Feasibility, satisfaction, and preliminary efficacy trial of text4FATHER for engaging expectant fathers in infant care from pregnancy through early infancy

Abstract

Engaging fathers perinatally improves infant outcomes and parent well-being, yet few strategies share evidence with fathers. We explored the feasibility, acceptability, and preliminary efficacy of text4FATHER–a texting intervention designed to improve fathers’ infant care beliefs, self-efficacy, behaviors, and partner support from mid-pregnancy to two-months post-birth. In this exploratory pilot randomized controlled trial, 97 adult expectant fathers with less than a college degree were randomized to receive text4FATHER or not. Self-reported outcomes by fathers and mothers were assessed at baseline (mid-pregnancy) and 2 months post-birth. We analyzed intent-to-treat effects using random coefficient regression models. We found recruiting expectant fathers feasible; of eligible father-mother dyads, 123/163 consented (recruitment feasibility=68%). All intervention fathers (100%) reported being satisfied with text4FATHER; 100% of mothers of intervention fathers also reported satisfaction with the father getting texts. first-time fathers’ antenatal attachment beliefs and coparenting support were higher in text4FATHER condition vs. control from baseline to 7-month follow-up; increases in first-time fathers’ confidence in fathering and infant care were also observed – the latter finding was corroborated by partners of first-time fathers. text4FATHER is a promising intervention, particularly for first-time expectant fathers with lower educational levels who have no natural clinical or public health touchpoints. Its efficacy and effectiveness should be confirmed using larger and more diverse samples.

Introduction

Fathers play a key role during the perinatal period in promoting infant health and development, even before birth (Alio, 2017; Alio, Salihu, Kornosky, Richman, & Marty, 2010; Lee, Knauer, Lee, MacEachern, & Garfield, 2018; Panter-Brick et al., 2014; Sarkadi, Kristiansson, Oberklaid, & Bremberg, 2008; Yargawa & Leonardi-Bee, 2015). While engaging fathers is widely advocated (Johnson et al., 2006; Office of Child Support Enforcement & Division of Policy and Training, 2016; Yogman & Garfield, 2016), maternity care settings have been insufficiently leveraged to promote expectant father engagement as part of prenatal visits, let alone engaging fathers with use of technology or in research. Because of this, we have made little progress linking expectant fathers with practice-based evidence shown to improve infant, mother, and father well-being (Fletcher, May, St George, Stoker, & Oshan, 2014; Lu et al., 2010; Smyth, Spence, & Murray, 2015; Steen, Downe, Bamford, & Edozien, 2012), especially fathers with lower income who may have fewer opportunities to learn about infant care.

Past research indicates that fathers report gaps in their infant care knowledge, skills, and support, especially in the first months after an infant’s birth (Allport-Altillo et al.; Dellmann, 2004; Fletcher et al., 2014; Genesoni & Tallandini, 2009; Smyth et al., 2015; Steen et al., 2012). Expectant fathers also report having unmet needs related to their role in maternity care – feeling excluded and not supported (Alio, 2017; Dellmann, 2004; Fletcher et al., 2014; Genesoni & Tallandini, 2009; Steen et al., 2012) – and limited access to prenatal support that is offered at inconvenient times due to work or other commitments (Entsieh & Hallstrom, 2016). As a result, many fathers miss out on educational content and support (Genesoni & Tallandini, 2009) despite their sharing that fatherhood is a life-changing event and they want to be involved in pregnancy, birth, and infant care and their child’s life (Smyth et al., 2015).

Father-inclusive perinatal education has been shown to improve father involvement through increased knowledge and skills (Lee et al., 2018). Coparenting support education also increases partner relationship quality and father involvement (Lee et al., 2018). Promoting positive relationships among fathers, mothers, and other caregivers is key to engaging fathers over time (Krishnakumar & Black, 2003; Ryan, Kalil, & Ziol-Guest, 2008). However, couple-based (Doherty, Erickson, & LaRossa, 2006; Feinberg et al., 2016; Feinberg & Kan, 2008; McHale et al., 2023) or father-focused (Diemer, 1997; Fagan, 2008; Magill-Evans, Harrison, Benzies, Gierl, & Kimak, 2007; Pfannenstiel & Honig, 1991; Westney, Cole, & Munford, 1988) interventions typically consist of mainly in-person, lengthy multi-session workshops that require trained facilitators that are difficult to access with limited reach. These limitations compromise intervention implementation fidelity, are costly, and restrict ease of scale-up. Further, few interventions are designed to connect with expectant fathers early during pregnancy (Fagan, 2008; Pfannenstiel & Honig, 1991). Addressing these fathers’ needs is key since research has demonstrated that fathers who are attached and bonded with their infant are more likely to continue to be involved postnatally (Zvara, Schoppe-Sullivan, & Dush, 2013) and through toddlerhood (Bellamy, Thullen, & Hans, 2015; Hwang & Lamb, 1990; Tamis-LeMonda, Kahana-Kalman, & Yoshikawa, 2009).

