Phase II interviews
Follow-up individual interviews were completed to elaborate on the study findings from the individual interviews, uncover any additional suggestions of supports or improvements to interventions for these fathers, mothers and young children, and seek input on intervention options. A purposive sample of interviewees was selected on the basis of identification of particularly articulate interviewees from the individual interviews (n = 6/37). Three additional participants were recruited (Quebec: n = 1; New Brunswick: n = 2) to provide a fresh supplementary perspective. Prior to follow-up interviews, fathers received 2 documents to review: (1) a brief report of the first phase of interviews, which included fathers' perspectives on sources of support, support needs, common barriers to accessing support, and ideal support preferences, and (2) a compilation of the ideal support interventions developed from the first phase of interviews. The follow-up semistructured interview guide consisted of 21 questions (see Table 1 for sample questions) designed to elicit feedback on findings and intervention options. Probes specifically sought to identify desirable support intervention agents (eg, professionals, peers), preferred format, and frequency, duration, and length of support intervention. Follow-up interviews typically took 60 minutes.
All interviews were audiotaped and transcribed verbatim. Thematic content analysis of interview data involved several steps, beginning with the creation of an initial coding framework.54 The coding framework was created iteratively by assigning research team members to read 2 to 4 transcripts each. At least 2 team members read each transcript. After reading assigned transcripts, each team member used a process of open coding to categorize the data. The team members then met and integrated their respective coding frameworks into an encapsulating framework. Finally, the integrated framework was revised several more times after team members read additional transcripts. Once the team including the NAC was satisfied that the framework was sufficiently comprehensive, 2 trained research assistants coded each transcript using NVivo version 8 (QSR International, Doncaster, Victoria, Australia). When the research assistants noted new categories emerge from the data, research team meetings were held as required to consider whether to add new codes or collapse codes into existing categories. Decisions were recorded to maintain the audit trail necessary to ensure adequate rigor.55
Qualitative analysis of phase I findings revealed that the fathers who experienced symptoms of depression associated with their partners' PPD (n = 16) and fathers who did not report any symptoms of depression (n = 24) were indistinguishable in delineating their support needs and support preferences. Moreover, data saturation was evident in both groups. Accordingly, the results of analysis of data from the 2 groups—fathers with and without depression—have been combined in the report of findings.
Phase I focused on delineating fathers' support needs and preferences for coping with their partners PPD and, if applicable, their own depressive symptoms. Overwhelmingly, fathers' expressed needs for support revolved around their perspectives of their partners' needs. In general, fathers did not separate their own from their partners' needs and rather spoke about the couple as a unit requiring support.
Fathers easily spoke about their perspectives of their partners' support needs, which were very similar to their own. They described a need for their partner to have someone to talk to (n = 13), access to professional healthcare services (n = 13) (eg, family doctors, psychiatrists, and nurses), support from family and friends (n = 10), and access to information about PPD (n = 9). When probed to discuss their own needs, fathers wanted someone to talk to (n = 13), emphasizing the value of sharing the burden as in the following quote:
It's like this big pressure. This massive amount of weight of things, thought, and feelings and just by expressing them to another human being, it was like giving a lot of it away. ...I don't know, it's a weird analogy I guess. It's like here, take this. (DAD 05)
Support needed from family and friends (n = 6) often revolved around having someone to talk to. One father noted that friends and family were often surprised at his desire to discuss parenting with other men, as such behavior does not cohere with the typical view of masculinity. As one father said: “It's just nice [o talk] and I mention it because I don't know, I've seen other people like surprised by it. What, dads talk about dads stuff? Yeah, you know it's not all about football” (DAD 08).
Fathers also desired access to information about PPD (n = 11). They believed that this information should be more readily available to new parents and the information that is currently available should feature fathers more centrally. Some men (n = 3) felt that PPD literature marginalized their role as parents, as support resources for their partners, and as potential sufferers of PPD. One father summarized these themes well:
Knowledge of what the father might experience during the time if there is postpartum depression and those sort of things, I'd like to hear a little bit more [about it], not after the fact but during the fact. I looked into more of those signs and symptoms, but it was all to see what I could do to help my wife at the time. It wasn't what I could do to help myself at the time, so in all the literature and stuff like that, it all talks about what you can do to help the mom. There's nothing to say you're getting your head served to you on a platter on a weekly basis, what can you do to support yourself or what are some of the support networks that a father might want to turn to and those sort of things, to help support the father but also to help to support the mother. (DAD 21)
Fathers described a need for healthcare professionals (n = 5), especially physicians and nurses, to have greater understanding of PPD and how it affects the whole family. This was considered essential to avoid missing the symptoms of PPD or paternal depression or even PPD symptom mismanagement, as 2 fathers describe:
My wife went because she felt that there was a problem but there was no push for her to go from the healthcare system ... the follow-up healthcare nurse did not emphasize that she thought she should go and that's kind of scary because she was definitely exhibiting textbooks symptoms. (DAD 02)
In my personal opinion and you know, there's some other things that have happened with this family doctor as of late or recently rather but that you know, I don't think there's any other way to state it, that she was basically just mismanaged. (DAD 23)
Physicians' primary role in treating women's PPD was, according to fathers, peripheral, consisting mostly of filling prescriptions and referring patients to specialists (n = 7). Nonetheless, this was appreciated, as one father said: “Her doctor ... was very helpful in making sure she was on dosages and you know, checking dosages and making sure it was the right dosage.... He was pretty on top of it” (DAD 32).
