545380 research-article2014

JMHXXX10.1177/1557988314545380American Journal of Men’s HealthSmith et al.

Article

Parenting Needs of Urban, African American Fathers

American Journal of Men’s Health 1­–15 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1557988314545380 ajmh.sagepub.com

Tyler K. Smith, MD, MPH1, S. Darius Tandon, PhD2, Megan H. Bair-Merritt, MD, MSCE3, and Janice L. Hanson, PhD4

Abstract Fathers play a critical role in children’s development; similarly, fatherhood positively affects men’s health. Among the larger population of fathers relatively little is known about the parenting knowledge of urban, African American fathers. Focusing on urban, African American fathers, the objectives of this study were to (1) understand the primary sources from which fathers learn about parenting, (2) determine where and how fathers prefer to receive future parenting education, and (3) explore the information perceived as most valuable to fathers and how this compares with the recommended anticipatory guidance (Bright Futures-based) delivered during well visits. Five focus groups, with a total of 21 participants, were conducted with urban fathers at a community-based organization. Study eligibility included being more than18 years old, English speaking, and having at least one child 0 to 5 years old. During the focus groups, fathers were asked where they received parenting information, how and where they preferred to receive parenting information, and what they thought about Bright Futures parenting guidelines. Fathers most commonly described receiving parenting information from their own relatives rather than from their child’s health care provider. Most fathers preferred to learn parenting from a person rather than a technology-based source and expressed interest in learning more about parenting at community-based locations. Although fathers viewed health care providers’ role as primarily teaching about physical health, they valued Bright Futures anticipatory guidance about parenting. Fathers valued learning about child rearing, health, and development. Augmenting physician counseling about Bright Futures with community-based parenting education may be beneficial for fathers. Keywords fathers, parenting, Bright Futures

Introduction Fathers play a critical role in children’s growth and development. Fathers perceive their parenting role as multifaceted, citing financial and emotional support, role modeling, discipline, and accessibility as critical aspects of fatherhood (Dubowitz, Lane, Ross, & Vaughan, 2004). A solid body of evidence documents that children’s health improves when fathers are involved in parenting. Specifically, fathers’ positive involvement in parenting has been linked to improved cognitive skills and educational achievement (Rosenberg & Wilcox, 2006), fewer child behavioral problems, increased normative socialization (Cabrera & Mitchell, 2009; Rosenberg & Wilcox, 2006), and increased nurturing activities for children (Cabrera, Ryan, Mitchell, Shannon, & Tamis-LeMonda, 2008; Rosenberg & Wilcox, 2006). In contrast, children without paternal involvement are at increased risk for a range of adverse health and developmental outcomes including behavioral problems, decreased academic achievement, and substance abuse (National Responsible

Fatherhood Clearinghouse, 2013). Just as fathers positively affect the lives of children, fatherhood also can be beneficial to men’s health (Bartlett, 2004). For example, compared with men who were not fathers, fathers had improved nutrition and physical fitness, decreased alcohol consumption, less risk-taking behavior, and better overall personal care (Garfield, Isacco, & Bartlo, 2010). Among the larger population of fathers, however, relatively little is known about the parenting knowledge and needs of urban, African American fathers (Julion, Gross, Barclay-McLaughlin, & Fogg, 2007). For example, it is 1

Mercy Medical Center, Baltimore, MD, USA Northwestern University Feinberg School of Medicine, Chicago, IL, USA 3 Boston Medical College, Boston, MA, USA 4 University of Colorado School of Medicine, Aurora, CO, USA 2

Corresponding Author: Tyler K. Smith, Mercy Medical Center, Department of Pediatrics, 345 Saint Paul Place, Baltimore, MD 21202, USA. Email: [email protected]

2 unclear from whom urban, African American men most commonly seek parenting information and what information would be most helpful. Better understanding parenting needs of urban, African American fathers is important in designing parenting programs that can efficiently and effectively convey this information. Social cognitive theory, which has been used as a model to explain patterns of father–son communication about sexual health (Dilorio, McCarty, & Denzmore, 2006), is one underlying theory that may explain how fathers learn parenting information. This theory posits that learning occurs through observing interactions within one’s environment, with additional core concepts including self-efficacy, goal-setting, and outcome expectations (Banduras, 2004). The background knowledge and needs of this group may differ from other racial and socioeconomic groups. African American families bear a disproportionate burden of poverty and unemployment in the United States (U.S. Bureau of Labor Statistics, 2013). Specifically, African American men experience higher rates of unemployment (14%) compared with their Asian (5.4%) and White (6.7%) male counterparts (U.S. Bureau of Labor Statistics, 2013). Additionally, the median weekly income for African American men is lower than the median weekly income for Asian and White men (U.S. Bureau of Labor Statistics, 2013). Urban, African American fathers also face significant challenges such as racism, stressors of the streets (Teti et al., 2012), incarceration (Lu et al., 2010; Perry & Bright, 2012; Teti et al., 2012), and limited opportunities for educational advancement (Lu et al., 2010). Prior studies of parenting in African American fathers are somewhat limited. Notably, recruiting urban, African American fathers may be challenging because African American men endorse barriers to research participation including distrust of the medical community and concern for exploitation by researchers and physicians (Byrd et al., 2011). Additional barriers to fathers’ research participation include investigators’ reported difficulties locating and engaging fathers (Roggman, Boyce, Cook, & Cook, 2002) and, at times, researchers’ biased perceptions that fathers are not involved in their children’s care and hence will not be good informants or participants in childfocused research (Phares, 1992). Much of the limited existing qualitative and quantitative research about African American fathers’ parenting has focused on the effects of mental illness on parenting (Wilson & Dubin, 2010), fatherhood and parenting expectations (Garfield & Chung, 2006), supportive services for fathers (Buckelew, Pierrie, & Chabra, 2006), and ways in which to improve parenting skills to decrease child maltreatment (Calam, Sanders, Miller, Sadhnani, & Carmont, 2008; Cornille, Barlow, & Cleveland, 2005; Duggan et al., 2004; Gershater-Molko, Lutzker, & Wesch, 2003). The ability

