Abstract
Background:
Expectant fathers may experience psychological distress during pregnancy, yet evidence on paternal mental health among tribal populations in India remains scarce. This study assessed depressive symptoms, anxiety symptoms, psychological well-being, perceived social support, and their psychosocial correlates among tribal expectant fathers.
Methods:
A community-based cross-sectional study was conducted among 80 tribal expectant fathers in Attappady, India. Data were collected using the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), World Health Organization-Five Well-Being Index (WHO-5), and Multidimensional Scale of Perceived Social Support (MSPSS). Depressive symptoms and anxiety symptoms were defined using PHQ-9 and GAD-7 scores of ≥5, respectively. Univariate logistic regression and multivariable Firth’s penalized logistic regression examined factors associated with depressive and anxiety symptoms. Spearman’s rank-order correlation assessed relationships among psychological outcomes.
Results:
Depressive symptoms were reported by 17.5% of participants, anxiety symptoms by 10.0%, and poor psychological well-being by 40.0%. Seasonal migration (AOR = 7.15, 95% CI: 1.93–26.52) and financial debt (AOR = 4.87, 95% CI: 1.30–18.25) were associated with depressive symptoms. Planned pregnancy was associated with lower odds of anxiety symptoms, whereas previous pregnancy loss was associated with higher odds. Depressive and anxiety symptoms were negatively correlated with psychological well-being and perceived social support.
Conclusions:
Depressive and anxiety symptoms and poor psychological well-being were present among tribal expectant fathers. Father-inclusive screening and psychosocial support addressing socioeconomic stressors may help meet paternal mental health needs in underserved tribal communities.
Keywords: Anxiety, depression, indigenous peoples, fathers, pregnancy
Key Messages:
Question: What is the burden of depressive and anxiety symptoms and their psychosocial correlates among tribal expectant fathers?
Findings: Seasonal migration and financial debt were associated with depressive symptoms, while planned pregnancy was associated with lower odds and previous pregnancy loss with higher odds of anxiety.
Meaning: Antenatal care should include culturally appropriate, father-inclusive psychosocial support that addresses socioeconomic stressors among tribal expectant fathers.
Paternal mental health during pregnancy is an important but less studied area of perinatal mental health. Fathers can experience depressive and anxiety symptoms during their partner’s pregnancy. Previous studies have shown that paternal mental health is related to social support, partner relationship, pregnancy-related experiences, and other psychosocial stressors.1,2 A systematic review and meta-analysis estimated that approximately 9.76% of fathers experience depressive symptoms during the prenatal period, highlighting paternal depression as an important concern in perinatal mental health. 3 Other studies have also reported an association between poor social support, unintended pregnancy, and poorer paternal mental health. 4
In India, paternal mental health during pregnancy has received less attention than maternal mental health. This gap is more evident among socially disadvantaged communities. Fathers may experience stress because of financial responsibilities and employment-related difficulties. Their relationship with the pregnant partner can also influence their psychological well-being. Fathers who receive limited emotional or practical support may have greater difficulty coping with pregnancy-related demands.5,6 These may include an unplanned pregnancy, concerns about the health of the mother or baby, and other pregnancy-related difficulties.
Tribal populations in India often experience social and economic disadvantages. Studies on maternal healthcare have reported difficulties related to transportation, geographical distance, socioeconomic conditions, education, and access to health facilities.7,8 Limited access to healthcare can reduce fathers’ involvement in antenatal services. Employment-related migration may also keep fathers away from their partners for certain periods. Financial difficulties may further increase the pressures associated with pregnancy and family responsibilities.9,10
Family and cultural factors may also influence paternal mental health. Gender roles can shape how men understand their responsibilities during pregnancy. Social expectations may discourage men from expressing emotional difficulties or seeking psychological support. 11 The role of the partner and family may therefore be important in helping fathers cope with pregnancy.11,12
Most research among tribal populations has focused on maternal and child health. Studies on paternal health have mainly been conducted in general populations. Therefore, findings from non-tribal fathers cannot be directly assumed to apply to tribal fathers. Similarly, findings from tribal women cannot be directly generalized to tribal men. Understanding these factors can help improve father-inclusive antenatal care. It can also support early identification of fathers experiencing psychological distress during the perinatal period.
Therefore, the present study examined depressive symptoms, anxiety symptoms, psychological well-being, and perceived social support among tribal fathers during their partners’ pregnancy. The study also examined psychosocial factors associated with depressive and anxiety symptoms.
Methods
Study Design
This study used a community-based cross-sectional design to investigate prenatal paternal depressive and anxiety symptoms and their psychosocial correlates among tribal fathers in the Attappady tribal region.
Study Setting
The study was conducted in the Attappady tribal settlements of Palakkad district, Kerala, South India, between July and December 2025. The region is among the most socio-economically disadvantaged areas in the state. The major tribal communities living in Attappady are Irula, Muduga, and Kurumba. The Kurumba community is classified as a particularly vulnerable tribal group (PVTG) due to its small population size and greater socioeconomic challenges.
