Recruiting Perinatal Fathers to Interventions and Research: A Conceptual Model of Engagement and Integrative Review of Barriers Encountered and Strategies Used
The University of Denver, Graduate School of Professional Psychology, 2450 S. Vine ST, Rm. 106, Denver, CO 80208, United States
Academic Editor: Jenn Leiferman
Received: May 31, 2022 | Accepted: August 31, 2022 | Published: September 14, 2022
OBM Integrative and Complementary Medicine 2022, Volume 7, Issue 3, doi:10.21926/obm.icm.2203041
Recommended citation: Holmberg JR. Recruiting Perinatal Fathers to Interventions and Research: A Conceptual Model of Engagement and Integrative Review of Barriers Encountered and Strategies Used. OBM Integrative and Complementary Medicine 2022; 7(3): 041; doi:10.21926/obm.icm.2203041.
© 2022 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.
Traditionally, the term “father” referred to the male parent and his contributions to childrearing which encompassed many roles (e.g., primary or co-caregiver, affective co-regulator for the child, playmate, co-provider of nutrition and daily needs as well as co-provider of basic family resources). Considerable research has shown that father involvement conveys protective and, at times, risk influences that contribute significantly to child and family outcomes such as normative developmental milestones, mental and physical wellness, and school readiness [1,2,3]. For this review, the terms father(s), dad(s), and paternal are used synonymously and without clarification as to male genetic contribution to the pregnancy or, due to the fluid and changing nature within families, the nature of the parents’ intimate partnership, marital, or cohabitation status. While there is no universally recognized definition, this manuscript adopts a broad definition of the “perinatal period”  as referring to a time of parent, child, and family transitions resulting from a new pregnancy that persists beyond the birth, until the child’s first or second birthday.
For fathers, the perinatal period and transition to parenthood, whether it be the first time or with a subsequent birth, has been deemed a “magic moment” by studies such as Fragile Families and Child Wellbeing [5,6]. The period is distinct due to the degree to which role changes contribute to parents’ openness to engage in support programs and developmentally focused research [7,8,9]. This period is also considered unique because perinatal fathers have, relative to other times in development, high engagement with the mother and child(ren) because parental intimate partnerships are still intact and they likely reside within the same household [10,11]. The perinatal period is further important because fathers are engaged in, potentially malleable, health risk behaviors that impact parenting, caregiving, and co-parenting [12,13,14,15,16]. Paternal health studies in the perinatal period find that many fathers experience increased health and mental health problems; but, relative to mothers, men are poor health care consumers and do not anticipate negative impacts of the birth on their own wellbeing [17,18,19,20,21,22,23]. Outcome studies of paternal-focused (i.e., specific for dads) and father-included interventions find that programs can increase resilience and reduce the impact of existing risk factors, which result in enhanced support for mothers, more adaptive caregiving and co-parenting, and better child development outcomes [24,25,26,27].
The perinatal period may be an opportune time to engage fathers but paternal-focused interventions and research studies report that recruiting, engaging, and retaining fathers is a nearly universal challenge [27,28,29,30]. Currently, the paternal recruitment and engagement literature is comprised of a few program evaluations and quasi-experimental studies (e.g., [31,32]), descriptive reviews (e.g., [33,34]), distilled opinions, beliefs, and recommendations from qualitative studies of fathers and other stakeholders (e.g., [29,35,36]), and recommendations from expert working groups [37,38]. A protocol for systematic review and meta-analysis of paternal recruitment and engagement strategies was proposed ; but, this step only articulates a process for distilling key findings and lessons from a large number of studies. The literature on recruiting, engaging, and retaining fathers likely is not yet adequately developed for those techniques. Yarmeych & Perskey  found that almost “no conclusive evidence” has surfaced regarding the most fruitful approaches to recruit fathers into interventions or research.
