Lay Health Workers Engaging Latino Fathers: A qualitative study

Abstract

Behavioral Parent Training programs (BPTs) are evidence-based interventions that have been shown to be effective when implemented in various contexts and with different racial/ethnic minority families. Despite evidence showing their effectiveness within the Latinx community, disparities in access to BPTs still persist. In addition, fathers continue to show low rates of attendance and engagement despite evidence suggesting positive outcomes for the youth and family when fathers are involved in BPT treatment. Lay health workers (LHWs), community members without specialized metal health training that often live in the communities they serve, have been identified as engagement specialists that are uniquely positioned to reduce racial/ethnic disparities in access to services. The current study utilized a qualitative approach to examine this workforce’s perspectives on engaging Latino fathers in parenting services in children’s mental health. Qualitative themes revealed that LHWs have generally positive attitudes towards engaging Latino fathers in parenting interventions (i.e., benefits to parent-child relationship) despite experiencing barriers to engagement (e.g., culturally defined gender roles, fathers being less likely to ask for help). Themes also elucidate various engagement strategies that LHWs use to engage fathers in treatment (e.g., adapting treatment setting). Considerations for future LHW trainings and workforce development are discussed with a focus on how to incorporate cultural values in the use of father-engagement strategies.

1. Introduction

An estimated 13–20% of children living in the U.S. meet criteria for a diagnosis of mental health disorder (e.g., anxiety, conduct disorder) in a given year (Perou et al., 2013). Among these children and adolescents in need, only approximately one half of them receive mental health treatment for their symptoms (Merikangas et al., 2010; Merikangas, Nakamura, & Kessler, 2009). Children who exhibit conduct and behavior problems at an early age are also more likely to experience long-term mental health issues, substance use, and future abuse of women and children (Fergusson, Horwood, & Ridder, 2005; Prinz, Sanders, Shapiro, Whitaker, & Lutzker, 2009). Early onset conduct problems can result in tremendous detriment to the individual, the family, and society. Behavioral parent training programs (BPTs) have been established as best-practice interventions for treating child conduct and behavior problems with strong evidence supporting child and family outcomes (Eyberg, Nelson & Stephen, & Boggs, 2008; Kaminski & Claussen, 2017). Numerous BPTs have been developed and tested to show effectiveness in treating disruptive behaviors by supporting parents to better manage their children’s behaviors. Although these interventions vary in their content and methods, most rely on teaching parents both common parenting techniques (e.g., praise, selective attention) intended to build or repair a positive parent-child relationship, and effective discipline strategies (Kaminski & Claussen, 2017). While BPTs were originally developed in more controlled research settings, they have been shown to be effective in community settings, where client needs are often more complex and client populations are more diverse (Michelson, Davenport, Dretzke, Barlow, & Day, 2013). This strong body of research suggests that there is a tangible solution to support children and families in need of services regardless of their racial/ethnic background.

1.1. Disparities in Access to Services

However, despite the dissemination efforts of numerous large-scale system reforms aimed to increase utilization rates of evidence-based practices including BPTs (e.g., Olin et al., 2014; Regan et al., 2017; Timmer et al., 2016), disparities in accessing and utilizing these services still exist, particularly for racial/ethnic minority populations (Barnett et al., 2019; Mcguire & Miranda, 2008; Henry et al., 2020). For example, compared to Non-Latinx, White families, racial/ethnic minority families have lower rates of enrollment in parenting interventions (Baker, Arnold, & Meagher, 2011). Racial/ethnic minority families also continue to experience higher rates of dropout and attrition and are more likely to face socioeconomic disadvantages that result in barriers to treatment (Fernandez, Butler, & Eyberg, 2011; Webster-Stratton & Hammond, 1990). Similar racial/ethnic disparities have been cited across various health care systems and contexts (Nelson, 2002) and even federal efforts to systematically address these disparities and advance health equity have resulted in modest (Fiscella & Sanders, 2016) or, in some cases, nonexistent improvements (Cook et al., 2017). The systems of care in this country as they currently function have room for growth and research aimed at reducing health disparities is far from finished.