American Journal of Men’s Health to fully understand the parenting needs of African American fathers may also be hindered because there is a dearth of qualitative studies in this area, such that there has been limited opportunity to gather fathers’ perspectives in an open-ended manner. The well child care visit is one setting in which parenting advice is commonly provided in the form of anticipatory guidance. Anticipatory guidance is the process by which health care professionals and families discuss ageappropriate, child-focused issues (e.g., behavior, injury prevention, nutrition) and health care providers offer recommendations to promote child health and development (Hagan, Shaw, & Duncan, 2008). The focus of anticipatory guidance for well child visits is guided by Bright Futures guidelines. Published jointly by the American Academy of Pediatrics and the Maternal and Child Health Bureau, Bright Futures serves as a framework for health promotion and disease prevention that is used by all professionals caring for children in outpatient, clinical settings (Hagan et al., 2008). Bright Futures specifically recommends that pediatric providers encourage parenting from mothers and fathers that promotes nurturing and supportive relationships for children, and that offers love, role models, security, and unconditional acceptance (Hagan et al., 2008). The guidelines recommend culturally sensitive interactions and information dissemination; however, Bright Futures does not contain a culturally specific framework or examples of how to provide culturally sensitive information to any specific population, including urban, African American fathers (Hagan et al., 2008). Pediatric providers who interact closely with African American fathers cannot effectively deliver the anticipatory guidance or parenting advice and education, however, without an improved understanding about what information would be most useful. Therefore, using Bright Futures guidelines and principles as the framework for parenting advice and focusing on African American fathers in an urban setting, the objectives of this study were to (1) understand the primary sources from which fathers learn about parenting, (2) determine where and how fathers would most like to receive future parenting education, and (3) explore the information perceived to be most valuable to fathers and how this compares to Bright Futures’ recommendations.

Method Study Design and Setting Study participants were recruited from a nonprofit, community-based organization (CBO) in Baltimore, Maryland, whose mission is to help fathers achieve stability and economic success. This organization serves predominantly African American fathers by providing

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Smith et al. general educational development and college preparation classes, job preparedness and training, and seminars about healthy relationships, parenting, and financial literacy. A study investigator developed a working relationship with the CBO and selected it as the study location.

Participants and Recruitment The Johns Hopkins School of Medicine Institutional Review Board approved all study procedures. Individuals receiving services at the CBO were eligible for study participation if they were at least 18 years old, were English speaking, and had at least one child 0 to 5 years old. Both biological fathers and men acting as father figures (e.g., mothers’ boyfriends, stepfathers, godfathers, grandfathers) were included based on other empirical work highlighting the central role father figures play in children’s lives within the African American community (Dubowitz et al., 2004). Determination of father figures was based on self-report by participants after defining father figures as men taking an active interest in rearing the target child through spending time together, mentorship, and providing emotional and/or financial support regardless of the frequency or the length of time of the relationship. Recruitment occurred from July 2010 through January 2011 through flyers, staff referral, and weekly in-person recruitment at the CBO by the research assistant trained on study eligibility criteria and recruitment procedures. The research assistant performed weekly screenings in a classroom at the CBO of fathers identified as potential study participants. Those interested in study participation were privately asked by the research assistant questions regarding their age, number of children 0 to 5 years old, and the ages of target children to confirm that fathers met eligibility criteria. In keeping with principles of qualitative research, study recruitment continued until reaching data saturation, for example, no new themes emerged through data analysis (Hanson, Balmer, & Giardino, 2011; Strauss & Corbin, 2008).

Procedures The research assistant contacted participants via telephone or email with information about the date, time, and location for the focus group. Telephone reminders occurred 1 week before, the day before, and the day of the focus group session for participants. Five focus groups were conducted, with each group containing between three and six participants. Four focus groups were conducted with biological fathers, and one focus group was conducted with father figures. Fathers and father figures were separated for focus group sessions because of the possibility that their thoughts about parenting could potentially differ. The moderator of the

focus groups was an African American, female physician working in a pediatric clinic providing medical care to minority and underserved children. The research assistant, who also attended each focus group and took notes during the session, was an East Indian, male, graduate student. All focus groups were conducted in a classroom at the CBO at a time deemed convenient for participants. The moderator first explained confidentiality procedures and focus group rules to all participants. Participants then provided written, informed consent. After consenting to study participation, participants answered a brief, investigator-created questionnaire that asked about age, race, level of education, current employment status, number of children 0 to 5 years old, and relationship to each target child and his or her mother. The moderator then shared the focus group goals of learning where and how fathers learned about parenting, what fathers would like to know about parenting, and where and how to best communicate that information to fathers. A focus group guide was created with structured questions and a series of follow-up probes (Figure 1). These questions were created by a study investigator using guidelines and principles from Bright Futures and reviewed by the research team. Additional questions were further developed based on focus group responses. The guide included structured questions in addition to three case scenarios that incorporated topics relevant to parenting children birth to 5 from Bright Futures that were presented to elicit information on fathers’ parenting knowledge, attitudes, and practices. For example, one scenario asked fathers to discuss their attitudes toward, and behavior related to, reading to their children. Focus group sessions were audiotaped to ensure collection of all participant responses. Study participants received dinner at the focus group session as well as a $25 gift card for their participation.