Use of mobile health (mHealth) approaches can improve upon traditional in-person methods that are limited in reach, time intensive, and often fail to engage those in greatest need, including fathers with lower income. Use of mHealth approaches have been shown to successfully promote health and change behaviors and make it easier to consistently provide evidence-based information and education tailored to the diverse needs of individuals (Armanasco, Miller, Fjeldsoe, & Marshall, 2017; Hall, Cole-Lewis, & Bernhardt, 2015; Mayberry & Jaser, 2018; Poorman, Gazmararian, Parker, Yang, & Elon, 2015; Suffoletto, 2024). One mHealth approach, short message service (SMS, or texting) has been shown to change behavior more than other mHealth approaches (e.g., apps) (Buller, Borland, Bettinghaus, Shane, & Zimmerman, 2014; Van Stee, Yang, & Falcone, 2025), engage difficult-to-reach groups (Armanasco et al., 2017; Hall et al., 2015; Mayberry & Jaser, 2018; Poorman et al., 2015), and be easily scalable. Texting is also used by almost all U.S. adults (YouGov, 2026). However, to our knowledge no texting intervention has ever been evaluated in the U.S. that promotes evidence-based practice for expectant fathers connected via maternity care that spans the pre- and post-natal periods.

U.S. parent-based mHealth approaches have been designed mainly for mothers (Davis et al., 2017; Evans, Wallace, & Snider, 2012; Whittaker et al., 2012) and have not supported evidence-based practice for expectant fathers (Davis et al., 2017; Xie et al., 2023). For example, Text4Baby provides information to pregnant women and mothers with infants and was designed to improve maternal and child health among underserved populations (Evans et al., 2012; Whittaker et al., 2012). Since 2010, more than 1 million people have signed up for Text4Baby; 26% of enrolled users enroll when pregnant (Text4baby, 2018), but, less than 3% of users were fathers (U.S. Department of Health and Human Services. Health Resources and Services Administration, 2015). Although a few father-focused strategies have leveraged mHealth directly with expectant fathers, connecting with fathers through home visiting (Lee, Lee, Xu, Steinke, & Weiland, 2024; Tandon, Hamil, Gier, & Garfield, 2021), with specific father types (e.g., veteran (Lee & Walsh, 2015)), on singular father outcomes (e.g., mental health) (Tandon et al., 2021), or in other country settings (i.e., Australia) (Fletcher et al., 2017), these approaches have not been rigorously evaluated or designed for use with expectant fathers more generally in the U.S.

Given the need to develop high-quality, low-cost approaches that can be easily scaled and deployed as a bridge to connecting with expectant fathers via maternity settings across the U.S, we developed text4FATHER, an evidence-based texting intervention, to increase their knowledge, beliefs, self-efficacy, and behavioral engagement in parenting and infant care. Informed by the Integrated Behavioral Model (Montano & Kasprzyk, 2008), text4FATHER consists of twice-weekly texts starting mid-pregnancy and continuing through after the infant is born to assist a father to collaborate with his partner in infant care, support his partner, engage in cooperative coparenting, and attend to his own well-being. Text design and content was also informed by: 1) systematically-collected consensus-based expert feedback (Aqil et al.), 2) evidence-based guidance (American College of Obstetricians and Gynecologists, 2015; Hagan, Shaw, Duncan, & eds, 2017), 3) formative feedback with cohabiting and non-cohabiting fathers and mothers in Baltimore with lower incomes (Allport-Altillo et al.), and 4) a 6-week feasibility pilot with 25 fathers in Baltimore.

This pilot study explored the feasibility, satisfaction, and preliminary efficacy of text4FATHER on fathers’ parenting knowledge, parenting beliefs, self-efficacy in parenting and infant care, infant care behaviors, and relational outcomes compared to usual care from mid-pregnancy through 2 months post-birth among an urban sample of lower income expectant fathers as reported by fathers and mothers about their partner. Study findings will help build an evidence base about the importance of connecting and intervening with expectant fathers, a population that has historically received little attention.

Methods

Trial Design

This exploratory feasibility, acceptability, and preliminary efficacy parallel randomized clinic pilot trial enrolled 97 expectant fathers in a mid-Atlantic city and their pregnant partners (NCT04101565, clinicaltrials.gov) (Marcell et al., 2021). Using a 1:1 allocation ratio, dyads were randomized to receive the text4FATHER intervention or the usual standard-of-care control group (see Figure 1 CONSORT Chart). The randomization sequence was computer generated and accessed only by the data analyst. The research study staff completed group allocation after eligibility criteria were verified and father and partner baseline assessments were completed. The Johns Hopkins Institutional Review Board and the Department of Obstetrics and Gynecology approved all study procedures, and all participants provided informed consent.

Figure 1. CONSORT Flow Diagram.

Participants

Participants were recruited from February 2020 to February 2022 from one maternity care setting and local social media advertisements (i.e., Facebook, Instagram). The trial was designed to connect with first-time fathers of pregnant persons during prenatal visits, including the 20-week ultrasound visit. However, due to restrictions imposed by the COVID-19 including a prohibition on fathers accompanying their partners to visits, the study protocol shifted to a virtual recruitment approach for all fathers. As part of maternity care, we phoned pregnant persons with maternity care appointments to connect us with their partners, facilitating the recruitment of both parents. We also distributed study materials during prenatal care and ultrasound visits, obstetrics/ultrasound staff introduced the study to potential participants, and we posted local social media ads on Facebook and Instagram. Participants were eligible if they were 18 or older, in a relationship with each other, with a pregnancy less than 25 weeks gestation, lived in the metro mid-Atlantic city of recruitment, spoke and read English, the father had less than a college education (as a proxy for lower-income status), and both parents were willing to receive text messages.

Eligible participants received study information, completed informed consent procedures, and, if interested, then completed the baseline survey instrument. Fathers received $35 remuneration to cover time and texting costs after completing the baseline survey and $75 for completing the exit survey seven months later (2-months post-birth); mothers received $15 and $30 after completing shorter baseline and follow-up surveys, respectively.