As the fastest growing minority group in the United States (U.S. Census Bureau, 2001), Latinxs have been a focus of decades of research aimed at understanding the nuance of these disparities in access and utilization (Kouyoumdjian, Zamboanga, & Hansen, 2003; Miranda, Nakamura, & Bernal, 2003). When we examine BPTs in particular, compared to their Non-Latinx, White peers, Latinx families, along with other racial/ethnic minorities, require more sessions and skills practice in order to complete treatment and are more likely to drop out of treatment prematurely (Kazdin, Mazurick, & Bass, 1993; Lavigne et al., 2010; K. McCabe & Yeh, 2009). Incorporating research and treatment recommendations on how to overcome these barriers and disparities (Kouyoumdjian, Zamboanga, & Hansen, 2006; Lau, 2006), many cultural adaptations to evidence-based services have been developed and, more recently, tested in community settings (Matos, Torres, Santiago, Jurado, & Rodríguez, 2006; Parra Cardona et al., 2012). Efforts have focused on making evidence-based interventions more culturally responsive and developing novel engagement strategies in order to reach communities where utilization of services remains low. One example of cultural adaptation to evidence-based parenting interventions comes from McCabe and colleagues who developed a culturally adapted version of Parent-Child Interaction Therapy (PCIT) entitled Guiando a Niños Activos (McCabe & Yeh, 2009; McCabe, Yeh, Lau, & Argote, 2012; McCabe, Yeh, & Zerr, 2020) which takes into consideration the cultural values of Mexican-American families (e.g., familismo) and focuses on overcoming family barriers to engagement. This research highlights the importance of engaging extended family members and addresses inappropriate treatment expectations at the onset of treatment in order to combat premature dropout.

1.2. Father Engagement in Services

Historically, parenting interventions were focused on mother-child relationships and supporting primary attachment figures in their development of positive parenting skills. Until recently, this meant that parenting interventions were developed, tested, and administered predominately without much focus on father engagement or coparenting (Panter-Brick et al., 2014). As family constellations change and an increasing number of children in the U.S. are being raised with fathers outside the home (Teti, Cole, Cabrera, Goodman, & McLoyd, 2017), recent research has begun to characterize fathers’ influences on child development. As the lens that describes parenting widens, research shows clear and unique impacts of father involvement on child development across various contexts and cultural settings (Lamb, 2010). Children with highly involved fathers have been shown to have increased levels of cognitive competence and empathy (Pleck, 1997; Campbell et al., 2015). Programs designed to improve fathering outcomes have also shown significant promise in their ability to improve father self-efficacy, co-parenting relationships, and father-child relationship outcomes in a wide range of family constellations, including families with CPS involvement (Nievar et al., 2020; Gallagher, Rycraft, & Jordan, 2014). Levels of paternal involvement are important for outcomes in children’s mental health services as well (Phares, et al., 2010).

In fact, numerous studies have shown that engaging fathers in parenting services can result in positive outcomes for both children and families. For example, meta-analyses have found that nonresident fathers who use effective parenting styles have children with fewer internalizing and externalizing problems (Amato & Gilbreth, 1999; Adamsons & Johnsons, 2013). A recent scoping review of father involvement in family home visiting services highlights how fathers remain underrepresented in this area of research and intervention even though their involvement is associated with a wide range of positive outcomes for fathers (e.g., increased confidence, positive parenting skills), mothers (e.g., higher rates of treatment completion, decreased parental distress), and the family system generally (Burcher et al., 2021). In addition, a meta-analysis of BPTs revealed that studies including fathers, compared with those that did not, reported significantly more positive changes in child behaviors and in desirable parenting strategies (Lundahl, Tollefson, Risser, & Lovejoy, 2008). Finally, in a study of father involvement and PCIT, Bagner and Eyberg (2003) compared treatment outcomes between involved-father families, uninvolved-father families, and absent-father families. All groups significantly benefited from treatment on measures of child-behavior, parental depression, and parenting stress and no group differences were found immediately after treatment. However, at a 4-month follow up mothers from involved-father families were the only group to maintain treatment gains, suggesting that father engagement in treatment may be related to the maintenance of treatment gains and more long-term positive family outcomes. A recent future directions piece highlights a need for a focus on the inclusion, engagement, retention, and measurement of father-related outcomes in research that hopes to better understand fathers’ unique roles in treatment (Fabiano & Caserta, 2018).

Despite what we know about how fathers contribute in important ways to child development and children’s mental health services, providers and agencies continue to experience barriers to father engagement in parenting interventions (Panter-Brick et al., 2014). Many researchers have now posed strategies that providers and agencies can employ in order to increase father engagement in parenting interventions. Hecker (1991) speaks to family therapists when suggesting talking to fathers directly, making it clear at initial contact that all caregivers are expected to participate, letting fathers know that many men tend not to seek help until needs are urgent, and highlighting that changes in the family depend upon the father’s participation in treatment. Phares and colleagues (2006) highlighted the importance of inviting fathers to session directly, intervening when fathers are reluctant to participate, and also drew attention to research showing that involvement of maltreating fathers may be contraindicated (Scott & Crooks, 2006). Lechowicz and colleagues (2019) have recommended stressing the importance of involving fathers in treatment at the organizational level, avoiding a father deficit model, engaging fathers as part of the parenting team, and providing training programs to providers on how best to engage fathers.