Data Management and Analysis Focus group audiotapes were uploaded to a professional transcription service where they were transcribed verbatim. For purposes of the audiotape and transcription, participants identified themselves using their first and last initial. To ensure accuracy of the transcription and fill in any comments that were unable to be transcribed, a study investigator listened to all audio recordings. Analysis of focus group transcripts consisted of three phases per the recommendations of Miles and Huberman (1984): data reduction, data display, and conclusions drawing. Data organization occurred with qualitative software, HyperResearch© 2.8. Data reduction was achieved by coding each focus group transcript into its smallest meaningful units of analysis. A study investigator developed a codebook after

4 I.     II.   

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Introduction/Icebreaker Question   A.  In your opinion, what makes a good father? How Fathers Learned About Parenting   A. There are lots of different ways for people to get information about parenting. How have you received or learned information about parenting in the past?       1.  How did you learn about parenting?       2.  Where did you learn about parenting i.e. at home, in church or in a parenting class?       3. What concerns have you had about parenting i.e. am I doing the right things, how do I do something such as making a bottle, how do I know if my child is sick?       4. Who did you speak to or who taught you how to be a parent i.e. parents, grandparents, brothers or sisters, aunts or uncles, cousins, friends, teacher, doctor? Do you consider these people experts or are there others not mentioned that you would include? III.  Information Fathers Learned About Parenting     A. I now have a better understanding of where, how and from whom you have learned about parenting, but I now want to shift gears. I would like to know what information have you learned about parenting?       1. What information have you learned that you found to be most helpful i.e. how to change a diaper and when to take a sick child to the doctor?       2.  In your opinion, what do you think is the importance of parenting education?       3.  One place where some people receive parenting information is in their child’s doctor’s office.         a.  Have you received information during a clinic visit?         b.  If so, what information did you receive?       4. Bright Futures is a “national health promotion initiative” that provides guidelines and recommendations for pediatricians and other health professionals caring for children to promote the best health and development for children, their families and community. I will present three (3) scenarios based on these guidelines. Please comment on your opinion of the guideline and how you would respond if you were in a similar situation.         a. Jaden is 9 months old and is very mobile and active. He crawls on the floor and uses the couch to pull himself to a standing position. He has recently learned to remove plugs from their socket and loves to put anything he can get his hands on into his mouth. His father often tells him “no” and “don’t do that” when he is getting into things that are dangerous. Bright Futures guidelines recommends limited use of the word “no” and using distraction as a means of removing a child Jaden’s age from harm or undesirable activities.           i.  What do you think and how do you feel about that recommendation?           ii.  How would you have handled Jaden if you were in the same situation as his father?         b. Aniya is 2 ½ years old. Her parents have placed her on a daily routine. Aniya’s mother gets her ready for daycare in the morning and her father drops her off on his way to work. After school, her grandmother takes her to the park and she usually sits down for dinner with her family each night. Her favorite time of the day is after bath time when her father plays “airplane” and reads her a story before bed. Bright Futures guidelines recommend that parents create a daily routine for children           i.  What do you think about the recommendation regarding daily routines for children?           ii.  Are they or are they not necessary?           iii.  What routines do you do with your child or children?         c. Nevaeh is 4 years old. He is excited that that he will be starting preschool in the fall. His mother and father read books to him every day in preparation for school. Bright Futures guidelines recommend that parents read to their child frequently and often for language development and to prepare them for school.           i.  What do you think about the guideline regarding reading to a child to prepare them for school?           ii.  Do you get a chance to read to your child and if so how often? IV.  Other Ways Fathers Would Like to Learn About Parenting     A. We have just discussed the type of parenting information that you have learned as well as going over some scenarios related to the Bright Futures guidelines. I would now like to talk about other ways that you would like to receive information about parenting. Where would you like to receive information about parenting?       1. There are many places where you could receive information about parenting. These places include your child’s doctor’s office, church, a community center, parenting class, school. Health programs have recently been done in barber shops.         a.  Do any of these locations appeal to you and if so, which ones?         b.  Are there other locations not mentioned where you would want to learn information about parenting?       2.  What methods would you prefer to receive information about parenting?         a. With the increased use of technology in society, would you prefer an e-mail, telephone text or voice message, written paper or brochure, in person communication?

Figure 1.  Focus Group Questions.

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Smith et al. reviewing the first three focus group transcripts. This codebook was subsequently used by the study investigator and a trained research assistant to independently code all focus group transcripts. To establish reliability of the coding process, after coding the first focus group transcript the coders discussed differences of opinion until agreement was reached with changes made to the codebook as needed. Independent coding then occurred of each focus group transcript by the study investigator and research assistant with coding differences discussed and reconciled in person. Data display involved organizing coded segments of text into charts to facilitate later interpretation of the data. Charts were created with a row for each code and a column for each focus group, which allowed for ease in reviewing the qualitative data. Conclusion drawing was then performed by reviewing coded text segments in these charts for emerging themes and patterns related to different focus group topics. The study investigator conducted a combined member checking group with fathers and father figures that participated in the focus group sessions in a classroom at the CBO. This process involved discussing and verifying the accuracy of themes emerging from the focus group sessions and coded transcripts. Another study investigator re-read all transcripts, verified a subset of coding and identified additional quotes to match the themes. Finally, the themes that emerged from this analysis were compared with the major themes of the Bright Futures guidelines for health supervision (Hagan et al. 2008).