Sampling and Recruitment
A community-based consecutive sampling approach was used for participant recruitment. Researchers identified pregnant women through records maintained at local primary health centers and the maternal and child health registries of Swami Vivekananda Medical Mission Hospital, Agali. The hospital provides a community-based maternal and child health program that monitors pregnant women across tribal hamlets in Attappady through a network of community nurses and social workers. During the data collection period, 155 pregnant women were identified from the study area, and their husbands who met the eligibility criteria were approached consecutively for participation. Of the 155 husbands approached, 50 declined to participate, and 25 could not be contacted despite repeated attempts. The remaining 80 husbands fulfilled the eligibility criteria, provided informed consent, and were included in the final study sample. The participation rate was 51.6% (80/155).
Eligibility Criteria
Men aged 21 years and above whose wives were currently pregnant were eligible to participate. Participants who were willing to provide informed consent and participate in the study were included. Men with a known history of severe physical illness, severe psychiatric illness, or cognitive impairment that could affect their ability to understand the study procedures, provide informed consent, or participate in the interview were excluded from the study.
Data Collection Procedure
Data were collected through face-to-face interviews. The researcher visited participants’ homes and conducted interviews in a private, convenient location to ensure confidentiality. After obtaining informed consent, the researcher collected data using the study tools through an interview-based approach.
Ethical Considerations
The institutional research ethics review committee approved the study. The study obtained administrative permissions from the relevant authorities. The study obtained written informed consent from participants who could read and sign the consent form. For participants who were not formally educated or could not read the consent form, the study information and consent process were explained verbally in a language they understood. In such cases, consent was documented in the presence of an impartial witness, in accordance with the approved ethical procedures. Participation was voluntary, and participants were informed that they could withdraw from the study at any time without any consequences.
Study Measures
To minimize information bias, the same trained researcher conducted all interviews using standardized instruments in a private setting. These instruments have been used in other populations. However, their cultural adaptation and validity have not been established in the present study population. The tools were administered through interviewer-guided interviews in Malayalam, which was the language used by the participants. The researchers read each item aloud and recorded the participants’ responses. When necessary, the researchers explained an item’s meaning in simple Malayalam without changing its intended meaning. The data collection tools are described below.
Tools
Sociodemographic and Obstetric Characteristics Data Sheet
The researcher developed a structured data sheet to collect participants’ sociodemographic details and their wives’ obstetric characteristics. The tool was reviewed for content validity by a panel of six experts comprising psychiatrists, psychologists, and psychiatric social workers.
Patient Health Questionnaire-9
The Patient Health Questionnaire-9 (PHQ-9) is a nine-item self-administered instrument used to assess depressive symptoms during the previous 2 weeks. Total scores range from 0 to 27, with higher scores indicating greater depressive-symptom severity. Conventional severity categories include minimal, mild, moderate, moderately severe, and severe depressive symptoms.13–15 For the regression analyses, a PHQ-9 score of ≥5 indicated depressive symptoms, whereas a score of <5 indicated no or minimal depressive symptoms.
Generalized Anxiety Disorder-7
Anxiety symptoms during the previous 2 weeks were assessed using the Generalized Anxiety Disorder-7 (GAD-7) scale. This seven-item self-report instrument yields total scores from 0 to 21. Scores of 5, 10, and 15 represent mild, moderate, and severe anxiety symptoms, respectively. 16 For the regression analyses, a GAD-7 score of ≥5 indicated the presence of anxiety symptoms, whereas a score of <5 indicated no anxiety symptoms.
The World Health Organization-five Well-being Index
The subjective psychological well-being was assessed using the World Health Organization-Five Well-Being Index (WHO-5). Each item is rated on a six-point scale ranging from 0 (at no time) to 5 (all the time). Raw scores range from 0 to 25, with higher scores indicating better well-being. Multiply the raw score by four to obtain a percentage score ranging from 0 to 100. A raw score below 13, equivalent to a percentage score below 52%, was considered indicative of poor psychological well-being and suggests the need for further assessment of possible mental health problems.17,18
Multidimensional Scale of Perceived Social Support
Perceived social support was assessed using the Multidimensional Scale of Perceived Social Support (MSPSS). It is a 12-item self-report scale that evaluates perceived support from three sources: significant others, family, and friends. Each item is rated on a seven-point Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly agree).19,20 The MSPSS assesses perceived social support from three sources: significant other, family, and friends. In the present study, only the total MSPSS score was used for analysis because the primary objective was to assess overall perceived social support rather than support from specific sources.
