Understanding the Barriers Fathers Face to Seeking Help for Paternal Perinatal Depression: Comparing Fathers to Men Outside the Perinatal Period
2. Materials and Methods
2.1. Design
The research used a cross-sectional between-groups design in which all the data were gathered online at one time point. The research compared fathers who had experienced PPD during the two years after their child was born with men who had experienced depression during the past two years but had not had a child during this time and, therefore, were not in the perinatal period. Variables were naturally occurring; no experimental manipulation was involved. All data were collected online to allow participants to take part anonymously, as it was hoped that this would make the research more accessible to some fathers who may not have otherwise taken part due to stigma or shame related to PPD.
The men who had experienced PPD in the past 24 months were also invited to complete a series of free text responses to questions. An expert by experience (EbE) was consulted when developing the research questions and questionnaires. The EbE was somebody with lived experience of PPD who now campaigns for improved mental support for fathers, and he had previously supported the authors in completing research in this area. He was involved particularly in supporting the wording of the qualitative questions and providing support and ideas for recruitment. A key recommendation from our EbE was to not include the term ‘postnatal depression’, as they felt this is so closely associated with mothers that it may discourage participation from fathers.
2.2. Participants
All participants had to meet the following criteria:
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Identifies as male;
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Has experienced self-reported depression in the past 24 months;
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Between 18–65 years of age.
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In addition, the FD group were required to meet the following:
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In the perinatal period (partner has given birth in the past 24 months);
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Biological fathers (i.e., not adoptive fathers or step-fathers).
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The exclusion criteria for all participants were as follows:
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No access to suitable technology to complete the study;
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Self-report of a history of serious mental illness. Following advice from experts by experience, no specific diagnostic labels were used as exclusion criteria, instead, participants could determine for themselves if they had a history of a serious mental illness.
2.3. Procedure
Data were collected online using Qualtrics between April and December 2021. Participants were recruited using electronic posters containing details of the project and URL and QR codes to access the survey. Electronic posters were shared across targeted social media platforms by researchers, campaigners and charity organisations, including the Fatherhood Institute, Andy’s Man Club and The Dad Pad. Efforts were made to recruit a diverse population by contacting support groups for fathers from minority populations and requesting their support with recruitment.
All eligible participants then completed a series of quantitative measures electronically, which are described below. After completing the quantitative measures, participants in the FD group were also invited to respond to five open questions. The FD group were asked (1) whether they had experienced any barriers to seeking help for paternal perinatal depression and, if so, (2) what these barriers were, (3) what help they would have liked to be available, (4) how they could have been supported to access this, and (5) if they had any further comments.
Upon completion of the survey, participants were directed to an electronic debrief page. This contained contact details for the researchers, as well as details of organisations that offer support to men struggling with their mental health.
2.4. Measures
The following measures were completed online using the Qualtrics platform. None of the items used forced-choice response, meaning that participants could choose not to complete certain measures or items within measures.
Demographics: The participants initially completed a demographic questionnaire, which captured age, ethnicity and number of previous children.
Participants were also asked to select ‘yes’ or ‘no’ to indicate if they were currently accessing any form of support for depression.
Participants were then asked whether they had previously experienced depression, if they had previously sought help for depression, and whether their partner (if applicable) was currently experiencing depression.
Awareness of services: Participants reviewed a checklist of nine support services and indicated which they were familiar with, as well as being asked to list any additional services they were aware of. These were totalled together to give a numerical value for awareness of services.
2.5. Analysis
3. Results
3.1. Participants
A total of 125 participants took part in the research: 64 men in the perinatal period (FD) and 61 men outside of the perinatal period (MD). Due to attrition, some participants did not complete all of the quantitative measures, which resulted in differing numbers of responses for each measure.
3.2. Comparing Fathers (FD) to Men with Depression Outside of the Perinatal Period (MD)
Similarly, no significant differences between the FD and MD groups were found for levels of self-stigma (t = 1.09, p = 0.27) or conformity to masculine norms (t = −1.63, p = 0.11). Due to the data not being normally distributed, a non-parametric Mann–Whitney U test was used to compare awareness of services between the FD and MD groups, which again identified no significant between-group difference (U = 1293, z = −1.334, p = 0.18). There were also no significant differences between the groups in terms of their current depression levels, history of depression, partner’s current depression, history of help-seeking or current help-seeking.
3.3. Evaluating a Proposed Model of Help-Seeking
The secondary hypotheses (3–6) related to exploring a proposed model of help-seeking amongst fathers. Prior to beginning the planned regression analysis, all statistical assumptions were checked. Our analysis identified that all assumptions were met, as there was a linear relationship between the predictor variables and the dependent variables. There was also homoscedasticity for the residuals, no significant outliers and the residuals were normally distributed. Additionally, the correlation coefficients between each predictor variable were all <0.7, and all tolerance values were >0.1, showing that there was no multicollinearity between variables.