Previous reviews of paternal recruitment and engagement found that most studies do not tally or describe the outreach strategies used (e.g., recruitment information found in only 2 of 200 studies) [40,41]. The lack of data on how programs are recruiting fathers leads to a presumption that programs use widely ranging systematic and non-systematic (i.e., convenience) approaches. Programs that do not evaluate the representative demographics of fathers who are engaged in their activity, relative to the community being served or the degree to which specific strategies were successful in engaging fathers may inadvertently be relying on convenience-based strategies. A problem with such an approach is convenience recruitment may routinely miss certain sub-populations including Black, Indigenous, and People of Color (BIPOC) fathers and those facing greater socio-economic adversity [42,43]. To date, very little has been published on how frequently perinatal father subgroups are disproportionately overlooked or not recruited for interventions and research studies. The few studies evaluating potential bias in paternal recruitment (i.e., mental health screening and child welfare services) found inadequate recruitment of BIPOC fathers (i.e., in studies of mental health screening and child welfare service engagement) and research studies using such approaches result in limited generalizability of findings [44,45].
Nonetheless, to advance work in this area there is value in summarizing the current findings from the literature on paternal recruitment and engagement during the perinatal period. To frame and articulate what is included in the process of paternal recruitment and engagement, this manuscript offers a descriptive conceptual model and then provides an integrative narrative of themes and strategies highlighted in this literature to date. Given the significant overlap found in publications related to paternal recruitment and engagement for social programs, preventive interventions, and research, the term “activities” will be used to represent the variety of opportunities for which fathers are recruited.
This manuscript chose the integrative review  approach due to little prior systematic study of paternal recruitment and engagement. Integrative reviews create a holistic representation of the issues and relevant concepts from diverse sources (e.g., quasi-experimental studies, program evaluations, organization reports, and recommendations from prior experience) to frame and inform future work on the topic. The steps of integrative review followed in this study were: (1) issue identification/problem formation, (2) literature search, (3) evaluation of findings, (4) data integration, and (5) interpretation of findings and presentation of results.
Specific search strategies included scanning relevant databases including Google Scholar, PsycInfo, Scopus, ProQuest, and PubMed. To identify relevant father-focused program evaluations and reports from social service initiatives and the private sector, electronic searches were repeated in ResearchGate and the Google web browser. Search terms included - paternal, father, recruitment, engagement, outreach, barriers, fatherhood, perinatal, and early childhood. Manuscripts written in English, published during or after the year 2000, and found to describe strategies to reach out to and engage fathers in programs of education, service, or research were read for inclusion in this review. Citations and articles were downloaded to Mendeley citation management software where keywords and references were searched to identify additional manuscripts. In this review of paternal recruitment and engagement, six articles represented program evaluations of which three used a quasi-experimental design. The remaining manuscripts described barriers faced, strategies used, and lessons learned from recruiting and engaging fathers.
3. A Model of Processes and Factors Related to Paternal Activity Involvement (PAI)
A model of Paternal Activity Involvement (PAI) is presented below to represent the process of recruiting and engaging fathers in activities such as parenting interventions, psychotherapy, and research [47,48,49]. Figure 1 visually depicts the PAI phases of father engagement and the influential factors (i.e., barriers and facilitators) which have been identified by the literature on paternal recruitment.
Figure 1 Phases of Paternal Activity Involvement.
Adapted from previous narrative conceptualizations and visual models [28,47,48,49], the PAI contains four overlapping periods of activity i.e., recruitment, engagement/participation, retention, and generalization. Recruitment includes steps such as identifying the father (i.e., invite partners from all new birth certificates or upon enrollment in the childcare setting), outreach (i.e., first contact), recruitment (i.e., discussion of what is offered and the degree of interest) and enrollment (i.e., formal acknowledgment of starting) . Each activity may operationally define recruitment differently (e.g., the father was contacted and discussed participation with staff vs. the father enrolled and participated in the initial session); for most, recruitment likely transitions to engagement during that first meeting. Paternal engagement represents the period of involvement across the full duration of the activity (e.g., asking about goals, using screening tools, delivery of the content, or completing research protocols). Across sessions, retention is an important aspect of engagement until the point in time when the father discontinues participation (i.e., attrition; actively indicating his stopping, passively such as through lack of response, or graduation/ending). Generalization of outcomes was added to the model as some activities have extensions from the initial episode of the activity (e.g., check-ups, boosters, or additional phases of longitudinal follow-up) and factors influencing engagement during this period of the activity may or may not differ from other phases (e.g., becoming a blended family with subsequent partners leading to lower interest in engagement among fathers).
