BACKGROUND

Men's mental health and wellbeing

Men's mental health and wellbeing during their transition to fatherhood is an important public health issue that is under-researched and poorly understood.1 A recent systematic review reported that the prevalence rates for any anxiety disorder in men ranged between 4.1 and 16.0% during their partners' pregnancy and between 2.4 and 18.0% during the postnatal period.2 Prevalence rates of antenatal and postnatal depression in fathers in a systematic review of 20 studies ranged from 1.2 to 25.5%.3 With the exception of one study, which assessed depression through a qualitative interview, the remaining studies in this review used standardized self-report instruments with established reliability and validity.3 A meta-analysis of 43 studies reported depression in 10.4% of fathers between the first trimester of their partner's pregnancy and one year postpartum, with the peak time being between three and six months after the birth, similar to findings for postnatal women.1 Studies included in the meta-analysis used variable methods of measuring and identifying depression: self-report rating scales were used in 40 studies, while interviews were used in the remaining three.1 Symptoms of anxiety and stress have also been reported alongside depression among men during and after their partner's pregnancy.4-9

Impact on the child

Poor mental health in fathers has been shown to impact on their child's cognitive, social and behavioral development. Ramchandani et al.10 in a prospective cohort study, which controlled for mothers' depression and for fathers' education levels, found that the presence of symptoms of severe postnatal depression in fathers (assessed using the Edinburgh Postnatal Depression Scale) was associated with emotional and behavioral problems in their children at around three years of age, particularly in boys. Moreover, children with two depressed parents were at higher risk of poor development outcomes.11 In addition to negative impacts on the child, poor mental health in fathers can impact on the mother and the couple's relationship.12 A recent study of first-time parents' transition to parenthood highlighted the importance of focusing interventions on strengthening couple's relationships and parents' feelings of unworthiness.13

Risk factors

Risk factors for anxiety and depression in men during their transition to fatherhood can include factors such as an unsupportive marital relationship, paternal unemployment, immaturity, an unplanned pregnancy,14,15 history of depression, young parental age and higher social deprivation,16 poor social and emotional support,17,18 having a partner with elevated depressive symptoms or depression, and poor relationship satisfaction.19 Data on 3219 biological resident fathers who participated in a longitudinal study of children in Australia found that risk factors associated with psychological distress postnatally included poor job quality, poor relationship quality, maternal psychological distress, having a partner in a more prestigious occupation and low parental self-efficacy.20 In a more recent cross-sectional study of first-time expectant fathers, factors associated with antenatal depressive symptoms in men included poorer sleep quality, family history of psychological difficulties, lower perceived social support, poorer marital satisfaction, more stressful life events in the preceding six months, greater number of financial stressors and elevated maternal antenatal depressive symptoms.21

Signs and symptoms

Symptoms of depression in fathers may manifest as low self-esteem, hostility, conflict and anger.22-24 Fathers suffering from depression may withdraw or engage in "escape activities" such as overwork, sports, gambling and excessive drinking.25,26 Some symptoms of depression during the perinatal period experienced by mothers and fathers are similar, such as deep feelings of abandonment and powerlessness; however, other symptoms such as alcohol and substance abuse may more frequently manifest in men.22 General population studies have also reported that depression symptoms manifest differently in men than in women.27-29 In a recent Delphi study of 14 international experts (including clinicians or professionals working directly with fathers, trainers, researchers and those who have published in peer-reviewed articles about "fathers"), paternal depression was described as low mood, negative thoughts, somatic issues (low hunger, weight loss and sleep issues), along with "masked male depression" symptoms such as irritability, withdrawal/isolation and increases in substance use (or other dopaminergic types of activities like gambling and cheating) during pregnancy or within a year or so postpartum.30 As men have different communication and coping styles compared to women,31 they may be reluctant to discuss their mental health symptoms or concerns due to wanting to put their partner's needs first.32

Current knowledge and gaps

The Royal Society for Public Health in the United Kingdom recommends that it is important to actively promote positive mental wellbeing rather than just focusing on preventing and treating mental illness.33 The World Health Organization defines mental health as "a state of wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community".34^(p.XIX) A Cochrane Library systematic review of group based parenting programs for improving parental psychosocial health found that only four of the 48 included studies reported separate outcome data for fathers.33 Although a statistically significant short term improvement in paternal stress following interventions that included cognitive and behavioral strategies was found, individual study results were inconclusive for any effect on depressive symptoms, confidence or partner satisfaction. The authors of this review concluded that this was "a serious omission given that fathers now play a significant role in childcare and research suggests that their psychosocial functioning is key to the wellbeing of children".35^(p.21)

A systematic review of interventions for prevention or treatment of depression in fathers identified four studies, all focusing on treatment rather than prevention, with findings inconclusive due to wide study heterogeneity.36 This review highlighted the need for randomized controlled trials to identify effective mental health interventions for men in the post-natal period, particularly preventative interventions.36 Another systematic review of intervention programs to prevent or treat paternal mental illness in the perinatal period included 11 studies - five of which described psychosocial programs (emphasizing skills, knowledge, emotional wellbeing and social wellbeing related to parenting), three that focused on the effects of massage techniques (partner massage and infant message) and three that used couple-based sessions (focused on the couple relationship and co-parenting).37 Eight studies were randomized controlled trials; however, six trials did not provide adequate information on randomization processes, and risk of bias cannot be ruled out. The review authors reported significant intervention effects for a variety of fathers' mental health outcomes (including stress, depression, anxiety, anger levels and self-esteem) for two of the psychosocial approaches38,39 and three that employed massage techniques.40-42 There were no significant changes reported in paternal mental health following couple-based interventions. Study limitations included poor reporting of study designs, variation in outcome measures used and limited statistical analyses.

