’s pregnancy and 2.4% – 18.0% during the 6-8 week postnatal period. In a separate meta-analysis which also included forty-three studies, Paulson and Bazemore (2010) reported a prevalence rate of depression in men both pre- and postnatally as 10.4%. Research from Denmark (Madsen et al, 2007) and the US (Paulson et al, 2006) showed that new fathers’ depression rates were double the national average for men in the same age group who were not fathers.
The period from an infant’s conception to the age of two is a crucial time for child development and experiences during this time are likely to influence the rest of the child’s life (Wave 2013). Similar to the impacts of maternal depression, a number of negative implications for the child have been associated with mental health problems in fathers.  This includes a father’s capacity for sensitive parenting, where they may not be able to attune to their baby’s cues and signals, and respond accordingly. Studies have shown that fathers who are affectionate, supportive and involved in their child’s care and upbringing, contribute positively to their child’s cognitive, language and social development (Cabrera et al, 2007), with the potential to generate social, academic and economic benefits in the future (Sarkadi et al, 2008; Flouri, 2005; Pleck and Masciadrellin, 2004). Close connections with their children are linked to positive outcomes for fathers themselves, such as greater satisfaction with family life (Feldman et al, 2004), unusually high levels of satisfaction in mid-life (Snarey, 1993), and less likelihood of experiencing separation/divorce (Olah, 2001). Other benefits to fathers include greater skill acquisition, confidence and self-esteem (Lewis et al, 1982; Stile and Ortiz, 1999).  Conversely mental health problems in fathers are associated with cognitive, emotional, social and behavioural problems in children (Ramchandani et al, 2005; Flouri, 2005; Brennan et al 2002; Phares, 1999). Fathers play a crucial role in supporting the health and wellbeing of their partners too (Fisher et al, 2006; Pilkington et al, 2015), and therefore support for new fathers and addressing their mental health needs could make an important contribution to the wellbeing of families and wider society.
Midwives and health visitors in the UK provide routine care to all pregnant and postnatal women and their partners (if present), as part of universal health services, with health visitors having the most extended period of contact. Therefore they are in an ideal position to offer interventions aimed at improving parents’ mental health and wellbeing during and beyond the 6-8 week postnatal period. The transition to parenthood was identified as one of six high impact areas by the Department of Health in England where early intervention can make a difference to family outcomes (DH, 2014). The national Healthy Child Programme (HCP) which was originally published in 2009 and its evidence reviewed and updated in 2015, recognised the importance of this early intervention and the need for health professionals to work effectively with parents to ensure that their children have the best start in life. As a result greater emphasis is placed on health visitors, as lead health professionals for the delivery of the HCP in England, to work more closely with fathers (PHE, 2015; DH, 2009). By focusing on a couple’s intimate relationship as well as the parenting relationship, health visitors can make a significant contribution to mental health and wellbeing of families with new babies (Coleman et al, 2013; Hewison, 2013).
In England every family with a child under the age of five will have access to a health visitor, who is required to undertake a minimum of five contacts (NHS England, 2014) as follows:

  1. Antenatal health promoting visit
  2. New baby review
  3. 6-8 week assessment
  4. 1 year assessment.
  5. 2 – 2 ½ year review

Through these contacts, health visitors can support parents in the transition to parenthood, promote child development, improve child health outcomes and ensure that families at risk are identified at the earliest opportunity (NHS England, 2014). The first three of the five contacts provide ideal opportunities to carry out comprehensive and holistic assessments of the expectant/ new mother’s and father’s needs. While clear guidance has been set out by NICE (2014) and the DH (2012) in England for assessing maternal mental health at these routine contacts, currently there are no national guidelines for assessing paternal mental health. This means that while the HCP emphasises the need for health visitors to work more closely with fathers, as mentioned earlier, there are no national guidelines for health professionals that recommends routine assessments of fathers’ mental health at these contacts, which represents a huge gap.
A recent report commissioned by the National Health Service (NHS) in England described the transformation necessary for prevention, access, integration, quality and a positive experience of care, relating to mental health over the next ten years (Mental Health Taskforce, 2016). While this report was based on mental health in the general population, the importance of focussing on maternal perinatal mental health was highlighted, but not paternal mental health. There are disparities between a growing evidence base, which suggest fathers’ mental health during the perinatal period is a significant issue, and national policy where assessment of fathers’ mental health is not highlighted within recommendations for routine practice. Consequently routine clinical practice around fathers’ mental health and wellbeing tends to vary significantly. Evidence to support the transition to fatherhood and the development, implementation and evaluation of effective interventions to promote and sustain their mental health and wellbeing are therefore important for policy and practice.
Many health visiting services across England use the Promotional Guide system, which is a programme to support the transition to parenthood by enhancing parental capacity and change in parenting attitudes and practices in a non-judgemental and supportive manner (Davis and Day, 2010).  It consists of two guides, an antenatal guide used with both parents around 4 to 6 weeks before their baby is due, and a postnatal guide which is used around 6-8 weeks after the birth of the baby.  The system is based on the Family Partnership Model and although designed for both parents, the HCP in England currently recommend its use with women during the antenatal contact and 6-8 week postnatal contact carried out by health visitors (PHE, 2015).  It is currently used face-to-face, by health visitors trained in its use, taking approximately 60 minutes to complete each guide.
These guides include questions based around five core themes:

  • Health, wellbeing and development of baby, mother and father
  • Couple relationship
  • Family and social support
  • Parent-infant care and interaction
  • Developmental tasks of early parenthood and infancy

Although the guides focus on the transition to parenthood as a whole, they could potentially improve fathers’ mental health and wellbeing during this period through the following processes:

  1. The intervention allows fathers to discuss their experiences of fatherhood, including any difficulties they may face.
  2. Using the guides, fathers’ strengths can be identified to address any difficulties.
  3. The intervention may have a therapeutic effect on fathers.
  4. The intervention may enable fathers to identify their need for additional mental health support requiring referrals.

Since its inclusion in the Healthy Child Programme (DH, 2009), the first study examining the implementation of the Promotional Guides in the UK reported that the guides were rated highly by both providers (health visitor) and recipients (women) (Barlow and Coe, 2013). This was a mixed-method evaluation which aimed to assess the level of implementation and stakeholder perceptions. Although this was a very small study, qualitative findings from interviews with seven women suggested that they were overwhelmingly supportive and appreciative of the listening, support and guidance provided by the health visitors through the Promotional Guide contacts (Barlow and Coe, 2013). More recently, the ‘Rapid Review to Update Evidence for the Healthy Child Programme 0–5’ stated that “further research is needed to examine how effective promotional interviews are in identifying women in need of further support, and improving outcomes” (PHE, 2015; pp-40). Despite the lack of robust evidence, the Promotional Guides are now used by health visitors in eighty five NHS trusts across England. While there are a number of service audits currently taking place at sites where this intervention has been implemented, no primary research studies are currently underway (as searched on UKCTG and ClinicalTrials.gov website), and questions relating to the level of engagement and its acceptability especially by fathers remain unknown.
1.3 Defining the research problem
The research problems identified are twofold:
Firstly as highlighted above, there is limited research available in the area of fathers’ mental health and wellbeing in the perinatal period. While the evidence that is available suggests that the rates of mental health problems in new fathers and impacts on the family are significant, UK policies for maternal and child health services do not currently address this adequately. To support men’s mental health and wellbeing during their transition to fatherhood it is essential to understand their experiences and the specific needs they may have during this period. The first two of the three planned phases of this study are crucial in constructing a better picture of how mental health and wellbeing are experienced by first time fathers and what their perceived support needs are relating to this. Findings will contribute to the existing limited body of knowledge in this important area, while informing the development of more adequate support interventions for new fathers.
Secondly, the Promotional Guide system mentioned above is an intervention aimed at mothers and fathers to support their transition to parenthood. However, there is little is known about its effectiveness and use with fathers, including whether fathers are routinely offered the intervention, whether they are willing to participate in it and whether they find it helpful with respect to supporting their mental health and wellbeing. In recent years another parenting programme, the Family Nurse Partnership, based on the Family Partnership Model was rolled out in the UK with minimal evidence of benefit in a UK population, and a recent trial found no positive association with anticipated benefits (Robling et al, 2016). Therefore more research on the use of the Promotional Guide system is necessary to inform good practice. The third phase of this study investigates whether the Promotional Guide System has the potential to support fathers’ mental health and wellbeing needs during their transition to fatherhood, and the health professionals’ views of delivering the intervention to fathers. This phase of the study will explore the level of engagement, feasibility, acceptability, fidelity of delivery and reported impact on first-time fathers’ mental health and wellbeing.
1.4 Research aims & objectives
The primary aim of this research is to explore first-time fathers’ needs and experiences during their transition to fatherhood (defined as the period from conception to one year after birth), with a particular focus on their mental health and wellbeing. Phases 1 and 2 of this study will provide evidence to support better understanding of the experiences of first time fathers and the level of information and support they consider could help their mental health and wellbeing.  Barriers and facilitators to first time fathers’ access to help or support will be also be identified.
The secondary aim is to test the feasibility of health visitors’ use of the Promotional Guide System with first time fathers, and assess if the new fathers found this to be an acceptable intervention which met their mental health and wellbeing needs. The findings of phase 3 of the study could help inform the development of a definitive trial, as well as highlight current gaps in meeting first-time fathers’ needs and how these could be addressed.
There are three research questions which will be answered through the three planned study phases:
Research question 1: What is already known about men’s mental health and wellbeing during their transition to fatherhood?
Study phase I: A systematic review of the qualitative evidence of first time fathers’ needs and experiences of transition to fatherhood in relation to their mental health and wellbeing.
Research question 2: How do first-time fathers perceive their mental health and wellbeing needs during this transition?
Study phase II: An in-depth qualitative study to explore first time fathers’ experiences and perceived mental health and wellbeing needs during their transition to fatherhood.
Research question 3: Is the use of the Promotional Guide System acceptable to first-time fathers as an intervention to support their mental health and wellbeing, and to the health professionals responsible for delivering the intervention?  How feasible is the implementation of the Promotional Guide system with new fathers by health visitors as part of their routine practice and what is the fidelity of programme delivery?
Study phase III: A feasibility study of the use of the Promotional Guide system by first-time fathers to support their mental health and wellbeing, and the health professionals responsible for delivering the intervention.