Within each phase of paternal engagement, activities have an opportunity to identify potential barriers that reduce enrollment and facilitators that increase participation. For example, programs need to look at the degree to which practical (e.g., outreach materials, languages available, means of communication, times of day services are offered), cultural issues (e.g., participation in a service without one’s partner, gender-based expectations of childrearing), relational (e.g., cultural competence, staff training, and skill, provider alliance), strategic (e.g., tele-sessions), and structural influences (e.g., program policies regarding fathers who are deployed during the intervention, and availability of sustained funding) impact father engagement and progression through an activity . Unfortunately, almost no systematic research has been conducted on the degree to which different approaches are effective with fathers or to what degree barriers create impediments to paternal recruitment in the perinatal period. As this manuscript is focused on fathers in the recruitment phase, the next section presents integrated findings regarding factors influencing paternal engagement.
4. Factors Impacting Paternal Identification, Outreach, Recruitment & Enrollment
4.1 Practical, Structural, and Strategic Barriers
The most basic practical barriers to engaging fathers are a) not explicitly stating services are intended for fathers (i.e., general “parenting” activity flyer) and b) lack of awareness - either fathers do not know about the opportunity and/or providers are not aware of eligible fathers . Programs that rely on passive recruitment (e.g., media advertisements, websites, and service listings) are far less likely to reach a majority of eligible fathers in a community. Passive approaches are more likely to engage highly motivated participants while missing socioeconomically stressed and marginalized dads, i.e., those who are most in need of support by their experiencing the greatest cumulative risks for negative child and family outcomes .
How activities are set up to engage fathers can create barriers to enrollment and participation (i.e., is it a parenting activity that is father-inclusive vs. father-specific, is participation done as part of a group or more 1:1, center-based vs. home-based, or allows for asynchronous engagement) . Qualitative studies presented mixed findings about the preferred format, as some find that fathers’ stated preference is for paternal-only/group-based activities, especially when those services are linked to trusted community organizations, and others prefer to participate in programs serving both parents . High-quality service delivery (e.g., high organizational and supervisory support, training to ensure facilitator expertise, low turnover) also likely impacts recruitment and engagement as it results in positive participant experiences and garners credibility in the community [53,54,55]. The quality of interpersonal connection or bond between participants and facilitators has also been cited as a vitally important aspect of recruitment in parenting programs. The degree to which this is applicable in father-focused activities has not been as widely studied [56,57].
Concrete barriers to paternal recruitment have been reported for issues such as transportation problems, the availability of remote/electronic participation, legal status requirements (e.g., immigration documented, biological father), hours the activity is available, and cost of or incentives for participating [28,52,58]. The idea that paternal engagement in perinatal activities is precluded by fathers’ employment has been essentially debunked, as scheduling flexibility successfully overcomes this barrier .
Inadequate attention to culturally relevant and responsive activity development and adaptations also represent observed barriers to father recruitment and engagement [59,60,61,62]. Successful activities directly address cultural and gender-based differences, common misconceptions, as well as negative assumptions about fathers (e.g., dads are not interested, fathers prefer to leave parenting to moms, teens dads are not involved, fathers are just stoic or unemotional) . Maintaining the status quo regarding attitudes, beliefs, and practices may contribute to professional gatekeeping or communications and behaviors that disenfranchise rather than successfully engage fathers [26,64]. Another culturally relevant barrier is making assumptions about technology access and acquired skills (e.g., smartphone, application navigation savvy) as they can create rather than reduce barriers to access for vulnerable fathers [65,66].
4.2 Barriers Linked to Family and Father Factors
A commonly reported family-associated barrier to paternal recruitment and engagement is gatekeeping. Gatekeeping refers to the father’s participation being regulated by the other parent or another family member (e.g., maternal grandmother) [67,68,69]. Examples include passive gatekeeping such as not telling the dad about the opportunity or active gatekeeping such as refusing to include the father in home-visiting sessions.
Low paternal readiness or openness to engage in a service or activity will likely impact recruitment and engagement [40,70,71,72]. Studies of fathers, relative to mothers, in parenting behavior training found the dads reported they were less ready for change, less confident about their ability to change, endorsed greater resistance to change, and saw their activity involvement as less central to affecting the child’s behaviors .