Statistical Analysis
Descriptive statistics and univariate logistic regression analyses were conducted using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY, USA). Exploratory multivariable Firth’s penalized logistic regression analyses were conducted using R software with the logistf package. 21 Descriptive statistics summarized sociodemographic characteristics, obstetric details, and study variables. Continuous variables were presented as mean ± standard deviation (SD) or median and interquartile range (IQR) as appropriate, and categorical variables were presented as frequencies and percentages. Univariate logistic regression analyses were performed to examine factors associated with depressive symptoms and anxiety symptoms, and crude odds ratios (ORs) with 95% confidence intervals (CIs) were reported.
Given the limited number of outcome events, parsimonious multivariable models were constructed using a small number of predictors. Candidate variables were initially identified from the univariate analyses and considered in conjunction with their clinical and theoretical relevance. Because only 14 depressive-symptom events and 8 anxiety-symptom events were observed, the final models were restricted to two predictors for each outcome to minimize overparameterization and model instability. 22 Seasonal migration and financial debt were retained in the depressive-symptom model, while planned pregnancy and previous pregnancy loss were retained in the anxiety-symptom model. The final variable selection was informed partly by the observed univariate findings and was therefore considered exploratory rather than fully prespecified.
Firth’s penalized logistic regression was used to reduce small-sample bias and address potential separation in the presence of sparse data.23,24 Adjusted odds ratios (AORs) with 95% CIs were reported. Given the small number of outcome events and sparse data, estimates with wide 95% CIs were interpreted cautiously, as wide intervals indicate substantial uncertainty in the magnitude of the observed associations. Large ORs were therefore not interpreted solely based on their point estimates, and emphasis was placed on the precision of the estimates and the width of their CIs. The multivariable analyses were considered exploratory, and the findings were interpreted as associations rather than definitive independent predictors.
Participants’ ages were categorized into predefined, contextually meaningful groups for descriptive and univariate analyses to facilitate interpretation. Education, occupation, seasonal migration, socioeconomic status, financial debt, family type, substance use, and pregnancy-related characteristics were categorical by design and were analyzed using their predefined categories. Crude ORs with 95% CIs were estimated using univariate logistic regression, and AORs with 95% CIs were estimated using Firth’s penalized logistic regression for the exploratory multivariable analyses. We considered a two-sided p < .05 statistically significant.
Spearman’s rank-order correlation analysis was used to examine the relationships among anxiety symptoms, depressive symptoms, psychological well-being, and perceived social support. All statistical tests were two-tailed, and a p < .05 was considered statistically significant.
Results
Participants’ Sociodemographic Characteristics and Spouses’ Obstetric Details
Among the 80 participants, the mean age was 26.11 years (SD = 4.25). More than half had high school or higher secondary education (57.5%) and were engaged in daily wage occupations (56.3%). The majority belonged to the below poverty line category (BPL) (82.5%) and lived in joint families (83.8%). Substance use was reported by 70.0% of participants. Substance use was defined as any reported use of alcohol, any form of tobacco (including smoked or smokeless tobacco), marijuana/cannabis, or any other psychoactive substance. Regarding their spouses’ obstetric characteristics, most wives were in the second trimester (42.5%) and had planned pregnancies (73.8%). Nearly half of the participants accompanied their wives to antenatal care visits sometimes (48.8%). 13 (16.3%) of the participants reported previous pregnancy loss in their wives. Previous pregnancy loss was defined as any previous medical termination of pregnancy, spontaneous abortion, or miscarriage experienced by the participant’s wife. High-risk pregnancy was reported in 16 (20.0%) pregnancies, while current pregnancy complications were reported in 27 (33.8%). Current pregnancy complications were recorded when documented during the obstetric assessment. They included gestational diabetes, hypertension or preeclampsia, anemia, low body mass index, fetal-related problems, and other severe medical conditions identified by the attending gynecologist. The attending gynecologist determined high-risk pregnancy status based on clinical assessment and classification during the obstetric visit, rather than on participant self-report.
Table 1 presents the participants’ sociodemographic and obstetric characteristics.
Table 1.
Participants’ Sociodemographic Characteristics and Spouses’ Obstetric Details.