Results A total of 21 African American fathers participated in the study; 18 of these men were biological fathers and 3 were father figures. After study investigators reviewed focus group transcripts and demographic information of participants, fathers and father figures were deemed similar in their responses and social make-up such that results were combined for both groups. Table 1 displays the demographic information for participating fathers. All of the study participants were African American with an average age of 34 years. Fathers generally had a high school education with half of the fathers being employed at the time of study participation. Each father had at least one child 0 to 5 years old with the average age for these children being 29 months old. Fathers were usually the boyfriend, fiancé, or husband to the mother of the target child. Information was not obtained regarding participants’ total number of children. The income of study participants was not obtained due to many fathers being unemployed at their initial presentation to the CBO and attending programs for the purpose of gaining employment. By the time of focus group participation, some fathers had become employed. The demographics of participating fathers were similar to the population of all fathers attending the CBO between July 2010 and February 2011. It should be

Table 1.  Paternal Demographics for Research Participants and Community Organization. Research participants Number of fathers n = 21 Average age, mean 34 years (standard deviation) (7 years) Race  Black/African 100% American Education   Less than high school 33% (n = 7)   High school graduate/ 48% (n = 10) GED   Some college 14% (n = 3)   Master’s degree 5% (n = 1) Employed 52% (n = 11) Average number of 1.8 (1) children 0 to 5 years old Average age of target 29 months child, mean (standard (18 months) deviation) Fathers with children 0 100% (n = 21) to 5 years old Relationship to mother of target childb  Boyfriend 11% (n = 2)  Fiancé 17% (n = 4)  Husband 17% (n = 4)  Ex-husband 0%  Friend 22% (n = 4)   No relationship 33% (n = 7)

Organizationa n = 42 32 years

100%

34% (n = 15) 55% (n = 23) 8% (n = 4)   10% (n = 4) N/A N/A 45% (n = 19)

8% (n = 2) 8% (n = 2) 15% (n = 3) 0% 31% (n = 5) 38% (n = 7)

a. Some demographic data for participants are not collected at the community-based organization; these rows will say N/A (not applicable). b. The relationship to the mother of target child per the organization reflects the relationship of men attending the community-based organization to the mother of their child at the time of the study. The term no relationship was used by fathers/father figures who believed that none of the terms provided in the survey explained their relationship to the target child’s mother especially if the mother and father/father figure were on poor terms. For example, some fathers described the relationship to the mother of the target child as “my child’s mother” or “my baby’s mother.”

noted that men attending the CBO may have differed from study participants in the categories of employment, number of children 0 to 5 years old, and relationship to mother, as information gathered during the initial intake and presentation at the CBO changing by the time of study participation and the CBO did not collect information specific to men identified as father figures. All fathers and father figures who participated in the study had also participated in a fathers’ group at the CBO. Three main themes emerged from the analysis; they are summarized and illustrated with quotes in Table 2.

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Theme 1: Urban African American fathers learn parenting information from many sources in many settings Yeah. My uncles and aunts were like an extension of the rest of the family that the aunts—I mean   Relatives: Relatives or family members taught fathers parenting information, for when grandma or my mother weren’t around, they would step in and do the part. example, mothers, fathers, siblings, aunts, uncles, cousins, grandparents, and/or godparents.   I guess my older sisters because I’m the only boy. They got kids and I watched them.   Community members: These fathers learned about parenting from people in their Well, I forgot, basically like in the past, it was the community, because where I grew up at your neighborhood, teachers, seminar presenters, and others. neighbors were like your parents, too.   Health care professionals: Doctors, nurses, and other health care professionals Yes, I had a real good doctor, I don’t want to mention her name, but I had a real good doctor for taught fathers about parenting. my child. She was more into developing both of us, and that’s why I really, really respected her. She was more into developing both of us, just the little side things, I would say. The one thing she told me that really is, let her run, because my child got a problem with running. One thing does come to mind that is TV. There were television shows growing up that we   Technology: Fathers mentioned learning parenting information via various forms watched. of technology, that is, email, Internet, PowerPoint presentation, television, text messages, voicemail, and websites—although technology as a medium got mixed reviews.   I say the technology—just leave it out. Leave technology out. Because first of all, I teach a computer class, right? Just basic computer knowledge. A lot of people just afraid of computers. They afraid of PowerPoint. I mean, you’re trying to teach somebody how to teach people with inanimate objects. You got to bring live bodies in. You got [to] bring kids in, and you got to bring people who have had them situations.   I wouldn’t like a voicemail. That would just annoy me. Because we’re living in different times now. And I’d like—not a text message because that would annoy me too. But sometimes an email because the email could be like a presentation.   I think the voice mail thing is good too and the text messages because I check text messages whether it’s from whoever. It don’t hurt to check the message, and you don’t have to respond, you know what I’m saying? I like to send off for books from other male counterparts.   Written documents: Fathers gathered parenting information from books, brochures, magazines, newspapers, and pamphlets.  I read those pamphlets too. They help out. They do. See, I’ve been knowing how to take care, I been taking care of my sister’s kids when she had hers.   Previous experience caring for children: Fathers described past experiences raising And I would take care of my niece and nephews and all that, change their Pampers and feeding or taking care of children from which they learned about, for example, changing a them. I was the uncle so I would take care of them. So that’s how I know how to change a kid’s diaper, feeding a child, burping a child, and watching a child. diapers and take care of them.   Basically I was learning too, so raising my sisters. I helped raise my sisters, so . . . Plus watching my kids, watching my sisters, taking care of my sisters growing up.   Home: Fathers learned parenting information at personal homes, homes of friends, Same thing I learned mine in my house or in my other relatives house and just basically paid and homes of relatives. attention a lot to what was going on as far as the parenting and different households in my family.   Church: Fathers described learning parenting information at centers for worship. Also, I would say at church too. Because at church you have pastors or leadership there, there are all parents and would understand if you would come in there and share with them what’s going on if you have some problems with your child or something that’s going on at home. And they would be able to help you do it maybe even spiritual-wise because basically you got to have some kind of spiritual root in order to deal with some other things that goes on so that you won’t act out. And keeping yourself from developing that relationship with your child.