A hierarchical regression model was then constructed using the FD data in a step-wise fashion (n = 53). Initially, only two predictor variables, conformity to masculine norms and awareness of services, were added to the model. The third hypothesis was accepted as adding self-stigma to the model, alongside conformity to masculine norms and awareness of services, significantly increased the amount of variance in help-seeking intentions that were accounted for (R2 = 0.19, p < 0.001). The overall model with all three predictors was significant (F[3, 49] = 3.88, p = 0.02).
3.4. Understanding the Barriers to Seeking Help for Paternal Perinatal Depression
3.4.1. Being a ‘Man’
The first theme described barriers to seeking help for paternal perinatal depression in terms of societal pressure on fathers to act in ways that are considered culturally and socially appropriate for men.
Do not talk about feelings: Fathers described pressure to not discuss their feelings. Fathers spoke of a “lack of practice” [WH13] discussing emotions as “men are not taught to tune into their emotional side” [BI11]. One shared that a “lack of experience discussing feelings, and a sense that I’d be thought of as just making a fuss about nothing” [ST01] was a barrier to seeking help. This suggests that, even if the fathers had sought help, they may have struggled to discuss their emotional experiences.
Men as providers: This subtheme described fathers prioritising providing for their family over attending to their own well-being: “there is very little time when supporting a newborn and wife to focus on yourself” [LO04]. Men described “needing to keep going to work to support my family” [FA08] and facing institutional barriers, such as workplaces offering “no time off to do so [seek-help]” [WY06].
Protecting others: Another barrier was the perceived societal pressure to protect others, resulting in concerns about becoming a “burden” [BI24]. Fathers described “not wanting to overshadow my partner’s needs” [BE17] and feeling “selfish” [SO20] for sharing their own struggles with low mood. Fathers worried about their partners as they had “actually had to give birth and have the physical stress of birth. I feel like surely my issues can’t be as serious as that of the mother” [SO4].
Staying strong: The final subtheme described societal expectations to appear “strong for family and not wanting to show weakness to friends” [ED20]. Fathers felt they should be strong, “as a dad, I didn’t want to show weakness” [QU09].
There was a sense that had fathers wanted to break these stereotypes and seek support for mental health difficulties, they may have struggled due to lack of practice, societal pressure and institutional barriers.
3.4.2. Changing Recognition and Understanding
The second theme spoke to the need to increase recognition and understanding of paternal perinatal depression to enable fathers to seek help. Fathers described a lack of public and professional knowledge, making it hard to recognise the signs of paternal perinatal depression or to access information and support.
Public awareness: Participants described a lack of public and professional awareness of paternal perinatal depression as a barrier to seeking help. One father reported that he could not access support for paternal perinatal depression as he “never knew it existed” [BI24], and another felt that the public held a “view that it’s not something that affects men” [BO17]. Fathers also felt that “there’s no awareness of GPs and other professionals for it” [SI02], which prevented men from seeking help as they worried about whether paternal perinatal depression “would be taken seriously” [ST01] by professionals.
Realising need for help: Due to this lack of awareness, men reported that “realising that you might need help is hard” [BI11]. Others struggled to recognise the signs of paternal perinatal depression as the concept “just doesn’t connect with me” [MS01]. This made it challenging for fathers to recognise they were experiencing paternal perinatal depression and “to accept that I needed it [help]” [OP14].
Missing information: Fathers described the difficulties they faced when searching for information about paternal perinatal depression. Men described not knowing “how to go about getting help, or what help I needed” [WH18]. Fathers were not “made aware of services by the midwife or health supporter” [RO21] and struggled with a “lack of available or clearly advertised services” [BE17]. One father reported “there’s no reference to it on Google’s first hits. There’s a lot on women scenarios and focus that makes me feel uncomfortable even to suggest paternal depression” [SI02]. This lack of information and understanding hindered fathers from recognising PPD or knowing how to seek support.
3.4.3. Finding a Voice
This theme represented the barriers fathers faced at each stage of being heard and supported by professionals, peers and family members.
Not asked: The first subtheme related to fathers “not being asked” [BE17] about their wellbeing by professionals. Fathers felt that “it’s [paternal perinatal depression] just not spoken about and I was never asked” [MS01]. Fathers felt that “any kind of engagement post birth to check in on my well-being” [WO16] would have been beneficial and advocated for “at least one occasion on which a medical professional talks to the father alone about their experiences and needs” [FI08].
Missing fathers: Fathers shared experiences of specialist services being unavailable to them as the “system is geared to mothers, not fathers” [ED20]. Many described the “lack of dedicated paternal depression resources” [MC08] and shared that “there should have been someone there and there wasn’t” [BI24]. This was compounded by COVID-19, with one father saying “I think due to the pandemic and not being able to attend anything fathers should be getting more support and they’re not. It’s all about the mum but the dad needs to get help too” [MC07], and another described becoming a “passenger” [SO4] in the process.