| Characteristics (n = 80) |
Frequency (n = 80) *Mean ± SD | No/% *Median (IQR) |
| Age | • 26.11 ± 4.25 | • 25 (23,29) |
| Community | Irula | 47 (58.8) |
| Muduga | 25 (31.3) | |
| Kurumba | 8 (10.0) | |
| Education | Primarily educated/upper primary | 26 (32.5) |
| High school or higher secondary | 46 (57.5) | |
| Degree and above | 8 (10.0) | |
| Occupational status | Daily wage | 45 (56.3) |
| Private sector | 24 (30.0) | |
| Government employee | 11 (13.8) | |
| Seasonal migration |
Yes | 25 (31.3) |
| No | 55 (68.8) | |
| Socioeconomic status |
Below poverty line (BPL) | 66 (82.5) |
| Above poverty line (APL) | 14 (17.5) | |
| Financial debt |
Yes | 30 (37.5) |
| No | 50 (62.5) | |
| Living arrangements |
Joint | 67 (83.8) |
| Nuclear | 13 (16.3) | |
| Substance use |
Present | 56 (70.0) |
| Absent | 24 (30.0) | |
| Pregnancy trimester |
First | 27 (33.8) |
| Second | 34 (42.5) | |
| Third | 19 (23.8) | |
| Planned pregnancy |
Yes | 59 (73.8) |
| No | 21 (26.3) | |
| High-risk pregnancy |
Yes | 16 (20.0) |
| No | 64 (80.0) | |
| Previous pregnancy loss | Yes | 13 (16.3) |
| No | 67 (83.8) | |
| Current pregnancy complications | Yes | 27 (33.8) |
| No | 53 (66.2) | |
| Accompany wife to ANC visit |
Always | 28 (35.0) |
| Sometimes | 39 (48.8) | |
| Never | 13 (16.3) |
Depressive Symptoms, Anxiety Symptoms, Psychological Well-being, and Perceived Social Support Among Participants
The mean PHQ-9 score was 2.30 (SD = 3.59), with 66 (82.5%) participants reporting minimal symptoms, 10 (12.5%) mild symptoms, and 4 (5.0%) moderate depressive symptoms. The mean GAD-7 score was 1.44 (SD = 2.55), with 72 (90.0%) participants having no anxiety symptoms, 6 (7.5%) mild anxiety symptoms, and 2 (2.5%) moderate anxiety symptoms. The mean WHO-5 well-being score was 14.88 (SD = 4.68), and the mean MSPSS score was 49.13 (SD = 19.79). The distributions of depressive symptoms, anxiety symptoms, psychological well-being, and perceived social support are presented in Table 2.
Table 2.
Depressive Symptoms, Anxiety Symptoms, Psychological Well-being, and Perceived Social Support Among Participants (n = 80).
| Variables | Categories | Frequency, n (%) | Mean ± SD | Median (IQR) |
| PHQ-9 (depressive symptoms) | 2.30 ± 3.588 | 0.50 (0,3) | ||
| Minimal depressive symptoms | 66 (82.5) | |||
| Mild depressive symptoms | 10 (12.5) | |||
| Moderate depressive symptoms | 4 (5.0) | |||
| GAD-7 (anxiety symptoms) | 1.44 ± 2.55 | 0 (0,0) | ||
| No anxiety symptoms | 72 (90.0) | |||
| Mild anxiety symptoms | 6 (7.5) | |||
| Moderate anxiety symptoms | 2 (2.5) | |||
| WHO-5 well-being index | 14.88 ± 4.68 | 15 (11,17) | ||
| Poor mental well-being | 32 (40.0) | |||
| Good mental well-being | 48 (60.0) | |||
| Multidimensional perceived social support (MSPSS) | 49.13 ± 19.79 | 48 (33.25, 69.75) | ||
| Low perceived support | 25 (31.3) | |||
| Medium perceived support | 30 (37.5) | |||
| High perceived support | 25 (31.3) | |||
PHQ-9: Patient Health Questionnaire-9, GAD-7: Generalized Anxiety Disorder-7, WHO-5: World Health Organization-Five Well-Being Index, MSPSS: Multidimensional Scale of Perceived Social Support. Continuous variables are presented as mean ± SD and median (IQR); categorical variables are presented as n (%).
Tribal Group-wise Distribution of Depressive and Anxiety Symptoms
Depressive symptoms were observed in 12.8% of participants within the Irula community, 24.0% within the Muduga community, and 25.0% within the Kurumba community. Differences across the three communities were not statistically significant (Fisher’s exact test, p = .375). Anxiety symptoms were observed in 14.9% of participants within the Irula community, 0% within the Muduga community, and 12.5% within the Kurumba community, with no statistically significant difference across the three communities (Fisher’s exact test, p = .110).
Univariate Analysis of Factors Associated with Depressive Symptoms
Univariate logistic regression analysis identified several factors significantly associated with depressive symptoms among the participants. Seasonal migration was significantly associated with depressive symptoms (p < .01), with higher odds observed among those reporting seasonal migration (OR = 8.50, 95% CI [2.33, 31.02]). Financial debt was also significantly associated with depressive symptoms (p = .007), with participants reporting financial debt having higher odds of depressive symptoms (OR = 5.75, 95% CI [1.61, 20.53]). Pregnancy trimester was significantly associated with depressive symptoms (p = .016), with the third trimester used as the reference category. High-risk pregnancy was significantly associated with depressive symptoms (p = .004), with higher odds among participants reporting a high-risk pregnancy (OR = 6.33, 95% CI [1.79, 22.37]). Current pregnancy complications were also significantly associated with depressive symptoms (p = .048), with higher odds among those reporting complications (OR = 3.30, 95% CI [1.01, 10.79]). Accompanying the wife to antenatal care was significantly associated with depressive symptoms (p < .001); compared with participants who never accompanied their wives, those who always or sometimes accompanied their wives had lower odds of depressive symptoms. Several associations had relatively wide 95% CIs, indicating uncertainty in the magnitude of the observed associations, particularly given the small number of depressive-symptom events. Table 3 presents the results of the univariate analysis of factors associated with depressive symptoms.