Corroborating the use of many of these strategies, Lee and colleagues (2016) amplify the voices of service providers and fathers who reported that lack of stable funding for father-specific programs, father’s masculine identities making it difficult to ask for support, and anti-father bias among human service agencies among the many barriers to engaging fathers in a wide range of services. Fathers and service providers in their study highlighted specific needs including supporting the co-parenting relationship, acknowledging unique needs of men returning from the criminal justice system, and integrating fathers into existing programs in a way that “normalizes the presence of men” within human service agencies (Lee et al., 2016, p. 81). Another group who spoke with fathers and fatherhood program providers suggested word-of-mouth recruitment using relatable messaging (e.g., father-specific images and language) and providing transportation or incentives as core strategies to increase father engagement and father-friendliness of programs geared towards parents (Stahlschmidt et al., 2013). Finally, a recent study interested in predicting change in rates of father engagement found that clinicians’ self-reported levels of confidence working with fathers, frequency of father engagement strategy use, and organizational supports of father engagement were all associated with higher rates of father attendance in services (Jiang et al., 2018).

Using these suggested techniques and strategies may benefit from considering cultural context and familial diversity in an effort to overcome barriers to father engagement. Integrating our understanding of disparities in access to services for Latinx families with our knowledge of the low rates of father engagement in parenting services exposes a particular intersecting need to address Latino father engagement (Moodie & Ramos, 2014; Acevedo-Polakovich et al., 2017). Previous work has attempted to highlight the considerations that may exist when engaging Latino fathers and has identified various cultural factors that may be related to this process. An earlier review on Latino fathers urges researchers to “develop theory embedded in cultural context [and increase] qualitative work to inform theory” (Campos, 2008, p. 152). Later, a dynamic model of Latino father influences on children development and review of recent literature suggests that Latino fathers invoke a hybrid style of fathering that includes both traditional and modern views on parenting roles and responsibilities (Cabrera & Bradley, 2012). The review highlights cultural values such as familismo and machismo that continue to be important defining features of Latino fatherhood, and emphasizes evidence against stereotypes including that Latino fathers, in fact show more warmth to their infants than do White fathers (Cabrera, Hofferth, & Chae, 2011). In addition, a recent mixed-method study highlights that Latino men prescribe to multi-dimensional views of masculinity and reject stereotypical notions of machismo. Walters and Valenzuela (2020) describe how Latino men in their study endorse a masculinity that is most closely aligned with caballerismo (i.e., humility, honor, responsibility) and defined by features of “respect, fairness, and affection” (p. 967). Finally, a comprehensive review of Latino father engagement in Head Start programs resulted in twenty-three engagement strategies, many of which focus on organizational supports and centering cultural sensitivity (Acevedo-Polakovich, Spring, Stacy, Nordquist, & Normand, 2017). But few studies have taken what we know about the importance of cultural values among the Latinx community, findings regarding stigma towards help-seeking in Latino males (Cauce et al., 2002), and sought to understand how Latino fatherhood and identity may be interacting with their involvement in parenting interventions specifically. It is increasingly important that our research considers Latino fathers specifically in order to maximize their engagement in parenting services. The current study illuminates the experiences of a unique workforce who are often positioned as engagement specialists (i.e., lay health workers) to identify their primary training needs in accomplishing this task.

1.3. Lay Health Worker Workforce

One strategy that has been posited as a means to address racial/ethnic disparities in engagement in BPTs for low-income, ethnic minority families is the utilization of lay health workers (LHWs) (Barnett et al., 2016; Barnett, Gonzalez, Miranda, Chavira, & Lau, 2018; Barnett, Lau, & Miranda, 2018). LHWs are typically community members without formal mental health training, who come from the communities they serve, and fulfill a variety of roles in children’s mental health services including outreach and parent support. Though this workforce operates under different names and titles (e.g., community health workers, promotoras de salud, natural helpers, parent support partners; Barnett et al., 2018; Gustafson et al., 2018; Olin et al., 2014), their purpose and drive uniquely centers community engagement. LHWs are passionately and selflessly addressing disparities from within their own community which highlights the importance of understanding their perspectives and experiences from the front line (Gustafson, Atkins, & Rusch, 2018). LHWs can function from members of grassroots organizations with little to no organizational support to paid staff members who are integrated into health organizations (e.g., parent partners within children’s mental health; Hoagwood, 2005; Olin et al., 2014; Barnett et al., 2021). For the purposes of this paper, experiences of LHWs across paid and volunteer workforces will be taken into consideration together in order to highlight shared barriers that are faced among LHWs regardless of their employment status.

