Recruitment, Engagement, and Retention of Fathers in Nutrition Education and Obesity Research

Abstract

This article provides a perspective about recruiting, engaging, and retaining fathers in research and programming related to nutrition education and childhood obesity prevention. Recent research emphasizes the importance of fathers in childhood obesity prevention, and while father-friendly approaches can emulate other underserved populations, some researchers have acknowledged that differences may exist. Family sciences and nutritional sciences related literatures are summarized to provide guidance for nutrition and obesity scholars. Best practices may vary by the type of study and father characteristics; and the venues, content, structure, timing, and approach of research and interventions may need to be tailored for fathers.

INTRODUCTION

Unique strategies to reduce obesity risk and improve nutritional status in families with young children are needed. New approaches should consider all family members who may influence feeding and activity decisions of young children. While mothers have long been the focus of nutrition education and obesity research for young children, fathers have been underrepresented, and best approaches for including them in research are less understood.^1,2 Further, on average, less than 1 out of 5 participants in a national nutrition education program (Expanded Food and Nutrition Education program) that serves low-income families is male.³

Fathers are important to include in childhood obesity research and intervention, as some recent research has found that fathers influence predictors of childhood obesity such as children’s physical activity⁴ and dietary habits,⁵ and also that father obesity might be more strongly predictive of child obesity than mother obesity.⁶ Unfortunately, fathers also are less likely to be engaged with their children’s health care overall and weight management behaviors specifically, and are less likely to be concerned about their children’s weight status.⁷ However, in a qualitative study, fathers reported that they feel responsible for teaching their children healthy eating and physical activity habits.⁸ As such, making specific efforts to include fathers in obesity research and interventions is of critical importance. As noted by Morgan et al.,²

“These findings suggest that failing to include fathers in childhood obesity treatment and prevention efforts may have considerable consequences for intervention efficacy. Indeed, scholars have argued that implementing parenting programs without meaningful father engagement is akin to poor practice, leads to wasted resources, provides incomplete evaluation, and may undermine the duty of care that researchers and practitioners have to optimize child well-being” (pp. 2–3).

They proceed to note that “To the extent that fathers may not be as concerned about their child’s weight, researchers may need to make concerted efforts to recruit them in future studies” (p. 8). Fathers influence their children, whether intentionally or not, whether via absence or engagement, and whether positively or negatively. If a father does not recognize his child’s weight as an issue, or does not see the need for his involvement in his child’s diet or physical activity, or engages with his child in unhealthy ways, targeted recruitment efforts and interventions become all the more necessary to truly optimize children’s health.

Other disciplines, such as human development and family sciences, have a more advanced understanding of how best to include fathers in child development research and outreach, but the field of nutrition is still emerging in this respect, and it is unknown whether general parenting intervention recruitment strategies will carry over into health behavior specific interventions and research. Previously published reviews^1,2 have summarized the current state of obesity or child health related research involving fathers, and some limited recommendations have been provided.² However, a comprehensive and succinct set of recommendations or summary of how to target fathers in nutrition and obesity research and intervention is lacking, as very few studies or interventions have even attempted to do so (Morgan et al. noted only 1 RCT out of 213 reviewed over a ten year period specifically targeted fathers). While similarities in best practices likely exist among reaching fathers and other underserved populations in nutrition and obesity prevention research, or with broader parenting interventions and programs, unique or notable differences should be evaluated and noted for researchers or outreach coordinators seeking to target or include fathers specifically in obesity research. Therefore, this perspective aims to summarize what is currently known about recruiting, engaging, and retaining fathers in research and programs related to nutrition and obesity, based on human development and family sciences and nutrition perspectives, to provide guidance for future research and outreach. Example strategies for recruitment, engagement and retention of fathers in nutrition education and obesity prevention programs are provided (Table)⁹ and described in further detail.

Table.

Examples strategies to recruit, engage, and retain fathers in nutrition education and obesity prevention programs

Objective	Example Strategies		Rationale
Recruit	Offer programs for fathers only	Hire male staff to deliver program	Women traditionally lead and participate in nutrition education programs and therefore more attention is needed for offering and staffing father-focused programs with men to establish rapport to recruit fathers
Engage	Deliver program at time convenient for fathers to attend	Educate fathers in ways that match men’s learning styles (i.e. hands on, interactive, opportunities for discussion)	Fathers may be more likely to work outside the home during normal business hours and therefore, more attention for a convenient program time is needed;
			Engagement with fathers should consider active and differing learning styles of men compared to women
Retain	Periodically survey fathers to determine their needs, concerns and interests related to the program	Monitor level of father involvement in the lives of children and recognize accomplishments	Assessing fathers’ needs and interests, which may vary from mothers, is important for retention;
			Recognition of the involvement of fathers in their child’s life may be lacking but important for retention

