Published online April 3, 2006
PEDIATRICS Vol. 117 No. 4 April 2006, pp. e637-e645 (doi:10.1542/peds.2005-1612)
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Fathers and the Well-Child Visit

Craig F. Garfield, MD, MAPPa,b and Anthony Isacco, MAa

a Department of Pediatrics, Evanston Northwestern Healthcare Research Institute, Evanston, Illinois
b Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
OBJECTIVE. Societal and economic shifts have expanded the roles that fathers play in their families. Father involvement is associated with positive cognitive, developmental, and sociobehavioral child outcomes such as improved weight gain in preterm infants, improved breastfeeding rates, higher receptive language skills, and higher academic achievement. However, father involvement in health care has been studied little, especially among nonmarried, minority fathers. Fathers are a significant part of the child's medical home, and comprehensive involvement of both parents is ideal for the child's well-being and health. Well-child visits (WCVs) represent opportunities for fathers to increase their involvement in their child's health care while learning valuable information about the health and development of their child. The objective of this study was to explore fathers' involvement in, experience and satisfaction with, and barriers to WCVs using qualitative methods.

METHODS. In-depth, semistructured, qualitative interviews were conducted in 2 cities with a subsample of fathers who were participating in the national Fragile Families and Child Wellbeing Study. The 32 fathers who participated in our study come from a nested qualitative study called Time, Love, and Cash in Couples with Children. Fathers in our study reside in Chicago or Milwaukee and were interviewed about health care issues for 1.5 hours when the focal child was 3 years of age. Questions focused on the father's overall involvement in his child's health care, the father's attendance and experiences at the doctor, health care decision-making between mother and father, assessment of focal child's health, gender/normative roles, and the father's health. The open-ended questions were designed to allow detailed accounts and personal stories as told by the fathers. Coding and analysis were done using content analysis to identify themes. Particular themes that were used for this study focused on ideals of father involvement and dis/satisfaction, barriers to, and experiences in the health care system.

RESULTS. Of the 50 fathers from the Time, Love, and Cash in Couples with Children study in the 2 cities, 3 had moved out of the state, 6 were in jail, 7 had been lost in earlier follow-up, and 1 had died, leaving 33 eligible respondents. Of those, 1 refused to participate, resulting in a final sample of 32 fathers and an adjusted response rate of 97%. The mean age was 31 years, and the sample was 56% black, 28% Hispanic, and 15% white; 53% were nonmarried. Only 2 fathers had attained a college degree or higher, and 84% of the fathers were employed at the time of the interview. The majority (53%) had attended a WCV and 84% had been to see a doctor with their child in the past year. Reasons for attending a WCV included (1) to gather information about their child, (2) to support their child, (3) to ask questions and express concerns, and (4) to gain firsthand experience of the doctor and the WCV. Fathers reported positive and negative experiences in their encounters with the health care system. The 3 main contributors to fathers' satisfaction with health care professionals were (1) inclusive interactions with the physician, (2) the perception of receiving quality care, and (3) receiving clear explanations. The negative experiences were often specific instances and noted along with positive comments. The negative experiences that were mentioned by the fathers included feeling viewed suspiciously by health care staff, being perceived as having a lesser emotional bond with their child than the mother, and the perception that they were receiving a lower quality of service compared with the mother. Major barriers to attending WCVs include employment schedules as well as their relationship with the focal child's mother. For example, some fathers stated that they did not attend WCVs because that was a responsibility that the mother assumed within the family. Other fathers lacked confidence in their parenting skills, which resulted in lower involvement levels. Also mentioned were health care system barriers such as inconvenient office hours and a lack of access to their child's records. Despite the presence of several barriers that seem to prevent fathers from attending WCVs, many fathers (20 of 32;63%) mentioned "situational flexibility," which enables them to overcome the stated barriers and attend doctor visits. For example, some fathers viewed the seriousness of the visit such as "ear surgery" as a reason to rearrange their schedules and attend a doctor visit with their child.

CONCLUSION. The majority of fathers from our sample have attended a WCV, and most have been to their child's doctor in the past year; WCVs and doctor appointments are ways in which fathers are involved in their child's health care. Fathers detailed specific reasons for why they attend WCVs, such as to support their child, ask questions, express concerns, and gather information firsthand. The fathers reported more positive than negative experiences with the health care staff, and, overall, they are satisfied with their experiences with the health care system. Reasons for satisfaction include feeling as though their questions had been dealt with seriously and answered appropriately. However, the fathers in our study did report a variety of barriers to health care involvement, including conflicting work schedules, a lack of confidence in their parental role, and health care system barriers. Professionals who care for children and families need to explore creative ways to engage fathers in the structured health care of their children. For example, pediatricians can stress the benefits of both parents being involved in their child's health care while reframing the importance of WCVs. Understanding that many fathers have situational flexibility when it comes to health care encounters may encourage physicians to suggest more actively that fathers attend WCVs. Pediatricians can also support existing public policies such as the national 2003 Responsible Fatherhood Act that provides grants and programs that promote the father's role in the family and advocate for additional policies that would foster quality father involvement. Continued collaboration among families, physicians, and other health care professionals is essential to support father involvement and ensure positive health outcomes for children.