Traditional masculine gender role beliefs, when strongly held and internalized by fathers, are reported as barriers to paternal activity engagement. Examples reported include men’s preference for gender-segregated parenting roles [73,74,75] and men prioritizing work commitments to ensure the provision of basic needs and expenses . Additional beliefs that were barriers to recruitment include stigma or fear of judgment by others ; a generalized avoidance of health and mental health providers [78,79,80,81,82,83] and rigidly held hegemonic masculine beliefs about accepting assistance from others (e.g., avoidance of vulnerability, dependence, and emotionality; the fierce need for independence and persevering without help) [30,84,85,86,87]. Culture-based mistrust of health and intervention providers also is reported as higher for fathers, relative to mothers, and especially among BIPOC fathers [88,89,90].
Following a new birth, many fathers engage in health risk behaviors [22,91], as they do not anticipate the negative impact of childrearing on their wellbeing [13,92,93]. Those behaviors can result in increased health problems [13,94,95] which can interfere with paternal activity engagement. Similarly, the perinatal period represents a period of increased stress, depression, anxiety, alcohol/substance misuse, and other mental health difficulties [96,97,98,99,100,101] which can interfere with motivation to engage in paternal-focused activities.
Despite a range of observed barriers, the literature also contains observations of facilitating factors and recommendations for successful paternal engagement. The next section integrates findings regarding strategies that have been successful, or at least promising, in terms of paternal recruitment and engagement.
4.3 Paternal Recruitment Facilitators & Promising Approaches
4.3.1 Organization Context Facilitators
By using methods such as the PAI model proposed above to frame the important phases and influences for paternal participation in activities, organizations have an opportunity to continually improve their sustained processes for paternal recruitment and engagement . Systematically tracking the impact of different recruitment and engagement strategies (i.e., including the perspectives of engaged clients as well as those who declined) and the occurrence of barriers to participation experienced can inform improvement over time . Gaining consumer perspectives and feedback on all aspects of recruitment and engagement has been consistently cited as a key to success [29,58,103,104,105].
Implementing activities through a “father-friendly” or a father-integrated organizational framework is regularly highlighted as important for engaging dads. Father-welcoming physical spaces, materials, communications, processes, and staff trained to deliver activities in inclusive and non-assuming ways are reported as central to “getting dads” [30,50,106,107]. Orienting staff and community champions on the specifics of how the activity is tailored for fathers and that there are ongoing efforts to reduce paternal barriers to engagement are also reported as important. An example of such an approach was presented by Denzmore and colleagues ; that paper described staff and collaborator training based on the acronym PATIENCE, which was developed to ensure success in recruiting African American fathers. The PATIENCE approach included strategies such as:
- Passive (or media-shared) information needs to be shared to create awareness of the opportunity for potential participants,
- Active recruitment by staff and champions to ensure paternal awareness and enrolment,
- Training to ensure competent delivery of program activities and cultural humility,
- Involving community champions as important for linking men to the program,
- Education involves orienting participants on how the activity will be meaningful and have a positive impact on them and their children,
- Nurturing participants speaks to listening closely to their needs, concerns, and making adaptations to the activity,
- Commitment represents how the team is supported to be integral to the activity,
- Evaluation for continual improvement to ensure delivery on the promise of the opportunity.
Additional organization-level factors found to impact paternal recruitment are the use of incentives and investments in quality improvement . Financial and/or in-kind incentives are used to reduce economic barriers to participation and increase motivation to engage paternal-focused activities. Barriers such as unreliable transportation and cost of childcare are often raised by fathers as lessening their opportunity for engagement. Another form of incentive that positively impacts paternal recruitment is offering additional service access (e.g., housing access, legal assistance, GED, job training, and placement) .
4.3.2 Passive Recruitment Strategies
The creation of father-specific “messaging” or advertising content impacts recruitment and includes planful decisions about content, delivery, and placement of those messages. Two quasi-experimental program evaluations demonstrated that paternal-specific content had a several-fold increase in successful paternal recruitment and engagement, relative to messages generically targeting parents [32,109]. Successful messages were reported to include: a) the father-specific vs. father-included nature of the activity, b) what dads will learn about and do, c) how the activity builds from fathers’ existing knowledge and strengths, d) assurances that activities will be conducted well (i.e., culturally informed, ethically delivered, and providers have content expertise) and e) highlights the barrier reduction strategies available and benefits to family functioning and child development from participating [28,30,62,110].