Taking numerous bodies of literature together we begin to see that addressing racial/ethnic disparities in access and utilization is a monumental task that requires a deep understanding of complex systems of care paired with a sensitivity and responsiveness to cultural needs. Partnership with LHWs offers a unique solution toward addressing these complex and dynamic community needs; these partnerships begin directly in the community and focus on addressing need from within. A recent example from global mental health shows promise in LHWs’ ability to address problem drinking and family engagement among fathers in an intervention delivered by male lay providers in Kenya (Giusto, Ayuku, & Puffer, 2021). LHWs have been shown to use social proximity (i.e., cultural and social closeness to the communities which they serve) as a strategy towards engaging vulnerable communities who may otherwise not seek services (Gustafson et al., 2018). While social proximity has been shown to be an important factor as to why LHWs are such successful engagement specialists, it is unclear how this sociocultural factor impacts the workforce’s relationship with fathers being engaged in services. For example, a recent qualitative study investigating Latino male perceptions of community health worker roles found that perceptions of the feminized role and the volunteer or low-paid aspect of the work conflicted with their views as providers for their families (Villa-Torres, Fleming, & Barrington, 2014). Further, as this workforce is predominately female, gender dynamics could perpetuate the emphasis of engaging mothers and not fathers within BPTs. For example, a culturally adapted LHW-delivered parenting prevention program is titled Madres a Madres (Mothers to Mothers), demonstrating that efforts aimed to leverage LHWs to deliver or support BPTs might further exclude Latino fathers from these services (Williamson, Knox, Guerra, & Williams, 2014).

The current study took place within a community-partnered research projected focused on refining and evaluating an LHW-delivered implementation intervention to increase and sustain Latinx parent access to and engagement in parenting interventions within community mental health settings (Barnett et al., 2019). To understand how different LHW workforces engage parents, LHWs were recruited from volunteer organizations (i.e., promotoras de salud) and paid workforces within children’s mental health (e.g., parent support partners, home visitors). Specifically, the current study sought to understand LHW attitudes, confidence, and use of father engagement strategies. This study was conducted in order to incorporate cultural complexities of LHWs into the development of the intervention as it relates to Latino father engagement and to identify targets for training on Latino father engagement specifically.

2. Materials and methods

2.1. Participants

LHWs were recruited through community-academic partnerships with a network of promotoras de salud and community mental health agencies in two counties in Southern California, which provided evidence-based BPTs. The total sample included twenty-three LHWs; 14 of these LHWs were working in a volunteer capacity (i.e., promotoras de salud) through a regional Promotora Network partnering with various sectors of health services in the county (e.g., Alzheimer’s, diabetes, mental health). Many of the promotoras had volunteered or been contracted to work on projects that provided prevention parenting programs. The remaining nine participants were paid employees (e.g., home visitors, parent support partners) embedded within mental health service agencies, which provided evidence-based BPTs (e.g., PCIT, SafeCare). Home Visitors work to deliver in-home mental health and behavioral supports for youth and families, especially parents of young children while Parent Support Partners serve as navigators and case managers for parents navigating social service systems (e.g., mental health, child welfare) which they themselves have also had experiences navigating. Participants were predominately Latinx (75%) and female (96%). Approximately one-fourth of participants (26%) were born in the US and more than half of participants (61%) identified as a primary caregiver of at least one child. A table of demographic characteristics is included below in Table 1.

Table 1.

Descriptive Statistics of Study Sample

Variable (response)	Frequency (%)	Mean (SD)
Gender (Female)	22 (95.7%)
Age		43.30 (19.17)
Race/Ethnicity
White	7 (30.4%)
Latinx	17 (74.9%)
Other	1 (4.3%)
Education Level (High School/GED or below)	7 (30.4%)
Country of Origin
U.S.	6 (26.0%)
Mexico	14 (60.9%)
Other	1 (4.3%)
Years in US		24.36 (14.22)
Years in LHW Position		5.35 (7.13)
Primary Caregiver (Yes)	14 (60.9%)

2.2. Procedure

Promotoras were initially recruited to participate in the study during a community-partnership meeting between study staff and the Santa Barbara Promotora Network. Study staff remained on-site to help answer questions and facilitate the data collection process. Participants were invited to enroll in the study if they had previous experience working with children and families in their roles as lay health workers. Participants were offered the option to decline participation and were informed of their rights as participants if they chose to enroll. Agency-embedded, paid LHWs whose information was collected from agency leaders at community mental health agencies providing evidence-based practices in two countries were invited to participate in the study via email. These participants “opted-in” to enroll in the study if they wanted to share their experiences working with children and families with study staff.

All participants were provided either electronic or paper-and-pencil versions of a demographic survey, which the completed after providing informed consent for the study. The survey was provided in both English and Spanish based on participant preference. After completing the demographic survey, all LHWs were offered the opportunity to schedule an hour-long interview regarding their experiences working with families and children. Within a two-month period following completion of the demographic surveys, 23 of the participants completed a 60-minute, semi-structured interview with study staff that was audio recorded and subsequently transcribed verbatim in the language in which it was conducted (Spanish or English). Participants received a $40 gift card for completing the interview. All study procedures were determined to be exempt by the Institutional Review Board at the University of California, Santa Barbara.

2.3. Measures

2.3.1. LHW Characteristics

Demographic variables of interest were included in the current study. Age was measured on a continuous scale as reported by participants. Race/ethnicity was measured categorically, allowing participants to endorse multiple group identities (e.g., Latina & White). Participants reported whether or not they identified as the primary caregiver of at least one child, country of origin, how long they have been living in the US, how long they have been working as a promotora, as well as their highest level of education.