Building opportunities: Participants indicated they would have benefitted from opportunities to form a “community of people with similar experiences” [MC08] through counselling or support groups. This felt important in creating a safe space for fathers to discuss their experiences. Men called for “a male friend to talk to” [CL10] and more professional input to access “group therapy” [LA20], “phone-based talking therapies” [BE17] or “self-help guides” [WH13].
Being supported: The final subtheme spoke to the sub-group of men who did find a voice and sought help, which was “just right” [WH18]. Although some fathers felt well supported, they reported that this help came typically from family or friends rather than from professionals. When asked about barriers to speaking with family and friends, the majority of fathers described the barriers highlighted in the other subthemes. However, approximately one-fifth of fathers felt “there were none, my family and wife were great” [MC07]. This suggests that existing networks could be a useful resource for fathers to access the support they need whilst barriers to accessing professional input remain in place.
3.4.4. Self as a Barrier
The final theme related to men frequently referencing themselves as a barrier due to negative beliefs and feelings about experiencing PPD creating high levels of self-stigma.
Not deserving: Several fathers described not seeking help for PPD, as they felt that they did not deserve help in the same way as mothers or other men experiencing depression outside of the perinatal period (“my form of depression wasn’t worthy” [ON5]). Others worried about not being “depressed enough” [BR27] to deserve help, with one father stating “I didn’t think it was bad enough and I didn’t want to take the service away from someone who needed it more” [WH18].
Self-stigma: Fathers shared self-stigmatising attitudes about PPD and how this prevented them from seeking help. Fathers described the “stigma of a man having paternal depression [and] thinking this should be happiest time of my life” [ON5], with one man reporting, “I was my biggest barrier” [MC08]. Others felt “scared of what people will say” [WI04] if they were to seek help. These internalised negative attitudes prevented fathers from seeking help.
Shame: The final subtheme described the emotional barriers associated with self-stigma. Fathers felt they “should be enjoying my newborn and not feeling down, so the shame and guilt that comes with that” [SE14]. Others stated that “shame prevented me from talking to friends” [ES11]. This theme highlights that, in addition to the societal, institutional and practical barriers men face to seeking help for PPD, they must also overcome their own internal barriers.
4. Discussion
To our knowledge, this paper is the first empirical study of help-seeking amongst fathers with postnatal depression. The results indicate that fathers with PPD are not significantly different to men with depression occurring at another time of life in terms of their attitudes to help-seeking, self-stigma, conformity to masculine norms or awareness of services. The proposed model of help-seeking amongst fathers was explored and supported by the current findings. Qualitative responses also highlighted additional societal, institutional and practical barriers fathers face to seeking help for postnatal depression.
The results clearly highlight the importance of perinatal mental health services including fathers in their mental health screening processes. Fathers described never being asked about their mental health. This serves as a barrier at multiple levels; it means that services are simply not made available to fathers, and it communicates to fathers that their own well-being is less important than the mother’s. This perpetuates the masculine stereotypes that fathers described in the ‘being a man’ theme. It is possible that if fathers were routinely asked about PPD, this would also support raising awareness and knowledge of PPD amongst the public and professionals.
Limitations
A further limitation is that comprehensive and objective data on participants’ perinatal and mental health history were not collected. The majority of participants in both groups had previously experienced depression, but it is unclear how long their recent episode of depression lasted, as no chronicity data were collected. Therefore, it is possible that some participants in the MD group were experiencing depression, which began in the perinatal period over 24 months ago. Whilst this would no longer be considered PPD, it poses a challenge to drawing firm conclusions about the lack of between-group differences. Additionally, the exclusion criteria of a self-rated history of serious mental illness were subjectively assessed, meaning that some potential participants with a history of depression may have been missed if they considered this a serious mental illness. It is also possible that men with depression who also experienced high levels of self-stigma would not identify as having depression and, therefore, would not have been included in the study. There were also no data collected on their partner’s pregnancy, birth, or their child’s development, all of which may have had an impact on the father’s mental health. Therefore, future research should collect more comprehensive data, including data on chronicity of depression and perinatal history, as well as introducing more rigorous exclusion criteria regarding fatherhood status and mental health history to allow for clearer conclusions.
This research gathered qualitative data online using free text boxes as part of a larger, mixed-methods study. This design was selected to allow fathers to take part in the research anonymously, following advice from our expert by experience that shame or stigma may prevent fathers from wishing to take part in less anonymous forms of research, such as interviews or focus groups. One benefit of this design is that some fathers may have taken part who may have otherwise chosen not to do so. However, it is also a limitation, as free-text responses to open-ended questions do not provide the same rich data as other forms of qualitative research, such as interviews. It also means that it was not possible to ask any follow-up questions or ask participants to share more details. It is important that future research utilises a range of designs, including interviews and focus groups, to allow the field to access rich data, as well as the views of harder-to-reach fathers.