Ethnic minority fathers’ experiences of the Neonatal Care Unit: barriers to accessing psychological support

ABSTRACT

Background

The Neonatal Care Unit is a challenging environment for parents. Previous literature documents the need for increased and more specialised understanding of support for fathers. There remains a dearth of literature on the experiences of ethnic minority fathers in particular, who may be less likely to access psychological support available.

Method

This project aimed to understand the barriers ethnic minority fathers face when accessing psychology support at a Neonatal Care Unit in England. Seven fathers from ethnic minority backgrounds participated in semi-structured interviews after their babies were discharged.

Results

Data were analysed using a Reflexive Thematic Analysis approach. Three main themes were identified: ‘Psychology is a Threat’, ‘It’s Not Really Talked About in our Culture’, and ‘A Space for Mum, Not Me’. These themes are discussed in reference to the extant literature, and recommendations are provided to improve access to support in this neonatal unit.

Conclusions

There is a need to recognise interacting influences of gender and cultural norms in supporting these fathers, including understanding the role of psychology, consideration of stigma, and knowing families in relation to their cultural context.

KEYWORDS:

• Neonatal Care Unit
• psychology
• ethnic minority
• father
• help-seeking

Introduction

Background

There is an increased focus on family-centred care in Neonatal Services in the United Kingdom, including in the National Health Service Long-Term Plan (NHS, 2019), in consequent recommendations such as the Neonatal Critical Care Review (NHS Improvement., NHS England, 2019), and most recently in the Getting It Right First Time (Getting It Right First Time, 2022) Neonatology Programme National Speciality Report. When parents play an active and substantive role in their baby’s care, there are numerous positive outcomes, including in family cohesion and attachment (Flacking et al., 2012), better parental mental health (O’Brien et al., 2018), and lower infant readmission rates (Ding et al., 2019).

Parents require adequate support to play this active role on the Neonatal Care Unit (NCU), an environment fraught with stressors which include medical procedures on fragile preterm babies, parent new-born separation, noisy and bright wards, as well as complex conversations with multiple professionals (Busse et al., 2013; Grosik et al., 2013; Mäkelä et al., 2018). Missing from our understanding of how to support parents is the paternal experience. A recent meta-analysis on interventions to reduce parental stress found many studies did not investigate or report father-specific outcomes, and only 3 of 36 studies enrolled fathers alone (Sabnis et al., 2019). This finding is replicated in a systematic review in which fathers are underrepresented, comprising only 38% of the sample (Loewenstein et al., 2019).

This lack of research on how to support fathers is concerning given findings that 10% of fathers experience paternal perinatal depression (PPD; Paulson & Bazemore, 2010), with figures rising to 30–40% when infants are in hospital (Cyr-Alves et al., 2018; Kong et al., 2013). Although for some fathers, symptoms of anxiety and depression diminish over time (Cajiao-Nieto et al., 2021), PPD has significant long-term consequences on children, including internalising and externalising behaviours in later childhood (Low et al., 2022). The emerging evidence base of qualitative studies (see Provenzi & Santoro, 2015) documents numerous vulnerability factors for fathers including the impact of traumatic births, simultaneously taking on more responsibility when mothers are physically unable to participate in care (Hagen et al., 2016), and also a felt sense of a lack of control (Arockiasamy et al., 2008).

Crucially, fathers report inadequate support for themselves, as well as a lack of essential information regarding the care of their baby (e.g. Garten et al., 2013; Merritt et al., 2022; Sloan et al., 2008; Thomson-Salo et al., 2017). The focus of healthcare professionals’ attention is felt to be on ‘mum and baby’ (Govindaswamy et al., 2020), leaving fathers unable to share emotional difficulties and without much-needed support (Coppola et al., 2013; Hugill et al., 2013; Pohlman, 2005).