Intervention Components

Fathers in the intervention group received text4FATHER, a multi-modal program that sends texts twice-weekly in English written at a 5^th grade reading level from mid-pregnancy through 2-months post-birth (total 7 months). We threaded text content to assist a father in collaborating in care with his partner for his infant, and to support his partner, engage in cooperative coparenting, and attend to his own well-being. For texts, we relied on behavioral change evidence and motivational language rather than just information, to actively involve learners with specific tasks to complete linked to desired behavior change, shared credible content, and personalized and tailored messages (Abroms, Whittaker, Free, Mendel Van Alstyne, & Schindler-Ruwisch, 2015). text4FATHER is programmed to push/receive texts that tailors content receipt based on: gestational/postnatal age and father’s cohabiting status (i.e., whether father lives with mother and child). A total of 71 texts were sent along with 5 responsive texts and 24 resource weblinks to further support behavior change (e.g., videos, infographics) focused on skills-building to support behavior change.

After text receipt, intervention participants can continue to review content on their own through text message history and with their partner. We used the secure and HIPAA-compliant EngageSpark text-message-campaign platform, an existing, flexible visual programming interface that allowed us to send message content, monitor real-time timing and frequency with visualization dashboards and link a mother’s texts to their partner.

Control Components

Fathers in the control arm received maternity care as usual. At baseline, for ethical reasons all participants in both arms received a handout about local birth resources/hotlines.

Study Outcomes

At baseline, fathers completed electronic surveys that assessed study outcomes and background characteristics and mothers completed shorter surveys that assessed on perceptions of select father measures and background characteristics (Table 1). At follow-up, 2-months post-birth, the same baseline measures were assessed along with process measures of intervention fathers that included questions about intervention satisfaction (Table 2).

Table 1. Father and mother baseline characteristics.

Background characteristics	Fathers				Mothers
	Control (n=44)		Intervention (n=53)		Control (n=44)		Intervention (n=53)
	N	%	N	%	N	%	N	%
Age group
18-29	19	43.2	20	37.7	17	38.6	27	51.0
30 or older	25	56.8	33	62.3	27	61.4	26	49.0
Race/ethnicity
Non-Hispanic Black	30	68.2	37	69.8	30	68.2	35	66.0
Non-Hispanic White	11	25.0	12	22.6	10	22.7	14	26.4
Hispanic	2	4.5	3	5.7	2	4.5	2	1.9
Other	1	2.3	1	1.9	2	4.5	2	5.7
Highest grade completed
Less than high school	9	20.5	8	15.1	2	4.5	1	1.9
GED	4	9.1	6	11.3	6	13.6	5	9.4
High school diploma	17	38.6	22	41.5	19	43.2	24	45.3
Some college	14	31.8	17	32.1	10	22.7	16	30.2
College degree or higher	-	n/a	-	n/a	7	15.9	7	13.2
Employed
No	10	22.7	14	26.4	22	50.0	29	54.7
Yes	34	77.3	39	73.6	22	50.0	24	45.3
In school/job training
No	40	90.9	43	81.1	37	84.1	42	79.2
Yes	4	9.1	10	18.9	7	15.9	11	20.8
Relationship status
Married	12	27.3	12	22.6	-	-	-	-
Romantically involved, not married	32	72.7	39	73.6	-	-	-	-
Other	-	-	2	3.8	-	-	-	-
Live with partner
No	5	11.4	10	18.9	-	-	-	-
Yes	39	88.6	43	81.1	-	-	-	-
First time father
No	28	63.6	25	47.2	-	-	-	-
Yes	16	36.4	28	52.8	-	-	-	-

Table 2. text4FATHER intervention engagement and satisfaction by parent.

text4FATHER engagement & satisfaction	N	%
text4FATHER engagementa
Responded to ≥1 of 5 interactive texts across text campaign	39	73.6
Linked out to website to learn more	26	49.1
	N	Mean (SD)	% Affirmative
text4FATHER satisfactionb
Father perspective
Overall satisfaction with text4FATHERc	40	3.60 (0.50)	100.0
Would recommend text4FATHER to a friendd	40	3.53 (0.51)	100.0
Mother perspective
Were satisfied with father getting text4FATHER textse	40	-	100.0
Report of negative experiences about text4FATHERe	40	-	0

^aEngagement was assessed among all fathers assigned to the intervention arm, n=53

^bSatisfaction questions were assessed at the follow-up survey at 2-months post-birth (7-months later), n=41, representing the retained sample and 1 father with missing data

^dFrom very dissatisfied (1) to very satisfied (4)

^dFrom no-definitely not (1), no-not really (2), yes-generally (3) to yes-definitely (4)

^eCoded from exit interview

Intervention satisfaction and engagement

In the text4FATHER arm, we assessed intervention satisfaction with two items (i.e., “Overall, how satisfied were you with text4FATHER?” on a 4-point Likert scale from 1 (very dissatisfied) to 4 (very satisfied) and “Would you recommend text4FATHER to a friend?” on a 4-point Likert scale from 1 (no-definitely not) to 4 (yes-definitely)). We also conducted separate brief exit interviews with all participants and asked mothers about their satisfaction with the father getting texts and coded their responses as satisfied/not satisfied. We also reviewed all mother responses and coded any negative experiences related to the intervention father receiving text4FATHER or mother-father interaction(s) because of the father’s receipt of text4FATHER. We assessed intervention engagement based on response to any of 5 responsive texts across the text campaign and use of any of the weblinks to learn more.