Key Words: fathers • medical home • parenting • pediatric • well-child visit

Abbreviations: AAP—American Academy of Pediatrics • WCV—well-child visit • TLC3—Time, Love, and Cash in Couples with Children

The expansion of the father's role in the family in the past several decades is the result of societal and economic shifts that challenge the long-held belief that fathers are merely providers and disciplinarians.1–6 Fathers are spending more time with their children, and their involvement can assume a broad range of roles and responsibilities.7,8 There are many positive socioemotional, cognitive, and developmental child outcomes associated with father involvement, such as improved weight gain in preterm infants, improved breastfeeding rates, higher receptive language skills, higher academic achievement, higher self-esteem, lower depression and anxiety, and lower delinquent behaviors.9–22 The importance of father involvement is implicit in recent American Academy of Pediatrics (AAP) Policy Statements that promote family-centered, preventive care in a medical home and anchored in the community with physicians who promote father-friendly practices.6,23–26

Despite beneficial evidence, fathers remain underrepresented in most research compared with mothers. For example, in the National Survey of Early Childhood Health study, parental input came from the parent or guardian who was identified as being the most responsible for the child's medical care, resulting in only 11% of respondents' being fathers.27 Often when fathers are considered, data on their involvement are obtained from the mother's report.10,13,28 In addition, much of the earlier research focused on white, middle- to upper-class fathers,29–33 with few recent studies examining more diverse populations of fathers in health care.34–36 These recent studies have made important contributions by identifying predictors and some barriers to father involvement in generally older children's care, but they either focused on homogeneous racial/ethnic groups (eg, African Americans35 or Mexican Americans36) or used convenience samples that were recruited primarily from health clinics, a potential source of bias because these fathers are already in the health care system.34,35 If the objective is to understand and improve father participation in the health of their child and the health care system, then experiences from a diverse sample of fathers from outside the system are essential. Furthermore, a more diverse sample better represents the estimated 66.3 million fathers in the United States who vary by marital status, race, ethnicity, socioeconomic status, and occupation.37

Well-child visits (WCVs) are opportunities wherein fathers can become involved in their child's health care and become comfortable in their child's medical home. WCVs are ideally positioned for fathers to learn about the growth and development of their child, expand their parental role, and meet and communicate with the child's doctor. Our study gathered information from a diverse non–clinical-based population of fathers from 2 major metropolitan cities. Using qualitative methods, we explored and examined fathers' experiences in, satisfaction with, and barriers to attending WCVs. Understanding these aspects of father participation in the health care system in the fathers' own words can help clinicians to address disparities in paternal involvement in WCVs and ultimately lead to improved health care engagement with fathers.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
We conducted in-depth, semistructured, qualitative interviews with 32 fathers who are a subsample from the national Fragile Families and Child Wellbeing Study of 3800 unwed couples' and 1200 married couples' randomly sampled hospital births in large US cities (details available at: crcw.princeton.edu/fragilefamilies/about.asp). Our sample comes from a nested qualitative study called Time, Love, and Cash in Couples With Children (TLC3), which follows 75 low- to moderate-income couples who were married, cohabiting, or at least romantically involved at the time of the birth and who were enrolled in Fragile Families and Child Wellbeing. Participants were recruited in each of 3 cities (Chicago, Milwaukee, and New York; N = 75 couples, 47 nonmarried and 28 married). Recruitment into TLC3 was based on the following additional characteristics: (1) mother's household income <$60000 a year, (2) geographic accessibility (eg, neither mother nor father living out of state or in jail), (3) child living with mother or father (eg, Child Protective Services not involved initially at birth), and (4) both parents English speaking. Fathers in our study resided in Chicago or Milwaukee and were interviewed about health care issues at home for 1.5 hours when their child was ~3 years of age. The fathers were given a nominal cash payment for their participation.

