Research shows that fathers can make a positive contribution to their partner's mental health (Fisher, 2016) and health behaviours such as breastfeeding, smoking and nutrition (Mannion et al, 2013; Sherriff et al, 2014; Hansen et al, 2018; Baldwin et al, 2021a) and their child's social, emotional, behavioural and cognitive development (Sarkadi et al, 2008; Goodwin and Styron, 2012; Cabrera et al, 2013; Machin, 2018). Supporting new fathers, as well as mothers, is therefore crucial to ensuring good health of the whole family. Health visitors are ideally placed to provide this support as ‘family workers'; however, research evidence continues to highlight barriers to father-inclusive practices and ineffective engagement of fathers with the health visiting service (Bateson et al, 2017; Menzies, 2019; Baldwin et al, 2019; 2021b; Leonard et al, 2020; Davenport et al, 2022). Consequently, there are few reports of success stories when it comes to fathers' experiences of the health visiting service.
This article has been co-authored by a MECSH service user who is a father and a health visitor researcher. In recent years, there has been a greater recognition of the importance of involving patients/service users in research to enhance the relevance of research and supporting its translation into improved health outcomes and services (Health Research Authority/Involve, 2016).
In November 2021, NHS England published Making research matter, setting out a policy framework for developing and investing in nursing related research activity across the NHS (NHS England, 2021). In their shared commitment to further public involvement, NHS England promised to ‘listen to and learn from the people and communities we involve and apply and share that learning’ (NHS England, 2023). Including the patient voice can bring unique insights into the understanding of the lived experience, and contributions from patients/service users have started to emerge in peer-reviewed publications (Oliver et al, 2022); however, the number of these types of articles remains low, especially within the field of health visiting.
This article presents a personal perspective of a father's experience of the MECSH programme delivered by the health visiting service. In addition to providing a case study, the article discusses the co-production process of writing, acknowledging the strengths and limitations, rewards and challenges, and the strategies used along the way. The father is referred to as the ‘service user author’ and the health visitor researcher as the ‘professional author’.
The MECSH programme
The Maternal and Early Childhood Sustained Home visiting (MECSH) programme is a structured model of health visiting designed for families needing additional support through targeted or specialist levels of service. Areas that use MECSH have all their health visitors trained in the programme, which is delivered from pregnancy until the child's second birthday. MECSH is currently implemented in 51 local council areas in England (11 in London), as well as in the Channel Islands (Jersey and Guernsey). Research to date shows positive outcomes for both mothers and children (Kemp et al, 2011; 2013; Goldfeld et al, 2019; Kemp et al, 2022; Price et al, 2023). While the MECSH programme is designed for the whole family and is inclusive of fathers, it has not been formally evaluated for fathers. The following case study is of a father (Yanick) whose family received the MECSH programme in one London-based setting.
Yanick's story
My experience of becoming a father was a scary moment in my life as this was my first time having to be in control of another person's life. I kept thinking, ‘What if I fail?’ and ‘Am I responsible enough?’ Insecurity coupled with ego can play a huge role in fathers shying away from help.
Before my son was born, we met our health visitor, who introduced us to the MECSH programme. We met her in our home; at the time we lived with my sister and uncle and our home was in a bad state. Our health visitor educated us on how to make our home environment safe for our baby to arrive. We were introduced to the children's centre where we saw parents like ourselves helped to socialise and come together. We were given resources such as information booklets to help and guide us with raising our son. We also received practical support to meet our basic needs through a local charity, where we were helped with clothes, nappies, a stroller and a cot, which we needed at the time.
Above all, the main thing that helped us get through this difficult period was our health visitor. She was someone we trusted and could rely on. She wasn't just doing her job, she took a real interest in our wellbeing. She made herself available to meet our needs and, most importantly, she made us feel safe and protected during this vulnerable period of our lives.
The relationship we had with our health visitor meant that both my partner and I felt very involved with the MECSH programme. We have learnt so much through the programme and being able to share our worries and concerns with our health visitor has been extremely helpful. I have been able to go to the library and parks with our son and have my alone time with him. The one thing I have learnt is that my son comes first and now I feel more confident as a father and am fully committed to be there for him. It has been a tumultuous journey, but with support received from our health visitor on the MECSH programme has enabled me to grasp the knowledge and skills needed to feel more confident as a parent and now I definitely enjoy my role as a father much more.