Table 2.  Themes with Illustrative Quotes.

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  Reading: These fathers endorsed the importance of reading to a child and discussed getting books for children, the importance of technology for reading and learning, reading to promote language development, taking children to the library, time spent reading with children, and watching educational programs.

  Keeping children safe: These fathers agreed with the importance of keeping children safe from danger and harm by using safety devices, visual aids, and verbal cues.

  Discipline: These fathers supported the importance of providing discipline for children, for example, using discipline techniques and telling a child “no.”

  Health information: These fathers valued health information about topics such as identifying illness and disease, how to begin appropriate medical treatment at home, giving medications, awareness of immunizations, taking a child’s temperature, and when to take a sick child to the doctor. Theme 3: Urban, African American fathers endorse parenting practices promoted in Bright Futures   Daily routines: These fathers agreed that daily routines are important, suggesting that they provide structure and teach children about discipline and responsibility.

  Effective communication with children: These fathers described the importance of learning how to effectively communicate with their children.

Theme 2: Urban, African American fathers appreciate learning parenting information   Child rearing: These fathers described learning about child rearing, which included how to feed a child, balanced meals, changing a diaper, the importance of physical activity, interacting with a child, and other tasks of daily parenting.   Developmental milestones: These fathers commented about the importance of learning about childhood developmental milestones.

  Community locations: Fathers noted community locations where they learned parenting information, that is, community agencies and organizations, neighborhoods, parenting classes, parks, playgrounds, and schools.   Health care facilities: Fathers learned parenting information at health care facilities, that is, community health centers, health clinics, and hospitals.  

Table 2. (continued)

I think it’s important about routines because that structure you set as a child and you do it right it will make your child’s discipline to be a better person, human being, when they grow up because they had that structure. The word no is not a hurtful thing, but you got to make sure when you say no, you have a reason for saying no, not just saying no just because they’re a child to be asking. There has to be an explanation behind it. My point of view on that is before my child gets in any harm’s way, I avoid it before it can even happen. So I basically tell them—I watch the newspapers, so I already know what’s going on— so I tell them, “What’s going on out there, you don’t want to go through that. And I tell them, “I’ve been through stuff that’s going on today, and I don’t want to see y’all go through that.” I think that reading to your child or with your child is one of the absolute most important things that you can do with your child.

I was just going to say at the doctor’s office they teach you about age ranges between 6 and 9 months the baby should be acting like this, like the average, like the normal what he should be acting like from a year to 2 years or a year to 18 months and what he should be doing as far as he should be talking by now, or he should be responding, or his eyes should be—you know what I’m saying? Basically, I think one of the most important things that I’ve learned is how you communicate with your child, the actual communication because I guess it’s all about the message that you portray to them, how they see you. You get down on their level. You communicate with them and try not to scream at them, and actually show them how something is done. Don’t always tell them, “Oh, this is wrong,” actually showing them, you know what I mean, what it is that they’re doing and what’s wrong and what’s right in an active corrective measure, you know what I mean? They told you to take care of them. When your kids get sick and they told you what to do, how to put the thermometer in their mouth, and they told you to check the thermometer. So you’ve got to check it what they told you what to do. And they told you what type of medicine you could give them because I take my son.

I learned how to change the diaper by my mother. My mother taught me how to do it because to tell the truth that was my first time being a father because I didn’t know how to do nothing.

Pretty much I learned some things here in the fatherhood, but outside of here I would say I guess going to some doctor’s appointments and the doctor inform you of your child. I learned at a doctor’s office, taking my kids to their clinic appointments, to their physical doctors and stuff like that, I learned that you wind up looking at and listening to a doctor and he’s explaining to you how your child is and what’s going on with your child.

And I’ve been in two different parenting classrooms already, and I graduated out of all them parenting classrooms and got my certificate proving I graduated out all of them.

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Theme 1: Urban, African American fathers learn parenting information from many sources in many settings. Theme 2: Urban, African American fathers appreciate learning parenting information (e.g., child rearing, developmental milestones, effective communication with children, and health information). Theme 3: Urban, African American fathers endorse parenting practices promoted in Bright Futures (e.g., daily routines, discipline, keeping children safe, and reading).

Theme 1: Urban African American Fathers Learn Parenting Information from Many Sources in Many Settings These fathers learned parenting information primarily from other people (community members, health care professionals, and relatives) in a wide variety of locations (churches and other places of worship, community organizations, health care facilities, home, neighborhoods, parenting classes, parks, playgrounds, and schools) in both formal presentations and informal interactions. They gained parenting information and skills primarily from their social groups, including mothers, fathers, siblings, aunts, uncles, cousins, grandparents, godparents, friends, neighbors, and pastors. “I think me, like the gentlemen said, as far as your grandparents, your parents. Me? I get mine from my mother. And I get mine from my father and my brother-in-law. My elders, my peers.” These fathers were open to learning about parenting from pediatricians and other health care providers, but in their experience health care providers had been a source of more specific health information. For example, when asked what he had learned from his child’s doctor, one father said, Well, just medical things. My son used to get ear infections all the time and I was wondering why that was something that always was reoccurring. And they gave me some insight about that. Just mainly medical facts. Not really anything about parenting.

Another answered, “Probably how to deal with the colds more and how to be more patient with them when they’re whining and feverish and things and such like that. Toothaches.” A third wished for more, saying, They don’t tell you nothing that you might want to read, talk—they don’t give you no information, but except like they said the right food, the right this, all of the health things. We need, I guess, more information because that’s what I was lacking, a lot of information.

Fathers’ desired additional information from their child’s health care provider, but implied that physicians’ busy schedule or focus on information directly related to physical health prevented them from receiving this information.