  1. Phase 1: Systematic review

Title: First time fathers’ needs and experiences of transition to fatherhood in relation to their mental health and wellbeing: A qualitative systematic review.
2.1 Review question/objective
This qualitative review seeks to identify first time fathers’ needs and experiences in relation to their mental health and wellbeing during their transition to fatherhood. This will include resident first time fathers who are either the biological or non-biological father.
The objectives are to focus on first-time fathers’ experiences in relation to:

  • How mental health and wellbeing are experienced
  • Perceived needs around mental health
  • The ways in which mental health problems are experienced, manifested, recognised and acted upon.
  • The contexts and strategies that are perceived to support their mental well-being.
  • Perceived barriers and facilitators to accessing support for their mental health and wellbeing.

 
2.2  Definition of key concepts

  • First time fathers: men becoming either a biological or non-biological parent for the first time.
  • Resident fathers: those residing with their expectant partner, or their partner and child during their transition to fatherhood.
  • Transition to fatherhood: the period from conception to 1 year after birth and will apply to both biological and non-biological fathers.
  • Mental health problems: this will include any psychological difficulty or distress including depression, anxiety, and stress. These may be diagnosed by health professionals or self-reported by fathers.
  • Mental wellbeing: this will include positive mental health, covering both the hedonic (feeling good) and eudemonic (functioning well) components of psychological wellbeing.

 
2.3  Method
A qualitative approach was chosen for the systematic review as it allows exploration and analysis of human experiences, as well as social and cultural phenomena which may influence experiences to be captured as well (Denzin and Lincoln, 2005). This method is necessary to identify and understand first time fathers’ needs and experiences in relation to their mental health and wellbeing, and identify the perceived barriers and facilitators to accessing support.
The systematic review is being conducted through the Joanna Briggs Institute (JBI), with training and review support provided by The Centre for Evidence Based Healthcare at Nottingham University, a designated Centre of Excellence within the JBI global network. The review title has been registered with JBI, and the protocol has been published in the JBI Database of Systematic Reviews and Implementation Reports and PROSPERO (Appendix – A). The findings of the systematic review will inform the content of the qualitative interviews in the next phase of the study and allow exploration of aspects relating to men’s transition to fatherhood.
The review questions were developed using the PICo mnemonic for qualitative research (Table 1).
Table 1: Structuring the research questions using PICo

Population (P) Expectant or first time fathers of infants under 12 months of age.
Phenomena of interest (I) First time fathers’ needs and experiences during their transition to fatherhood in relation their mental health and wellbeing.
Context (Co) Between conception and up to 12 months postnatally.

 

  1.  Inclusion criteria

This review considered studies that included resident first time fathers (biological and non-biological) during their transition to fatherhood, from pregnancy commencement until one year after birth. Study participants included first time fathers of healthy babies born with no identified terminal or long term conditions.
Certain groups of fathers may have specific mental health needs during their transition to fatherhood. As this review focuses on the mental health and wellbeing of fathers in general and not of those with specific additional needs, the following were excluded:

  • Studies on non-resident/ absent fathers (those not residing with the mother/child during the period between conception to 1 year after birth)
  • Studies on fathers experiencing bereavement following neonatal death, stillbirth, pregnancy loss, sudden infant death
  • Studies on fathers whose infants are born prematurely (<37 weeks gestation)
  • Studies on fathers with a child with terminal/ long term conditions

This review considered studies undertaken in high income countries as defined by the World Bank (2016) (for example countries which are members of the European Economic Community, the UK, the United States, Canada, Australia and New Zealand) that investigated first time fathers’ experiences, during any time from conception to one year after birth.  The majority of these countries have similar healthcare systems (with a mix of public and privately funded and universal service provision), social and political systems, meaning that review findings are likely to be more transferable.

  1. Search strategy

The search strategy aimed to identify published and unpublished studies. A three-step search strategy was utilised. An initial limited search of MEDLINE (using Ovid) and CINAHL was undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms was then undertaken across all included databases. Thirdly, the reference list of all identified reports and articles was searched for additional studies.
Studies published in English were considered for inclusion in this review due to the difficulties associated with resources for translation. Searches of bibliographic databases for studies published between 1960 and April 2017 were considered for inclusion due to the changing role of fathers’ which gradually took place over the second half of the 20th century (Milkie and Denny, 2014; Atkinson and Blackwelder, 1993).  A full list of all databases searched and papers identified are presented in Appendix – B. Keywords used for the searches are presented in Appendix – C, and the search results in Appendix – D.
The development of the systematic review is in progress at the time of preparing this report and selected papers are being assessed for methodological quality independently by two reviewers (SB and DB).
 

  1.      Assessment of methodological quality

Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix – E). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer (JS).

  1. Data collection

Qualitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix – F). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
2.8 Data synthesis
Qualitative research findings will where possible be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form.

  1. Phase 2: Qualitative exploratory study

Title: Exploratory study of first time fathers experiences and perceived mental health and wellbeing needs during their transition to fatherhood.
 
3.1 Research Question/ Aims
Research Question: How do first-time fathers perceive their mental health and wellbeing needs during their transition to fatherhood?
The aim of this study is to create wider understanding of first-time fathers’ mental health and wellbeing experiences during their transition to fatherhood by exploring new fathers perceived needs, as well as further exploring the findings from the systematic review and any unknown aspects of it.

  1.   Methodology

A qualitative research design informed by a phenomenological approach was chosen. Phenomenology is a qualitative strategy which enables the researcher identify the essence of human experiences about a phenomena as described by the participants in the study (Creswell, 2014). The notion of fatherhood is considered a social construct (Mead 1969), and it is based on the ontological belief that multiple realities of fatherhood are constructed through individual father’s lived experiences, their interactions with others as well as through historical and cultural norms that operate in individuals’ lives (Creswell, 2003). As the aim of this study is to increase understanding of fathers’ experiences during their transition to fatherhood relating to their mental health and wellbeing, this philosophical framework would allow the exploration of fathers’ individual interpretations of their lived experiences and the ways in which they express them (Parahoo, 2006).
Phenomenological approaches emphasise the importance of personal perspective and interpretation and epistemologically based in a paradigm of personal knowledge and subjectivity. The interpretive and exploratory nature of the research question is consistent with a phenomenological research tradition rather than that of generating theory or explanatory models, and therefore a grounded theory design was ruled out. In qualitative research it is recognised that the researcher’s own background and experiences can impact on the interpretation of the participants meaning of their experiences, however an essential component of phenomenology is ‘bracketing’, which allows the researcher to disconnect from their own experiences in order to understand those of the participants in the study (Nieswiadomy, 1993).
In-depth interviews will be carried out with up to 20 fathers depending on when data saturation is deemed to have been reached. With respect to achieving saturation, while there are no definitive numbers, according to Green and Thorogood (2009, p.120), “the experience of most qualitative researchers is that in interview studies little that is ‘new’ comes out of transcripts after you have interviewed 20 or so people”.  Initially qualitative interviews and focus group methods were explored, but feedback from a local fathers’ group in a children’s centre who provided expert PPI during the design of the study helped influence the chosen method. In this PPI group, new fathers were of varying ages and from diverse cultural and ethnic backgrounds. They expressed that individual one to one interviews would be preferable to a focus group approach, which would enable fathers to talk more “openly and honestly”. Qualitative interviews are also likely to produce data rich in nature; and due to the interviewer being able to assess the participant’s level of understanding, reduce the danger of questions being misinterpreted (Polit and Beck, 2013).
Fathers will be recruited from two sites (as detailed below) through a number of different routes using posters, leaflets (Appendix – G) and invitation letters (Appendix – H) developed specifically for the study, which explain the aims and objectives and how to contact the researcher. Health visitors during their routine ‘New Birth’ contacts, and midwives during their routine postnatal contacts will be asked to offer invitation letters and study leaflets to all first-time fathers who meet study inclusion criteria. In cases where the father is not present during the contact, these will be offered to their partners. Recruiting fathers through their partners is considered to be a helpful strategy by the Fatherhood Institute, which is the leading charitable organisation for fathers and fatherhood in the UK (www.fatherhoodinstitute.org). The researcher will also approach local religious, community and social groups to disseminate study leaflets and posters. Approaching religious and community groups was shown to be particularly effective in recruiting fathers from African and African-Caribbean communities (Williams et al, 2012). In addition to this, local father’s groups, GP practices, health centres, children centres, nurseries, child health clinics, and sports and recreation centres will be asked to display the study poster and disseminate leaflets.
Only first-time fathers with children under 12 months of age will be included. Maximum variation sampling will be used to ensure diversity in ethnicity, age, religion, education levels, and social class, where possible. The sites chosen for this study have diverse and multicultural populations, with minority ethnic groups representing between over 44 – 69% of the total population (ONS, 2011). Fathers from different backgrounds may exhibit a wide range of attributes, behaviours, experiences, incidents, qualities and situations, and therefore this sampling technique will allow the identification of common themes that are evident across the sample. Participation will on a voluntary basis, details of which are outlined in the participant information sheet (Appendix – I) and written informed consent (Appendix – J) will be obtained. Prior to obtaining consent, the researcher will discuss the inclusion/ exclusion criteria with the participant and only those meeting the criteria will be included. Table 2 outlines the inclusion and exclusion criteria for this study.
Table 2: Inclusion / Exclusion Criteria for study phase 2

Inclusion Criteria Exclusion Criteria
  • First-time fathers with children under the age of 12 months
  • Resident fathers (biological or non-biological)
  • Those living within the health catchment area of the two study sites
  • Non-English speaking fathers as there are over 300 different languages spoken across the five study sites.
  • Fathers experiencing bereavement following neonatal death, stillbirth, pregnancy loss, sudden infant death
  • Fathers who are new parents with existing severe mental illnesses, such as schizophrenia and schizoaffective disorder, and severe forms of other disorders, such as personality disorders, major depression and bipolar disorder.