Research on fathers' experiences of health services
To date, a number of studies have reported on fathers' experiences of health services where men have reported feeling excluded and unacknowledged by health professionals during the perinatal period (Backstrom and Hertfelt Wahn, 2009; Dheensa et al, 2013; Palsson et al, 2017, Baldwin et al, 2019). In a qualitative study of 15 first-time fathers, Palsson et al (2017) highlighted that, while fathers desired antenatal strategies to deal with the changes brought about by new fatherhood, they lacked active guidance from health professionals to access reliable information. Fathers were also not acknowledged as equal parents by health professionals (Palsson et al, 2017).
Studies from in the UK suggest the health visitor role is often perceived by fathers as a service provided ‘by women, for women’ (Williams et al, 2013). A literature review on service users' views suggested that some fathers welcomed the opportunity to express their feelings and emotions about fatherhood when asked by a health professional (Greening, 2006), but did not always have the opportunity to do this (Salway et al, 2009). In a qualitative study of fathers' experiences of the health visiting service, Menzies (2019) reported that many fathers were unaware of the health visiting role and health visitors continued to deliver mother- and child-centred care with fathers often left on the periphery.
In the recent three-part New Dad Study (NEST), men's experience with health visitors varied, with only a small proportion of fathers feeling ‘included’ and ‘listened to’ by health visitors (Baldwin et al, 2018; 2019; 2021b; 2022). Fathers feeling ignored and sidelined by health professionals has also been reported in other studies since (Black, 2023; Davenport and Swami, 2023). Accounts of fathers feeling included are often not discussed in the literature, with the focus instead being on the gaps in service delivery.
Reasons for health professionals not engaging with fathers have been attributed to a lack of training on working with fathers, a lack of confidence to work with fathers, and a lack of policies requiring the inclusion of fathers (Whitelock, 2016; Oldfield and Carr, 2017; Davenport and Swami, 2023). The personal account shared in this article clearly shows that health visitors already have the skills and qualities needed to work with fathers. Having good communication skills, being non-judgemental, and taking the time to listen to parents (Brook and Salmon, 2015), are all key factors to developing the health visitor–client relationship, which is one of the fundamental components of health visiting practice (Cowley et al, 2013; Cowley and Bidmead, 2021).
This case study demonstrates the importance of the client–health visitor relationship. It was this trusting relationship that provided a safety net for Yanick and his family during their most vulnerable time. By fostering this relationship, health visitors can address fathers' needs as men, as well as fathers (like they do with women), enabling them to truly take a family-focused approach, as ascribed to their role. The personal story shared in this article demonstrates that MECSH is a father-inclusive programme, and the training prepares health visitors to use a reflective, restorative and partnership-based model to support the whole family. It utilises a salutogenic approach that is proactive, anticipatory and aspirational, to enable parents to adapt and self-manage and ‘parent effectively despite’ the adversity experienced and difficulties they face (Kemp, 2018). While there has not been any formal evaluation of fathers' experiences of the MECSH programme, this case study demonstrates that taking the time to build a relationship with the father, as well as the mother, has benefits for the whole family.
The co-authoring process
The idea of co-authoring this article came about following the service user sharing his experience of the MECSH programme in a steering group meeting. The professional author approached the service user through their health visitor to ask if he would be interested in providing a case study to be incorporated in a publication about fathers. Through further discussion with Yanick, it was clear that he was interested in sharing his views and contributing more to the article; therefore, a more collaborative approach to writing seemed appropriate and this is where the idea for co-authoring originated.
The professional author presented an initial outline of the article to Yanick to consider, which went through several iterations during the writing process before the final format was agreed. This was the service user's first experience of writing for publication, and it was agreed that the professional author would lead the publication process. The stages involved in preparing and submitting for publication were discussed at the outset, along with agreeing roles and responsibilities of the authors. This helped to address some of the power imbalances that may occur between the authors (Lobban et al, 2019).