At times they learned from more formal sources, such as teachers at a parenting class or community center in a neighborhood or health care professionals who provided advice. Some of these fathers also gained parenting information from media sources such as email, PowerPoint presentations, television, text messages, voicemail, and websites, although technology as a medium received mixed reviews and they preferred to learn from other people more directly. Fathers found technology an impersonal method for learning about parenting and endorsed in-person instruction with a teacher or educator as more interactive. Some of the fathers had read books, brochures, magazines, newspapers, and pamphlets. Their personal experience caring for children also played an important role in their learning. They described past experiences raising or taking care of children from which they learned about, for example, changing a diaper, feeding a child, burping a child, and watching a child. These urban, African American fathers acquired their parenting information and skills in their personal homes, homes of friends and relatives, churches, community centers and organizations, the neighborhood, parks, playgrounds, and schools. Homes, churches, community centers, and the neighborhood were endorsed as the main locations for learning parenting information. Especially us in this room, the number one place that I know we got parenting from was our neighborhoods. Because back then, our neighborhoods cared more than anything. So that’s where you learned most of your parenting from, because you had different parents coming at you, because you had the whole neighborhood on you.

Although playgrounds and parks appeared to be unconventional places to learn parenting information, fathers endorsed learning how to speak to a child and keeping a child safe through both personal instruction and direct observation of others’ parenting styles. They sometimes learned parenting information at health clinics and hospitals, although they tended to go to these locations for specific health-related issues. One father described a helpful health clinic when he said, When I went to the doctor they showed me how to do it, and they talked to me, and they told me how to raise a baby, and how to take care of a baby and stuff, how to give them formula and change their Pamper, and [bathe] them and all that. And they told me how to burp them. Put the towel on your shoulder and they taught me how to hold the baby and stuff and pat them on the back.

When asked where and how they would like to receive future parenting education, fathers indicated that they would like to continue learning about parenting in the

9

Smith et al. locations where they have been learning—particularly in their homes and in community locations such as barbershops and recreation centers. I would say, like he said—for one, the community center, because therefore if you don’t have a strong community, your kids ain’t going to be strong. So therefore I would say first your community center or your church, because those have been backbones of any families, I don’t care what time or generation it is. That’s always been the backbone of every family—church or community center. Which, we got a lot of churches, but we ain’t got many community centers, because they shut them down. . . . Whereas if you go to a library or a doctor or something like that, you pretty much not going to get the rundown on how to really handle it. They’re going to give you the quick version of it, whereas a church or community, they’re going to show you how to get that situation quick and nip it in the bud where that situation don’t come up no more. Or to better the situation. You know what I mean?

When asked, fathers liked the idea of access to parenting information in community locations that they frequent in their neighborhoods, such as barbershops and recreation centers. One father said, “They need them in more family centers or Boys and Girls clubs and Rec’s that they could teach the kids and the adults. And they need more fatherhood programs everywhere.” Another commented, “I like that idea going to the barbershop. If they had somebody periodically come through I guess maybe once a week or something like that just to talk because that’s a talking environment.” A third father explained why these locations make sense. “I like a couple of places like my father, my mother, the barbershop, car wash; these are places where I be at.”

Theme 2: Urban, African American Fathers Appreciate Learning Parenting Information Fathers highlighted information about child rearing, developmental milestones, effective communication with children, and their children’s health as particularly important aspects of parenting information they learned. When they described learning about child rearing, fathers mentioned very practical tasks such as feeding a child, preparing balanced meals, changing a diaper, the importance of physical activity, interacting with a child, and other tasks of daily parenting. I guess when my kid was born; there [were] a lot of things [we learned] . . . my wife had . . . brochures and all of that stuff and we used to read it together. And when he was born, the doctors they [came] in [the hospital room] and they tell you how to hold them, feed them, when to feed them, how to—everything like that.

Some of these fathers also commented about the importance of learning about childhood developmental milestones and how to support their children’s development through the things they helped their children do. There was a little thing on the internet where it tracked the development of your child. And as they grow, it’ll tell you like different things you could expect from them. And a lot is right on, as far as like when they start cutting teeth, or when they start crawling, or their first words when they should start talking. So I think the internet is real helpful with things like that.

They also valued learning how to effectively communicate and build good relationships with their children. One father described the communication he had been learning about in this way: Basically I think one of the most important things that I’ve learned is how you communicate with your child, the actual communication because I guess it’s all about the message that you portray to them, how they see you. You get down on their level. You communicate with them and try not to scream at them, and actually show them how something is done. Don’t always tell them, “Oh, this is wrong,” actually showing them, you know what I mean, what it is that they’re doing and what’s wrong and what’s right in an active corrective measure, you know what I mean?

These fathers also valued health information about topics such as identifying illness and disease, how to begin appropriate medical treatment at home, giving medications, awareness of immunizations, taking a child’s temperature, and when to take a sick child to the doctor. They saw doctors and others in health facilities as an important source of this information. For example, Whenever the doctor prescribe like medicine, how to [get] prescriptions, you know, and everything, as far as like what your child needs, how it’s supposed to be [taken], what time it’s supposed to be [taken]. How much you’re supposed to give a child.

Theme 3: Urban, African American Fathers Endorse Parenting Practices Promoted in Bright Futures When presented with scenarios that illustrated some of the Bright Futures recommendations for parents of young children, these fathers explained why they agreed with these recommendations and gave examples from their experiences with their children. They agreed that daily routines are important, suggesting that they provide structure and teach children about discipline and responsibility. One father said,

10 I think routines are extremely important, because it teaches boundaries, one, and it teaches responsibility, and again, as the brother said, it also establishes their day, their daily [routine]—what they can expect. It gives them some normalcy in their day.