Across qualitative studies, fathers report placement of messages is also important. To maximize fathers noticing activity advertisements, messages need to be placed frequently, through a variety of outlets, and in locations where men are present. Fathers described that such a multipronged approach conveys that the activity is solidly established (and potentially lasting) to contrast it with fly-by-night projects or those mainly serving the interests of providers or researchers . Widespread communication was also rated by fathers (and mothers) to reduce their perception of stigma associated with engaging in parenting activities . These studies identified priority locations for message placement to be recreation and youth sports centers, churches, clinics, barber shops, and mass transit. Fathers also recommended the use of multiple father-child images and text in applicable languages to reach immigrant and BIPOC fathers as well as marginalized subpopulations such as teen dads [29,40]. Not only does such an approach help with recruitment reach, but it was also noted to convey important information about the culturally-grounded nature of the activity .
There are mixed observations about the use of high-profile people’s images and voices (i.e., celebrities, athletes, actors, artists) as messengers to reach fathers for recruitment. Some studies indicate high-profile messengers help reduce paternal barriers like stigma . Others observed greater success using local leader voices, as they lend credibility to the initiative and conveys how involvement is approachable for diverse and marginalized fathers .
Passive recruitment via the Internet (e.g., listservs, placed ads) and social media approaches are increasingly used to recruit fathers. When these approaches were evaluated, relative to other strategies, there were reportedly cost- and time-efficient . Given the shifting nature of what media outlet is most widely used at any one time (e.g., TV or radio ads, MySpace, Craigslist posts, ads on Meta or Google), it is difficult to study whether one will consistently be the most successful for paternal recruitment . Similarly, the relatively new approach of recruiting fathers through “crowdsourcing” and the use of paid services (e.g., ResearchMatch, Amazon Tuk, or MTuk) was also reportedly effective [113,114]. These types of services actively maintain information about available activities and lists of potentially interested participants or use small efforts from large groups to actively outreach to and engage potential participants . Such approaches may have unidentified or unintended drawbacks that need to be considered (e.g., another form of convenience sampling, high homogeneity from the self-selective nature of fathers reached through these methods, participant online privacy, and identity protection).
4.3.3 Direct Recruitment Strategies
The most traditional (and frequently cited as successful) recruitment strategy is directly inviting potential father participants either face-to-face or by phone . This type of recruitment is conducted by organization staff, collaterals from other services, recruiters nested in the community, through influential community champions, or participants engaged with the organization. Face-to-face recruitment by staff is the most personal approach and, when it is done in settings wherein fathers already are and feel comfortable, this method is consistently cited as successful in engaging a range of fathers [28,31,40,116,117]. Staff outreach is time intensive but ensures accurate information is delivered and it can address barriers or sources of resistance to enrolling (e.g., from low understanding of the program or problematic past experiences) . Even when activity staff is doing the outreach, there are reported benefits from developing relationships with community stakeholders and other program providers to effectively position staff to reach dads for recruitment (e.g., education settings at pick-up time, school festivals, community events) [28,29,118].
Two additional, program-based, personal-outreach approaches are kinscription and snowball recruitment. Kinscription is where paternal recruitment is facilitated by already service-engaged family members (e.g., mothers in group-based obstetric care, and antenatal classes) [76,119,120,121]. Similarly, programs report success by asking participating fathers to help with “snowball” recruitment or inviting fathers from their networks of friends, colleagues, and social settings to participate . A downside of these approaches is the systematically selective nature of the recruitment which likely results in engaging less diverse and fewer higher need fathers in the activity [2,122].