One of the difficult decisions about how to write the article was to decide whether there would be a section written by the service user author and another written by the professional, so that readers could clearly identify the voice of each. In other words, would it be a ‘salad’, where the separate ingredients remained distinct and identifiable, or a ‘soup’ where they are all blended together into one (East Midlands Academic Health Science Network, 2023).
The authors eventually decided that it would mainly be ‘soup’ with some elements of ‘salad’ within it, such as ‘Yanik' story’ section. This was necessary to keep separate in order to truly appreciate his lived experience as father and service user. Each author contributed something unique to the writing process. Yanick contributed his ‘lived experience’ as a new father and his insights on the MECSH programme, while the professional author contributed her research expertise and experience of writing for publications.
One of the main challenges was competing commitments and work schedules of both authors. A variety of communication methods were adopted including emails, telephone/video calls and messaging services. Regular, open and honest communication was maintained throughout, recognising strengths and challenges. Talking about differences of opinions and how they will be presented helped the authors to work collaboratively throughout the process.
To evaluate how well the authors worked together as co-authors, the Patient Authorship Experience (PAE) self-assessment tool was used on completion of the article, which evaluates eight publication relevant domains using a bipolar, five-point, psychometric, Likert scale (Woolley et al, 2019). This tool is a publication-specific adaption of the Patient Engagement Quality Guidance (Deane et al, 2019), and it has two versions – one for patient authors, and one for non-patient authors (Arnstein et al, 2020). The outcome was a rating of 98% for each author.
Both authors acknowledged how rewarding the process had been and how much they had learned from each other. Writing the article has been a new and exciting experience for the service user, enabling him to be reflective, learn about the publication process and contribute to the evidence base by sharing his story to help other families and practitioners. The professional author learnt about the importance of adopting a flexible approach to maintaining regular communication with her co-author and the mutual trust required for this collaborative process to work. Both identified that more face-to-face meetings would enhance future collaboration.
Conclusion
Father involvement by health visitors is seen as a gap in service delivery; nonetheless, there are many occasions when fathers do feel included and have a positive experience of health visiting care. This article is an example of such an experience presented in a father's own words. These examples need to be celebrated, shared and added to the evidence base for health visiting practice so that the narrative for fathers' inclusion by health professional can be improved. Learning from such personal accounts will also be beneficial for practitioners, as they demonstrate how health visitors can use the skills and knowledge they already have, to build trusting relationships with both parents and help them feel safe, build confidence and achieve positive outcomes for themselves and their children.
The MECSH programme, through its structured home visits over a long-term period, provides an ideal opportunity for health visitors to work closely with fathers. MECSH is designed to help expectant parents to better prepare for parenthood, provide better access to information and health services, use a variety of resources and services to support families, and offers assessment and support for parental mental health and wellbeing. Research shows that these are the types of support that fathers want from health visiting services (Baldwin et al, 2019).
Further research involving MECSH fathers is needed to explore their involvement with and experience of the programme. Considering the experiences of other family members and care givers (such as grandparents, foster parents, stepparents, adoptive parents, carers) would enable a broader understanding of the MECSH programme's impact. Such studies would contribute to the evidence base for structured home visiting programmes for parents/carers who are not mothers, a gap that currently exists.
This article has been co-authored by a service user and a professional, which is considered an innovative way to present the information that includes the voice of lived experience. The co-authoring process has been a learning opportunity for both authors, enabling them to reflect on their own writing and helping them to adapt a different writing style when necessary. Using the PAE tool enabled the authors to evaluate how well they worked together and where the partnership could be enhanced. Understanding and learning from the experience of both the service user and professional author is equally important, and the PAE self-assessment tool helped to unlock these insights. This tool could be utilised by other authors planning such collaborations. Both authors presented at a national MECSH conference held in London in September 2023. It is hoped that this collaborative relationship will continue so that future projects could be considered.
Service user co-authorship is a novel approach within health visiting peer-reviewed publications, which provides the lived experience perspective, contributing to the richness of the paper. Researchers, patient/service user partners and publication professionals may draw on these resources as they start or continue to collaborate on patient involvement in publications.