 
 

  1.   Study Setting

Ealing, Brent and Harrow, served by London North West Healthcare Trust, and Lambeth and Southwark, served by Guy’s and St. Thomas’ NHS Foundation Trust have been selected as the study sites to represent fathers from inner London and outer London boroughs. These boroughs have diverse and multicultural populations, with minority ethnic groups representing over 44% of the total population Lambeth (Lambeth Council, 2016), 48% in Southwark (Southwark Council, 2015), 69% in Harrow (ONS, 2011), 64% in Brent (Brent Council, 2014) and 50% in Ealing (Ealing Council, 2012). As a health visitor, the researcher has good links with health visiting managers in both NHS settings. Preliminary discussions have already taken place with the managers and they are supportive of this study.

  1.   Data collection

A topic guide will be developed for the qualitative interviews to provide structure and focus to the research questions.  The guides will reflect findings from the systematic review and input from the PPI group of fathers, which has been specifically set up to provide Expert PPI to this project. Each interview will be audio-recorded with the participant’s permission and each participant will be offered an opportunity to check their interview transcripts for accuracy prior to analysis. A draft interview topic guide has been developed (Appendix – K), however the definite guide will be based on the findings of the systematic review. Each interview is likely to last for around 45-90 minutes and will be undertaken in settings ensuring privacy. This may be the participant’s home or a community setting. The researcher will follow the Trust’s Lone Worker policy and ‘Working Safely at King’s’ (KCL, 2009) policy to ensure personal safety.

  1.   Data Analysis

Data will be analysed using Interpretive Phenomenological Analysis (IPA) (Smith, 2011), a method which combines interpretative processes to help understand and uncover meaning of the phenomenon under scrutiny based in a social context (Larkin et al, 2006). IPA acknowledges that while the researcher tries to make sense of the participant’s world, their own conceptions will affect the way in which they interpret that information, and therefore requires the use a dual faceted approach – phenomenological and interpretative analysis (Smith et al. 1999). This method was chosen over other descriptive phenomenological approaches (Collaizzi 1978; Giorgi, 1985; Moustakas, 1994) as it would allow fathers to express their own experiences and needs, while also allowing the researcher to contextualise the broader themes and concepts (Larkins et al 2006).
The 5 step approach outlined by Smith and Osborn (2011) below will be used to analyse the data:

  1. Read and reread interview transcripts to become familiar with it and make notes highlighting areas of interest.
  2. Transform initial notes into themes or phrases that represent the essence of what the text says.
  3. List developed themes and seek connections.
  4. Organise themes to make consistent and meaningful statements of the meaning and essence of the participants’ experience grounded in their own words.
  5. Repeat the process above for each transcript separately, considering the similarities and differences between the individual superordinate themes and further develop as necessary.
  1. Phase 3: Feasibility Study

Title: A feasibility study of the use of the Promotional Guide system by first-time fathers to support their mental health and wellbeing, and the health professionals responsible for delivering the intervention.
 
4.1 Research questions/ aim
The aim of the feasibility study will be to consider if use of the promotional guide system is acceptable to first time fathers. It will test study procedures and gain feedback on the feasibility and acceptability of the intervention, and pilot the outcome measures, which can then be used in a future main trial (Cambell et al, 2000).  Important parameters such as first time fathers’ willingness to participate, health visitors’ willingness to recruit fathers, the characteristics of the proposed outcome measure, response rates to questionnaires, and follow-up rates will be considered. A process evaluation will be undertaken to consider the acceptability, feasibility and fidelity of programme delivery of the system. Impact on first time father’s mental health and wellbeing outcomes will also be considered. It will explore:

  • Is it possible to recruit first time fathers to a study of promotional guide systems?
  • Do first-time fathers engage with the Promotional Guide System at antenatal and postnatal contact points?
  • Are first-time fathers’ more likely to be asked about their mental health and wellbeing through the use of Promotional Guides?
  • Are first-time fathers’ mental health and wellbeing needs more likely to be identified through the use of Promotional Guides?
  • Are there barriers to health visitors using the Promotional Guide System with first time fathers?
  • How acceptable are the use of Promotional Guide by first time fathers and health visitors?
  • What is the reported impact of the Promotional Guide system on first-time fathers’ mental health and wellbeing as assessed at 3 months and 4 months after birth?

4.2  Method
A prospective observational cohort study will be conducted incorporating both quantitative and qualitative data collection methods. Feasibility will be assessed using recruitment and retention rates, data completeness; and acceptability by quantitative survey, qualitative interviews and observations. Currently little is known about the use of the Promotional Guide system with fathers, such as whether fathers are routinely offered the intervention, whether they are willing to participate and whether they find it helpful. A process evaluation, following Steckler and Linnan’s (2002) framework will be undertaken as it provides a logical approach to evaluating the intervention, as outlined in Appendix – L. A process evaluation within this phase would enable better understanding of the causal assumptions underpinning the intervention and how it works in practice, which are vital in building an evidence base that informs policy and practice (Craig et al, 2008).
While randomised controlled trials (RCTs) are considered to be the ‘gold standard’ and the most robust method for assessing effectiveness of interventions due to the processes used during the conduct minimises the risk of confounding factors influencing the results (Evans, 2003), a RCT was not considered to be appropriate for this particular study. Firstly, the Promotional Guide System is an intervention that is delivered by health visitors universally to all parents and therefore it would be difficult to exclude a group of fathers from receiving this intervention.
Secondly, this study is testing the feasibility and acceptability of the Promotional guide system, which can be achieved through a cohort study design (Chaudron et al, 2004). Thirdly, a RCT would require additional time and resources, which is not practical for this study which is being undertaken as part of a doctoral programme.  Following this feasibility study, the plan would be to undertake a definitive trial as part of a post-doctoral research study.
4.2.1 Recruitment
Expectant fathers will be recruited from antenatal clinics and health visitor contacts using leaflets, posters (Appendix – M) and participant information sheets (Appendix – N). Midwives will be asked to offer leaflets to fathers and their partners during routine antenatal contacts after 20 weeks gestation. Health visitors will be asked to send out study leaflets to fathers when informing them about the antenatal Promotional Guide contact which is usually before their partner reaches 28 weeks gestation. Details of the study website with information about the study and how to participate will be included in study posters and leaflets, which fathers who are interested will be able to follow. In addition to this, the researcher will recruit expectant fathers from the antenatal scan departments in the hospitals within the two sites. First time fathers attending the routine 20 week scan appointment will be asked whether they would like to participate in the study and those interested will be offered further information, including the leaflet and participant information sheet.
Once fathers who are interested in participating contact the researcher, the study procedure will be explained in detail face-to-face where possible or over the phone, and fathers who wish to take part will be given details on how to complete the questionnaires. Written consent will not be necessary as by completing the questionnaires it will imply that they are consenting to take part in the study.
 
4.2.2 Sample size
As this is a feasibility study, the sample size will not be powered to detect statistically significant differences in outcomes of interest. Rather than looking for effectiveness of the intervention. The findings from this study could inform future sample size calculation.
In total up to 50 first-time fathers will be recruited, 25 from each site. Teare et al (2014) recommend that an external pilot study which aims to estimate key parameters for the design of the definitive trial, has at least 70 measured subjects (35 per group) when estimating the SD for a continuous outcome. This suggests that 35 fathers would be sufficient for this type of cohort study. However to allow for drop-out and to enable more reliable estimates of change in the outcome measures, up to 50 fathers will be recruited across the two sites.
4.2.3 Data Collection
We will consider if the selected measures are appropriate for study aims and objectives, whether they are acceptable to fathers and whether fathers are willing to complete them at the proposed follow up times, with a view to using in a potential future definitive trial.
Fathers willing to participate will be directed to the study webpage to complete an online baseline questionnaire (Appendix – O) containing questions regarding the fathers socio-demographic details and study outcome measures between 24-28 weeks of their partner’s pregnancy. This questionnaire needs to be completed prior to their antenatal Promotional Guide contact with the health visitor, which usually takes place between 8-12 weeks before the expected date of delivery. These fathers will then be asked to complete two further questionnaires (Appendices – P & Q) at three and six months after the birth of their baby. These questionnaires will include some process measures, as well as the information in the baseline questionnaire. The postnatal promotional guide contact is typically delivered around 4-8 weeks after the birth of the baby and therefore these questionnaires will be completed at least one month after the postnatal Promotional Guide contact and again at least four months later. Reminders to complete the second and third questionnaires will be sent via email or text messages by the researcher. Fathers who do not have access to the internet will be directed to contact the researcher, who will send out postal questionnaires with prepaid return envelopes at the three different stages.
Feasibility of completing the range of measures planned, including completion and response rates will be assessed.
4.2.4 Outcome measures
Quantitative data: first time fathers
Three validated psychological health measures along with validated measures to assess general health, couple relationship and perceived social support have been selected, as follows:

  • Short Warwick-Edinburgh Mental Well-Being Scale (SWEMWBS)
  • Edinburgh Postnatal Depression Scale (EPDS)
  • General Anxiety Disorder 7-item Scale (GAD7)
  • EQ-5D
  • Couple relationship Index (CSI)
  • Multidimensional Scale of Perceived Social Support (MSPSS)

Please refer to Appendix – R for further details on these outcome measures.
 