Table 3.
Univariate Analysis of Factors Associated with Depressive Symptoms (n = 80).
| Variable | Depressive Symptoms N (%) (n = 14) |
No Depressive Symptoms N (%) (n = 66) |
Crude OR (95% CI) | p | |
| Seasonal migration |
*<.01 |
||||
| Yes | 10 (71.4) | 15 (22.7) | 8.50 (2.33–31.02) Reference | ||
| No | 4 (28.6) | 51 (77.3) | |||
| Financial debt |
*<.01 |
||||
| Yes | 10 (71.4) | 20 (30.3) | 5.75 (1.61–20.53) Reference |
||
| No | 4 (28.6) | 46 (69.7) | |||
| Pregnancy trimester |
*.02 | ||||
| First | 3 (21.4) | 24 (36.4) | 0.21 (0.05–0.98) | ||
| Second | 4 (28.6) | 30 (45.5) | 0.23 (0.06–0.93) | ||
| third | 7 (50.0) | 12 (18.2) | Reference | ||
| High-risk pregnancy |
*<.01 |
||||
| Yes | 7 (50.0) | 9 (13.6) | 6.33 (1.79–22.37) Reference |
||
| No | 7 (50.0) | 57 (86.4) | |||
| Current pregnancy complications |
*.05 |
||||
| Yes | 8 (57.1) | 19 (28.8) | 3.30 (1.01–10.79) Reference |
||
| No | 6 (42.9) | 47 (71.2) | |||
| Accompany wife to ANC |
*<.001 | ||||
| Always | 1 (7.1) | 27 (40.9) | 0.01 (0.001–0.120) | ||
| Sometimes | 3 (21.4) | 36 (54.5) | 0.03 (0.004–0.143) | ||
| never | 10 (71.4) | 3 (4.5) | Reference | ||
Values are presented as n (%). OR: Odds Ratio, CI: Confidence Interval, ANC: Antenatal Care. Crude ORs and 95% CIs were estimated using univariate logistic regression. Reference categories are indicated as “reference.” Overall p values are reported for categorical variables with more than two categories. *p < .05.
Univariate Analysis of Factors Associated with Anxiety Symptoms
Univariate analysis identified several factors significantly associated with anxiety symptoms among the participants. Seasonal migration was significantly associated with anxiety symptoms, with higher odds observed among participants reporting seasonal migration compared with those who did not (OR = 4.33, 95% CI [0.95, 19.84], p = .044). Financial debt was also significantly associated with anxiety symptoms (OR = 6.00, 95% CI [1.13, 31.99], p = .021). Participants with a planned pregnancy had lower odds of anxiety symptoms compared with those whose pregnancy was not planned (OR = 0.03, 95% CI [0.004, 0.30], p < .001). Previous pregnancy loss was associated with higher odds of anxiety symptoms (OR = 27.86, 95% CI [4.70, 165.21], p < .001); however, the very wide 95% CI indicates considerable uncertainty and imprecision in the magnitude of this association, given the small number of anxiety-symptom events and sparse distribution of the variable. Age group (p = .264), pregnancy trimester (p = .181), and high-risk pregnancy (p = .192) were not significantly associated with anxiety symptoms. Table 4 presents the results of the univariate analysis of factors associated with anxiety symptoms.
Table 4.
Univariate Analysis of Factors Associated with Anxiety Symptoms (n = 80).
| Variable | Anxiety Symptoms N (%) (n = 8) |
No anxiety Symptoms N (%) (n = 72) |
Crude OR (95% CI) | p | |
| Age group | .26 |
||||
| ≤23 | 5 (62.5) | 24 (33.3) | 3.13 (0.56–17.55) | ||
| 24–26 | 1 (12.5) | 18 (25.0) | 0.83 (0.07–9.86) | ||
| ≥27 | 2 (25.0) | 30 (41.7) | Reference | ||
| Seasonal migration |
*.04 | ||||
| Yes | 5 (62.5) | 20 (27.8) | 4.33 (0.95–19.84) | ||
| No | 3 (37.5) | 52 (72.2) | Reference | ||
| Financial debt |
*.02 | ||||
| Yes | 6 (75.0) | 24 (33.3) | 6.00 (1.13–31.99) | ||
| No | 2 (25.0) | 48 (66.7) | Reference | ||
| Pregnancy trimester | .18 |
||||
| First | 2 (25.0) | 25 (34.7) | 0.30 (0.05–1.84) | ||
| Second | 2 (25.0) | 32 (44.4) | 0.23 (0.04–1.43) | ||
| Third | 4 (50.0) | 15 (20.8) | Reference | ||
| Pregnancy planned |
*<.001 | ||||
| Yes | 1 (12.5) | 58 (80.6) | 0.03 (0.004–0.30) | ||
| No | 7 (87.5) | 14 (19.4) | Reference | ||
| High-risk pregnancy | .19 | ||||
| Yes | 3 (37.5) | 13 (18.1) | 2.72 (0.58–12.86) | ||
| No | 5 (62.5) | 59 (81.9) | Reference | ||
| Previous pregnancy loss | *<.001 | ||||
| Yes | 6 (75.0) | 7 (9.7) | 27.86 (4.70–165.21) | ||
| No | 2 (25.0) | 65 (90.3) | Reference | ||
Values are presented as n (%); OR: Odds Ratio, CI: Confidence Interval. Reference categories are indicated as reference. Statistical significance was set at p < .05.