Background characteristics

Respondents reported their age (categorized as 18-29 and 30 or older), race/ethnicity (categorized as non-Hispanic Black, non-Hispanic White, Hispanic, and other), highest grade completed (less than high school, general education degree (GED), high school diploma, some college, and, for mothers only, college degree or higher), current employment status (yes/no), in school/job training status (yes/no), relationship status (married, romantically involved but not married, other), cohabiting with partner (yes/no), and first-time father status (yes/no).

Parenting knowledge

We assessed fathers’ knowledge of infant development at baseline and follow-up using the Knowledge of Infant Development (KIDI) (MacPhee, 1981) index that consisted of 15 items (e.g., “Babies should not be held when they cry because this will make them want to be held all the time”) from agree, disagree, to not sure with each item scored as 0 (incorrect/not sure) or 1 (correct) based on correct responses and total score ranging from 0 to 15 (Cronbach α at baseline/follow-up=0.65/0.79 (original α=0.82)). Higher scores represent greater knowledge.

Parenting beliefs

We assessed fathers’ parenting beliefs at baseline and follow-up using two measures: antenatal attachment beliefs using the Paternal Antenatal Attachment Scale (PAAS) (Condon, 1993) that consisted of five items (e.g., “Over the past two weeks I have thought about, or been preoccupied with the developing baby”) rated on a 5-point Likert scale from 1 (least) to 5 (greatest) (Cronbach α at baseline/follow-up=0.77/0.66 (original α=0.70-0.80)) and the importance of the father’s role in child development using the Role of the Father Questionnaire (ROFQ) (Palkovitz, 1980) that consists of seven items (e.g., “It is essential for the child’s well-being that fathers spend time playing with their children”) rated on a 4-point Likert scale from 0 (strongly disagree) to 3 (strongly agree) (Cronbach α at baseline/follow-up=0.40/0.49 (original α=0.63)). For each measure, higher scores represent greater agreement.

Parenting self-efficacy

We assessed parenting self-efficacy of fathers and mothers about their partner at baseline (expected self-efficacy) and at follow-up using the Parenting Sense of Competence (PSOC) (Johnston & Mash, 1989) that consisted of 15 items (e.g., “Being a parent is manageable, and any problems are easily solved”) rated on a 6-point Likert-type scale from 1 (strongly disagree) to 6 (strongly agree) (fathers: Cronbach α at baseline/follow-up=0.72/0.81 (original α=0.73); mothers: baseline/follow-up=0.78/0.90). We assessed infant care self-efficacy of fathers and mothers about their partner at baseline (expected self-efficacy) and at follow-up using the Karitane Parenting Confidence Scale (KPCS) (Crncec, Barnett, & Matthey, 2008) that consisted of 10 items (e.g., “I know what to do when my baby cries”) rated on a 4-point Likert scale from 0 (no, hardly ever) to 3 (yes, most times) (fathers: Cronbach α at baseline/follow-up=0.87/0.91 (original α=0.88); mothers: baseline/follow-up=0.87/0.93). We assessed fathers’ expected confidence in the father role at baseline and perceived father role confidence at follow-up using the Fathering Self-Efficacy Scale (FSES) (Sevigny, Loutzenhiser, & McAuslan, 2016) that consisted of 15 items (e.g., “I am a positive role model for my child”) rated on a 9-point Likert scale from 1 (completely disagree) to 9 (completely agree) (Cronbach α at baseline/follow-up=0.81/0.92 (original α=0.88)). Higher scores represent greater self-efficacy.

Infant involvement

We assessed fathers’ and mothers’ expected infant care behavioral involvement at baseline and actual involvement at follow-up of fathers and of mothers perceptions about their partner: infant care behaviors using the Father Engagement Scale (FES) (Dyer, Kauffman, Fagan, Pearson, & Cabrera, 2018) that consisted of 11 items (e.g., “I read to them”) rated on a 5-point Likert scale from 0 (never) to 4 (every day or almost every day) (fathers: Cronbach α at baseline/follow-up=0.87/0.93 (original α=0.79-0.94); mothers: baseline/follow-up=0.80/0.94). Higher scores represent greater infant care involvement.

Relational outcomes

We assessed fathers’ and mothers’ relational outcomes at baseline and follow-up: coparenting support using the Coparenting Support subscale (Feinberg, Brown, & Kan, 2012) that consisted of six items (“The baby’s mother asks my opinion on issues related to parenting”) rated on a 7-point Likert scale from 0 (not true of us) to 6 (very true of us) (fathers: Cronbach α at baseline/follow-up=0.91/0.90 (original α=0.87); mothers: baseline/follow-up=0.78/0.91) and relationship quality using the McMaster General Functioning subscale (Epstein, Baldwin, & Bishop, 1983) that consisted of 12 items (“In times of crisis we can turn to each other for support”) rated on a 4-point Likert scale from 1 (strongly disagree) to 4 (strongly agree) (fathers: Cronbach α at baseline/follow-up=0.90/0.89 (original α=0.92); mothers: baseline/follow-up=0.91/0.93). Higher scores represent more positive relational outcomes.

Monitoring

We developed a safety plan for this behavioral intervention by adapting strategies and principles described by Horigian et al (2010) (Horigian, Robbins, Dominguez, Ucha, & Rosa, 2010; Marcell et al., 2021) that monitored stress in interactions between the father, mother, and other caregivers across the study period and provided support resources, as needed.