Qualitative data: first time fathers
A sub-group of 15-20 fathers from the same cohort will be invited to participate in in-depth qualitative interviews following the completion of the third questionnaire or 6 months following the birth of their baby. The groups of fathers that will be invited in the interviews are outlined in table 3.

Table 3: Fathers who will be invited to participate in the qualitative interview
  • Those not involved in the Promotional Guide Contacts: to ascertain reasons for non-involvement
  • Fully involved in the Promotional Guide Contacts (participated both antenatally and postnatally): to understand whether the Promotional Guides were helpful and whether they identified /addressed their mental health and wellbeing needs.
  • Partially involved in the Promotional Guide Contacts (participated only antenatally or only postnatally): to determine reasons for partial participation, barriers and fathers’ perception of the Promotional Guides.

The interviews will be conducted using an interview topic guide (Appendix – S). This will enable better understanding of the processes and underlying mechanisms in relation to context, setting, professionals and patients (Byng et al 2008; Jansen et al, 2007). A choice of face-to-face and telephone interviews will be offered and written consent will be obtained prior to these interviews.
 
Health Visitors
A purposive sample of 10 health visitors across both sites, who have had experience of delivering the Promotional Guides will be interviewed to assess feasibility of delivering this intervention to fathers. The researcher will liaise with the managers of the health visiting teams within both Trusts in the first instance and ask them to disseminate information about the study amongst their teams. Health visitors working within both trusts will be informed about the study through staff meetings and emails, and will be invited to participate in either an in-depth interview about their Promotional Guide visits or to participate in observations of their Promotional Guide contact. An invitation letter has been designed (Appendix – T), which will be used for recruiting health visitors. Participation will be on a voluntary basis and those interested in participating will be given the participant information sheet (appendix – U) and asked to sign a consent form (Appendix – V), so that they can make an informed choice about their participation. The plan is to conduct 5 qualitative interviews and 5 observations at each site.
An interview topic guide will be used for these qualitative interviews (Appendix – W), which may be carried out by telephone or face-to-face. In addition to this observation of 10 health visitors across both sites carrying out the Promotional Guide contact will be undertaken to assess feasibility and fidelity. A fidelity checklist will be used during these observations (Appendix – X).
A combination of quantitative data on key process variables from all participants with in-depth qualitative data from samples purposively selected along dimensions expected to influence the functioning of the intervention is considered to be useful in process evaluations of interventions (Moore et al, 2015).

  1. Inclusion/ Exclusion Criteria

Inclusion Criteria:
Fathers

  • First-time fathers with children under the age of 12 months
  • Biological or non-biological resident fathers
  • Those living within the health catchment area of the two study sites

 
Health Visitors (Phase – 3 only)

  • Qualified health visitors
  • Trained to use Promotional Guides
  • With experience of using Promotional Guides in practice

Exclusion Criteria:
Fathers

  • Non-English speaking fathers will be excluded for a number of reasons:
    • There are over 300 different languages spoken across the five London Boroughs included in this study and it is not practical to include them all.
    • There are difficulties associated using interpreters for qualitative interviews, as the essence of the interview may get lost during translation.
    • Fathers who do not speak English may have specific needs relating to isolation and non-integration.
    • Although the Promotional Guides have been translated into Spanish and Japanese, currently the intervention is offered universally across the country in English only. These two languages are also not the most commonly spoken languages other than English, in the two research sites.
    • It is not practical to have all relevant documentation relating to this research translated in different languages due to resource and time constraints.
  • Fathers experiencing bereavement following neonatal death, stillbirth, pregnancy loss, sudden infant death
  • Fathers who are new parents with existing severe mental illnesses, such as schizophrenia and schizoaffective disorder, and severe forms of other disorders, such as personality disorders, major depression and bipolar disorder.

Health Visitors (Phase – 3 only)

  • Student health visitors or specialist health visitors who are not involved in carrying out routine antenatal and postnatal visits, as they will have limited experience of using the Promotional Guides in practice.
    1. Data Analysis

Quantitative data
Analysis of quantitative process data will begin with descriptive statistics relating to questions such as fidelity, dose, and reach. Analysis of the outcome measures at baseline along with recruitment rates, intervention participation, and withdrawal will include calculating the mean and standard deviation for approximately normally distributed continuous variables, medians and inter-quartile ranges for non-normally distributed variables, and frequencies and percentages for categorical variables. Mean and standard deviation estimates for pre-post change in SWEMWBS, EPDS, GAD7, EQ-5D, CSI and MSPSS will be computed and used to inform sample size calculations for a larger study. Data will be analysed using the latest version of IBM SPSS.
 
Qualitative data
The qualitative data will be analysed using framework analysis using NVivo version 10. Framework analysis is a method which enables in-depth exploration of data while simultaneously maintaining an effective and transparent audit trail, which enhances the rigour of the analytical processes and the credibility of the findings (Ritchie and Lewis, 2003). A framework to guide the stages of data analysis will help the Student Researcher develop the skills required to undertake robust qualitative data analysis, with support from the expert supervisory team.
The feasibility study (Phase 3) will be developed based on findings from phase 1 and 2 of this study and therefore is likely to be subject to further development.

  1. Overview of thesis structure

This thesis will be presented in six chapters. The first chapter will present an introduction to the topic, and outline the research problem, objectives of the study and define the central ideas and concepts. It will also provide an overview of the background literature and rationale for the chosen research methodology.
The second chapter will present a review of all literature relating to fathers’ mental health and wellbeing during their transition to fatherhood. This will include the definition of mental health and wellbeing, the changes fathers’ may experience with regards to their mental health and wellbeing during this period, the risk factors, signs and symptoms, impact of poor mental health and any literature on interventions to support fathers’ mental health and wellbeing.
Chapter three will present results from phase 1, which is a qualitative systematic review conducted through the Joanna Briggs Institute. This chapter will describe the literature search process, present the findings of the review and conclude with implications for practice and research.
Chapter four will present phase 2, which is a qualitative study of first-time fathers. It will present the theoretical framework for the study, the study aims and objectives, rationale for the methodology, as well as details of data collection, findings, limitations and implications for practice and research.
Chapter five will present phase 3, which is a feasibility study. This chapter will provide a background to the intervention being tested, the theoretical framework, research aims and objectives, rationale of methodology used and conclude with presenting the finding and recommendations of this study.
Chapter six is the final chapter of this thesis, where an overview of the whole research project will be presented.  It will discuss the study findings of each stage and how they link with each other. It will also discuss the overall findings in the context of existing literature, any limitations and implications for practice, policy and future research. In this chapter the author’s reflections of the whole project will also be included.
 
5.1 Outline of the proposed thesis chapter by chapter

  
Chapter 1: Introduction
 

  1.   Background of the study
  1.   Significance of the study
  1.   Research aims & objectives
  1.   Research design & methodology
  1.   Chapter summary

Chapter 2: Literature Review

  1.  Introduction
  2.  Mental health & wellbeing
  3.  Men’s mental health & wellbeing during their transition to fatherhood
  4.  Risk factors for mental health problems
  5.  Signs and symptoms of mental health problems
  6.  Impact of fathers’ mental health problems
  7. Interventions to support first-time fathers’ mental health and wellbeing
  8.  Policy context and engagement with fathers
  9.  Chapter summary

Chapter 3: Study 1 – First time fathers’ needs and experiences of transition to fatherhood in relation to their mental health and wellbeing: A qualitative systematic review

  1.   Introduction
  1.   Background

3.2.1 Current knowledge & gaps

  1.   Review question/objective
  1.    Inclusion Criteria
    1.        Types of participant
    2.        Phenomena of interest
    3.        Context
  2.     Search Strategy
  1.     Methods of the review
  1.      Data synthesis
  1.      Results
  1.      Conclusion
    1.   Implications for practice
    2.   Implications for research

CHAPTER 4: Study 2 – Exploratory study of first time fathers perceived mental health and wellbeing needs during their transition to fatherhood.
 
4.1    Introduction
4.2    Background
4.3    Theoretical Framework
4.4     Research Methods
4.4.1 Study Aims & Objectives
4.4.1.1 Research Questions
4.4.2 Study Design
4.4.3 Study Setting
4.4.4 Recruitment
4.4.5 Sample Size & Data Collection Process
4.4.6 Data Collection & Analysis Procedures
4.4.7 Ethical Considerations
4.5     Findings
4.6     Discussion
4.6.1 Limitations
4.7     Conclusion
4.7.1 Implications for Practice
4.7.2 Implications for Research
CHAPTER 5: Study 3 – Testing the feasibility and acceptability of the Promotional Guide system to improve first time fathers’ transition to fatherhood, focusing on mental health and wellbeing.
 
5.1     Introduction
5.2     Background
5.3    Theoretical Framework
5.4     Research Methods
5.4.1     Study Aims & Objectives
5.4.1.1  Research Questions
5.4.3     Study Design
5.4.4     Study Setting
5.4.5     Recruitment & Sample Size
5.4.6     Data Collection
5.4.6.1  Outcome Measures
5.4.6.2  Process Evaluation
5.4.7     Data Collection
5.4.8     Data Analysis
5.4.9     Ethical Considerations
5.5 Findings
5.6 Discussion
5.6.1   Limitations
5.7 Conclusion
5.7.1   Implications for Practice
5.7.2   Implications for Research
CHAPTER 6: Overall summary, recommendations & reflections
 
 
REFERENCES
 
APPENDICES
 

  1. Timetable for completion of the thesis

The total duration of this Clinical Doctoral Fellowship is 4 years, April 2016 – March 2020.