Experiences of ethnic minority fathers

Outside of the NCU, factors such as stigma, alternative models of distress, misidentification of needs, and cultural exclusion within services contribute towards discrepancies in access to support for ethnic minority groups (e.g. Gureje et al., 2006; Mclean et al., 2003; Memon et al., 2016; Punthmatharith et al., 2007; Rabiee & Smith, 2013). It may be hypothesised that these factors contribute to how fathers experience the NCU; however, the inclusion of minority groups in the literature on the paternal NCU experience is significantly lacking. The need for research that represents the diversity of racial and ethnic groups of families accessing Neonatal Care Units is underscored in a review of NCU parental mental health (Roque et al., 2017).

In order to support ethnic minority fathers during their NCU stay as well as in their transition to fatherhood, specific knowledge about their experience is required. This project therefore adopts a phenomenological approach by seeking fathers’ own stories to understand the barriers and facilitators to accessing psychological support on one individual NCU.

Method

Setting

This project took place at a large Neonatal Care Unit in the South of England which supports parents from a range of backgrounds. The unit is classified as a Neonatal Intensive Care Unit (NICU), which provides the highest level of care, often including surgical and cardiac services to new-born babies who are ill or born prematurely.

Psychological support is available to all parents on the NCU through a small team of clinical psychologists. This involved or couple sessions for either or both parents, offered in a confidential space or cotside. The psychology team offered assessment and formulation driven interventions, taking into consideration the diverse needs of families and drawing upon a range of psychological models. Channels of engagement include self-referral via leaflets, open psychology information session on the ward, and other healthcare staff mentioning support available, as well as staff referral following discussion with parents.

Psychologists on the unit noted a long-standing trend of fathers being less likely to take up the offer of psychological support and identified ethnic minority fathers as a group that they engage with least. This Service Evaluation project was therefore designed to understand the barriers to support for these fathers.

The project was classified as a Service Evaluation by the NHS Trust’s Study Classification Group in October 2021 and was subsequently approved by the Psychological Medicine’s Governance Committee. As a Service Evaluation, further ethical approval was not required.

Procedure

Parents whose babies were being discharged from the NCU were given a form requiring their consent to be contacted about service evaluation projects by members of psychology staff. Adult fathers who identified as non-White-British and who had not experienced infant fatality and who consented to be contacted were contacted via telephone or email. Approximately 30 fathers were contacted over the course of 6 months. Efforts to recruit were later increased through a poster on the unit which detailed the project and a Facebook post shared on a charity group for parents whose babies had been on the unit.

A semi-structured interview schedule was designed for this study; fathers were asked about their general NCU experience, experiences of support, their understanding of and response to being offered psychological support, and how well they thought the unit met their emotional or psychological needs. A flexible approach was adopted to allow participants to bring forth experiences important to them.

Interviews were conducted and transcribed via Microsoft Teams and lasted between 43 and 65 min. To preserve the confidentiality of our interviewees, all potentially identifying information from extracts has been removed.

Patient and public involvement

Three fathers from ethnic minority backgrounds with NCU experience supported the development of this study but did not participate in interviews. Each father met virtually with the first author and was given the opportunity to input into and shape the project including the participant information sheet, consent sheet, and the semi-structured interview schedule.

Participants

A total of seven fathers from ethnic minority backgrounds participated in the project. The majority of these fathers were between the ages of 30–40 years old, one father was between 20 and 30 years old, and two fathers were between 40 and 50 years old. Five fathers were from a South Asian background, one from an Australasian background, and one father was from the Caribbean. English was the first language for all fathers except for one, who was interviewed through an interpreter. The duration of time spent in the NICU varied from 0 to 1 month to 4–5 months, and two of the seven fathers had accessed psychological support on the unit while five fathers had not taken up the offer of psychological support.

