Targeted mobile apps for fathers over the perinatal period
Fathers can often feel side-lined over the perinatal period with information and education typically directed towards the mother.
Becky K. White, School of Public Health, Curtin University, Australia
Jane A. Scott, School of Public Health, Curtin University, Australia
Fathers can often feel side-lined over the perinatal period with information and education typically directed towards the mother. Targeting health information and health promotion interventions to fathers is important for their own health, as well as the health of their families. Mobile apps offer opportunities to reach fathers, yet are largely under-utilized in this space. This article summarizes the current state of play of perinatal father-focused mobile apps, including a case study of a breastfeeding app for fathers.
Pregnancy, childbirth and early parenting is a time of significant change for new and expecting parents. It is a life-stage where people are likely to look for and be receptive to health information (Laws et al., 2019; Rost & Johnsmeyer, 2014). As well as information on childbirth and parenting, parents also seek out information about a range of other health issues such as mental health, healthy lifestyles and balancing work and family life (Da Costa et al., 2017). Mothers’ and fathers’ health and wellbeing are both important, yet there is evidence that fathers can often feel excluded from traditional methods of education and information delivery in the perinatal period and want more targeted, accessible information (Sherriff et al., 2014).
Access to and use of mobile technology has changed the way people search for and engage with health information. Health promotion practitioners and researchers, amongst many others, have seen the opportunity to use technology to deliver evidence-based information to target populations, including new and expecting parents. Yet the growth in perinatal mobile apps has not expanded proportionately. Most apps are targeted to mothers (Thomas et al., 2018), and despite fathers also expressing a need for more targeted information and support over the perinatal period (Da Costa et al., 2017; Tohotoa et al., 2011), the mobile landscape may be another example of fathers being sidelined. In this article, we explore the current state of paternal perinatal apps and look to future opportunities in this space to engage fathers and impact positively on health.
MOBILE TECHNOLOGY AND HEALTH PROMOTION
In Australia, 89% of those aged over 18 years own a smartphone, and more Australians can access a smartphone than they can any other device. Australians access the internet more from mobile phones than they do desktop computers (Deloitte, 2018c). These figures are similar to those seen in other developed countries. In the UK, 87% of those aged 16 years or over own or have access to a smartphone, and smartphones are the most frequently used device, ahead of laptops, tablets or desktop computers (Deloitte, 2018a). Similarly, in the US, ownership is estimated to be 85%, with the smartphone being the most accessible device (Deloitte, 2018b).
The growth in mobile technology offers health promotion professionals an opportunity to reach individuals directly with health information and interventions (Yardley et al., 2016). This, along with the wide potential geographic and demographic reach of smartphone-based interventions, makes mobile technology an attractive option when developing health interventions. The spread of mobile technology has resulted in significant enthusiasm about the potential for mobile health (mHealth) interventions to help public health researchers better reach populations and impact positively on health (Becker et al., 2014); however, robust evidence of their impact on health behavior change remains limited.
mHealth studies in the literature vary widely in terms of research rigor, sample size and area of health focus (Byambasuren et al., 2018). Two recent systematic reviews have focussed on mobile apps and pregnancy (Daly et al., 2018; Overdijkink et al., 2018). The first examined the feasibility and acceptability of mobile apps to support health care during pregnancy and found that although most included studies showed positive results, the evidence on effectiveness was limited, many studies were of low power and more research was needed (Overdijkink et al., 2018). The second examined the impact of mobile apps on maternal health behavior and outcomes during pregnancy (Daly et al., 2018). The authors found wide variation in study design and results and could draw no firm conclusion on efficacy. A 2018 overview of systematic reviews across multiple health areas found that while mobile health apps offer the potential to positively impact on health, the current evidence is of low quality (Byambasuren et al., 2018).
There is a need for more research involving larger sample sizes, diverse populations and robust evaluation of health outcomes. However, although the evidence base for behavior change may be limited, mobile apps are being widely used by health consumers and can be people’s primary source of information (Taki et al., 2019; Kraschnewski et al., 2014).
IMPORTANCE OF TARGETING FATHERS
Supporting the mental health of fathers is an area requiring significant investment and resources
When considering health over the perinatal period, fathers are clearly a key demographic. Fathers, as well as mothers, can experience increased health risks and want additional health related information and support (Rominov et al., 2016). The perinatal period provides a window of opportunity to connect with fathers at a time when they are experiencing change and are highly motivated to look for support (Laws et al., 2019; Rost & Johnsmeyer, 2014). Fathers want more information about parenting and infant care (including breastfeeding), supporting and improving their relationship with their partner, and managing stress (Da Costa et al., 2017). As well as the importance of promoting good health for fathers themselves, the wellbeing of fathers can have a significant impact on the health of their partners and their children (Rominov et al., 2016; Ramchandani et al., 2005; Goodman, 2003). Yet fathers can feel left out of antenatal education and traditional programs are often targeted to the mother and fail to actively include fathers (Brown & Davies, 2014; Sherriff & Hall, 2014; Tohotoa et al., 2011).