2.3.2. Semi-Structured Interview

A semi-structured interview guide was used to collect LHW attitudes towards, use of, and confidence using father-specific engagement strategies, among other information regarding LHW roles, training needs, and attitudes towards working with caregivers. Qualitative interviews lasted approximately 60 minutes. Prior to asking the questions regarding father engagement in services, participants were prompted to the fact that the subsequent sections would be asking about their previous experiences working with father or engaging fathers in services. Regarding Attitudes the interviewers asked, “What are your attitudes towards engaging fathers in services?” and “Do you believe engaging fathers in services is important, why/why not?”. Participants were next asked about their Use by asking “How often do you engage fathers in services?” and “What experiences do you have engaging fathers in services?”. Finally, LHWs were asked to describe their Confidence engaging fathers in services through various questions including, “How comfortable do you feel engaging fathers in services?” and “What barriers do you perceive/have you encountered engaging fathers in services?”.

3. Theory and data analytic plan

3.1. Thematic Analysis

Interview audio files were transcribed and audited by undergraduate research assistants and graduate students. Transcripts were then uploaded to qualitative software analysis program NVivo in order to perform qualitative coding. Qualitative data were coded by four independent coders using thematic analysis (Meyers, Durlak, & Wandersman, 2012). Qualitative analysis began with initial coding which took place using a priori codes based upon interview questions and background literature (e.g., attitudes towards father engagement). This initial coding process also allowed for emergent codes to develop based on participant responses. An iterative consensus process was utilized in which members of the coding team met regularly in order to discuss emergent codes, resolve coding discrepancies, reduce coder drift, and establish the final code book. Once coding was completed, thematic analysis occurred within the NVivo program which consisted of analyzing quotes that emerged within specific co-occurrences of codes (e.g., Barriers + Father Engagement) to produce themes. As is recommended in qualitative methodology, a member check was conducted with original participants in order to establish trustworthiness and accuracy of the data (Morse, Barrett, Mayan, Olson, & Spiers, 2002). Feedback from study participants was incorporated into the final codebook consisting of 28 codes, some of which are nested within parent codes. To increase consistency and understanding, themes are presented from core ideas relating to LHW Attitudes towards, Use of, and Confidence using, father-specific engagement strategies.

4. Results

4.1. Benefits of Father Engagement

Qualitative data illustrated the extent to which LHWs had positive attitudes towards father engagement in parenting programs and expanded upon this finding with subthemes regarding the reasons why they viewed this engagement positively. LHWs described that involving fathers in parenting programs provides benefits to the parent-child relationship and allows fathers to learn firsthand. Highlighting the benefits of having both parents in treatment, one LHW stated, “It would be a wonder because the two are a couple/pair. […] It’s different when you go and then tell your husband what you heard because that is already second hand. If he came with you and listened firsthand, he would have the full impression. So, I feel that it would be best to involve both parents.” It became clear when listening to LHWs that the positive attitudes they had towards engaging fathers was driven by a desire for the fathers to directly receive services and learn parenting skills. It was common for LHWs to report this dilemma of information being passed through the mothers involved in treatment. LHWs spoke of how information that was passed from wife to husband was often diluted or less impactful and described how direct father engagement would help solve this problem. In addition to increasing the impact of information that was being delivered in parent training programs, LHWs also stated that having fathers engaged in treatment would help them “learn how to navigate and strengthen the parent-child relationship.” These reports from LHWs highlight the importance of striving for positive relationships between children and all caregivers involved in children’s lives. Finally, one LHW sums up the sentiment of positive attitudes reported across both types of data by stating, “I see it as key to serve the whole family. If you’re not serving that, you’re missing a big component. So, for me, it’s a plus that I have to engage them. […] I know that engaging the father is key to that child’s success.” It is clear that LHWs reported that engaging fathers in treatment can provide unique benefits for the family and child.

4.2. Limited Confidence in the Face of Barriers to Engagement

Qualitative data suggested participants experienced less confidence in engaging fathers than mother, with subthemes illustrating the potential drivers of this difference in confidence. These themes related to difficulties of engaging fathers in treatment and specific culturally bound barriers to engaging Latino men. LHWs spoke of culturally defined gender roles (e.g., machismo) that make it difficult to engage fathers in parenting programs. One LHW admitted that “sometimes the culture is a barrier to doing that because the machistas think that women are the ones who need to do it all. That we are the ones in charge of raising the children”. These sentiments were shared among others who reported that these culturally defined gender roles outline what is and is not acceptable for Latino fathers to engage in when it comes to parenting. When asking herself why, out of twenty families in a program, were only three men involved, one LHW stated “Because they think the primary role of raising the children is the mother’s”. These findings are supported by another LHW who explains,

“Well because the men don’t involve themselves very much in the house. It’s like the house is the mother […] and the father the work. The father is the provider and the mother is the caregiver. I think that these roles are this way in our Latina society, and it is very hard to change. I tell you, I am trying”.