Data analysis

Interviews were analysed using Reflexive Thematic Analysis with a combined inductive and deductive approach (Braun & Clarke, 2006, 2021). This allowed the exploration of a range of possible themes and is effective in highlighting key patterns within exploratory data. This methodology also amplifies the fathers’ voices, allowing their views to influence the service. A critical realist position was adopted: assuming that participants’ motivations, perspectives, and experiences reflect a truth about their world, while recognising that these are filtered through the researcher’s own assumptions and experiences.

The first author is a British-Pakistani Trainee Clinical Psychologist who is visibly Muslim due to her observation of hijab (Islamic code of modesty). Her ethnic minority status aided her in establishing rapport and trust, enabling participants to discuss sensitive cultural issues and experiences. However, participants may also have seen her as ‘one of them’, making them less likely to elaborate on their responses. Care was therefore taken to assume a curious approach and clarify participants’ responses as necessary. The researcher does not have children of her own, but her cultural background meant she analysed the data through a lens of familiarity with a hesitance to seek support for mental health across a variety of settings. As a female interviewer, she was conscious that fathers may see her as an ‘outsider’ to their experience but felt that fathers engaged well during the interview process.

Findings

Fathers reported a diverse range of experiences of support as well as barriers to accessing the psychology service on the unit. These are summarised in Table 1.

Table 1. Summary of themes and subthemes.

Theme	Subtheme
1. Psychology is a Threat	1.1. Needing to be Strong
	1.2. Incompatible with Masculinity
2. It’s Not Really Talked about in our Culture
3. A Space for Mum, Not Me

Theme 1: psychology is a threat

In this theme, we explore how fathers perceived psychologists as a threat, both in the acute NCU environment where they felt a need to be strong to protect their families in the face of significant adversity, as well as to live up to expectations of masculinity in wider society. Although this pressure to conform to expectations is experienced cross-culturally, we explore how it is distinctly nuanced and piqued for these fathers.

Needing to be strong

Fathers in our study described expectations of them to ‘play the supporting role’. To do this, they had to be and appear to be strong, as one father described needing to be ‘the vision of strength’.

This father elaborates on the need for him to be strong:

I had to cover myself with probably a stronger shield at the time. If I was broken down, then it would have been even more difficult for my wife to cope with the situation. So, I had to put that shield on. I had to be strong at the time and I did, I think.

We see here a father shielding and protecting himself in order to support his wife. There is a sense that if he were to ‘break down’ under the weight of their experience, he would be adding to the burden already felt by the couple. Other fathers shared this need to protect, and described feeling ‘guarded’ and ‘defensive’ in the NCU.

For many, the weight of this expectation was experienced as challenging, as this father describes:

I had to ensure that look, I was carrying her as well as the whole situation. Umm, so yeah it was you know. Difficult. I’ll just say it was very … probably the most difficult time of my life.

By reacting to the most difficult time in his life by ‘carrying’ his wife as well as ‘the whole situation’ we see not only the sense of responsibility felt by this father but also an active and sometimes practical response in the face of difficulty.

In order to support others, fathers felt unable to attend to their own emotional turmoil, and saw expressions of emotions as destabilising and counterproductive. They described strategies to disengage emotionally, such as ‘keep your emotions at bay’, ‘brushing off comforting phrases from family’, and ‘bottle it up and throw it away and lock it somewhere’.

Psychologists were seen as a threat to their efforts to maintain composure:

Well of course there’s a fear towards the psychologist. The man may feel that, generally they feel that, it’s a threat to them. And that they’re going to be exposed.

This fear of being ‘exposed’ and made vulnerable by a psychologist was shared by another fathers who stated that a psychologist may ‘prod you to a point where you kind of break down in a heap’, or ‘poke buttons that will make you feel more vulnerable than you already are’.

When viewed more positively, psychologists were described as ‘a sounding board’ or someone to ‘vent to’, but were not seen as being able to provide active coping strategies or support for fathers to ‘be strong’.