 Project Plan Year 1 Year 2 Year 3 Year 4
  April 16 – March 17 
 
April 17 – March 18 April 18 – March 19 April 19 – March 20
Ethics & RD Approval                                
Study Phase – 1                                  
Study Phase – 2 
 
                               
Study Phase – 3                                  
Data Analysis 
 
                               
Writing up, dissemination                                

 
Table 4: Gantt chart of timetable for completion of thesis
 
 

  1.  Progress to date

a) Study Phase 1: The systematic review is currently in progress. The final selections of studies have been made and the data is currently being synthesised.
b) Ethical approval: The study protocol (Appendix – Y), IRAS form and all supporting documentation have been approved and signed off by Guy’s and St Thomas’ NHS Foundation Trust R & D department for sponsorship approval, and submitted to HRA for full REC review (appointment booked 15th May 2017).
c) Fathers’ group: A PPI group of 4 first time fathers has been set up, and participants have been involved in the development of all supporting research documents to date.
d) Study website: A website development is currently underway for this project, which will be ready before the second phase of the study commences. A study logo has been designed. Website: www.newdadstudy.com
7.1 Training Plan
 

Topic 
 
Completed Date Planned
Literature review workshop for Health & Clinical Sciences postgraduates Oct 2015  
Search Techniques for Systematic Reviews Oct 2015  
Presentation Skills Oct 2015  
Writing A Literature Review for the Sciences Dec 2015  
Promotional Guide Train the Trainer Programme Feb 2016  
Effective Speed Reading May 2016  
Fundamentals of Good Writing May 2016  
JBI Systematic Review Training Sept 2016  
Introduction to Good Clinical Practice eLearning Sept 2016  
Preparing for the Upgrade from MPhil to PhD March 2017  
Elite interviewing March 2017  
1:1 session with Royal Literary Fund Writing Fellow March 2017  
Presenting Magically   May 2017
Implementation Science Masterclass   July 2017
Creativity & Problem Solving   Sept 2017
Writing the Thesis   June 2018
Preparing for the Viva   Feb 2019
Design and analysis of randomised controlled trials   June 2019

 
Table 5: training plan
 
 
 
 
 
 
 
 
 