LHWs also spoke of barriers they experienced engaging men in services in general. A second theme was identified from reports that men tended to be less open to expressing themselves, opening up, and asking for help, making engagement in parenting programs difficult. One LHW attempted to quantify these difficulties by stating, “[Working with men] will be three times harder than doing a presentation with a group of women because they are not going to be very open. […] It is more difficult for men to express things.” Inspired to work against these identified barriers, one LHW stated “They [men] can say that asking for help is a sign of weakness. And it isn’t”.

Lastly, reports regarding logistical concerns of father engagement were reported throughout numerous interviews. A final theme was identified regarding the experience of practical barriers limiting the availability that fathers have to participate in parenting programs. Time and time again, LHWs stated that the fact that most fathers in families they serve are working long hours makes it difficult to find times where they are available to attend services. One LHW stated, “Unless it’s, you know - every now and then cause it’s a rainy day, you know, since they work in the agriculture, then I’ll find them home. But you know, most of the time nope, they’re working”. It becomes clear that LHWs experience barriers to feeling confidant to engaging Latino fathers. LHWs reported that engaging fathers was more difficult than engaging fathers and reported various cultural and gender specific reasons as to why this might have been the case. This leads us to our third and final construct and to understand how we can best support LHWs in overcoming the barriers they experience engaging Latino fathers in parenting programs.

4.3. Inventive Strategies and Desire for Additional Resources and Training

LHWs spoke of numerous strategies that they used to engaged fathers but reported having limited success in engaging fathers consistently. For example, one LHW spoke about involving fathers through traditionally masculine activities such as sports. “Sometimes what we do is if the father likes sports, like soccer or baseball, I say, ‘You know, we need to start teaching your son. We’re going to the park and the best person to be there is you’”. Another LHW simply stated “I feel like fathers need fathers” in support of pairing fathers in groups with other fathers and perhaps even engaging them with male service providers. The use and description of these engagement strategies shows that even without concrete training, LHWs are making concerted efforts to engage fathers in treatment. At the same time, LHWs also made a point to advocate for their own needs as a community of providers. LHWs reported a hopeful outlook based on limited successes and expressed a desire for additional resources and training. “There’s really not much activity going on with it. I would definitely be interested in being able to connect my fathers into more different resources that are individualized for challenges that fathers face,” said one LHW, advocating for individualized supports for fathers. Acknowledging that the needs of fathers may be different from other caregivers and family members, this quote identifies a local gap in services. Another LHW reported similar concerns regarding parent training materials, “It’s always a mom, or it’s always referring to a mother and a child. So having the right materials to present the fathers so they feel [included]”. The way that materials are presented made a difference to LHWs and this quote showed that what is used in parenting interventions often refers only to mothers. Finally, requests for father-specific training were identified as one LHW stated, “As a parent partner I feel that they need to do more training on dads, like how to incorporate dads.” Despite some success with their own engagement strategies, various providers stated their need for training and support on the specific strategies that could be used to engaged fathers. Although not every LHW had specific ideas for what these trainings would include, all participants were generally supportive of the idea of receiving additional training on father engagement.

5. Discussion

Various studies show that there are unique positive outcomes in children’s mental health services when fathers are engaged in treatment (Lamb, 2010). While literature does identify strategies for father engagement (e.g., collecting father-specific outcome data, inviting fathers personally to treatment, incorporating fathers in treatment planning and goal setting), these strategies have not been widely disseminated or rigorously tested (Phares et al., 2006). Further, as we consider the wide range of racial/ethnic disparities in access to care, Latino fathers emerge as an understudied group for which an increased sensitivity from providers is warranted (Cabrera & Coll, 2004). For Latino fathers, research needs to better consider and understand culturally defined gender norms and roles that may impact service delivery, engagement, and successful completion of treatments in community mental health.

5.1. Acknowledge Latino culture to engage Latino fathers

The current study illuminates the perspective on father engagement from a unique workforce that focuses on engaging parents to address disparities in access to services (Barnett et al., 2019; Gustafson et al., 2018). LHWs in the current study shared their experiences overcoming barriers to Latino father engagement and highlighted a number of specific training needs that help inform future research and program development. One of the most promising notes of reflection from the current study is the fact that LHW perspectives on engaging fathers is in line with much of the theoretical and empirical research suggesting that when all available caregivers are involved, everyone has the opportunity to benefit (Teti et al., 2017). The positive attitudes towards engaging fathers that were found in our study can be seen as a parallel a paradigm shift that has slowly taken place over decades in this country that honors fathers for their diverse contributions to child development above and beyond breadwinners (Lamb, 2010). It is possible that as we look towards how to improve father engagement in children’s mental health services, our interventions can begin with strategies aimed to build confidence and teach effective strategies as opposed to foundational attitude changes. This finding is in line with previous research suggesting that particularly for Latinx families, having fathers and extended family members involved in treatment is recognized as important (McCabe, Yeh, Garland, Lau, & Chavez, 2005).