Incompatible with masculinity

Accessing psychological support was also seen as incompatible with understandings of masculinity and fatherhood. Here, an interviewee describes a father figure as someone who can cope without any external support:

He’s strong enough to deal with his own concerns, and he doesn’t need anybody to guide him in any direction. Who has any concerns, he should be able to manage and navigate the situation by himself. If other people are supporting you, then how are you a man?

This father identifies an inherent conflict between ‘being a man’ and accessing support or relying on others to help him cope. For some, seeking support was explicitly associated with stigma:

If you’re going to psychologist and if you’re a man, then that means you’re going there because you’re mad, because, you’re crazy. For women its easier, but if you’re a man, then there’s a perception of a stigma.

This father draws attention to gender-based narratives around help-seeking, which for men, are laden with labels such as ‘mad’ or ‘crazy’. Other consequences for men who seek support included ‘diminishing their sense of manhood’, becoming ‘ostracized’, and being perceived as ‘weak’. Cultural understandings of poor mental health involved attributing blame to the individual in distress, such as a result of their committing sin, or as ‘karma’, or having ‘a devil or jinn inside them’. This stigma contributed to a hesitancy to seek support, as one father stated: ‘people are worried and scared about coming forward’.

Fathers who did seek support, did so in private spaces away from the main ward. Often this was sought from other fathers; recognition of shared experiences seemed to be enough to overcome the potential tarnishing of their masculinity or fatherhood. Fathers who did seek support (from other fathers or from staff) chose not to disclose this to their partners or families.

Theme 2: it’s not really talked about in our culture

The choice to not access support, or to not share acts of help-seeking may be understood through the lens of cultural norms and expectations. This theme explores the impact of generational and familial beliefs, norms around sharing negative news, and culturally appropriate coping strategies.

A number of fathers talked about drawing support as well as their own coping styles from their families. In this extract, a father describes why the generation above him may not understand seeking support on the NCU:

In history in terms of our elder parents and the older generations like especially in Pakistan, it was quite common that you know, you’d have many children. […]and they would pass away. And like, you know, just, that’s what happens. It’s just a kind of ‘get over it’ kind of situation almost. […] They would just see it as normal life as opposed to an event, that this is something that requires something more than that, they might question what’s the need for it (psychology) basically.

The generational difference in how the loss of a child is experienced and processed makes help-seeking behaviours harder to justify. His description suggests that women in the generations above him would also be expected to ‘get over it’. This may add another level to his fear of emasculation whereby in comparison, his need for support as a man, is even less understood.

He goes on to compare accessing support on the NCU to the acceptability of seeking support for an event such as a car accident:

But as for the accident, it’s like okay, something negative has happened[…]Because that wouldn’t be seen as every day, they’d say, okay, something else happened. You know, they would tell family, oh, you know, she had an accident, whereas they wouldn’t like for miscarriages and things like that. They’re not really, they’re not really talked about in our culture, for sure.

This father carves clear distinctions between events that are ‘talked about’ and therefore sought support for, as compared to ‘non-events’, or that which is silenced, such as miscarriage. Other fathers spoke about the cultural framing of a baby’s birth as positive event, such as: ‘a baby being born, obviously in our culture is a very, very positive thing’. It may therefore feel harder to access support for an event which is perceived socially as positive albeit in challenging circumstances.

The impact of culture on sharing information was talked about by other fathers, one of whom described their NCU experience as ‘a private time’. Here a father explains why in his culture, the loss of, or hospitalisation of a baby is not shared:

So in our culture … you don’t, you don’t, share negative news.[…] And so I think there’s this test, and you keep yourself to yourself and don’t get too many people involved because you don’t know their intentions and everything else. […] so that that kind of links itself to the ‘just get on with it’, and kind of you know, do what you need to do behind closed doors, put on a face for the world kind of thing.

Here, we see the cultural expectation of this father to cope privately, and to pretend to cope in front of others. Other fathers spoke of coping strategies which were in line with cultural and religious practices, such as engaging in private prayer.