PART B
Chapter 2: LITERATURE REVIEW
2.1 Introduction
This chapter explores the literature relating to fathers’ mental health and wellbeing during their transition to fatherhood. It begins with defining mental health and wellbeing in general and then reviews the literature on men’s mental health and wellbeing as they become fathers for the first time. It includes discussions of the risk factors for mental health problems, the signs and symptoms men may display and the impact of mental health problems in fathers. Evidence on interventions to support fathers’ mental health and wellbeing, the current policy context and barriers to engagement are presented. This chapter concludes with a summary of the literature reviewed and the gaps identified.
2.2 Mental health & wellbeing
In recent years there has been an increased emphasis on improving mental health by promoting mental wellbeing rather than just treating mental health problems, as discussed earlier. The Royal Society for Public Health in the UK recommends that it is important to actively promote positive mental wellbeing rather than just focussing on preventing and treating mental illness (RSPH, 2014). Good mental health and wellbeing not only influences a wide range of outcomes for individuals, but also brings about a multitude of social and economic benefits (WHO, 2005; DH 2011). While this is clear, the terms mental health and wellbeing are often used interchangeably in the literature and many definitions exist for these concepts.
According to the World Health Organisation (WHO) mental health is not just the absence of mental disorder. It is “a state of wellbeing in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (WHO, 2004). The three core components of this definition are (1) well-being, (2) effective functioning of an individual, and (3) effective functioning for a community (WHO, 2005, p.10). Mental health therefore influences how a person thinks and feels about themselves and others, how they interpret events, their capacity to form, sustain and end relationships, and their ability to cope with change, transition and life events (Friedli, 2000).
Research on mental wellbeing, which is one component of mental health, differentiates between two types of wellbeing: hedonic wellbeing, and eudaimonic well-being. Hedonic wellbeing is described as subjective wellbeing that involves emotions such as feelings of happiness, satisfaction, and interest in life (Keyes 2007), whereas eudaimonic wellbeing is psychological wellbeing and it focuses on individual strivings and optimal functioning (Ryan and Deci 2001; Ryff 1989). A number of longitudinal studies show an association between high levels of psychological wellbeing and decline in mental illness, suggesting psychological wellbeing could act as a protective factor against mental disorders (Weiss et al, 2016; Lamers et al, 2015; Wood and Joseph, 2010; Keyes et al, 2010). In addition to subjective and psychological wellbeing, Keyes (2002) believes that social wellbeing is necessary for one to be ‘mentally healthy’. Therefore mental health could be described as the ‘umbrella’ term for emotional, psychological and social well-being (Westerhof and Keyes, 2010; Keyes, 2005; 2007).
The UK government’s call to action in the mental health strategy (DH, 2011), highlights the need for improved interventions to enhance mental health and wellbeing of the population. In a recent meta-analysis of 27 randomised control trials Weiss et al (2016) reported a positive effect of behavioural interventions on psychological wellbeing. They concluded that it is possible to improve psychological wellbeing with behavioural interventions, and that face-to-face interventions were the most promising (Weiss et al, 2016). However the heterogeneity of studies in the meta-analysis was a limitation.  While the terms mental health and wellbeing are both complementary to one another, they are also inter-linked and indivisible in the literature and therefore will be used interchangeably throughout this study.
2.3 Men’s mental health and wellbeing during their transition to fatherhood
Mental health during the transition to parenthood is often referred to as perinatal mental health, which is an umbrella term that encompasses mental health problems, psychological distress and psychological wellbeing from conception to one year after birth. It can include pre-existing mental health conditions as well as the onset of new ones (O’Hara and Wisner, 2014), and focuses not only on treating and preventing mental health problems, but also incorporates the promotion of psychological wellbeing (Weiss et al, 2016; NICE, 2014).
Men’s mental health and wellbeing, including first-time fathers, is an important public health issue which to date has been under-researched and poorly understood (Paulson & Bazemore, 2010). Previous studies which asked men about their role have reported that they felt unsupported during their transition to fatherhood due to lack of opportunity to learn parenting skills from their own fathers, although this could reflect a time when fathers were likely  to be less involved with childcare (Condon et al, 2004). In addition to this, fathers may feel side-lined during the perinatal period, with the focus mainly being placed on the mother and baby. A literature review of thirty two studies published between 1989 – 2008 on men’s psychological transition to fatherhood, found pregnancy to be the most demanding period for the fathers’ psychological reorganisation of self, and labour and birth to be the most emotional moments involving highly mixed feelings, ranging from helplessness and anxiety to pleasure and pride (Genesoni and Tallandini, 2009). The postnatal period (defined as up to one year following birth)  however was the most challenging time due to fathers having to balance the various demands placed on them  including personal and work related needs, their  new role as a parent, emotional and relational needs of the family, and societal and economic pressures (Genesoni and Tallandini, 2009). A key element highlighted in this study was the importance of the quality of the man’s relationship with his partner, which was related to all three periods, antenatal, intrapartum and postnatal. While this review focussed on men’s experiences from Western cultures, most of the studies were from the USA (11) and Australia (9), with a small number from the UK (4), Canada (3) Ireland (1), Sweden (3), and Finland (2). Although this study reports to have extracted thirty two articles, there were actually thirty three presented in the paper. The study included resident fathers, but it did not include non-biological fathers such adoptive fathers, stepfathers or fathers in same sex relationships. Therefore the experiences of non-biological fathers during their transition to fatherhood remains unknown.
There are wide variations in the reported prevalence rates of depression in fathers in the perinatal period. In an integrative review of twenty studies Goodman (2004) reported depression in fathers (both first-time and subsequent) to range from 1.2% – 25.5% in the first year following birth of their baby. With the exception of one study, which assessed depression through the signs and symptoms reported in a qualitative interview, all studies in this review used standardised self-report screening instruments with established reliability and validity, including the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al. 1987), Beck Depression Inventory (BDI) (Beck et al,1996), General Health Questionnaire (GHQ) (Goldberg 1978), and the Center for Epidemiological Studies-Depression (CES-D) (Radloff 1977). There are some limitations associated with comparing the results of the studies included in this review. Firstly, the timing of data collection varied significantly from 1 week to 8 weeks post birth, and secondly, a number of different instruments were used across the studies to measure depression which had differing sensitivities. These make comparison of the results across studies problematic.
As part of the Avon Longitudinal Study of Parents and Children (ALSPAC), which is a large longitudinal cohort study including 8431 fathers, Ramchandani et al (2005) reported the presence of depressive symptoms in 4% fathers 8 weeks after birth using the EPDS. While the EPDS is not a diagnostic tool and initially developed to screen mothers (Cox et al, 1987), it has been validated for use with fathers (Matthey et al, 2001; Cox et al, 1996) and a score of over 12 is associated with a major depressive disorder with a high specificity (94.9%) and sensitivity (100%) (Massoudi, 2013). However a more recent meta-analysis of forty-three studies reported depression in 10.4% of fathers between the first trimester of their partner’s pregnancy and one year postpartum, with the peak time of 3 to 6 months postnatally, similar to findings for postnatal women (Paulson & Bazemore, 2010). Therefore prevalence rates based on figures from 8 weeks postnatal may not be an accurate reflection of the extent of this problem. Similar to the study by Genesoni and Tallandini (2009) discussed earlier, studies included in the meta-analysis used variable methods of measuring and identifying depression: self-report rating scales were used in forty studies and interviews used in three (Paulson & Bazemore, 2010).
In another literature review of twenty-one studies exploring mental health problems experienced by fathers in the first year after their baby’s birth, Bradley and Slade (2011) reported a prevalence of depression around 1% to 8% in the first 6 weeks, and 5% to 6% at 3 – 6 months after birth. However few studies incorporated matched control groups, again making comparisons of prevalence rates across studies difficult. Nonetheless findings from this review and the previous meta-synthesis (Paulson & Bazemore, 2010) suggests that men may be more at risk of experiencing depressive symptoms during the first 6 months after becoming a father.
Other mental health problems, including anxiety and stress have also been reported by men during and after their partner’s pregnancy (Matthey et al, 2003; Johnson & Baker, 2004; Gao et al, 2009; Moss et al, 2009; Skouteris et al, 2009; Figueiredo and Conde, 2011). A systematic review which included forty-three papers reported that the prevalence rates for any anxiety disorder in men ranged between 4.1% – 16.0% during their partners’ pregnancy and 2.4% – 18.0% during the postnatal period (Leach et al, 2016). Anxiety disorders included were Generalised Anxiety Disorder (GAD); Acute Adjustment Disorder with Anxiety (AADA); Panic Disorder (PD); Obsessive Compulsive Disorder (OCD); and Post-Traumatic Stress Disorder (PTSD). This review included papers on expectant fathers, as well as first-time and multiparous fathers in the first twelve months postpartum. Anxiety was assessed either by structured clinical diagnostic interviews or validated self-report anxiety scales. 82% of the studies in this review reported depression measures as well as anxiety, suggesting that both depression and anxiety may coexist. However, as this review only focussed on prevalence rates of anxiety, it may not represent the complete picture of mental health problems experienced by fathers during the perinatal period. Many papers within the review did not report on men’s past psychiatric history and therefore, it is unclear whether anxiety reported during the perinatal period were of ‘new cases’ or pre-existing ones.
Other severe mental health illnesses relating to mothers in the perinatal period are bipolar disorders and psychosis (Jones et al, 2014), however there is little research available on these areas relating to men’s perinatal period. In their review, Bradley and Slade (2011) found only one paper relating to bipolar disorder in fathers (Davenport and Adland, 1982), which did not clearly identify whether any of the bipolar episodes were first-time episodes. It is therefore unclear whether becoming a father had triggered bipolar disorder in previously well men. Bradley and Slade (2011) also identified 11 studies relating to psychosis in fathers. On synthesising the findings from these studies involving 21 individuals, they reported 13 of the men to become psychologically unwell after the births of their babies, and 8 men to presenting with psychological symptoms during their wives’ pregnancies which worsened after their babies were born (Bradley and Slade, 2011). The risk factors for psychosis in fathers identified in this review were problematic relationships with their own parents, loss of parents when young, parental psychological problems, difficult early experiences, problems in the marital relationship, service in the armed forces and higher socio-economic status. Apart from one study, which reviewed the case records of 169 men admitted to hospital with paranoid psychoses (Retterstøl,1968), there were no further details provided about the total sample size, characteristics or how psychoses were assessed in the remaining included studies. This is a major limitation, which makes interpretation of these results difficult. Further research in these areas is necessary to build a better picture of fathers’ mental health problems in the perinatal period.
While reviewing the literature, only two qualitative study were found which specifically explored men’s own experiences of mental health and wellbeing during the perinatal period. The first was a study by Edhborg et al (2015), which involved semi-structured interviews with 19 first-time fathers in Sweden. These fathers were purposively selected as they reported to experience depressive symptoms 3 to 6 months postpartum. Depressive symptoms were measured using two self-reported questionnaires – Scoring 10 or more on the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al, 1987) and/or 13 or more on the Gotland Male Depression Scale (GMDS) (Zierau et al, 2002). The GMDS has been validated in Sweden, and a score of 13 or more indicates possible depression (Zierau et al., 2002), and it was used in this study as a complement to EPDS to improve the recognition of depression in new fathers. Findings suggest that fathers’ pre-birth expectations of fatherhood often did not reflect the reality post birth, leaving them feeling a ‘loss of control and powerlessness’ (Edhborg et al, 2015). They experienced difficulties in balancing the competing demands of family, work, and their own needs, similar to findings of the literature review by Genesoni and Tallandini (2009). Fathers also reported struggling with impaired relationships with their partners. While the fathers in this study reported to experience depressive symptoms 3 – 6 months postpartum, many were no longer depressed when they were interviewed between 6 and 14 months postpartum. Some fathers were offered interventions for their depression, including counselling and self-help books. Additionally as the interviews were retrospective, it is possible that some fathers’ recollection of their experiences may not have been as accurate, increasing the risk of recall bias. It is also possible that data saturation was not achieved through the interviews conducted as recruitment did not continue till the point of saturation. Another limitation of this study was the lack of social heterogeneity of the participants, as most of the fathers had a university degree and all lived in Stockholm. Interestingly in this study fathers scoring 10 or above on the EPDS were considered to be depressed, whereas when validated for fathers (Matthey et al, 2001; Cox et al, 1996), a score of over 12 was associated with a major depressive disorder with a high specificity (94.9%) and sensitivity (100%) (Massoudi, 2013).
The second qualitative study identified was of 19 first-time and subsequent fathers, carried out as part of Born and Bred in Yorkshire (BaBY) (www.bornbredyorks.org), which is a population-based prospective cohort study of babies and their parents (Darwin et al, 2017). This study was undertaken in four sites across North Yorkshire and East Lincolnshire between 2011 and 2014. Through in-depth interviews with fathers 5-10 months postpartum, Darwin et al (2017) reported four main themes: ‘legitimacy of paternal stress and entitlement to health professionals’ support’, ‘protecting the partnership’, ‘navigating fatherhood’, and, ‘diversity of men’s support networks’. While fathers in this study reported to experience increased levels of stress in the perinatal period, they did not feel that their needs were as important as their partners, and felt that their partner’s needs should be prioritised over theirs. The authors concluded that “men may be reluctant to express their support needs or seek help amid concerns that to do so would detract from their partner’s needs” (Darwin et al, 2017).
There were however a number of limitations of this study, including the lack of diversity concerning ethnicity and socioeconomic background of the participants, similar to the last study discussed (Edhborg et al, 2015). All participants were White and the majority were employed (18). Fathers from different ethnic and socioeconomic backgrounds may have differing views and experiences concerning paternal perinatal mental health, which may not have been captured in this study. Furthermore, the inclusion criteria of this study required the completion on a Mental Health and Wellbeing questionnaire which contained a number of psychological outcome measures, including the Public Health Questionnaire (PHQ-8 and PHQ-15), Generalised Anxiety Disorder scale (GAD-7) and the List of Threatening Events (LTE). Those not completing the questionnaire were not eligible to take part, and this may have excluded a significant number of fathers from the study, especially those whose first language were not English. The authors also reported that data saturation had not been reached through the 19 interviews carried out, which suggests that additional useful information relating to fathers’ experiences during the perinatal period may have been missed. This study only included biological fathers and so the experiences and views of non-biological fathers remain under-researched.
.2.4 Risk Factors for mental health problems in fathers
Risk factors for anxiety and depression in men during and following the period of  transition to fatherhood can include factors such as an unsupportive marital relationship, paternal unemployment, immaturity, an unplanned pregnancy (Bradley and Slade, 2011; Schumacher et al, 2008; Ballard & Davies, 1996); history of depression, young parental age and higher social deprivation (Dave et al 2010); poor social and emotional support (Boyce et al, 2007; Castle et al, 2008), having a partner with elevated depressive symptoms or depression, and poor relationship satisfaction (Wee et al, 2011).
In a cross-sectional study of online questionnaires from 622 first-time expectant fathers in Canada, Da Costa et al (2015) reported factors associated with antenatal depressive symptoms to include poorer sleep quality, family history of psychological difficulties, lower perceived social support, poorer marital satisfaction, more stressful life events in the preceding 6 months, greater number of financial stressors, and elevated maternal antenatal depressive symptoms. Data collected in this study was from expectant fathers during their partner’s third trimester of pregnancy. The sample in this study was well-educated, consisting predominately of middle-class expectant fathers, which limits the generalisability, nonetheless the large sample size enabled the identification of a broad range of risk factors affecting first-time expectant fathers. These findings are not dissimilar to those reported in the previously mentioned studies focusing on fathers in the perinatal period (Bradley and Slade, 2011; Wee et al, 2011; Dave et al 2010; Boyce et al, 2007; Castle et al, 2008).
Hanson et al (2009) found that before the birth, fathers often expressed fear for the safety of the woman and the baby, anxiety and fear about observing their partner in pain, feelings of helplessness, lack of knowledge about the birthing process, and concerns about risks of interventions such as operative delivery, limited finances and parenting skills. High anxiety and depressive symptoms during pregnancy were reported to be the most significant predictors of depression in men in the postnatal period among those participating in the ALSPAC study referred to earlier (Ramchandani et al, 2008). Younger fathers are more likely than older fathers to have pre-existing serious anxiety, depression and conduct disorder, and some young fathers may enter parenthood with existing poor mental health (PHE, 2016), increasing their risk during the perinatal period.
An Australian longitudinal study of 327 healthy couples with a first-time pregnancy, which included repeated measures of outcomes of interest, reported 20% of mothers and 12% of fathers were significantly ‘distressed’ at mid-pregnancy, which persisted until the early postpartum period (Morse et al, 2000). The outcome measures used in this study included the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al, 1987), Positive and Negative Affect Scales (PANAS) (Watson et al, 1985), Depression Inventory (short form) (Reynolds and Gould, 1981), State Anger and Anxiety Scales (Spielberger, 1979), Spanier Dyadic Adjustment Scale (short form) (Sharpley and Rogers, 1984), the Intimate Bonds Questionnaire, Social Support Questionnaire (Wilhelm and Parker, 1988), Masculine and Feminine Gender Role (Gillespie and Eisler, 1992). Younger age, negative mood, poor relationship functioning, gender role stress (particularly performance failure regarding work and sex in males) and low social support predicted distress in mid-pregnancy; whereas negative mood in partner and self, and poor relationship functioning at mid-pregnancy predicted vulnerability to postnatal distress (Morse et al, 2000).
In another Australian longitudinal study, data on 3219 biological resident fathers reported risk factors associated with psychological distress postnatally were poor job quality, poor relationship quality, maternal psychological distress, having a partner in a more prestigious occupation and low parental self-efficacy (Giallo et al 2013). This study was undertaken as secondary analysis of data from fathers participating in the infant cohort of the Longitudinal Study of Australian Children (LSAC). While due to this being a cross-sectional study causality cannot be inferred, the findings are similar to those discussed in the previous section, and maternal depression has been identified as the strongest predictor of paternal depression during the postpartum period (Wee et al, 2011; Goodman, 2004). This was also highlighted by Edward et al (2015) in an integrative review of 63 articles on paternal depression where they stated that mental health problems in fathers following the birth of their child was associated with a father’s personal history of depression and with the existence of depression in their partner during pregnancy and soon after delivery.