5.2. Incorporating LHW and father perspectives to overcome barriers

In addition to having positive attitudes towards father engagement, our participants also encountered their own lived experiences of what the research has shown regarding difficulties engaging fathers. Many of the results shared echo previous research showing that providers often hold their own experiences and negative perceptions of fathers’ willingness or ability to engage in services that may negatively impact their ability to engage fathers (Brewsaugh et al., 2018). Without discounting individual provider experiences, it is important that we support them in finding ways to hold an inviting stance towards fathers to avoid recreating systems that leave them on the outside of family life and stereotype Latino fathers specifically. Wanting to engage fathers in treatment is not enough to overcome the various barriers seen when engaging fathers in treatment (e.g., work schedules, father reluctance, rigid gender norms; Lamb, 2010, Hecker, 1991). Not only that, but the strategies posed to overcome low rates of father engagement in services have not taken into consideration cultural factors that may be interacting with these low levels of engagement. While recent research does suggest that Latino fatherhood has taken a hybrid form that values teaching children and valuing education (Cabrera & Bradley, 2012), we also see research suggesting that lower levels of father acculturation to U.S. mainstream cultural values is related with poorer outcomes in parent training programs (e.g., attendance, homework completion, therapist-reported caregiver engagement) (Miranda et al., 2005). Our study began to address an important task which is to understand what aspects of machismo are leading to these negative engagement outcomes and highlight specific training needs among a valued workforce. In addition, the results shine light on the importance of programs and agencies meeting fathers where they are and developing interventions that consider their unique perspectives so as to avoid having an anti-father bias to programs that are implemented within the community (Stahlschmidt et al., 2013). From the LHW perspective, it was seen that the rigidity around parenting roles and responsibilities, and lack of emotional openness were among the most challenging barriers to engaging Latino fathers. On the other hand, much of the literature speaking with Latino fathers directly shows their multidimensional views of defining their own masculinities and roles as fathers (Lee et al., 2016; Walters & Valenzuela, 2020). Therefore, future research should aim to incorporate father and LHW perspectives into developing programs and trainings that support how providers, including LHWs, enhance Latino father engagement in their children’s mental health services.

5.3. Navigating machismo and culturally defined gender roles

Notably, given that the majority of the LHW workforce is comprised of women (Ingram et al., 2012), it is important to understand also how the intersecting identities of LHWs themselves impacts their experiences when engaging Latinx fathers. The Latina LHWs had lived experiences and cultural understanding of machismo being of the culture and subject to problematic aspects of the rigid gender norms that can exist. Regarding their work with fathers, these cultural insights and lived experiences may have served to reinforce the challenges experienced engaging fathers rather than allowing them to serve as cultural bridges. In fact, a recent study investigating rural service provider perspectives on father engagement highlights how assumptions of masculinity and how fathers define gender-roles may impede father engagement in services (Molloy & Pierro, 2020). Our findings beg the question: Would male promotores, parent support partners, or other LHWs be more successful in overcoming these barriers of Latino father engagement? As posited by one of the providers who stated, “fathers need fathers,” do Latino fathers need to hear from other Latino fathers like themselves? Select LHW programs have employed a fathers-to-fathers approach for engaging fathers in racial/ethnic minority communities and have shown promise (Mcallister & Burgess, 2012). However, limited research suggests that engaging Latino males as promotores may be difficult due to their perspectives about the work being feminized conflicting with their roles as providers (Villa-Torres et al., 2014). It remains to be seen what the true challenges and benefits of scaling up these types of programs would be. A critical and ongoing consideration of how cultural identity and gender roles / expectations emerge for both LHWs and the communities they serve is needed in any future efforts.

5.4. Limitations and recommendations for future research

Findings of this study should be considered within its limitations, which include the small sample size, inability to investigate within-group differences, and reliance on LHW perspectives to assess father engagement. For each limitation, recommendations for future research are included. First, the limited sample size of LHWs who were working among a specific context in Santa Barbara, allowed for mostly local knowledge to be generated. The degree to which the results from the current study may generalize to Latino fathers more broadly is certainly in need of further investigation. Future research may survey a wider range of LHWs working in various regions across the US to better understand their experiences working in their local context. Second, the interview questions and participant demographics did not allow for rigorous investigation of within-group differences that exist within the broad category of “Latinx” individuals. Future investigation should develop more considered means of understanding the within-group differences that exist within this incredibly heterogenous demographic category, particularly given that the vast majority of participants from our sample share the same country of origin (see Table 1). Third, the current study relies exclusively on LHW perspectives towards father engagement without examining fathers’ perspectives directly. Future research may involve further investigation of father perspectives on treatment engagement barriers from multiple male stake holders and explore the possibility that these barriers are experienced differently for male LHWs. While the current study included perspectives of one male home visitor, the results are presented from a predominately female group of LHWs. However, despite these limitations, the participants interviewed in the study represent LHWs who are working in various community contexts including both paid and volunteer staff which strengthens the level of methodological rigor.