Supporting the mental health of fathers is an area that requires significant investment and resources. In Australia, one in ten fathers will experience postnatal depression or anxiety (Paulson & Bazemore, 2010). The main factors impacting on paternal mental health have been identified as the challenges of becoming a father, forming their new fatherhood identity and the associated fears and negative feelings (Baldwin et al., 2018). Poor paternal mental health can be a risk factor for maternal mental ill-health (and vice-versa) (Goodman, 2003) and may impact negatively on infant development and a child’s behavioral, emotional, cognitive and physical development later in life (Rominov et al., 2016; Ramchandani et al., 2005). Social support can be a vital protective factor for positive mental health (Colquhoun & Elkins, 2015; Schumacher et al., 2008), yet fathers can often lack social support opportunities over the perinatal period (Halle et al., 2008; Tohotoa et al., 2009). New fathers in particular place high value on peer support (Brown & Davies, 2014) and one barrier to being able to access this is a lack of tailored information and resources (Baldwin et al., 2018). Encouraging couples to work together before the birth of their baby to reflect and plan for the challenges ahead can be a strategy that offers protection from poor mental health for both parents (Colquhoun & Elkins, 2015).
A significant amount of international research shows us that the support of fathers is critical to breastfeeding success, yet fathers may not understand how to best support their partner (Brown & Davies, 2014; Tohotoa et al., 2011; Tohotoa et al., 2009). Fathers want information about how to support their partner, about breastfeeding in general and about their own role in breastfeeding (Mitchell-Box & Braun, 2012; Tohotoa et al., 2011). Delivering this information to fathers is important, as when fathers are supportive of breastfeeding, mothers have better breastfeeding outcomes (Maycock et al., 2013; Scott et al., 2006; Wolfberg et al., 2004). Interventions targeted to the father can impact positively on maternal breastfeeding duration (Mahesh et al., 2018; Yourkavitch et al., 2017; Mitchell-Box & Braun, 2013).
PERINATAL mHEALTH INTERVENTIONS
Increasingly, new and expecting parents are turning towards mobile apps and social media for information about pregnancy and early parenthood (Taki et al., 2019; Lupton, 2016). For pregnant women, turning to technology to fill gaps in information from health professionals is common and mobile apps can be the first information source about their new pregnancy, even before they have seen a health professional (Kraschnewski et al., 2014). There are thousands of pregnancy and parenting apps on the two major app stores (Thomas & Lupton, 2016; Taki et al., 2015). The choice can be overwhelming, and the information is not guaranteed to be correct. One recent study reviewed nutrition apps for pregnant mothers and concluded none could be recommended due to low quality (Brown et al., 2019). Similarly, a review of websites and mobile apps for infant feeding found none comprehensively addressed a variety of infant feeding topics and quality ratings were low (Taki et al., 2015).
Fathers have identified barriers to accessing support over the perinatal period. For instance, antenatal classes are generally directed at the mother and men perceive that they pay limited attention to their role, and their information and support needs (Sherriff et al., 2014). Work commitments may limit a man’s involvement in their partner’s pregnancy care and the number of antenatal classes and appointments that they can attend. Consequently, the use of information technology has been recommended as one way to overcome these barriers (Tohotoa et al., 2011). The growth in targeted mHealth initiatives for pregnancy and early parenting has not expanded
equally - there are many more apps for mothers than fathers (Thomas et al., 2018). A study of pregnancy related apps found a total of 1806 apps, only 13 of which were aimed at new or expecting fathers, and even among those were duplicates (Thomas et al., 2018). An additional nine were found offering general parenting advice to fathers.
APPS FOR FATHERS
Despite the comparative lack of paternal-focused mobile apps, there is great potential to use them to engage with fathers. Mobile technology offers unique benefits such as the provision of readily accessible information despite geographical distance or time constraints, and the ability for off-line access (Lupton, 2016). Paternal peer-support can be provided through app-based online forums and can assist the transition to fatherhood by providing fathers with the opportunity to share information and experiences, provide mutual support and the recognition that they are not alone with their concerns (White et al., 2018; Niela-Vilén et al., 2014). Research has shown that when appropriately targeted, fathers will use online sources to connect with others and share a wide range of information (Teague & Shatte, 2018; White et al., 2018).
Fathers use online resources to connect with others and share information
There are few father-focused perinatal mHealth interventions in the literature. A 2014 review of father-focused breastfeeding interventions found none, and only one that was web-based (Sherriff et al., 2014). Since then, there have been a few additional studies published. Two recent publications describing father-focused web interventions that were designed to provide fathers with perinatal information reported good acceptability of the approach (Da Costa et al., 2017; Mackert et al., 2017). The mDAD app was a social work app that aimed to deliver tailored information to new fathers to help them engage with their infants (Lee & Walsh, 2015). The SMS4Dads project is an Australian text message-based mobile intervention targeted at the mental health of new fathers (Fletcher et al., 2016). SMS4Dads aims to support the mental health of fathers who are either expecting a baby or have a baby under the age of three months. The intervention has demonstrated good acceptability and fathers found it was useful in starting conversations with their partner.