Interviews covered the following domains: (1) father's overall involvement in his child's health care, (2) father's attendance and experiences at visits to the doctor, (3) health care decision-making between mother and father, (4) assessment of focal child's health, (5) gender/normative roles, and (6) father's health and medical care. The interview protocol covered normative views of fathers in health care as well as the individuals' experience. We designed the interview questions on the basis of literature review, previous qualitative interview protocols in the TLC3 study, and pilot interviews with fathers who were not in the study. Questions were deliberately open ended allowing the fathers to provide detailed accounts and personal stories. We audiotaped and transcribed all interviews; our Institutional Review Board approved the study.

We used content analysis methods to analyze the presence and the meaning of concepts and themes within the transcripts.38 After reviewing the transcripts, we created a code book to aid in identifying themes. The code book began with our initial, preordained codes (based on the interview protocol and literature review) and developed with emerging codes (derived from iterative interview reading, team discussions, and investigator triangulation). These codes gave way to emerging themes. For example, after coding 7 interviews, we noticed that a number of fathers were reluctant or fearful in performing certain tasks (ie, changing diapers, administering medicines) for their child. As a result, the new code "FAFEAR" was established to account for this theme, and all past and future transcripts then were coded for this theme. Codes were inputted and analyzed using Atlas.ti. 5.0.39 For this study, we examined themes surrounding ideals of father involvement and dis/satisfaction, barriers to, and experiences in the health care system.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
Of the 50 fathers from the TLC3 study in the 2 cities, 3 had moved out of the state, 6 were in jail, 7 had been lost in earlier follow-up, and 1 had died, leaving 33 eligible respondents. Of those, 1 refused to participate, resulting in a final sample of 32 fathers and an adjusted response rate of 97%.40 Overall, the sample was 56% black, 28% Hispanic, and 15% white, with a mean age of 31 years. A total of 28% had some high school or less, 34% were high school graduates, 31% had some college or technical training, and 6% had a college degree or higher; 47% were married (Table 1). In our sample 53% had attended a WCV and 84% had been to see a doctor (ER, sick visit, etc) with their child in the past year.


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  		TABLE 1 Summary of Respondent Characteristics

 
The fathers expressed 4 main themes as to why fathers should attend a WCV: (1) to gather information about their child, (2) to support their child, (3) for the opportunity to ask questions and express concerns, and (4) to gain firsthand experience of the doctor and the visit (Table 2). In addition to the 4 main themes expressed, less common reasons were given, such as trust ("make sure the doctor is on the up and up") and to support both the child and the mother while examining the bedside manner of the doctor. Other fathers believed that it was part of their role and responsibility to attend the checkup. As 1 father stated: "I think it would just be the role of the father period to know the well-being of his child."


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  		TABLE 2 Major Themes of Why Fathers Attend WCVs and Representative Quotes

 
The majority of fathers have been satisfied with their encounters with health care professionals such as doctors, nurses, and office staff. Three main factors contribute to this satisfaction: (1) inclusive interactions with the physician and health care staff, (2) the perception of receiving quality care, and (3) receiving clear explanations (Table 3). Far fewer fathers had negative experiences; 8 fathers mentioned negative interactions, but even these were specific and often noted alongside positive comments. Fathers enjoyed being complimented by health care staff and perceived that they were receiving equal quality service as mothers. One father stated, "They (staff in the office) just look at it in a different aspect, like, ‘Oh, what a great dad, he's caring, loving, bringing his sick child in.’ It's not like, ‘OK, here he is, here's dad, let's bring him to the doctor,’ but more of, ‘Oh, isn't that cute, a loving father.’" The few negative interactions mentioned included feeling as though they were viewed suspiciously, being perceived as having a lesser emotional bond with their child, or being provided with lower quality service compared with the mother. One father said, "I think that they (staff in the office) don't believe that the males provide enough empathy with the child, and so they sort of have to spell everything out for me more I would think, whereas they assume that the mom has a tighter emotional bond with the child. And so the nurses can exchange knowing looks with mothers."


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  		TABLE 3 Major Reasons for Father Satisfaction With Child's Health Care and Representative Quotes

 
Although most fathers reported attending a WCV with their child, 80% of fathers reported barriers to their involvement in the child's health care (Table 4). Many of the fathers expressed multiple barriers that often overlap rather than a single, isolated obstacle. Among those who mentioned barriers (n = 26), work-related factors were most common (65%) followed by relationship barriers (62%) and then personal barriers (50%). Systemic barriers, such as inconvenient office hours and lack of access to their child's records and insurance information, also impede fathers' involvement in their child's health care. Nevertheless, 20 (63%) of 32 fathers mentioned "situational flexibility" that enables them to overcome many of these barriers and attend important doctor visits. As 1 father stated, "Yeah, because I mean I work around the clock. But I mean, if the mother can make it, then I won't go. But if she needs me to go, then I'll go." Another father said, "It depends on the situation and times that she goes. If it's a time that I'm not working, I'll be glad to go. But when I'm working, it has to be something major for me to go, she has surgery, like I think it was the beginning of last year on her ears, and I basically went to that to make sure everything was fine with that."