Health professionals' failure to engage with fathers during or around the time of birth could be a reason for the lack of evidence on first-time fathers' mental health and wellbeing.43 Fathers may feel marginalized and unacknowledged by health professionals during the perinatal period and report a lack of appropriate information on pregnancy, birth, child care and balancing work and family responsibilities.44-46 Research into health visitors' practice has found that they do not routinely involve fathers47 and are perceived by fathers as a service provided "by women, for women".48 A Department of Health for England funded literature review on service users' views suggested that some fathers welcomed the opportunity to express their feelings and emotions about fatherhood when asked by a healthcare professional,49 but did not always have the opportunity to do this spontaneously.50

A systematic review of evidence on parenting interventions, which included men as parents or co-parents, showed that insufficient attention was paid to reporting the father's participation and the father's impact on child or family outcomes.51 The importance of assessing men's mental health in the perinatal period52 and identifying the best methods for supporting fathers53 is clear. Few studies distinguished between biological or non-biological fathers, or if fathers were resident or non-resident in the family home. Better understanding of the experiences of first-time fathers, whether biological or non-biological, during their transition to fatherhood and identifying what information and support they consider could help their mental health and wellbeing, would enable the development of appropriate and timely healthcare-professional-led interventions likely to be more acceptable to fathers. Barriers and facilitators to enable first-time fathers to access help or support for their mental health and wellbeing needs could also be identified. This systematic review will create a deeper knowledge of first-time fathers' experiences, needs and help seeking behaviors relating to mental health and wellbeing during their transition to fatherhood and how fathers could be better supported during this time.

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

Searches of the JBI Database of Systematic Reviews and Implementation Reports, Cochrane Library, MEDLINE, PROSPERO and DARE were carried out and although a small number of systematic reviews relating to this topic were identified and cited above, there were no qualitative systematic reviews found that attempted to answer this review question.

INCLUSION CRITERIA

Types of participants

The current review will consider studies that include resident first-time fathers (biological and non-biological) during their transition to fatherhood, from pregnancy commencement until one year after birth. Study participants will include first-time fathers of healthy babies born with no identified terminal or long-term conditions.

Certain groups of fathers may have specific mental health needs during their transition to fatherhood. As this review focuses on the mental health and wellbeing of fathers in general and not of those with specific additional needs, the following will be excluded:

* Studies on non-resident/absent fathers (those not residing with the mother/child during the period between conception to one year after birth)

* Studies on fathers experiencing bereavement following neonatal death, stillbirth, pregnancy loss and sudden infant death

* Studies on fathers whose infants are born prematurely (<=37 weeks gestation)

* Studies on fathers with a child with terminal/long-term conditions

Phenomena of interest

First-time fathers' needs and experiences during their transition to fatherhood in relation to their mental health and wellbeing.

Context

The current review will consider studies undertaken in high-income countries as defined by the World Bank54 (e.g. countries that are members of the European Economic Community, the United Kingdom, the United States, Canada, Australia and New Zealand) that investigate first-time fathers' experiences, during any time from conception to one year after birth. The majority of these countries have similar healthcare systems (with a mix of public and privately funded and universal service provision), social and political systems, meaning that review findings are more likely to be transferable.

Types of studies

The current review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography and action research. The review will also consider qualitative data reported within quantitative surveys for inclusion, where open questions relating to the phenomena of interest have been asked.

Search strategy

The search strategy aims to identify published and unpublished studies. A three-step search strategy will be utilized. An initial limited search of MEDLINE (using Ovid) and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies.

Studies published in English will be considered for inclusion in this review due to the difficulties associated with resources for translation. Computerized searches for studies published between 1960 and the present will be considered for inclusion due to the gradual shift in fathers' roles which took place over the second half of the 20th century.

The databases to be searched include:

MEDLINE (Ovid)

CINAHL

Embase

PsycINFO

Maternity and Infant Care

HMIC

British Nursing Index

Web of Science

A search of The Fatherhood Institute, website will also be conducted. The Institute is UK's leading charitable organization for fathers and fatherhood and collates and publishes international research on fathers and the impact of their role on children and mothers.

The search for unpublished studies such as theses and dissertations will include:

ProQuest Dissertations and Theses Global

WorldCatdissertations and Theses (OCLC)

Initial keywords will include: Father, men, paternal, dad, male, partner, support, intervention, prevention, therapy, counselling, help, programme, service, education, treatment, online, health, health promotion, professional, midwife, doctor, GP, health visitor, nurse, self-help, partner, friend, family, sport, social support, physical activity, parenthood, fatherhood, transition, perinatal, postnatal, postpartum, antenatal, antepartum, prenatal, intrapartum, pregnancy, baby, child, mental, mental health, emotional, psychological, wellbeing, sad, distress, depression, anxiety, stress, postnatal depression, feeling, PTSD and trauma.

ASSESSMENT OF METHODOLOGICAL QUALITY

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

DATA EXTRACTION

Qualitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.

DATA SYNTHESIS

Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.

Acknowledgements

The review is being undertaken as part of a Clinical Doctoral Fellowship funded by the UK National Institute for Healthcare Research.

SB is funded by a National Institute for Health Research (Clinical Doctoral Fellowship, ICA-CDRF-2015-01-031). This paper presents independent research funded by the National Institute for Health Research (NIHR). DB is part funded by the NIHR CLAHRC South London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Appendix I: Appraisal instruments

QARI appraisal instrument

Appendix II: Data extraction instruments

QARI data extraction instrument

References