Excerpts⁹ derived from The Father Friendly Check Up™

Recruitment

According to fathers, underrepresentation in research and programming is often due not to disinterest, but rather, to not being directly asked to participate.^1,10 To address this, it is recommended that researchers directly recruit fathers to participate in father-focused programs versus generically recruiting “parents,” which fathers generally assume (often correctly) really means mothers or may not be exclusive to fathers.^1,2,10–12 Additionally, when only recruiting fathers through mothers, the participating fathers are usually married, have a higher education level, and have a functional coparenting relationship with the mother, thus resulting in a non-representative sample.¹³ To counter this, the definition of father can be extended beyond the biological father to also include other “family men” such as mothers’ cohabiting partners, grandfathers, or uncles serving in a father-figure position.¹⁴ This is especially important in longitudinal studies, because various non-biological father figures may enter and exit a child’s life during the course of a study.¹³

Nonresident biological fathers are particularly underserved, despite many maintaining an active role and influence in their children’s lives.¹⁵ Therefore, it is recommended that researchers engage in more efforts to recruit biological fathers directly rather than just through mothers. Targeted recruitment should include relatable photos of fathers¹² who represent the intended audience on advertisements, in locations that fathers feel comfortable¹ or on billboards, TV, radio, or newspapers.¹⁶ Researchers can consider recruiting online, at community sports events, parks or recreation areas, social services programs, doctors’ offices, health centers, churches,¹ through the workplace, or directly via mail.¹² For non-white fathers, recruitment efforts could include public transit, playgrounds, and barber shops.¹ The home¹² environment and other convenient, familiar, or reputable locations such as a child’s school may be more trusted, and therefore best for recruitment and program implementation.^{1, 12, 17}

Although not always representative, use of snowball sampling may be most effective with fathers.^13,16 Word of mouth can enhance trust between fathers and program staff,¹⁶ especially non-white fathers.¹ Another strategy to establish trust is finding a champion in a community organization to help reach out to fathers, debrief the father on the study, and endorse legitimacy of the study.^1,13 This may include a family advocate, community outreach coordinator, team sport coaches, teachers or staff at a child’s school and can be more effective if the champion is a male, specifically also a father (Table). Although phone calls or text messages are an option for recruitment, face-to-face interactions may be more efficient. Even a drop-by technique at a time that is convenient for fathers can offer the opportunity to build rapport.¹⁶

There may be differences in best approaches to recruit fathers in research and for programs, based upon the type and purpose of the research or program. For example, if the research involves a one-time interaction such as in a cross sectional survey, characteristics of research personnel may not matter as much compared to a longitudinal research project or intervention where establishing long-term rapport and trust among fathers is more important.

Engagement and Retention

As with most research involving underserved populations, providing transportation and incentives are recommended to encourage participation when focusing on fathers, especially low-income fathers.¹⁶ Long-term benefits of the research project should be emphasized, especially as it relates to benefitting a father’s children, such as serving as a role model or teaching their children an appropriate work ethic.¹⁴ However, while incentives to participate can help recruit and retain fathers, money alone does not always encourage fathers to participate.¹³

The name or title of the study or intervention should also be considered. For example, “parenting class” or “parent education” has a negative connotation for many fathers, as it may be associated with Child Protective Services¹¹ or imply the father lacks parenting skills.¹⁷ Instead, it is recommended that researchers use more neutral terms such as “program” or the name of the activity (e.g., Cooking Time with Dads), focus on the positive, express the value of the father’s input and why his participation is important, and emphasize confidentiality.¹³ It is likely that a combination of these targeted efforts is required for success. In a recent Australian study, fathers were successfully engaged by providing them with incentives and being recruited through a champion at the workplace, a men’s health fair, and by using frequent follow-ups using face-to-face, phone, and email methods.¹⁸

The time commitment involved is a concern for fathers, and in general, 30 to 45 minutes per session has been recommended, although fathers may be willing to stay for longer periods of time if their child is involved and a meal is included.¹ Recruitment and programs should be held during times or days that are convenient for fathers.^1,10,12,17 Evenings and weekends have been recommended while being mindful of children’s sleep schedules and father’s work schedules, and weekends devoted to spending time with children, especially among non-custodial fathers.¹⁷ Flexible scheduling and alternative methods of collecting data (e.g. online or mail) is also recommended.