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  		TABLE 4 Major Categories and Subcategories of Barriers to Father Involvement in Child's Health Care and Representative Quotes

 
Of note, 6 (19%) fathers, all attendees at a WCV in the past year, stated that their involvement was sufficient and did not report any barriers. Two of these fathers were unemployed and consequently had extra time during the day to take their child to doctor appointments. A third father worked at night, which allowed him to attend daytime doctor appointments.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
WCVs and doctor appointments are ways in which fathers are involved in their child’s health care. The majority of fathers from our sample had attended a WCV and most had been to their child’s doctor in the past year. Fathers detailed specific reasons for why they attend WCVs, such as to support their child, ask questions, express concerns, and gather information firsthand. The fathers reported more positive than negative experiences with the health care staff, and, overall, they are satisfied with their experiences with the health care system. Reasons for satisfaction include feeling as though their questions had been dealt with seriously and answered appropriately. However, the fathers in our study did report a variety of barriers to health care involvement, including conflicting work schedules, a lack of confidence in their parental role, and health care system barriers.

WCVs are key components of the pediatric health care system; they are designed to relay important information about growth and development in a timely manner while addressing unique concerns for individual patients and families. Important topics to discuss include diet, breastfeeding, immunizations, infant sleep position, medications, and psychosocial issues.27,41 Whereas most previous research enlisted the mother's perspective, our study shows that fathers have definite and well-articulated interests in being involved in their child's WCV. Pediatrics has a growing appreciation of the role that families and parents play in the health of their children, identifying them as "the most central and enduring influence in children's lives"42; incorporating fathers seems only natural. A present and engaged father along with the mother gives pediatricians the opportunity to observe family and parental functioning, the root of family pediatrics.

The AAP recognizes that pediatricians are well positioned to communicate with fathers during a WCV, thereby encouraging involvement, informing the father of his child's health and development, and providing anticipatory guidance for the child.6,41 According to the AAP statement, doctors can make intentional efforts to foster father involvement through providing helpful information, directing conversation to the father, and answering questions that are certain to be posed. As father involvement is on the rise7,8 and parents strive to balance work and home responsibilities, addressing the need for paternal parity in health care involvement is of increasing importance. This necessitates understanding the perceived and real barriers to involvement as well as considering ways to encourage or facilitate involvement.

Fathers generally were satisfied with the care that they received and felt respected as parents (Table 5). A major reason for why fathers felt satisfied was because they often perceived that their child was receiving quality care. This is an important finding, especially in light of health disparity research that reports that low-income and minority children receive lower quality of health care in comparisons with middle- to high-income and white children.43,44 Additional research in this area could better inform the experiences of these populations within the health care system. To its credit, few barriers within the health care system itself were reported in the present study. Nevertheless, barriers to attending WCVs for some fathers are present. Some of these barriers seem easy to overcome, such as by offering copies of medical cards or immunization records to each parent; others seem more complex, such as extending office hours into evenings and weekends. Still others seem insurmountable; a frank inability to leave work or a poor relationship with the child's mother can discourage even the most well-intentioned parent. Yet 63% of fathers mentioned "situational flexibility" in their ability to participate in the health care system despite barriers, suggesting that pediatrics could reframe WCVs to increase father attendance.


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  		TABLE 5 Recommendations for Pediatricians to Facilitate Father Involvement in Child's Health Care

 
Situational flexibility describes the ability of many fathers to rearrange work and other commitments on an ad hoc basis to attend their child's important health care encounters. Important health care encounters may be determined by the parent (eg, the child is sicker than usual) or by health care professionals (eg, surgeons suggesting the presence of both parents). In either case, often with short notice, many fathers stated that they are able to rearrange their schedules to engage the health care system and increase their involvement on behalf of the child. There is a sense that this is reserved for illnesses or procedures that are beyond the usual WCVs. Historically, working mothers may have been more likely and socially expected to assume multiple roles than working fathers.45 As >50% of mothers age 15–44 years who have given birth in the past 12 months are in the workforce, paternal situational flexibility may arise out of family necessity.46 If pediatricians believe that WCVs are important opportunities for parents to learn about their child's development and receive crucial anticipatory guidance, then perhaps a reframing for parents is in order. Parents may believe that a simple checkup is not worth the forethought and planning to ensure that both parents are present. Reframing scheduled visits as the "4-month assessment" for example, would impart the sense that these periodic visits are not simply boxes to check off for the child as he or she matures but rather a forum where key information is communicated. This situational flexibility may allow those who face scheduling or employment barriers to overcome the barrier and participate in their child's health care. Pediatricians can encourage mothers who attend visits without their partners to schedule the next WCV at a time when both parents can attend.