Men’s own expectations of what it means to be a man and a father can play a significant role in their mental health and wellbeing. For example, men have reported their gender role identity as the need to be strong, successful, in control and able to deal with their own problems (Heifner, 1997). Men who identify more closely with these cultural expectations of the male role have been found to be more likely to be depressed and less likely to seek help (Good and Mintz, 1990). The social and cultural expectations of fatherhood are often conflicting. Recent years have seen a cultural shift in the father’s role. Traditionally viewed exclusively as family breadwinners, fathers are now often expected to be more involved in caring for and nurturing their children (McBride et al, 2005), thus moving away from the traditional authoritarian function to one that is more loving and interactive (O’Brien, 2005; Genesoni and Tallandini, 2009). However, a study by Hauari and Hollingworth (2009) across four ethnic groups in England found the concept of ‘good fathering’ still linked to this breadwinner role. While the transition to parenthood presents stresses associated with changes to lifestyle, relationships, sleep deprivation and financial pressures, the role of being a father may also include additional pressures to be a ‘good father’ and to fulfil the societal and cultural expectations of both ‘father’ and ‘man’ (Wee et al, 2013). These factors may contribute to the levels of stress fathers experience during the perinatal period, especially after the birth of their baby (Genesoni & Tallandini, 2009), however more research is needed to explore these issues further (Wee et al, 2013).
2.5 Signs and symptoms of mental health problems
Signs and symptoms of depression in fathers may manifest as low self-esteem, hostility, conflict, and anger (Madsen, 2011; Wang & Chen, 2006; Condon et al, 2004) and some men may withdraw or engage in ‘escape activities’ such as overwork, sports, gambling, and excessive drinking (Veskrna, 2010; Diamond, 2005). Some signs and symptoms of depression during the perinatal period experienced by women and men are similar, such as deep feelings of abandonment and powerlessness, however other symptoms such as alcohol and substance abuse may more frequently manifest in men (Madsen, 2011).
General population studies have reported that depression symptoms manifest differently in men than women (Brownhill et al, 2002; Winkler et al, 2006; Grigoriadis and Robinson, 2007; Johnson et al, 2012). In a recent Delphi study of 14 international experts (including clinicians or professionals working directly with fathers, trainers, researchers and those who have published in peer-reviewed articles about ‘fathers’), paternal depression was described as low mood, negative thoughts, somatic issues (low hunger, weight loss, sleep issues), along with ‘masked male depression’ symptoms such as irritability, withdrawal/ isolation and increases in substance use (or other dopaminergic types of activities like gambling and cheating) during pregnancy or within a year or so postpartum” (Freitas et al, 2016). As men have different communication and coping styles compared to women, they may be less likely to access health services, more reluctant to discuss their mental health symptoms or concerns due to wanting to put their partner’s needs first, or even present with different mental health symptoms and needs (Darwin et al, 2017; Robertson et al, 2015; Meighan et al, 1999; Morgan et al, 1997). In their integrative review of paternal depression, Edward et al (2015) highlighted that men and women differ in their knowledge and beliefs about the symptoms and causes of postnatal depression. It was perceived by women as having a biological rather than psychosocial cause, therefore making it more difficult to recognise the symptoms in men, who have less contact with health professionals during the perinatal period compared to women.
While there is some evidence of different signs and symptoms of mental health problems in men and women in the general population, research into men’s presentation of mental health problems in the perinatal period remains limited and little is known about their needs and challenges during this period (Darwin et al, 2017; Rominov et al, 2016).  Using the same methods for assessing and managing men’s and women’s mental health needs may not adequate, as there appears to be clear gender differences in the presentation of mental health problems. The different signs and symptoms displayed by men highlight some of the complexities around the mental health needs of fathers during their transition to fatherhood, and emphasises the need for better understanding of these gender differences by health professionals.
2.6 Impact of fathers’ mental health problems 
As discussed in the last chapter, the impact of mental health problems can be wide ranging, effecting fathers themselves, their partners’, their children, as well as society on the whole (WHO, 2003; DH, 2011). Depression and anxiety in fathers during the perinatal period can affect their own working and short-term memory loss (Pio De Almeida et al, 2012), as well as negatively impact on their ability to perform tasks in their work place (Melrose, 2010). It can also have a profound impacts on their relationships, both with their partner and their child (Fletcher et al, 2015; Amato, 2001).
A number of studies have reported on declining marital satisfaction, reduced partner support and increased conflict between parents to be associated with the challenges and adjustments during the transition to parenthood (Howard and Brooks-Gunn, 2009; Huston and Holmes, 2004; Shapiro et al, 2000; Cowan & Cowan, 2000; Belsky and Kelly, 1994). Decline in relationship satisfaction and conflict is linked to the reduction in positive couple communication after having a baby (Cowan & Cowan, 2000; Pinquart and Teubert, 2010), and the use of destructive problem solving being the highest in couples during the first three months after the birth (Houts et al, 2008). Belsky & Kelly (1994) reported mothers’ satisfaction declining most sharply during the first year, while Cowan and Cowan (2003) reported fathers’ in the second year.
In a longitudinal study of 218 couples in the United States, Doss et al (2009) examined the effect of the birth of the first child on relationship functioning over the course of the first 8 years of marriage. They reported that parents showed sudden deterioration following birth on observed and self-reported measures of positive and negative aspects of relationship functioning, compared with pre-birth levels and trajectories. Couples who did not have children showed a more gradual deterioration in relationship functioning during the first 8 years of marriage without the sudden changes seen in parents, suggesting that the results seen in the parent sample may be due to birth (Doss et al, 2009). Similarly, Lawrence et al (2008), reported greater declines in marital satisfaction in first-time parents compared to nonparents. This was also a longitudinal study of 156 married couples (104 parent couples and 52 nonparent couples). In addition, Lawrence et al (2008) found that couples with planned pregnancies had higher pre-pregnancy satisfaction scores, and the planning slowed the fathers’ (but not mothers’) postpartum declines in relationship satisfaction, therefore suggesting that pre-pregnancy marital satisfaction may act as a protective factor for relationship decline during the transition to parenthood for fathers (Lawrence et al, 2008).
If relationships between mothers and fathers following the birth of their child are fraught, postnatal depression may be more likely to develop in both parents in the first year of birth (Davé et al, 2010). Depression in parents may result from or be stimulated by a declining couple relationship (Gottman et al, 2010) and therefore it is important to focus on interventions on strengthening couple relationships and parents’ feelings of unworthiness when promoting mental health and wellbeing during the transition to parenthood (Parfitt and Ayers, 2014).
Mental health problems in fathers can contribute to negative interactions between the father and child, as well as negative impacts on the child. Ramchandani et al (2005), in the ALSPAC cohort study discussed earlier, which controlled for mothers’ depression and for fathers’ education levels, found that the presence of symptoms of severe postnatal depression in fathers (assessed using the Edinburgh Postnatal Depression Scale) was associated with emotional and behavioural problems in their children at around three years of age, particularly in boys. In a later study, Ramchandani et al (2008) also reported an increased risk for psychiatric, behavioural, and conduct disorders in children aged 7 years, if their fathers had been depressed in the antenatal and postnatal periods.
There is also a strong association between father-child conflict and behaviour problems in children (Flouri, 2005; Phares, 1999). Several studies have suggested a link between poor cognitive, behavioural, social, and emotional development in children, and a negative father-child relationship (Sethna, et al, 2012; Fletcher et al, 2011; Paulson et al, 2009; Wanless et al, 2008; Paulson et al., 2006). Ramchandani et al (2013) in a more recent study identified that disengaged interactions of fathers with their infants at 3 months postpartum predicted behavioural problems in children. Fathers suffering from depression may not have the capacity to engage and be involved in their child’s education, and low interest by fathers in children’s education has a stronger negative impact on their achievement (Blanden, 2006). Davis et al (2011) in a cross-sectional study of interview data from secondary analysis of 1746 fathers of 1-year-old children reported that depressed fathers were less likely to spend time reading to their children and more likely to smack them  compared to non-depressed fathers, thus negatively effecting the father-child relationship. This study was carried out as part of the Fragile Families and Child Wellbeing Study, which is an ongoing, nationally representative study in the United States following a cohort of children born between 1998 and 2000, and their parents.
Paternal depression may not just affect fathers’ own levels of interaction with their children but may also interfere with the interactions between the child and their mother (Bradley and Slade, 2011).  In a study of the effects of maternal and paternal depression on parenting behaviours from data on 5089 two-parent families, Paulson et al (2006) reported an association between depression in both mothers and fathers with lower levels of positive enrichment activity with the child (reading, singing songs, and telling stories). Children with two depressed parents therefore are likely to be at a higher risk of poor development outcomes (Brennan et al 2002). Paulson and Bazemore (2010) suggest that prevention and intervention for parental mental health in the perinatal period should focus more on the couple and family, rather than the individual.
Mental health problems in fathers also impacts negatively on society. While the actual cost of paternal perinatal mental health problems are currently unknown, it is likely to be considerable given that maternal perinatal mental health problems carry a total economic and social long-term cost to society of about £8.1 billion for each one-year cohort of births in the UK (Bauer et al, 2014).
2.7 Interventions to support first time fathers’ mental health and wellbeing
A Cochrane Library systematic review of group-based parenting programmes for improving parental psychosocial health reported that only 4 of the 48 included studies reported separate outcome data for fathers (Barlow et al, 2014). While these showed a statistically significant short-term improvement in paternal stress following interventions that included cognitive and behavioural strategies, individual study results were inconclusive for any effect on depressive symptoms, confidence or partner satisfaction. The review authors concluded that this was: “a serious omission given that fathers now play a significant role in childcare and research suggests that their psychosocial functioning is key to the wellbeing of children” (Barlow et al, 2014, p-21).
A systematic review of interventions for prevention or treatment of depression in fathers identified four studies, all focussing on treatment rather than prevention, with findings inconclusive due to wide study heterogeneity (Wee et al, 2013). This review highlighted the need for randomised controlled trials to identify effective mental health interventions for men in the postnatal period, particularly preventative interventions (Wee et al, 2013). Another systematic review of intervention programmes to prevent or treat paternal mental illness in the perinatal period included eleven studies – five of which described psychosocial programmes (emphasising skills, knowledge, emotional well-being, and social well-being related to parenting), three focused on the effects of massage techniques (partner massage and infant message), and three which used couple-based sessions (focused on the couple relationship and co-parenting) (Rominov et al, 2016). Eight studies were randomised controlled trials; however, six trials did not provide adequate information on randomisation processes and risk of bias cannot be ruled out. The review authors reported significant intervention effects for a variety of fathers’ mental health outcomes (including stress, depression, anxiety, anger levels and self-esteem) for two of the psychosocial approaches (Li et al, 2009; Tohotoa et al, 2012), and three that employed massage techniques (Cheng et al, 2011; Field et al, 2008; Latifses et al, 2005). There were no significant changes reported in paternal mental health following couple-based interventions. Although study limitations include poor reporting of study designs, variation in outcome measures used, and limited statistical analyses; the findings relating to couple-based interventions have interesting implications especially as increased emphases are now being placed on focusing on couple relationships and family interventions (Parfitt and Ayers, 2014; Paulson and Bazemore, 2010).
A systematic review of evidence on parenting interventions which included men as parents or co-parents showed that insufficient attention was paid to reporting fathers’ participation and fathers’ impacts on child or family outcomes (Panter-Brick et al, 2014). The importance of assessing men’s mental health in the perinatal period (Burgess, 2011), and identifying the best methods for supporting fathers (Barlow et al, 2008) still remains.  Face-to-face behavioural interventions may be useful in improving psychological wellbeing of first-time fathers, as discussed earlier in this chapter (Weiss et al, 2016), and high levels of psychological wellbeing could act as protective factors against paternal mental health problems (Weiss et al, 2016; Lamers et al, 2015; Wood and Joseph, 2010; Keyes et al, 2010). This however needs further exploration through research.
2.8 Policy context and engagement with fathers
There has been a recent drive for increased father involvement in the UK policy context. In Supporting Families (Home Office, 1998), the New Labour Government recognised that: ‘Fathers have a crucial role to play in their children’s upbringing’. This message continues to be reflected in the consistent ongoing UK directives, recommendations and guidance ever since.  The national Healthy Child programme (PHE, 2015; DH, 2009) puts a major emphasis on parenting support, specifically concentrating on supporting strong couple relationships, engaging with fathers, and supporting the transition to parenthood for first time mothers and fathers. In the UK there has also been a change in legislation, with the introduction of two weeks’ paid paternity leave in 2003 and the right for fathers to share parental leave or request ‘flexible working’ in 2015. While these changes are positive steps towards encouraging greater father involvement in children’s lives, in reality they are often not exercised in practice (Miller, 2011; Featherstone, 2009). Similarly, engaging fathers with child health services has always been difficult and while there may be a changing landscape to engage with fathers more within the policy context in the UK, gaps continue to be evident in practice and it is an area that requires more attention.
Historically child health has always been perceived as the woman’s domain and therefore services delivering these tend to be women and child centred. There is also little known about effective interventions by professionals to support fathers’ mental health and wellbeing. Health professionals’ failure to engage with fathers during or around the time of birth could be a reason for the lack of evidence on first time fathers’ mental health and wellbeing (Roberts et al, 2006). Men are reported to be less expressive and less inclined to talk about negative feelings compared to women (Daniel, 2004; Matthey et al, 2001; Goldschmidt and Weller, 2000), and therefore likely to be less willing to talk to health professionals. Fathers may feel marginalised and unacknowledged by health professionals during the perinatal period, and report a lack of appropriate information on pregnancy, birth, child care, and balancing work and family responsibilities (Palsson et al, 2017; Dheensa et al, 2013; Williams et al, 2011; Backstrom and Hertfelt Wahn, 2009).
In a recent qualitative study on 15 first time fathers, Palsson et al (2017) highlighted that while fathers desired prenatal strategies to deal with the changes brought about by new fatherhood, they lacked active guidance from professionals to access reliable information. Fathers were also not acknowledged as equal parents, by health professionals (Palsson et al, 2017).
Research of health visitors’ practice has found that they do not always involve fathers (Williams, 1999) and are perceived by fathers as a service provided ‘by women, for women’ (Williams et al, 2013). A Department of Health for England funded literature review on service users’ views suggested that some fathers welcomed the opportunity to express their feelings and emotions about fatherhood when asked by a healthcare professional (Greening, 2006), but did not always have the opportunity to do this spontaneously (Salway et al, 2009). Fathers whose partners had postnatal depression reported barriers such as not knowing where to look for resources for postnatal depression and the difficulty in reaching out for support, including social supports and referrals to health care professionals (Letourneau et al, 2011). In a study of 66 first-time expectant fathers, Castle et al (2008) reported perceived social support to be a protective factor for fathers as fathers reporting higher levels of perceived social support throughout the pregnancy reported to experience significantly lower levels of depression and distress 6 weeks post-delivery.
Health professionals’ limited experience of working with fathers, and their inability to assess fathers’ mental health and wellbeing, resulting in not recognising fathers with postnatal depression have been highlighted in previous studies (Massoudi et al, 2010; Hammarlund et al 2015). Similarly in a recent study of UK health visitors, a number of anxieties were identified relating to the lack of support they provided to fathers (Whitelock, 2016). These included the lack of training they received to working with fathers and around fathers’ mental health, lack of confidence, fears of own safety and a lack of policies to screen fathers’ mental health. Similar themes were also highlighted in a recent qualitative, interpretative phenomenological analysis (IPA) study, where student health visitors (n=3) felt that paternal mental health was not addressed in their training and that they were inadequately prepared to support fathers in practice (Oldfield and Carr, 2017).
There is some suggestion that having a workforce that is primarily female could act as a barrier to engaging fathers (Page et al, 2008). This would apply to the UK midwifery workforce which is 99% female and the health visiting workforce which is 99.6% female (DH, 2012). However recommendations from a large literature review by the Movember Foundation suggests that staff characteristics, skills and qualities such as being non-judgemental, male positive and empathic to men’s needs are far more important than the sex of the staff (Robertson et al, 2015). In order to work successfully with fathers, practitioners have to consider addressing fathers needs as men, as well as fathers (similar to the way in which a family-focused approach is used with women) and not just as child carers (Ghate et al, 2000).
While UK policies such the Healthy Child Programme (DH, 2009), outlines good practice for engaging fathers, in reality there is clearly a gap in achieving this in practice. Therefore there is an urgent need to explore what supports are required by professionals in engaging with fathers, and how fathers can be supported in developing safe and positive relationships with their children (Featherstone, 2003).
Men’s perinatal mental health is not given the same level of priority as is women’s in the UK. Tools such as the EPDS, which is commonly used by health visitors in the UK, has been validated for use with men in the antenatal and postnatal period (Matthey et al, 2001; Cox et al, 1996). Despite this, as mentioned in the last chapter, the UK National Institute for Health and Care Excellence guidelines on antenatal and postnatal mental health (NICE, 2014) do not include fathers in the recommended routine assessment and management of perinatal mental health. So with the lack of government direction, the gap in service delivery for fathers continues.