These fathers supported the importance of providing discipline for children, for example, using discipline techniques and telling a child “no.” In fact, one father explained why he thought discipline was especially important when he said, So that’s all I preach to my son is about discipline, respect, defense, anything he need to know that’s going to keep him alive more than anything because a lot of kids die, or they’re standing in the wrong place at the wrong time, hanging out late at night.

These fathers also agreed with the importance of keeping children safe from danger and harm by using safety devices, visual aids, and verbal cues. One father gave this example: Like my son, he likes to play with plugs. So I had got—I went to Wal-Mart and bought a lot of those plastic plug inlet—input plugs that you—and I got them all over the house, so he wouldn’t put his hands inside a plug.

Finally, these fathers endorsed the importance of reading to a child and discussed getting books for children, the importance of technology for reading and learning, reading to promote language development, taking children to the library, time spent reading with children, and watching educational programs. As one father said, I think reading is definitely one of the best things you can do for your kids. I mean, I definitely I took my daughter, took her to get her library card, her first library card. It was me. I went with her and my son too as well. And I try to keep them [with] some kind of books in their hand.

The themes were compared with the ten principles on which the Bright Futures guidelines for pediatric health supervision were built (Table 3). Seven of the 10 principles figured prominently in the conversation of these urban, African American fathers. They spoke about the importance of providing family support for their children, promoting their children’s development, providing healthy nutrition, promoting physical activity, and building community relationships/using community resources. They endorsed practices that promote mental health and keeping children safe. They did not mention healthy weight as an area of concern. They mentioned oral health just once, with a comment about the importance of helping children brush their teeth. Promoting healthy sexual

American Journal of Men’s Health development and sexuality also did not emerge as a theme among these fathers. Although specific questions about sexuality were not asked during focus groups, fathers expressed their desire to have doctors teach about abstinence and safe sex. In addition to these principles, they emphasized their need to learn practical information about parenting tasks, ways to communicate effectively and build relationships with their children, and specific health information about how to care for their children when they are sick.

Discussion This qualitative study assessed urban, African American fathers’ views on parenting and parenting information. Although there are significant social and historical factors that affect the availability of African American fathers, this study’s rich focus group data suggest that this group of African American men valued their role as fathers. Although information was not elicited from fathers about the effects of parenting on their health and well-being, participants repeatedly expressed the importance of parenting and active involvement with their child. Furthermore, this group of men was open to parenting advice in many forms and expressed their commitment to continued learning about fatherhood. Fathers most commonly received parenting information from people familiar to them such as relatives. Fathers reported in-person teaching was the preferred method for learning parenting information, as compared with technologybased sources. Fathers expressed wanting to learn about parenting both at home and in community locations such as barbershops and recreation centers. Fathers reported only learning a limited amount about parenting from their child’s physician; however, they did endorse learning about specific health related topics. Fathers tended to look for parenting information in their homes, neighborhoods, and communities, which is consistent with the key tenet of social cognitive theory that learning occurs through observing interactions within one’s environment (Banduras, 2004). Fathers supported future learning in barbershops and recreation centers. Prior research has demonstrated the effectiveness of using community locations—such as barbershops, churches, and community centers—for health promotion and intervention, especially among African American and urban men (Holt et al., 2009; Linnan et al., 2011; Victor et al., 2011). These locations were often considered “guy friendly” as patrons were usually peers with similar backgrounds. For example, African American men in the FITStop pilot study were interested in learning more information about health topics including exercise, healthy eating, heart disease, and stroke at their local barbershop. FITStop participants also were amenable to

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Smith et al. Table 3.  Comparison of Study Results to Bright Futures’ Recommendations. Themes of bright futures recommendationsa Promoting family support Promoting child development

Parenting information perceived as valuable by fathers in responses to open-ended questions Emotionally and physically available, present with his children when needed, financial provider, role model Urban, African American fathers appreciate learning parenting information—Developmental milestones: Childhood developmental milestones

Promoting mental health  

Promoting healthy weight Promoting healthy nutrition Promoting physical activity Promoting oral health Promoting healthy sexual development and sexuality Promoting safety and injury prevention Promoting community relationships and resources

Urban, African American fathers appreciate learning parenting information—Child rearing: “Child rearing” includes how to feed a child and balanced meals Urban, African American fathers appreciate learning parenting information—Child rearing: “Child rearing” includes . . . the importance of physical activity There was just one mention of the importance of helping children brush their teeth While this did not emerge as a theme among these fathers of young children, there were a few comments about the importance of doctors teaching abstinence and safe sex

Relatives: Relatives or family members taught fathers parenting information, for example, mothers, fathers, siblings, aunts, uncles, cousins, grandparents, and/or godparents Community members: These fathers learned about parenting from people in the neighborhood, teachers, seminar presenters, and others Home: Parenting information was acquired at personal homes, homes of friends, and homes of relatives

Parenting information perceived as valuable by fathers as endorsed in responses to scenarios   Urban, African American fathers endorse parenting practices promoted in Bright Futures—Reading: The importance of reading to a child, for example, getting books for a child, importance of technology for reading and learning, reading promoting language development, taking child to the library, time spent reading with child, and watching educational programs. Urban, African American fathers endorse parenting practices promoted in Bright Futures—Discipline: Discipline for children, for example, techniques and telling a child “no” Urban, African American fathers endorse parenting practices promoted in Bright Futures—Daily routines: The importance of daily routines, fathers’ examples of daily routines, and what children learn from daily routines, for example, discipline, responsibility, and structure    

 

   

Urban, African American fathers endorse parenting practices promoted in Bright Futures—Keeping children safe: How to keep children safe from danger and harm, including safety devices and measures, visual aids, and verbal cues  

 

 

(continued)

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American Journal of Men’s Health

Table 3. (continued) Themes of bright futures recommendationsa

 