Whether because of employment, relationships, or some other paternal barrier, many mothers will continue to be the primary contact for the pediatrician. This study reminds pediatricians that concerned and interested fathers who are unable to make an office visit frequently are awaiting health information from that visit later at home. Pediatricians therefore can work to improve information sharing between doctor and parent and between parents. First, an initial discussion with the child's mother or the child's mother and father together about how they plan to deal with parental responsibilities for child health may set up some ground rules regarding how information might be shared, especially among nonmarried, noncohabiting parents. The pediatrician's role in facilitating parental involvement (eg, writing a note from the doctor to the employer explaining the parent's necessary absence) could be part of that discussion. Second, to help parents share information, written notes from the visit highlighting important issues around growth and development, behavior, safety, and any new medications would be useful. Many electronic medical records have this capability built in. Third, if fathers are unable to attend WCVs, then encouraging them to submit their questions or concerns may help them to feel included. Finally, consider using technology (eg, cell phones, e-mail) to improve information exchange and encourage involvement. These strategies may be useful for including fathers in the medical home but are equally helpful for including any of the child's major caregivers (eg, grandparents).

As advocates for children and families, pediatricians can also promote public and employment policies that support father involvement. On a national level, the US Senate enacted the Responsible Fatherhood Act of 2003 to compliment past task forces that were initiated by the US Senate, Congress, governors, and mayors47 to support and encourage greater father involvement through the allocation of grant funds, the development of media campaigns, and the promotion of community resources that assist fathers. Also in 2003 (and recently extended), Illinois adopted a similar act, entitled the Illinois Council on Responsible Fatherhood, which strives to establish support structures that enable fathers to develop and maintain relationships with their children and to promote ways to reduce negative outcomes for children who are affected by divorce, separation, and disputes concerning custody and visitation.48 Of the 2 states in our sample, only Illinois has a School Visitation Rights Act (established in 1992), which provides parents with a total of 8 unpaid hours during any school year to attend a parent conference or related school activity,49 and neither state offers policies to encourage attending WCVs. In 1998, Massachusetts established the Small Necessities Leave Act,50 which allows employees to have 24 hours of unpaid time off per year to participate in a child's school-related activity and to accompany a child to a routine medical appointment, such as a WCV. Pediatricians therefore can support the creation of similar laws to the Small Necessities Leave Act in their states.

There are limitations to our study. Our study is qualitative, which is exploratory in nature and draws on a small sample size. Although our sample is diverse and comes from 2 metropolitan areas, these findings may not generalize to other urban fathers. Because these were father self-reports of involvement, there is a possibility of social desirability bias. Interviews were conducted without mothers or others present in hopes of reducing this potential bias. We believe that the benefit of hearing from this generally underrepresented population in their own words outweighs the limitations. Finally, the fathers in our study had to exhibit an initial level of involvement at birth to be recruited; that is, fathers whose involvement ended before the child's birth are not in our sample. We cannot comment on the important issues for this subpopulation. However, from a clinical perspective, our study focuses on the population of fathers who potentially could be more engaged in their children's health care.


   CONCLUSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
Clearly, fathers want to be involved in the WCVs of their children. They often are present at WCVs and have unique concerns and questions, and, if not present, then they are interested in the information that pediatricians provide in regard to their children. Many fathers have some degree of situational flexibility that may permit them to attend important WCVs. Identifying creative ways to include fathers and overcome barriers may strengthen their involvement. Reframing the importance of WCV for the child and the family will remind parents of the role that pediatricians can play in maximizing healthy child growth and development. Pediatricians play a vital role in supporting fathers and families as they engage the health care system, all working together to seek the most positive health outcomes for the child.


   ACKNOWLEDGMENTS
 
This study was funded in part by a Robert Wood Johnson Generalist Physician Faculty Scholars award (to C.F.G.) and an ENH Research Institute Pilot Grant award.


   FOOTNOTES
 
Accepted Sep 15, 2005.

Address correspondence to Craig Garfield, MD, MAPP, Department of Pediatrics, Evanston Northwestern Healthcare Research Institute, 1001 University Ave, Evanston, IL 60201. E-mail: c-garfield{at}northwestern.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.

This work was presented in part at the annual meeting of the Pediatric Academic Societies; May 16, 2005; Washington, DC.


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 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics



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