Fathers described needing healthcare professionals who are respectful, understanding, and responsive to expressed needs of mothers and fathers. Finally, fathers reported that what they needed most was to have healthcare professionals bring their partners “back” from PPD (n = 5).
Timing and duration
Some fathers (n = 21) thought that interventions should begin at a set time, ranging from 1 week to several months after childbirth, whereas others (n = 12) felt that treatment should begin as soon as symptoms first become apparent. Some observed that professionals should be more proactive in seeking contact with new parents after childbirth and at prescribed follow-up points to identify possible cases of PPD. Fathers agreed that services should be offered for as long as required.
Intervention mode and level
Both group (n = 35) and one-on-one (n = 26) support services were desired. Fathers tended to prefer one-on-one support for themselves while more often prescribing group sessions for mothers. However, most thought that each support method should be available to both partners. Fathers favored face-to-face meetings for both group (n = 21) and one-on-one (n = 27) sessions. The biggest advantage fathers' reported for face-to-face meetings was the greater personal connection they offered. Telephone interventions were the next most popular choice for group (n = 8) and one-on-one (n = 20) support. Some fathers (n = 4) appreciated the anonymity telephone support could provide, and others (n = 6) thought it would allow healthcare professionals to easily contact parents and identify potential PPD symptoms. The Internet, though the least popular choice for group (n = 8) and one-on-one (n = 10) support, was still considered desirable by a few fathers who wanted to receive support anonymously (n = 3). Fathers who suggested the Internet spoke about a central Web site containing vast amounts of information on PPD symptoms, tips on coping, and links to local and national support resources. Ultimately, though, many fathers (n = 8) favored an intervention program that incorporated all 3 modes—face to face, telephone, and online.
Fathers whose partners attended support groups reported that such groups had largely positive effects on their partners. They indicated that the forum allowed women suffering from PPD to share their feelings with each other in a supportive environment, offering them a much needed outlet for their frustrations and an opportunity to talk through their problems with a room full of supportive listeners (n = 18). As one father perceived it, the group gave his wife a support he himself could not provide, as it was composed of women who had experienced or were experiencing PPD directly, and thus could validate each other's experience and provide insight into each step of the recovery process.
She could tell me some of the stuff, I just—it's hard to understand unless you go through it, but these women would totally understand. And they could explain to her what was happening—what they thought was happening and say “you don't have to—nobody's going to take your baby.” I could say that to her and she'd get mad at me, “oh, you don't know that.” But these women might be able to talk to her and actually calm her down a little bit and make her realize “wait a second, okay, nobody's going to come and take [our daughter].” I think, yeah, they were a big help. (DAD 03)
Although fathers described support groups as a popular and, for the most part, successful experience for mothers, they themselves were far less likely to make use of such groups (n = 4). Large class sizes were a potential source of fathers' reluctance, as in the following: “I did attend a couple times, but the group was so big that I found it wasn't really intimate. It wasn't a place where I felt super comfortable opening up” (DAD 11).
Considering the ideal facilitator for group support, fathers posed arguments supporting both peers (n = 25) and professionals (n = 28). Peers were valued for their firsthand knowledge of PPD and new parenthood and their ability to empathize and remain nonjudgmental, as in the following quote:
[He] never ever judged I mean, sometimes you know, two guys get talking and you're sitting there like, “Christ what am I telling this guy this stuff” but he was the type that you could feel comfortable doing that. (DAD 07)
On the contrary, fathers also reported that professionals had the skills needed to effectively facilitate conversations and the knowledge to refer parents to other resources. For this reason, many fathers (n = 13) wanted their facilitators to have a combination of personal and professional experience.