Exploratory Multivariable Analysis of Factors Associated with Depressive and Anxiety Symptoms
Given the small number of outcome events, exploratory multivariable analyses were conducted using Firth’s penalized logistic regression. For depressive symptoms, the parsimonious model retained seasonal migration and financial debt. Seasonal migration was associated with higher odds of depressive symptoms (AOR = 7.15, 95% CI [1.93, 26.52], p = .003), as was financial debt (AOR = 4.87, 95% CI [1.30, 18.25], p = .019). The relatively wide CIs indicate uncertainty in the magnitude of these associations and warrant cautious interpretation given the limited number of depressive-symptom events.
For anxiety symptoms, planned pregnancy and a history of previous pregnancy loss were included in the parsimonious model. Planned pregnancy was associated with lower odds of anxiety symptoms (AOR = 0.04, 95% CI [0.001, 0.40], p = .006). Previous pregnancy loss was associated with higher odds of anxiety symptoms (AOR = 25.80, 95% CI [3.21, 207.67], p = .002). However, the very wide CI indicates substantial imprecision in the adjusted estimate, and the magnitude of this association should therefore be interpreted cautiously in view of the small number of anxiety-symptom events and sparse distribution of previous pregnancy loss. The multivariable findings were considered exploratory associations rather than definitive predictors. Table 5 presents the results.
Table 5.
Exploratory Multivariable Logistic Regression of Factors Associated with Depressive and Anxiety Symptoms Among Husbands (n = 80).
| Outcome and Predictor | AOR (95% CI) | p | |
| Depressive symptoms (n = 14) | |||
| Seasonal migration | 7.15 (1.93, 26.52) | <.01 | |
| Financial debt | 4.87 (1.30, 18.25) | .02 | |
| Anxiety symptoms (n = 8) | |||
| Planned pregnancy | 0.04 (0.001, 0.40) | <.01 | |
| Previous pregnancy loss | 25.80 (3.21, 207.67) | <.01 | |
Estimates were obtained using Firth’s penalized logistic regression because of the small number of outcome events and sparse data. Reference categories were no seasonal migration, no financial debt, unplanned pregnancy, and previous pregnancy loss, respectively. Multivariable models were intentionally restricted to a small number of theoretically relevant variables because of the limited number of outcome events. AOR: Adjusted Odds Ratio, CI: Confidence Interval.
Correlations Among Anxiety and Depressive Symptoms, Psychological Well-being, and Perceived Social Support
A negligible and non-significant negative correlation was observed between anxiety and depressive symptoms (ρ = −0.027, 95% CI [−0.238, 0.193], p = .813). Anxiety symptoms were negatively associated with perceived social support (ρ = −0.314, 95% CI [−0.516, −0.086], p = .005). Depressive symptoms were negatively associated with psychological well-being (ρ = −0.253, 95% CI: −0.452 to −0.019, p = .023) and perceived social support (ρ = −0.371, 95% CI: −0.562 to −0.145, p = .001). Psychological well-being was positively associated with perceived social support (ρ = .390, 95% CI: .149 to 0.592, p < .001). No statistically significant association was observed between anxiety and depressive symptoms (ρ = −0.027, 95% CI: −0.238 to 0.193, p = .813). Table 6 presents the correlations.
Table 6.
Correlations Among Depressive and Anxiety Symptoms, Psychological Well-being and Perceived Social Support (n = 80).
| Variable | 1 | 2 | 3 | 4 |
| 1. Anxiety symptoms | – | |||
| 2. Depressive symptoms | −0.03 [−0.238, 0.193] | – | ||
| 3. Psychological well-being | −0.24* [−0.461, −0.004] | −0.25* [−0.452, −0.019] | – | |
| 4. Perceived social support | −0.31** [−0.516, −0.086] | −0.37** [−0.562, −0.145] | 0.39** [0.149, 0.592] | – |
N = 80. Values represent Spearman’s rank-order correlation coefficients (ρ), with 95% confidence intervals presented in brackets. *p < .05; p < .01. All correlations were two-tailed.
