- LMIC —
- low- and middle-income countries
The discipline of pediatrics focuses on ways to optimize the health and development of children. Increasingly this entails engaging parents, which historically has meant mothers. However, as evidenced by the recent 2016 American Academy of Pediatrics Clinical Report,1 father contributions are becoming better understood and appreciated. With evidence pointing solidly to the benefits of paternal involvement for early child development in high-income countries, in this issue of Pediatrics, Joeng et al set out to describe the prevalence of paternal stimulation in 38 low- and middle-income countries (LMIC) among children <5 years old and showed that it relates positively to the Early Childhood Development Index, which measures early child development in literacy/numeracy, physical, social-emotional, and learning contexts.2 The effect sizes of high paternal stimulation were similar in magnitude to those of mother completing primary school and an increase in wealth that delivers the family out of the poorest quintile. Furthermore, the associations between paternal stimulation and Early Childhood Development Index were more pronounced for children receiving less stimulation from others (mother or education professionals).
Unfortunately, only 6% of primary caregivers reported high paternal engagement levels, and 48% of the sample did not engage in any paternal stimulation. This may be partly due to culture-specific interpretations of the activities that were assessed, as well as a lack of awareness of fathers’ activities on the part of the primary caregiver (given that paternal involvement tends to occur precisely when the primary caregiver, mostly the mother, is away). Nevertheless, the low levels of paternal engagement reported here are consistent with ethnographic accounts of childrearing in many cultural communities, and are important to consider in light of opportunities to enhance child development.
With such positive associations between paternal involvement and child outcomes, why aren’t more fathers involved with their children in LMIC? The answer may lie in paternal constraints on money and time. In many developing countries, fathers spend almost all their time on income and food provisioning and are indeed expected to do so when food and health security are low. Under such circumstances, fathers may simply not be in a position to spend time on direct child-focused activities. In fact, it appears that a significant portion of the variation in father engagement at the country level can be explained by poverty indices. For example, the correlation between the percentage of unengaged fathers (taken from Appendix C)2 and the United Nations Human Development Index among the 38 countries is an astonishing 0.70. Furthermore, the World Bank’s gross national income rankings of 7 of the 10 countries with the highest percentages of unengaged fathers are in the bottom quartile compared with none of the 10 countries with the lowest percentages of unengaged fathers. Thus, financial contributions by fathers may take priority over hands-on involvement. The issue is not confined to LMIC countries; the United States also continues to debate the benefits of public policies, such as paid family leave,3 that could help lower-income fathers with the competing demands of time spent in the workplace providing for his family with time spent at home engaged with his child.
Nevertheless, fathers (and mothers) around the world want what is best for their children. However, many parents may not be aware of how to achieve this, especially those who are perforce focused primarily on ensuring basic child survival. When quality time is structurally scarce, care providers may advise fathers to make the time that they do spend with their children more stimulating by, for example, “subtitling” their own and the child’s ongoing activities and characteristics of the immediate environment. Examples of such actions include subtitling fathers’ own behaviors (“Now I’m going to cut this fruit so we can eat the sweet, yellow inside”), child behaviors (“Are you picking up all the dark stones?”), labeling the environment in response to the child’s focus or gaze direction (“That’s a blue chair”), or elaborating on cause-and-effect processes (“If we leave the gate open, the goats will wander away”). This way, fathers can foster children’s natural inquisitiveness. Alternatively, in contexts where verbal interactions with children are less common and potentially less culturally appropriate,4 fathers might be encouraged to involve their children in their own activities in the house and the community so that the child’s range of experiences becomes larger and offers another form of learning. Engaging fathers starting soon after the birth of a child is likely to be most effective because during this phase transition, many men are open to changes in their roles and responsibilities.5,6
This unique and commendable study begins a discussion of how to find harmony between the often-competing needs of financial stability and father engagement in LMIC populations. The next step would ideally include active involvement of scholars from those countries to share their unique perspectives in analyzing and interpreting research results and suggesting interventions to improve the health and well-being of children in LMIC. Doing so holds the greatest promise for increasing the number of fathers who actively engage in promoting their child’s healthy development across economic boundaries and across the globe.
- Accepted July 26, 2016.
- Address correspondence to Craig Garfield, MD, MAPP, Feinberg School of Medicine, 633 St. Clair, Suite 19-059, Chicago, IL 60611. E-mail:
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: CFG is supported in part by National Institutes of Health grant K23HD060664 from the Eunice Kennedy Shriver National Institute for Child Health and Development. Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2016-1357.
- Yogman M,
- Garfield CF; Committee on Psychosocial Aspects of Child and Family Health
- Joeng et al
- ↵Healthy Families Act, HR 932, 114th Congress (2015–2016)
- Lancy DF
- Copyright © 2016 by the American Academy of Pediatrics