My immediate thought was a combination of things. I mean, while I'm not accusing healthcare providers of always pathologizing and turning things into what seems sometimes to sound more serious than they are. I see that to have someone who can identify men who are in places of either crisis or risk, and perhaps [offer] more than just peer support [would be] helpful. (DAD 14)
Whether it was with professionals or peers, when a father discussed wanting to talk things over, he described the ideal candidate as someone to whom he felt comfortable divulging deeply personal information. This would have to be someone with whom the father had developed some sort of bond. Otherwise, he would be less likely to reveal his true feelings.
I don't think I could meet somebody and half hour later be telling them about personal matters, I'd need some get acquainted time before I could share something on a deeper level. At least when I'm in the middle of it. It's easier now. In hindsight, I could do that, but at that time I don't think I could share anything, you're so closing off and protecting yourself because you don't know what the hell is going on. (DAD 04)
For one-on-one support, fathers favored meeting in their homes (n = 16) over a community center (n = 9). Fathers felt speaking about personal matters at home would be easier than doing so in an unfamiliar place. Also, not having to worry about transportation to and from a community center or doctor's office simplified matters for parents (n = 5). For group support, fathers were almost exclusively in favor of a community setting (n = 14) over at-home support (n = 2).
On the basis of the findings of phase I, 2 sets of intervention options (see Table 2) were developed and validated during telephone interviews with selected participants (n = 9; 6 respondents from phase I interviews and 3 respondents who were new to the study) to further inform the design of a support intervention. Fathers reported that the summary reflected their experiences dealing with their partners' PPD and, if applicable, their own depressive symptoms. Fathers regarded the 2 sets of intervention options favorably, agreeing that no single intervention, derived from either option, should prevail as the ideal. Instead, fathers agreed that a combination of supports for both themselves and their partners would be preferred. They noted that the combination of these strategies would be largely dependent on the needs of the individuals and couples affected by PPD. Fathers' main goal was that their partners received support. One father reported, “For me it's more important that my wife get help. I'd feel better if she got the help that she deserved and needed” (DAD 2-03).
Fathers (n = 6) mostly preferred option 2 (ie, telephone peer support for mothers, professionally facilitated couples support, professional counseling for fathers, and physician connection for mothers' medication and referral) to option 1 (ie, professionally facilitated peer group for mothers, connection with knowledgeable physician for mother and father, and peer information for fathers). Some participants (n = 4) believed that a PPD peer support group would be most appropriate for their partners, and in contrast to Phase I findings, most (5) fathers reported that telephone peer support would have been most suitable for partners as well as themselves. Five fathers felt that they would have benefited from individual counseling. In general, fathers agreed that interventions must be as flexible as resources allow (ie, support should be offered in person, over the phone, and over the Internet) and still effectively reduce families' complex burdens.
Increasing public and professional awareness of PPD was recommended by fathers during all the phase II interviews despite the fact that neither was offered as an intervention option. Fathers reported that healthcare professionals, and thus families affected by PPD, could benefit from improved understanding and identification of PPD and depression and provision of supportive and appropriate treatment. Increasing public awareness of, and dispelling false or negative beliefs about, PPD could, in their view, promote earlier recognition of symptoms and encourage individuals and families experiencing difficulty with depressive symptoms to seek support and treatment. As one father noted, “Education is the key” (DAD 2-05). This participant also believed that the general public's erroneous perception of PPD was “just something that happens to your wife, it doesn't have much of an effect on you [men]” (DAD 2-05).