Data Analysis

Recruitment feasibility was calculated by the proportion of eligible fathers consenting to participation. Retention feasibility was calculated as the proportion of enrolled participants completing follow-up surveys. Separately for fathers and mothers, we generated frequencies for all variables by condition (Tables 1 and 3). Among intervention fathers and measures of intervention satisfaction, we summarized the percent who responded in the affirmative and generated means and standard deviations (SD) for each and proportion of engagement with responsive texts and weblinks (Table 2). Next, we examined the effect of the randomization scheme and missing data due to survey non-response and attrition and found no differences in participants’ background characteristics nor study outcomes between intervention versus control arms and those who were retained and not retained in the study. Finally, using an intent-to-treat approach, we applied separate random coefficient regression models for each study outcome, accounting for two levels of nesting (repeated measures and individuals). We examined this for the entire sample and then conducted sensitivity analyses among first-time fathers only – given first-time fathers’ greater needs and vulnerability for parenting an infant for the first time and more limited exposure to support, advice, and direction. Each model estimated differences among intervention and control arms identifying change in each study outcome between baseline and follow-up, using list-wise deletion. These analyses allowed for examining within-individual change over time in an outcome, accounting for dependency among observations within individuals by modeling within-person error (Singer & Willett, 2003), between-individual variation over time (Raudenbush, Bryk, & Congdon, 2002), and between-subjects effects based on group assignment to identify differences in text4FATHER versus usual care. For these analyses, to convert the study outcomes to the same scale, we transformed the original values to standardized variables (z-scores) with zero as mean and one as standard deviation. All data were prepared using SPSS 31.0 and analyzed with Stata version 18.0.

Table 3. Descriptive statistics and bivariate linear regression of study outcomes for fathers and their partners regardless of parenting history.

	Fathers						Mothers
Outcomes	Control (N=34)		Intervention (N=41)		Standardized Beta (SE) j	p-value	Control (N=35)		Intervention (N=40)		Standardized Beta (SE) j	p-value
	Baseline	Follow-up	Baseline	Follow-up			Baseline	Follow-up	Baseline	Follow-up
	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)			Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)
Knowledge
Infant developmenta	9.38 (2.57)	9.24 (3.22)	9.56 (2.78)	9.15 (3.56)	−0.095 (0.224)	0.673	-	-	-	-	-	-
Beliefs
Antenatal attachmentb	4.11 (0.75)	4.05 (0.65)	4.31 (0.60)	4.25 (0.63)	0.019 (0.251)	0.939	-	-	-	-	-	-
Father roled	2.42 (0.28)	2.24 (0.46)	2.44 (0.31)	2.28 (0.31)	0.066 (0.269)	0.805	-	-	-	-	-	-
Self-efficacy
Parentingd	4.53 (0.56)	4.49 (0.60)	4.40 (0.58)	4.49 (0.79)	0.208 (0.263)	0.428	4.68 (0.51)	4.77 (0.80)	4.79 (0.57)	4.77 (0.94)	−0.191 (0.225)	0.397
Infant caree	2.70 (0.31)	2.63 (0.44)	2.64 (0.36)	2.57 (0.49)	0.057 (0.255)	0.823	2.66 (0.37)	2.53 (0.56)	2.64 (0.39)	2.52 (0.60)	0.055 (0.256)	0.830
Fatheringf	8.19 (0.75)	7.57 (1.49)	8.04 (0.88)	7.77 (1.15)	0.314 (0.197)	0.112	-	-	-	-	-	-
Behaviors
Infant careg	3.80 (0.31)	3.43 (0.67)	3.83 (0.39)	3.48 (0.82)	−0.027 (0.267)	0.921	3.79 (0.25)	3.28 (0.88)	3.73 (0.43)	3.32 (1.06)	0.189 (0.248)	0.447
Relational
Coparenting supporth	5.34 (0.91)	5.09 (1.22)	5.02 (1.45)	4.91 (1.32)	0.165 (0.265)	0.533	4.41 (0.71)	5.09 (1.32)	4.37 (0.92)	5.11 (1.43)	0.067 (0.234)	0.775
Partner relationship qualityi	3.36 (0.45)	3.25 (0.50)	3.42 (0.49)	3.26 (0.59)	−0.098 (0.203)	0.631	3.45 (0.47)	3.37 (0.54)	3.52 (0.50)	3.32 (0.71)	−0.216 (0.223)	0.333

^aIndex score of 15 true/false items, range 0 to 15

^bRange 1 (least) to 5 (greatest)

^cRange 0 (strongly disagree) to 3 (strongly agree)

^dRange 1 (strongly disagree) to 6 (strongly agree)

^eRange 0 (no, hardly ever) to 3 (yes, most times)

^fRange 1 (completely disagree) to 9 (completely agree)

^gRange 0 (never) to 4 (ever day or almost every day)

^hRange 0 (not true of us) to 6 (very true of us)

ⁱRange 1 (strongly disagree) to 4 (strongly agree)

^jFor each father and mother outcome (row), respectively, we applied separate random coefficients regression models accounting for two levels of nesting (repeated measures and individuals). Each model estimated the difference among intervention and control arms identifying change in each study outcome between baseline and follow-up. To convert the study outcomes to the same scale, we transformed the original values to standardized variables (z-scores) with zero as mean and one as standard deviation and betas from random coefficients regression model effect size interpretation: small 0.1-0.29, medium 0.3-.49, large 0.5 and over.

Missingness

This study had very little missing data; two father participants and one mother participant who completed pre- and post-test surveys had some missing data. This missingness was not related to respondents’ background characteristics or study variables.