Our team has reported on the development, testing and implementation of the Milk Man app, a highly targeted breastfeeding app for fathers. As the support of fathers is such a key facilitator for breastfeeding, Milk Man aimed to deliver information that increased paternal support for breastfeeding which we hypothesized would impact positively on breastfeeding duration (White et al., 2016). There was little in the literature to guide the development of such an app and in shaping Milk Man, we looked to both the academic and grey literature, conducted an audit of male-focused health campaigns, and consulted with new and expecting fathers.
The resulting Milk Man app used engagement strategies such as gamification, social connectivity and push notifications to encourage fathers to use the app and participate in a conversation forum (White et al., 2016). With the importance fathers placed on peer support, the connection of fathers through the app was a key feature. Fathers were placed into groups depending on when their babies were due to enable conversation between fathers at the same perinatal stage. The app also contained a comprehensive information library with a focus on breastfeeding, but which also covered a range of issues such as fatherhood, relationship changes, infant sleep and healthy lifestyles, among others.
The Milk Man app was trialed in a large randomised control trial (Maycock et al., 2015) and fathers (n=586) had access to the app from approximately 32 weeks’ gestation to six months postpartum (White, Giglia et al., 2019). We have reported the process evaluation results and found that Milk Man was well received by both fathers and mothers (White, Giglia et al., 2019; White, Scott et al., 2019). Fathers used the app in a range of different ways to access information and support. Mothers were supportive of their use of an app for breastfeeding information and could see benefit both for their partners in terms of their knowledge and social support, and for themselves in terms of their partner being more supportive (White, Scott et al., 2019).
The conversation forum was a central feature of Milk Man and the main motivators to app use were the push notifications and seeing what other fathers had posted. We also found fathers used the app most in the weeks around the birth of their baby which may be a key time to target information to new and expecting fathers (White, Giglia et al., 2019).
Milk Man was the first breastfeeding app for fathers, and the first that we are aware of to describe specific ways that apps can encourage fathers to engage with health information over the perinatal period. An important finding was the acceptability of the app. Fathers were willing to use an app to source information about becoming a new dad. In addition, many fathers used the conversation forum to engage with other fathers to seek support, ask questions about their experiences and share information (White et al., 2018). The comprehensive process evaluation
of Milk Man (White, Giglia et al., 2019; White, Scott et al., 2019) will be of interest to anyone planning to reach fathers via mobile technology.
COMMERCIAL FATHER-FOCUSED MOBILE APPS
Despite the gap in the research, or perhaps because of it, there is an increasing number of examples of highly targeted, father-focused commercial apps. This demonstrates a real-life need and market for this type of information. In 2019, the UK app ‘Dadapp’ was launched worldwide (Dadapp, 2019). The app aims to socially connect fathers via an online platform and offers information and advice for new and expecting fathers. Its release follows a number of other father-focused apps in recent years, albeit nothing on the scale of what is offered to mothers. In 2017, two father-focused pregnancy apps were released - the Australian ‘Who’s your Daddy?’ app that substituted the traditional fruit size comparisons for describing the unborn baby at various stages of pregnancy with comparisons such as a 14 week old fetus being the ‘weight of a Yoda Star Wars figure (vintage in packaging)’ (Who’s your Daddy?, 2017); and the US ‘Daddy Up’ app that refers to infants as ‘cubs’ and an unborn baby as a ‘rugged mountain boot’ (Spur, 2019).
What all of these commercial apps have in common is that they are highly targeted to fathers, and take a colloquial, peer-like approach that often includes humor. It has been suggested that humor can trivialise the role of fathers (Thomas et al., 2018); however, in our research, the use of humor and a light-hearted approach were both suggested and received well by fathers ( White, Giglia et al., 2019; White et al., 2018; White et al., 2016). Research into how new and expecting fathers receive and engage with mobile apps remains limited and more research is needed to better understand how to reach fathers and positively impact on health.
IMPLICATIONS FOR PRACTICE
The health of fathers over the perinatal period is important, both for their own personal wellbeing, and for the impact their health has on maternal and child health. Fathers are sourcing information online and want information in easy to access formats; yet antenatal and postnatal education and services are not always inclusive.
The Milk Man app intervention showed that fathers were prepared to seek support and information about a variety of topics over the perinatal period through a socially connected app. Facilitating social support for fathers through virtual means has been demonstrated as successful in a number of settings. Releasing Milk Man publicly in Australia would allow for further research on how to engage fathers on a larger scale and would help improve understanding of paternal app engagement.
Fathers and mothers are increasingly turning to digital sources for their information; yet there is a dearth of evidence-based apps available for fathers. Commercial apps are emerging to fill the void but the quality of the information contained in these apps is unknown. There is still much researchers don’t know about how we can reach and support fathers over the perinatal period, yet it is clear that new solutions are needed. There is an enormous opportunity for public health organizations to build on what we do know about reaching fathers using mobile apps in order to develop targeted products to reach fathers and positively impact on health.
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