5.5. Practical Implications

Our participants and previous research suggest that we have work yet to do when it comes to addressing the lack of Latino father engagement in children’s mental health services, and that the way forward is one that acknowledges and celebrates culture. The primary practical implication of our study is that culturally sensitive trainings for LHWs are needed to provide strategies on engaging Latino fathers and overcome barriers to engagement. LHWs agree that engaging fathers is important, have experienced limited success in this engagement, and advocated for the addition of future trainings and groups to overcome these barriers to engagement. The implications of this shared knowledge present us with a crucial and important task: to develop nuanced, culturally sensitive and -informed trainings for front-line service providers, including LHWs, in order to support their efforts to serve the entire family system. This training may include utilizing previously cited strategies for father engagement in services (e.g., inviting fathers personally, providing transportation, relevant messaging to their roles as fathers, highlighting the importance of their involvement in child development, focusing on treatment’s evidence-base, avoiding a father deficit model; Stahlschmidt, Threlfall, Seay, Lewis, & Kohl, 2013; Hecker MS, 1991; Lechowicz et al., 2019; Panter-Brick et al., 2014) but must also be considerate of the fact that these recommendations were not developed or tested with culturally diverse families at the forefront of their considerations.

Second, trainings that incorporate knowledge of culturally defined gender roles should embrace non-traditional definitions of machismo to avoid a deficit model for Latino fathers. Traditional definitions of machismo have focused on rigid gender roles that characterize Latino fathers as emotionally distant and uninvolved in childcare responsibilities (Falicov, 2010). Recent research that expands this definition highlights aspects of Latino fatherhood that embrace nurturance and protection (Concha, Villar, Tafur-Salgado, Ibanez, & Azevedo, 2016; Cruz et al., 2011; Englar-Carlson & Kiselica, 2013). In developing trainings that are culturally informed, the concept of machismo should be included to acknowledge the challenges LHWs may have had engaging fathers due to machismo. Using positive definitions of machismo will help avoid stereotyping Latino fathers as uninvolved and instead build on cultural strengths of Latino fathers as nurturing members of the family.

5.6. Conclusion

LHWs are vital members of our healthcare systems and are uniquely positioned to engage Latino fathers in children’s mental health. To continue addressing previously documented barriers in access to services for marginalized children and families, LHWs may benefit from targeted, culturally sensitive trainings that provide strategies for engaging Latino fathers and honor their complex roles in the family. This work builds on research that suggests a need for interventions to focus on co-parenting and advocates for more systematic training to overcome barriers to father engagement (Fabiano & Caserta, 2018; Zanoni et al., 2013). As we continue to develop supports for those at the forefront of disparity reduction, it will be increasingly important that we incorporate cultural values and knowledge into the implementation support that is developed.

Table 2.

Qualitative themes including illustrative quotes

Theme / subtheme	Illustrative quote
Benefits of father engagement
Involving fathers in parenting programs provides benefits to the parent-child relationship and allows fathers to learn firsthand	“I see it as key to serve the whole family. If you’re not serving that, you’re missing a big component. So, for me, it’s a plus that I have to engage them. I know that engaging the father is key to that child’s success.”
Limited confidence in the face of barriers to engagement
Culturally defined gender roles (e.g., machismo) that make it difficult to engage fathers in parenting programs	“Because they think the primary role of raising the children is the mother’s”
Men tended to be less open to expressing themselves, opening up, and asking for help, making engagement in parenting programs difficult	“[Working with men] will be three times harder than doing a presentation with a group of women because they are not going to be very open. It is more difficult for men to express things.”
Practical barriers limit the availability that fathers have to participate in parenting programs	“Most of the time nope, they’re working”
Inventive engagement strategies and a desire for additional resources and training
Fathers may be more likely to engage in treatment settings that utilize traditionally masculine activities (e.g., sports)	Sometimes what we do is if the father likes sports, like soccer or baseball, I say, ‘You know, we need to start teaching your son. We’re going to the park and the best person to be there is you’”
Fathers may benefit from hearing from other fathers and other male service providers	“I feel like fathers need fathers”
Additional training materials and resources that are father-specific are needed	“As a parent partner I feel that they need to do more training on dads, like how to incorporate dads.”

Highlights.

• Latino fathers experience barriers to engagement in children’s mental health

• Lay health workers (LHWs) are positioned to address their low rates of engagement

• LHWs have generally positive attitudes towards engaging Latino fathers

• Barriers reported include culturally defined-gender norms (e.g., machismo)

• Future support for LHWs may incorporate cultural values into training