Sample Size

With a sample size of N=75 (control n=34; treatment n=41), we will have 80% power to detect small effect size (i.e., d ≥ 0.38) in outcomes. We used one of the few studies that evaluated changes in parenting constructs comparing treatment for father engagement to a control group only at the end of treatment to inform these calculations and expected effect size (Fagan, 2008).

Results

Most participating fathers and mothers were aged 30 or older and non-Hispanic Black, respectively (Table 1); participants’ race/ethnicity mirrored the city of recruitment. Most fathers were employed, not in school/a job training program, romantically involved with the mother but not married, and lived with their partner. On average, 45% were first-time fathers.

Feasibility

We demonstrated feasibility of recruiting and retaining fathers-to-be with lower educational levels despite restrictions of the COVID-19 pandemic. Overall, we connected with 901 of 1612 potentially eligible father participants (56%) and conducted eligibility screening with 69% (620/901) (see Figure 1). Overall, 181/620 (29%) of fathers met our inclusion criteria (i.e., less than college education); 3% declined participation, and 71% were ineligible; the main reason for ineligibility was “too much education” despite interest in participation (47% had a college degree or more; 207/439). Of eligible fathers, 123 of 181 both parents consented (recruitment feasibility=68%); 99 of 123 both dyad parents completed the baseline survey (completion rate=81%); and we enrolled 97 of 99 dyads (participation rate=98%): 83% from maternity; 18% social media. Over the study course three non-related study events occurred: two pregnancy losses, one premature birth (36 weeks) and one father who was incarcerated during prenatal period, resulting in a sample of 93 dyads; 75 fathers and mothers each completed the (2 months post-birth) follow-up exit procedures 7 months later (retention rate=80% for fathers and mothers, respectively).

Intervention Satisfaction and Engagement

All intervention fathers (100%) reported being satisfied/very satisfied with text4FATHER and would generally/definitely share it with a friend (Table 2). All partners of intervention fathers (100%) reported being satisfied with the father getting texts; none (0%) reported negative comments about their or their partner’s experience. Most intervention fathers (74%) responded to at least one of the 5 interactive texts across the text campaign and 49% linked out to the intervention’s website to learn more.

Preliminary Efficacy

Using an intent-to-treat analysis, we applied separate random intercept coefficient regression models for each study outcome to estimate differences among intervention and usual care arms from baseline to 2-months post-birth. Among all father participants, we did not find any meaningful differences in study outcomes given that effect sizes were small to low-medium between the intervention and usual care arms.

Among first-time fathers, we observed larger effect size increases in attachment beliefs and cooperative coparenting in the intervention compared to the control arm across 7 months of follow-up (Table 4). We also observed larger effect size increases in first-time fathers’ confidence in infant care and the father role in the intervention as compared to the control arm; the former finding was corroborated by partners of first-time fathers – we observed a similar result in mothers’ perceived confidence of their partner’s infant care among mothers with first-time fathers in the intervention versus control arm.

Table 4. Descriptive statistics and bivariate linear regression of study outcomes for first-time fathers and partners of first-time fathers.

	First-time fathers						Mothers (Partners of first-time fathers)
Outcomes	Control (N=14)		Intervention (N=21)		Standardized Beta (SE) j	p-value	Control (N=13)		Intervention (N=20)		Standardized Beta (SE) j	p-value
	Baseline	Follow-up	Baseline	Follow-up			Baseline	Follow-up	Baseline	Follow-up
	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)			Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)
Knowledge
Infant developmenta	10.29 (2.13)	10.00 (3.00)	9.57 (3.28)	8.67 (3.83)	−0.141 (0.278)	0.612	-	-	-	-	-	-
Beliefs
Antenatal attachmentb	4.37 (0.47)	3.96 (0.67)	4.17 (0.74)	4.30 (0.66)	0.847 (0.409)	0.038	-	-	-	-	-	-
Father roled	2.52 (0.27)	2.33 (0.27)	2.36 (0.34)	2.31 (0.29)	0.473 (0.391)	0.226	-	-	-	-	-	-
Self-efficacy
Parentingd	4.64 (0.47)	4.52 (0.64)	4.36 (0.58)	4.53 (0.67)	0.500 (0.356)	0.161	4.63 (0.50)	4.72 (0.93)	4.68 (0.59)	4.78 (0.86)	−0.031 (0.334)	0.927
Infant caree	2.74 (0.30)	2.58 (0.49)	2.53 (0.38)	2.60 (0.42)	0.624 (0.377)	0.098	2.72 (0.27)	2.43 (0.72)	2.59 (0.42)	2.58 (0.41)	0.587 (0.321)	0.068
Fatheringf	8.34 (0.63)	7.53 (1.63)	8.07 (0.82)	7.85 (1.12)	0.515 (0.291)	0.076	-	-	-	-	-	-
Behaviors
Infant careg	3.82 (0.26)	3.43 (0.76)	3.89 (0.20)	3.52 (0.81)	−0.099 (0.301)	0.743	3.81 (0.24)	3.44 (0.85)	3.83 (0.24)	3.49 (0.92)	0.000 (0.276)	0.999
Relational
Coparenting supporth	5.62 (0.62)	4.87 (1.49)	5.05 (1.45)	5.12 (1.24)	0.740 (0.314)	0.018	4.41 (0.92)	5.29 (1.09)	4.41 (1.01)	5.19 (1.42)	−0.073 (0.378)	0.847
Partner relationship qualityi	3.45 (0.43)	3.27 (0.50)	3.50 (0.43)	3.27 (0.52)	−0.091 (0.298)	0.759	3.53 (0.46)	3.45 (0.56)	3.50 (0.49)	3.26 (0.71)	−0.240 (0.306)	0.432