For multi-session programs or studies, specific strategies can help decrease attrition. Raffles for small prizes held at each session, or raffle tickets collected at each session towards prizes awarded at the end of the program/study, can help improve father’s attendance by tapping into both father’s enjoyment of competition¹⁹ and the reinforcement properties of rewards. Certificates of completion, graduation ceremonies, or other recognition of completion of multi-session programs (or a certain number of sessions) also can be highly motivating for fathers. This is particularly true for fathers with low educational attainment who might never have graduated or completed a program before, and so for whom such a certificate or ceremony can hold special meaning and be a source of personal pride.

When appropriate, it is sometimes helpful to include children in the programs, as this removes the element of having the study or program compete with children for father’s time. Nonresident fathers particularly appreciate being able to spend time with their children, and having children involved or at least providing child care helps to eliminate barriers and promote participation. With interventions, involving children in the program provides the opportunity for fathers to get hands on experience and also to be scaffolded in their practice of the techniques or behaviors being taught, which fathers particularly appreciate.^11,19 The consideration of learning styles of men is recommended by including hands on, interactive approaches and opportunities for discussion. (Table)

An aspect of social support, such as group discussions or peer mentoring, is recommended in intervention research because fathers tend to have less social support than mothers.^10,11 To provide a safe environment, fathers tend to prefer programs exclusive to fathers, as they may feel secondary or even unwelcome/excluded when mothers are present.^1,19 A male facilitator, preferably one who is a father, whom participants can relate to^12,19 and who is approachable and grounded is recommended for recruitment, retention as well as engagement.¹⁹

To retain fathers in longitudinal studies, it is important that the original recruiter or researcher maintain contact with the father regularly including several methods of contact information for the research team.¹³ And finally, particularly for low income fathers who more frequently have changes in residence or living situations, it is recommended that researchers also obtain contact information for friends or family members of the fathers (from the fathers themselves) who can assist in providing current contact information when fathers have moved or changed phone numbers.

DISCUSSION

In general, due to gender norms, fathers may be less prepared for their role as a parent, require education on different topics from mothers, and need more assistance overcoming barriers that prevent them from being involved with their children.¹² Because fathers of different racial, ethnic, or socioeconomic statuses may have different needs, researchers should consider conducting formative research to determine needs and interests of their specific target group,^14,20 but simple, basic information may be best.¹⁹ Cultural competence is also an important consideration, especially as it relates to program content and timing, preferred language, and food provided.¹⁹ For example, the authors once inadvertently scheduled a cooking and nutrition education program during Ramadan, a mistake they have been careful to avoid since.

Because fathers tend to focus on long-term, family-focused benefits, it is recommended that researchers emphasize how participation will benefit a father’s family, other fathers, or the child’s health.^1,18 It is also recommended that programs be active, hands-on, and include aspects of competition for fathers to increase motivation.¹⁹ While fathers are not opposed to participating in experiential sessions with their children,¹⁹ they may need time to master material before their children are invited to sessions. The ‘Healthy Dads, Healthy Kids’ intervention program, which focused on the father’s influence over the child’s health, provides an example of how father-child sessions can be interspersed with father-only sessions.²¹ While the workplace has been suggested as a viable option for programs, fathers may not be motivated to spend extra time at the workplace for education, and instead may be more enthusiastic about an offsite or online program.¹⁸

For interventions, it is recommended that support materials be available in several formats including online, videos, modules, CDs, and discussion forums.¹ Researchers may also need to consider that father engagement in programs fall on a continuum, as opposed to simply enrolled in the program or not enrolled in the program.¹⁰ Fathers could be fully engaged and attend all sessions, invited to critical sessions, or they could be asked to complete assessments without being engaged in sessions.¹⁰

IMPLICATIONS FOR RESEARCH AND PRACTICE.

By only including mothers in obesity related research, especially related to children, researchers dismiss the individual and synergistic role and impact of a father on his child’s health.² While recent research has begun to recognize the importance of better understanding and intervening with fathers when it relates to childhood obesity prevention or treatment^1,2, much more work is needed to determine the best practices for recruiting, engaging, and retaining fathers in nutrition and obesity research studies and programs. Strategies to reach fathers in research may mimic strategies similar to other difficult-to-reach populations, but further work is needed, and intersections across various additional identities (e.g., religion, race/ethnicity/country of origin, age, SES, immigration status, age and number of children) likely result in different strategies being needed for different groups. Particularly given the cultural importance and meanings of food and mealtimes, awareness of the values and practices of the particular group of fathers being targeted is important.

As noted earlier, failure to include fathers represents “poor practice” as well as a failure to leverage all available resources in pursuit of the optimization of children’s well-being. Fathers, like many other underserved populations, require particular considerations when including them in research and interventions. This article provides scholars a conceptual framework and advice to aid in engaging fathers as a critical ally and resource in the prevention of childhood obesity.