 

 

Parenting information perceived as valuable by fathers in responses to open-ended questions Church: Parenting information was acquired at a center for worship Community locations: Parenting information was acquired at community agencies and organizations, neighborhoods, parenting classes, parks, playgrounds, and schools Health care facilities: Parenting information was acquired at health care facilities, that is, community health centers, health clinics, and hospitals Urban, African American fathers appreciate learning parenting information-Child rearing: “Child rearing” includes . . . changing a diaper . . . interacting with a child, and other tasks of daily parenting Urban, African American fathers appreciate learning parenting information—Effective communication with children: How to effectively communicate and build relationships with children Urban, African American fathers appreciate learning parenting information—Health information: Health information, for example, identifying illness and disease, how to begin appropriate medical treatment at home, giving medications, awareness of immunizations, taking a child’s temperature, when to take a sick child to the doctor

Parenting information perceived as valuable by fathers as endorsed in responses to scenarios    

 

 

 

 

a. Based on Kagan et al. (2008, p. xix).

receiving health screenings at barbershops including blood pressure, cholesterol, and weight (Linnan et al., 2011). Fathers valued what their children’s doctors told them about parenting, but generally viewed physicians primarily as a source of specific health information. Anticipatory guidance is an integral component of well child care (Hagan et al., 2008). Fathers have positive experiences and find satisfaction in health care visits when questions are sufficiently answered and needs are met (Garfield & Isacco, 2006). However, within the context of a busy practice, pediatric providers clearly need to consider optimal ways in which to target parenting-related anticipatory guidance to fathers (Schor, 2007). Although fathers in this study stated that they had obtained information from their child’s health care provider, they implied that physicians’ busyness during clinical encounters hindered the ability to adequately deliver health and other

information. Thus, fathers felt that they were receiving the “quick version” of parenting advice, desiring more guidance from their child’s physician. Actively building alliances with children’s primary caregivers is critical, and physicians need to be cognizant of fathers’ perceptions of the value of information provided during the pediatric visit. Evidence suggests that counseling about health topics is beneficial for child outcomes. For example, anticipatory guidance provided by pediatricians about healthier eating habits has proven effective in promoting healthier eating habits in infants (French et al., 2012). Similarly, physicians offering books to parents and children during well child visits improved early childhood literacy and language development (Sharif, Rieber, & Ozuah, 2002; Silverstein, Iverson, & Lozano, 2002). Parents have been found to appreciate information regarding children’s development and readiness for early childhood education

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Smith et al. (Brown, Girio-Herrera, Sherman, Kahn, & Copeland, 2013) and to value information provided about injury prevention and improved safe storage of firearms in households with children (Carbone, Clemens, & Ball, 2005). The perspective of the African American fathers in this study about topics often addressed during well child care suggests that they, too, would be receptive to receiving counseling and information in these areas. There was strong support for the parenting principles covered by Bright Futures, although the parenting topics these fathers emphasized differed somewhat in focus from the themes of Bright Futures. Consistent with Bright Futures, fathers most commonly described the importance of child development and rearing, daily routines, discipline, keeping a child safe, reading and talking to a child, and building relationships with children. Discussing these health and parenting topics with fathers may open an important discourse about parenting and strengthening the provider–father relationship. The findings from this research should be viewed in light of several limitations. All of the participating fathers were African American and recruited from one urban, community-based program. It is uncertain if fathers from suburban or rural communities would have shared the same opinions as those highlighted in this study. Therefore, results of this study may not transfer to fathers of other ethnicities, geographic location, and socioeconomic status. In order for future studies to discern the differences in parenting by different socioeconomic circumstances, participation criteria could include fathers of certain educational or income levels. Furthermore, fathers participating in the research study were already participating in self-improvement programs at the CBO and therefore had a vested interest and motivation in personal improvement. These men may have wanted to provide responses that would make them look favorable as fathers and parents. The small sample size of fathers for this study reflects the hard-to-reach population at the recruitment site; however, participants in all focus groups contributed actively, and recruitment continued until reaching data saturation (Hanson et al., 2011; Strauss & Corbin, 2008). Father figures included in this study were based on self-report regardless of the length of time of the relationship, therefore allowing the potential participation of father figures who had limited parenting experience with the target child; however, study participants shared similar thoughts and ideas regardless of whether they identified themselves as fathers or father figures. No pretesting occurred with the focus group guide, though the guide was iteratively revised after each focus group. Demographic information was not obtained from study participants about either income or total number of children, factors which could potentially influence their feelings.

These findings have implications for the next steps in future studies. Future research should explore whether fathers of different ethnicities and from different socioeconomic backgrounds share similar views regarding parenting. The feasibility and implementation of parenting education specifically geared toward fathers in community-based locations should be studied. Additionally, future research should investigate the parenting education provided by health care professionals to fathers during well child visits and should assess how to augment this information to meet fathers’ learning needs. Finally, future researchers should investigate ways of sharing parenting information with fathers that support the value they place on parenting their young children and build self-efficacy in relation to filling their role as fathers.

Conclusions Fathers play an important role in children’s growth and development. Although the fathers in this study more commonly received parenting information from sources other than pediatric providers, they felt that parenting recommendations provided by Bright Futures guidelines were both important and relevant. Augmenting physician counseling with community-based parenting education may be beneficial for fathers. Pediatric providers should also consider exploring novel approaches for communicating parenting topics to fathers at well child visits and conducting needs assessments with fathers using their practices to determine which parenting topics are deemed to be of greatest importance. Acknowledgment We acknowledge the contributions of Mr. Amir Fayek for his assistance with this study.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Academic Pediatric Association/Maternal and Child Health Bureau Bright FuturesYoung Investigator Award Program.

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