  1.  Chapter summary

 
This chapter has provided an overview of the literature relating to men’s mental health and wellbeing during their transition to fatherhood. While there are clear distinctions between the terms mental health and mental wellbeing, in the literature they are often used collectively. A number of studies have looked at the prevalence rates of and risk factors for paternal perinatal mental health problems, but they have mainly focussed on anxiety and depression. There is limited evidence of other perinatal mental health issues affecting men such as bipolar and psychosis. The signs and symptoms of mental health problems in men presented in this chapter mainly relate to the general population as there is a paucity of research focussing specifically on paternal perinatal mental health. There were only two qualitative studies specifically exploring fathers’ own perinatal mental health views and experiences. Most studies focussed on biological fathers and the needs to non-biological resident fathers remain unknown.
The impact of paternal mental health problems on the wellbeing of fathers themselves, their partners, their children and society on the whole is apparent. More research is needed to identify effective interventions to support fathers’ during their transition to parenthood. There is a current push by the UK government towards providing father-inclusive child health and perinatal health care services, however there are no clear guidance for healthcare professionals around how this should be done. There is currently no requirement to routinely assess men’s mental health during the perinatal period, as there is for women, even though a number of validated tools are available for use with fathers.  Barriers to assessing first-time fathers’ mental health and wellbeing, and providing them with adequate support during this period persists. Further research is necessary to bridge the identified gaps. Better understanding of the experiences of first time fathers, whether biological or non-biological, during their transition to fatherhood and identifying what information and support they consider could help their mental health and wellbeing, would enable the development of appropriate and timely healthcare professional-led interventions likely to be more acceptable to fathers.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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