Discussion
The present study examined depressive symptoms, anxiety symptoms, psychological well-being, perceived social support, and their psychosocial correlates among tribal expectant fathers in Kerala. The findings of the study indicate that emotional difficulties may be relevant among expectant fathers in this underserved population. Research evidence similarly indicates that paternal mental distress is not uncommon during pregnancy. A meta-analysis of observational studies estimated the prevalence of paternal prenatal depressive symptoms at approximately 9.8%, although estimates varied considerably according to the instrument and threshold used. 25 The relatively higher proportion observed in the present study may partly reflect differences in measurement instruments and thresholds, as well as the socioeconomic context of the study population.
The finding of anxiety symptoms in 10.0% of fathers is also consistent with evidence showing that pregnancy can be associated with substantial worry among men. A systematic review identified concerns related to childbirth, the health of the baby and partner, transition to fatherhood, relationships, healthcare interactions, and financial circumstances as important dimensions of paternal pregnancy-related anxiety. 26 More recent evidence found that paternal prenatal anxiety was associated with depressive symptoms, lower social support, and maternal anxiety.27,28 Although Indian evidence remains limited, a recent study among fathers in urban Bengaluru and Goa also identified anxiety and depressive symptoms during the perinatal period and found higher anxiety among fathers reporting an unplanned pregnancy. 29 This finding is relevant to the present study because planned pregnancy was also associated with lower odds of anxiety symptoms.
In exploratory multivariable analyses using Firth’s penalized logistic regression, seasonal migration and financial debt were associated with depressive symptoms, while planned pregnancy and previous pregnancy loss were associated with anxiety symptoms. These findings are plausible within the socioeconomic context of the tribal population, where employment insecurity and migration may separate fathers from their pregnant partners and increase financial responsibilities. The study was cross-sectional, and the regression models were based on only 14 depressive-symptom events. In addition, the CIs were relatively wide, indicating uncertainty around the magnitude of the observed associations. Similar concerns apply to the large ORs observed for previous pregnancy loss and anxiety symptoms. Although the point estimate was high, the 95% CI was extremely wide, reflecting substantial imprecision associated with only eight anxiety-symptom events. Thus, these findings should be interpreted as exploratory signals that require confirmation in larger studies rather than as evidence of strong or definitive predictors. Similar associations have nevertheless been reported in previous studies, with financial difficulties linked to depressive symptoms and previous pregnancy loss associated with anxiety symptoms among fathers during the perinatal period.30,31
Depressive and anxiety-symptom proportions varied descriptively across the Irula, Muduga, and Kurumba communities, but the differences were not statistically significant. The small number of Kurumba participants (n = 8) limits the ability to detect subgroup differences.
The association between planned pregnancy and lower odds of anxiety symptoms is noteworthy. Pregnancy planning may indicate greater preparedness for the transition to parenthood and may reduce uncertainty about financial, family, and caregiving responsibilities. However, the cross-sectional design does not establish that pregnancy planning reduces anxiety symptoms. This interpretation is consistent with recent Indian evidence in which fathers of unplanned pregnancies reported greater anxiety, although that study examined fathers during the postnatal period. 29
Perceived social support showed an inverse association with both depressive and anxiety symptoms, while psychological well-being was positively associated with social support. These findings are consistent with broader evidence identifying social support as an important correlate of paternal perinatal mental health. The recent meta-analysis of paternal anxiety similarly identified low social support as associated with greater prenatal anxiety. 32 This relationship may be particularly relevant in tribal communities where migration, economic hardship, and limited access to formal mental health services may increase dependence on family and community networks.
A negligible and non-significant negative correlation was observed between anxiety and depressive symptoms (ρ = −0.027, 95% CI [−0.238, 0.193], p = .813). This differs from much of the perinatal literature, in which depressive and anxiety symptoms commonly co-occur. However, this finding should not be interpreted as evidence that anxiety and depressive symptoms are unrelated among tribal fathers. The small sample size may have limited the statistical power to detect an association, and the distribution and variability of symptom scores may also have influenced the correlation estimate. Larger studies with adequate statistical power are needed to determine whether this pattern is reproducible.
Overall, the findings suggest that depressive and anxiety symptoms and poor psychological well-being need attention among tribal expectant fathers. Screening fathers using brief symptom measures may help identify men who experience emotional difficulties but are not routinely assessed during pregnancy. Research evidence supports greater inclusion of fathers within perinatal mental health services. 33 The observed associations with migration, financial debt, pregnancy planning, and social support provide useful areas for further investigation. Given the modest sample size, low event rates, wide CIs, and cross-sectional design, these findings should be regarded as exploratory associations rather than definitive risk factors or causal relationships. Larger longitudinal studies across different tribal communities in India are needed to confirm these patterns and to examine how paternal mental health changes across pregnancy and the postpartum period.