^aIndex score of 15 true/false items, range 0 to 15

^bRange 1 (least) to 5 (greatest)

^cRange 0 (strongly disagree) to 3 (strongly agree)

^dRange 1 (strongly disagree) to 6 (strongly agree)

^eRange 0 (no, hardly ever) to 3 (yes, most times)

^fRange 1 (completely disagree) to 9 (completely agree)

^gRange 0 (never) to 4 (ever day or almost every day)

^hRange 0 (not true of us) to 6 (very true of us)

ⁱRange 1 (strongly disagree) to 4 (strongly agree)

^jFor each father and mother outcome (row), respectively, we applied separate random coefficients regression models accounting for two levels of nesting (repeated measures and individuals). Each model estimated the difference among intervention and control arms identifying change in each study outcome between baseline and follow-up. To convert the study outcomes to the same scale, we transformed the original values to standardized variables (z-scores) with zero as mean and one as standard deviation and betas from random coefficients regression model effect size interpretation: small 0.1-0.29, medium 0.3-.49, large 0.5 and over.

Discussion

This is one of the first randomized controlled pilot trials in the U.S. to explore the feasibility, satisfaction, and preliminary efficacy of an mHealth intervention designed to engage expectant fathers with lower educational levels starting early in pregnancy through 2-months post-birth. This exploratory pilot intervention study found it was feasible to recruit an urban sample of expectant fathers with lower educational levels and their partners to join this study and retain them over a 7-month period. We also found that all fathers who received the text4FATHER intervention reported very high satisfaction levels as did their partners. This study also demonstrated initial support of text4FATHER on father-focused beliefs, self-efficacy, and relational outcomes among first-time fathers only. Findings provide promising findings, especially for first-time fathers, about the impact of a texting intervention that connects with expectant fathers with lower educational levels mainly from the context of maternity care – a group who report feeling excluded and not supported and having unmet needs related to their role in maternity care (Alio, 2017; Dellmann, 2004; Fletcher et al., 2014; Genesoni & Tallandini, 2009; Steen et al., 2012). Study findings can also inform anticipated effect sizes for a larger formal randomized controlled trial.

In this exploratory pilot intervention trial, we found that first-time fathers in the text4FATHER intervention designed to thread content to support a father’s involvement with his infant, partner, and own health via twice weekly texts from mid-pregnancy to 2-months post-birth had higher father-focused belief and self-efficacy outcomes (i.e., antenatal attachment beliefs and self-efficacy in infant care and the father role) than first-time fathers in the control condition. The fact that first-time fathers benefited from the intervention should not be a surprise, given past work that has shown first-time parents demonstrated reduced perceived self-efficacy than experienced parents during early infancy (Liyana Amin, Tam, & Shorey, 2018). It is possible that covered content in text4FATHER might be better aligned with the needs of first-time fathers. Future work should determine whether different content may be more applicable to share with experienced fathers. This trial’s findings on father-focused outcomes are also consistent with and extend results from a different texting intervention conducted with fathers in Kenya that demonstrated similar improvements in father-focused outcomes using a pre-post evaluation design (i.e., increases in fathers’ infant attachment beliefs and childcare involvement) (Angwenyi et al., 2024). However, our current study utilized a more rigorous design with a control group and improves upon this prior study’s pre-/post-intervention evaluation that cannot attribute study findings to the intervention since other factors may have influenced the study’s outcome.

We did not observe increases in intervention fathers’ infant care behaviors, as reported by both parents. However, this study found that partners of first-time fathers in the intervention versus control arm corroborated the observed positive findings for increases in these fathers’ confidence in infant care. This study identified positive findings in first-time fathers’ infant care self-efficacy from the perspectives of both parents, which is a pre-requisite for behavioral change (Bandura, 1986). Lack of observed behavioral change findings may be due to follow-up assessments having been conducted at 2-months post-birth, which may not have been sufficient time for fathers to engage in behavioral change and for mothers to also observe these behaviors. Reports of infant care behaviors in both conditions were also generally high, as were mothers’ reports of fathers’ behaviors; thus, there may have been little room to measure improvement. Despite texting content relying on behavioral change evidence and motivational language, it is possible that text content alone was not sufficient to support behavior change. We also did not see changes in fathers’ knowledge or role beliefs; however, the knowledge construct measured knowledge about infant development rather than infant care, which was the focus of the intervention, and reliability was lower in this sample than reported in past work. The limited number of validated extant measures of fathers’ knowledge and role beliefs suggests that future work could focus on measure development and refinement to ensure reliability across diverse samples of fathers. One unique aspect of the current study was that it included fathers’ partners in the study’s design to better triangulate data on father-focused outcomes. While couple-based interventions typically involve assessing both parents (Fagan, 2008; Feinberg et al., 2016; Feinberg & Kan, 2008), it is the rare father-focused intervention that also collects partner-level data about the father; the current study improves upon limitations in the rigor of measurement from prior work in this area.