Fathers reported that greater awareness would have helped their employers to be more understanding of PPD and the related family issues. As one father noted, a supportive workplace would have helped him to take time off of work to support his partner's recovery:
Work support would be another area that would be helpful. Having time off to assist with the home situation. Taking time to make sure that all the support pieces are in place. Probably an area that needs to be worked on and developed. (DAD 2-07)
With respect to professional awareness, fathers spoke about the inadequacy of the healthcare system in educating parents, screening mothers and fathers, and identifying PPD (n = 5). Others agreed that some healthcare providers, especially physicians, required more knowledge of PPD (n = 3). To support his point and the need for physicians with knowledge of perinatal mood disorders, one father recalled his frustration regarding his family doctor's failure to recognize that he was experiencing depressive symptoms and reluctance to refer the father for additional support. He noted that the doctor told him, “You just need to get more sleep,” and he felt that he was “on his own to find someone to talk to ... someone to help with the issues” (DAD 2-02). Another father reiterated concerns regarding professionals lack of understanding of his partner's PPD stating:
I cannot overstress the importance of the family physician knowing what the hell he's doing. If you don't have that, unfortunately they are the gatekeepers of the healthcare system. If they don't understand we're not getting anywhere [...] You can have all of the information you want and the access to information that you want but if you don't have the support of healthcare professionals or if you don't have healthcare professionals educating people ... like for instance, if you think about prenatal classes. There is absolutely nothing discussed about PPD. So, information can be there but if the public is unaware, if there is no support within the actual profession that is a significant barrier. Oftentimes people who experience PPD or their partners don't even know what is going on. (DAD 2-07)
All participants agreed that education about PPD should begin prenatally and that fathers should be taught about potential signs and symptoms to observe in their partners. Fathers strongly suggested that they wanted to be involved to help identify symptoms of PPD. This is especially important considering that fathers are likely to be the first individuals to observe changes in their partners' emotional status. One father noted, “...the more you know about PPD, the more likely you are going to be aware of what's going on and be able to take more action” (DAD 2-06). Another father agreed that early information is essential: “If the information is there early on then dads can make more informed choices” (DAD 2-05). Yet, another father felt this information could be as simple as a list of “warning signs that you may need help” (DAD 2-02). Fathers wanted nurses to involve them in identifying depressive symptoms, as expressed in the following quote:
They discharge you, the health nurse comes to check on your wife and your kid. I wasn't home for any of that stuff. They never once asked about me ... they're trained to check moms for any of the symptoms for depression and baby stuff. They don't even request the dad to be there so that they can ask the dad a few simple questions that could determine if things aren't right. (DAD 2-02)
In addition to the intervention options suggested, fathers (n = 3) believed that extended family should be considered as part of the intervention strategy, especially pertaining to accessing information about PPD. One father indicated, “Extended family should be afforded some educational sessions on what's going on ... they would like to help but if they don't understand what is going on, what's the point?” (DAD 2-07). Although the Internet was not preferred as a method for accessing support (n = 7), all of the fathers agreed that it would be a suitable method for receiving information about PPD and to help them identify regional resources. One father stated, “One of the things if you're going help dads and probably the cheapest is a Web site. Putting the info on it and dads will find it.” (DAD 2-05).
Although PPD has traditionally been viewed as a woman's issue, the findings of this study underscore the need for consideration of the implications and impacts of PPD for fathers as well as mothers. Objective 1, describing the support needs and support preferences of fathers whose partners have had PPD was met by phase I interviews. Objective 2, soliciting fathers' perspectives on innovative support intervention, was met by phase II interviews. Moreover, fathers voiced the same needs and preferences for support whether or not they reported a history of depressive symptoms.
Fathers offered thoughtful and thorough advice about an ideal intervention program for their partner and themselves. Opinions varied, but, overall, fathers felt most comfortable with a flexible, multitiered program covering a broad spectrum of topics, styles, and media. Although they described their ideal program in detail, few fathers elucidated the difference between an optimum support intervention for themselves and one for their partners. With few exceptions, support for parenting and facilitating children's development was likewise not discussed.
Increased community awareness of PPD
Fathers unanimously agreed that the greatest barrier to the early identification of their partners' PPD and access to treatment was poor public knowledge. Similarly, Davey et al11 found that Australian men faced with psychological-based family difficulties felt socially isolated in their work and social lives as a result of the lack of available forums for men, perceptions that were exacerbated by conflict and uncertainty regarding role expectations for men in Australian society. These men felt that improved community awareness about PPD would encourage them to seek support.11
Like mothers' perspectives, fathers regarded themselves as an important source of support for their partners' afflicted with PPD. Fathers could be the first line of defense against PPD, because they are most likely to identify early changes in their partner's emotional status. Other family members should also be considered as part of the support and care treatment network, particularly in terms of education about PPD signs and symptoms. In a prospective study, Chinese women who received inadequate or poor postpartum support from family members, particularly husband and parents, were at increased risk for PPD.56 In order for fathers to provide the best support possible to their partners, the importance of their role must be recognized and their contributions actively encouraged. Fathers themselves may also experience PPD, which if left untreated may limit their capacity to provide emotional support to partners and mediate the potential deleterious impact of maternal PPD on children.57 Men's emotional health should not be overlooked, particularly during their partners' pregnancy and first year of postpartum. Postpartum depression in men can be difficult to assess, especially because fathers' depressive symptoms may appear more akin to anger and anxiety than sadness.12
Regardless of their symptoms, fathers in this study were most concerned that their partners receive adequate assistance, advocating for a combination of peer and professional support from a variety of sources. Most of the fathers in this study agreed that there was no single intervention that would meet all of their needs and that an array of services and supports tailored to the needs of families would be ideal. Fathers also wanted help but viewed this as less important than the needs of their partners. They did not consider their partners' support needs to vary greatly from their own. According to fathers, both they and their partners needed informational and emotional support from an objective, nonjudgmental, and sympathetic peer. According to fathers, women are more likely to be comfortable sharing in a face-to-face group setting whereas men may have to rely on less intimate connections until they are more familiar with their support networks. A few fathers suggested that attending sessions with their partners would be desirable, but the majority reported that seeking help separately would allow each partner to be totally candid, thereby increasing the efficacy of the treatment.