Strengths and Limitations
This study has several strengths. It is among the first community-based studies to examine prenatal mental health among tribal expectant fathers in South India. The study evaluated a broad range of sociodemographic, pregnancy-related, and psychosocial factors.
However, several limitations warrant consideration. The cross-sectional design limits causal inference. The relatively small sample size and limited number of depressive and anxiety-symptom events may have reduced the precision of the regression estimates and resulted in wide CIs. No a priori sample size or power calculation was performed. Given the small sample and limited number of outcome events, consider the findings exploratory and hypothesis-generating. Therefore, interpret the observed associations cautiously. The univariate analyses involved multiple comparisons without adjustment for multiple testing, which may have increased the possibility of Type I error. Therefore, these findings should be considered exploratory and interpreted cautiously. Self-reported measures may have introduced reporting bias. The PHQ-9, GAD-7, WHO-5, and MSPSS were administered through interviewer-guided interviews in Malayalam. However, these instruments were not specifically culturally adapted or validated among tribal fathers in the study setting. This may have affected the interpretation of some items. Of the 155 husbands approached, 50 declined participation, and 25 could not be contacted. Therefore, non-response or selection bias cannot be excluded, as non-participants may have differed from participants in factors such as migration, employment, socioeconomic circumstances, or psychological distress. Because the study was conducted in a single tribal region, the findings may not generalize to other populations. Larger prospective studies are needed to confirm these findings.
Conclusion
This study found depressive and anxiety symptoms among tribal expectant fathers during their partners’ pregnancies and identified several contextual factors associated with these symptoms. Seasonal migration and financial debt were associated with depressive symptoms in exploratory multivariable analyses, whereas planned pregnancy and history of previous pregnancy loss were associated with anxiety symptoms. Given the small number of outcome events, wide CIs, the exploratory nature of the multivariable analyses, and the cross-sectional design, interpret these findings cautiously; they do not establish causal relationships.
The findings highlight the potential importance of considering fathers’ psychosocial and socioeconomic circumstances within perinatal mental health services. However, the present study did not evaluate the effectiveness of any intervention or measure maternal or child mental health outcomes. Therefore, implications regarding potential benefits of interventions for fathers, mothers, or children should be considered hypotheses for future research rather than conclusions supported by the present data.
Supplemental Material
Supplemental material for this article is available online.
Acknowledgments
The authors sincerely acknowledge the support and cooperation of the District Health Department, Palakkad; Vivekananda Medical Mission; the Kerala State Tribal Development Department; and the Forest Department, Government of Kerala. The authors received no financial or material support from any of these institutions. The authors also thank the participants for their valuable contributions to this study.
Footnotes
Reporting Guideline: Name: STROBE 34
Citation: von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. J Clin Epidemiol 2008; 61(4): 344–349. DOI: 10.1016/j.jclinepi.2007.11.008.
Data Sharing Statement: The datasets generated and analyzed during the current study are not publicly available because they contain potentially identifiable participant information and are subject to institutional ethical and privacy restrictions. The corresponding author may make de-identified data available upon reasonable request and with approval from the relevant institutional ethics committee.
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Prabha S Chandra serves as a member of the Editorial Board of this journal. The authors declare no other competing interests.
Declaration Regarding the Use of Generative AI: No generative AI tools were used for study conception, study design, data collection, statistical analysis, interpretation of findings, or generating scientific conclusions. The authors critically reviewed, revised, and approved all content and take full responsibility for the manuscript’s accuracy, integrity, and originality.
Disclaimer: Not applicable.
Editorial Process: Because Dr. Prabha S Chandra is a member of the Editorial Board of this journal, the authors had no involvement in the peer review, editorial assessment, or editorial decision-making for this manuscript.
Ethical Approval: Name of Ethics Committee/Review Board: Institutional Research Ethics Review Committee, NIMHANS, Bengaluru, Karnataka, India. Because the study was conducted among tribal communities in the Attappady region of Kerala, India, we obtained formal administrative permission from the Government of Kerala’s Scheduled Tribes Development Department (Permission No. STDD/4549/2024-B2). The department reviewed and approved the research protocol before field implementation.
Reference number: 077-2559
Date: 14 June 2024
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
Informed Consent: The authors obtained informed consent from all participants before participation. For participants with limited formal education, we obtained witnessed verbal consent after clearly explaining the study’s purpose, methods, and voluntary nature.
Positionality Statement: Not applicable.
Citation Diversity Statement: We are committed to equitable citation practices and have made conscious efforts to include relevant scholarship from authors representing diverse genders, geographic regions, career stages, and historically marginalized or underrepresented groups. We paid particular attention to scholarship from the Global South, including India, to support a more inclusive, balanced, and representative scholarly record.
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