Regarding relational outcomes, this trial found text4FATHER higher reports of relational coparenting support outcome among first-time fathers in the intervention as compared to the control arm. These findings are consistent with the Angwenyi et al Kenya-based texting intervention with fathers that demonstrated pre-post improvements in partner support among intervention participants (Angwenyi et al., 2024). Example items in the current study’s coparenting support measure asked parents to report on, for example, how well the other parent supported their opinion on issues related to parenting, how hard they work at being a good parent, and how well they are doing as a parent (Feinberg et al., 2012). Given first-time intervention fathers also reported greater confidence in infant care and parenting, higher reported levels of coparenting support may thus reflect fathers’ perceptions of their partner’s recognition of this greater confidence. While we did not observe similar findings for mothers of first-time intervention fathers, this could be related to the measure itself rather than inconsistencies across parent report. This could have also been due to the timing of our follow-up assessment (i.e., 2-months post-birth) that resulted in the lack of sufficient time for mothers to endorse similar perceptions about coparenting support; past coparenting-focused interventions that have demonstrated positive findings among mothers have typically assessed similar measures starting at 6-months post-birth or later (Feinberg et al., 2016; Feinberg & Kan, 2008). Future work should consider conducting additional follow-ups with both parents since mothers may require additional time to perceive greater coparenting support from their partner. Regarding relationship quality, in this trial we did not observe the intervention impacted the partner relationship quality as reported by fathers or mothers. These findings are consistent with past perinatal research focused on father involvement to enhance maternal-paternal relations that have not found worsening relationships because of greater father involvement (Lee et al., 2018).

Despite restrictions imposed by the COVID-19, it was feasible to recruit and retain into this study an urban sample of expectant fathers with lower educational levels and racial/ethnic backgrounds that mirrored the recruitment city via their partners connected mainly from maternity care. While past in-person father-focused interventions have shown promising results, these studies have also been limited by homogeneous sampling of mainly more educated fathers (Diemer, 1997; Doherty et al., 2006; Feinberg et al., 2016; Feinberg & Kan, 2008; Pfannenstiel & Honig, 1991). Recruitment feasibility and intervention results in the current study show promise that text messaging can be a successful strategy to connect with underserved fathers with lower educational levels. Most of the recruited study fathers were cohabitating with their partners. While text4FATHER’s texts were available as tailored drips based on whether the father cohabited with their partner or not, due to the small sample of non-cohabiting fathers we were unable to explore study outcomes based on fathers’ cohabitation status. Future work should evaluate this intervention with non-cohabiting fathers since many of these fathers are often still in a relationship with their partner (Edin & Nelson, 2013) and a growing population in the U.S. over the past 50 years (Curtin, Ventura, & Martinez, 2014); about 20 million children (27%) live apart from their fathers (U.S. Census Bureau, 2016). Yet, strategies that connect with non-cohabiting fathers are limited and past interventions that engage this father population focus mainly on fathers with older children rather than during the pregnancy period (Julion et al., 2016; Perry & Langley, 2021). This study also found all intervention fathers were highly satisfied with the text4FATHER intervention and would recommend it to a friend. All intervention fathers’ partners also shared similarly high satisfaction levels about their partner’s experience. Most fathers also engaged in the texts themselves or linked out to the intervention’s website to learn more. Future work should examine whether intervention fathers who were more engaged in the intervention were more likely to demonstrate improvements in father-focused outcomes. While prior studies have demonstrated both feasibility and satisfaction with mHealth interventions for fathers (Fletcher et al., 2017; Lee et al., 2024; Mackert et al., 2017; Teague, Shatte, Fuller-Tyszkiewicz, & Hutchinson, 2025), as far as we are aware, this is the first texting intervention that has used a rigorous evaluation design and demonstrated recruitment feasibility, high levels of satisfaction, and intervention results for improving father-focused and relational outcomes, specifically among first-time fathers with lower educational levels.

This study has several potential limitations. This exploratory pilot study was designed to assess the feasibility, satisfaction, and preliminary efficacy of text4FATHER with a smaller sample size of fathers with lower educational levels and their partners from one maternity care location in one urban setting. Future work should aim to replicate this study in the context of a larger formal efficacy trial and recruit a larger, more diverse sample of participants across maternity care settings and geographic locations. This study relied on participant self-report measures. While we collected data from mothers to triangulate outcomes within father-mother dyads that improved upon use of just single-informants, future work should consider also collecting observed behavioral data post-intervention; for example, by observing father-infant behavioral interactions and, subsequently, coding father, father-infant, and infant behaviors (Barnett, Deng, Mills-Koonce, Willoughby, & Cox, 2008). Delivery of text messages can increase the consistency of content receipt and thus improve upon fidelity issues that plague standard in-person interventional approaches. However, standard short message service (SMS) texting does not generate read receipts. Future work should consider using texting platforms that could monitor read receipt and ensure SMS read fidelity. This study did not assess total time spent using SMS or other digital platforms (Sun & Lee, 2022); future work should assess this and its potential contribution to any attenuation of study findings, especially among experienced fathers. Finally, the duration of this study was 7 months, with follow-up data collected at two months post-birth. Collecting follow-up data when the infant is older could allow for more time to observe behavioral outcomes as reported by both fathers and mothers. However, a major strength of this study is that it is one of the first randomized controlled trials in the U.S. to examine the feasibility, satisfaction, and intervention results of a texting intervention using a rigorous design to engage expectant fathers starting early in pregnancy through after their infant is born.

Conclusions and Implications

Findings in this exploratory pilot study suggest that tailored text messaging could improve father-focused and relational outcomes among first-time expectant fathers with lower educational levels. Future work should aim to validate these findings since use of this mHealth approach can easily translate and disseminate existing evidence on the positive impacts that engaging fathers starting early during the prenatal period can have on the health of the infant, mother, and father (Burgess, 2009; Fletcher et al., 2014; Lu et al., 2010; Smyth et al., 2015; Steen et al., 2012). Tailored text message interventions, such as text4FATHER, have the potential to help maternity care connect with underserved fathers, and especially first-time fathers, and address not only maternity care but also paternity care.