The use of non-staff recruitment surrogates (e.g., staff from health care settings, community centers, legal clinics, or court) is also cited as successful in recruiting fathers . When using surrogate recruitment, programs report that it is important to implement orientation strategies that help non-program staff understand core aspects of the activity (e.g., key contacts, how the activity benefits dads) and establish a sense of shared ownership in the recruitment process [29,99,108,124]. Another reportedly helpful, community-grounded, surrogate paternal recruitment strategy is subcontracting to recruitment champions from the community, especially when involving recruiters from backgrounds similar to those of fathers you seek to engage . A specific example of surrogate recruitment was the Community Engagement Corps project which was grounded in “oral-culture” recruitment . This approach coordinates key, organically identified, community leaders who ensure information is disseminated to specific groups of fathers by talking with a wide range of individuals within a community. This approach was described as uniquely successful in instilling fathers with trust in the activity and thereby impacting recruitment .
5. Conclusion and Recommendations
In the past decade, paternal research in the perinatal period has flourished [1,80,125,126,127,128]. Most fathers are active caregivers, they engage in many roles and contribute significantly (i.e., protective and at times risk influences) to a healthy child and family outcomes [1,2,3]. The perinatal period represents a unique developmental window for families and an opportunity to reach and engage fathers in preventive interventions and research. While previously underacknowledged, fathers struggle with the transition to parenting, and many report increased health and mental health problems during this time; but, compared to mothers, they are less likely to enroll in programs and services that could mitigate those difficulties [82,129]. Intervention programs and research studies have found recruiting, engaging, and retaining fathers is difficult due to factors such as men’s low knowledge of available resources as well as logistical, internalized barriers (e.g., values, beliefs), and program level impediments [27,29,130]. Aside from a few quasi-experimental studies on the impact of changing advertisement text to specifically state they are seeking fathers, there has been no systematic study of or conclusive evidence on effective paternal recruitment strategies.
The Phases of Paternal Activity Involvement model (PAI) was developed as a framework to facilitate program evaluations and research on the distinct but interwoven periods of paternal participation in interventions and research activities as well as the multiple factors (e.g., barriers and successful strategies) that affect fathers’ participation during the perinatal period. Within phase influences (i.e., barriers and facilitators) were identified from prior studies of parent recruitment and participation, with some specific studies related to fathers [28,32,47,48,131]. Previous research on barriers and facilitators of paternal recruitment and engagement led to organizing these influences within the PAI model as practical, structural & organizational, strategic & relational, and father & family linked factors.
To further work in this area, the following are proposed as the next steps related to paternal recruitment. 1) Activities are encouraged to use some form of logic model, such as PAI, to structure their thinking about specific influences and strategies used to facilitate paternal recruitment and engagement [48,108]. 2) Activities that engage fathers are encouraged to collect and summarize the degree to which methods of recruitment result in differing levels of paternal enrollment and whether interactions by demographic variables are evident to suggest differential success in recruiting socioeconomically marginalized and BIPOC fathers. 3) As this literature evolves, the degree to which similarities and differences between paternal recruitment for engagement in interventions/parenting programs vs. participation in research need to be clarified. 4) Passive approaches to paternal activity engagement were reported to be important but, alone, they are reportedly less successful in recruiting BIPOC, underserved, and socioeconomically marginalized fathers. Thus, additional approaches need to be developed and evaluated as to what leads to the most successful recruitment . 5) Personal outreach to fathers for recruitment is cited as successful, especially when coupled with efforts to establish long-term relationships with community partners, but these approaches can be augmented by innovative strategies grounded in oral traditions of BIPOC groups such as seen in the “Community Engagement Corps” approach . 6) Previous studies found that soliciting consumer feedback and making adaptations based on that information positively impacts paternal recruitment and engagement, by addressing fathers’ perceived needs and removing identified barriers (e.g., [40,60,103]). The generalizability of those findings needs to be further studied. 7) Initial studies found that the relatively new approaches to paternal recruitment via social connection technology and crowdsourcing were effective [113,114], but there may be as of yet unidentified drawbacks which need to be studied.
The author wants to acknowledge the concept development and planning contributions to this manuscript by Jenn Leiferman, Ph.D., James F. Paulson, Ph.D., Tracy Moran-Vozar, Ph.D., Jessi Walls, MPH, and Rachael Lacy, MPH.
The author did all the research work of this study.
This work was supported by a grant from the Kirkpatrick Family Foundation.
The author has no competing interests to disclose.
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