Support interventions need to be as flexible as resources allow (ie, offered in person, by phone, or via the Internet). One especially critical element is an informative and accessible network of information about PPD, such as maternity discharge packets, advertisements, and online listings of resources for couples affected by PPD. Although fathers did not regard the Internet as a direct source of emotional support, a well-designed, easy-to-navigate, and interactive Web site could meet their informational and support-seeking needs. The Internet is also a highly effective means for providing healthcare professionals with the tools to successfully engage, screen, diagnose, treat, and refer women with PPD.58 Telephone support lines may provide the one-on-one support that fathers did not envision being provided by the Internet.
Implications for nursing practice and education
An important finding in this research was fathers' perception that their own mental health was minimized by healthcare professionals and they were often not included in their partners' care plan. Similar research suggests that child healthcare nurses may provide fathers with less emotional support because they are ambivalent about fathers' caring abilities. Efforts must be made to involve both parents in the care of their children.59 Clinical nurses can contribute to public awareness by including information about PPD and paternal depression in existing prenatal and postpartum programs.12 Support could be coupled with other reproductive services (ie, mother-baby clinic visits) to lessen the burden on busy families, and PPD education should be reinforced in the hospital after birth, during Well Baby checkups and inoculations, and should be accompanied by PPD screening.
Given the clinical significance of paternal PPD, fathers could be assessed for mood disorders in the postpartum period, particularly if their partner is depressed.6 Perinatal services, such as antenatal and postnatal education, could be offered to both mothers and fathers,60 as well as referrals to group or one-on-one support and follow-up for families who are affected by PPD.12 Evidence suggests that providing pediatricians with additional training in the diagnosis of depression may enhance physicians' abilities to recognize parental depression, and use of brief screening tools in pediatric settings may facilitate nurses and other healthcare professionals in the identification of mothers with symptoms of depression.17
Limitations of the study
These findings should be interpreted with caution, given the potential for selection bias in this sample. The fathers who responded to the recruitment advertisements for this study may not reflect the support needs and preferences of the larger population of fathers affected by PPD. Furthermore, despite direct probes in qualitative interviews in phases I and II, fathers persisted in placing a greater priority on accessing support for their partners than for their own needs and intervention preferences. Nonetheless, fathers' abilities to infer the support needs and wants of their partners may be questioned. Fathers did not mention the impact PPD exerted on their interactions with their children. Apart from highlighting the importance of providing childcare services, children did not feature in fathers' recommendations for an intervention program. Further study is required to better understand how PPD affects parenting needs. Fathers discussed mothers' support needs and barriers at length, but when asked to detail the attributes of an ideal PPD intervention program, few fathers distinguished between support for themselves and their partners. Although some distinctions can be drawn from their discussions, it is difficult to disentangle fathers' support needs from those of mothers. Further study will offer a better understanding of how to frame interventions targeting parents as a couple versus programs for mothers and fathers individually. Finally, although the fathers who participated in our study came from both rural and urban backgrounds, they nevertheless encompassed a fairly narrow range of human experience. Furthermore, research focusing on families from different ethnic, cultural, and socioeconomic backgrounds is needed7 to develop more inclusive or targeted intervention programs.
Although PPD is better understood now than it has been in the past, a lack of public and professional awareness remains. Findings from this research revealed that the ideal PPD support intervention does not favor a single strategy or mechanism. To reach the full spectrum of parents, ideal programs must be multitiered, accessible, and as flexible as funding allows. Professionals should be available for confidential, individual sessions and to facilitate peer support group meetings where mothers and fathers, both together and individually, can discuss their feelings and concerns in a secure, nonjudgmental environment. Telephone services could also be available to handle crises and provide ongoing supplementary support as necessary.
Postpartum depression, if left untreated, can have a profound impact on fathers' ability to support their partners and promote appropriate development of their children. For this reason, treatment methods should strive to include both partners. Furthermore, support resources should stress that both mothers and fathers can experience PPD, and even if only the mother has a diagnosis of PPD, the symptoms physically and emotionally tax both parents. Far from downplaying men's roles in PPD care, resources should encourage their participation and offer support to them.
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Keywords:© 2012 Lippincott Williams & Wilkins, Inc.
fathers; men's mental health; men's support needs; postpartum depression