Theme 3: a space for mum, not me

The idea of fathers needing to cope in private was reinforced by perceptions of who the psychology service was for. In this final theme, we discuss this in terms of fathers viewing support as necessary for mothers, and their perception of psychology as female dominated.

Fathers in our study recognised the benefits of their partners accessing support. Here, a father describes his wife’s need for support given her experience of pregnancy and premature labour:

Because the mums, are the ones that goes through the labour and the pregnancy and the sickness and the, the, the nine months building up to up to having a baby and in our case 28 weeks and then having to go through baby being born and so I can understand where a mum’s mental side would suffer more than the dad’s.

His understanding of why his wife’s mental health may suffer is grounded in the corporeal experiences of pregnancy and childbirth, without which, support is not seen as necessary.

This idea was reinforced by fathers noticing that the psychologists were often interacting with mothers on the unit:

I guess if I did have reservations of doing it and then every time I saw them, they were talking to other women. Yeah, I guess it probably would kind of further enhance those reservations because you might just think that’s not a space for me. That’s for mum.

Whether they could access the service as men was also influenced by the fact that the psychology team on the NCU were all women: ‘a panel of like three women as well. Like it’s kind of very, very female’.

Practical barriers added to the perception that the psychology service is for mothers, including time pressures and the office hours of the team:

Your visits to the hospital are post working hours and the counselling team are only visible kind of in your core working hours. You probably gonna get a mismatch … And then you kind of got that discord of if you’re only there for a couple of hours, do you wanna spend an hour of it talking to someone or do you wanna spend it with your kid that you’ve kind of, you’ve been away from all that time?

Fathers are therefore left in a position of having to choose between spending time with and supporting their families and accessing support for themselves. The ‘mismatch’ described here is reflected throughout this analysis not only in the practical sense of who the service is for, but also at the intersection of cultural norms and gendered expectations.

Discussion

The aim of this project was to understand the barriers experienced by ethnic minority fathers when accessing psychology support on this Neonatal Care Unit. These barriers largely pertained to the perceived consequences of accessing support both in the immediate NCU setting, as well as wider social costs, cultural norms around having a baby on the unit, and perceptions of the service as being for mothers. In our evaluation, ethnic minority fathers were not only influenced by the social norms of their gender, but also their cultural beliefs: it is this intersectionality that marginalised their ability to access support.

The barriers to help-seeking in our data can be understood through a lens of sociocultural norms, where for ethnic minority fathers, salient cultural factors may compound gendered expectations around how masculinity should be enacted (Baia et al., 2016; Noergaard et al., 2016). These barriers are evidently multi-layered: at a microlevel through the need to be strong to protect their partners and newborns, enacted as a mesolevel through familial norms and expectations which may be multigenerational, and at a macro level where hegemonic masculinity and stigma dictates a need to be emotionally stoic and self-sufficient.

Although these findings speak to the experiences of fathers on one specific NCU, they add to growing literature on the differences in experience of support between mothers and fathers, with fathers primarily experiencing the NCU as outsiders (see Govindaswamy et al., 2020). The idea of needing to be the ‘strong partner’ is also in line with previous research (e.g. Hagen et al., 2016), but central to the stories in this project is the perception of psychologists as a threat.

It was notable that the fathers we spoke to perceived support to be primarily for the mothers and did not have an understanding of the role of a NCU psychologist. Some fathers’ understanding of a psychologist’s role was based on their exposure to psychological or wellbeing ideas in their places of employment, including the need for a confidential space, and as someone to talk to about anxiety. Despite this, they described the role of the psychologist as one that could have been fulfiled by any other member of staff, as one father highlighted, ‘you could be speaking through to anybody really’. This issue was compounded by the perceived lack of visibility of the psychology team, as fathers highlighted that they were unable to build rapport with the psychologists, and were therefore more likely to speak to other staff members.

Another finding central to this project is the impact of stigma as a result of cooccurring and interacting social identities. This is in line with a recent scoping review which highlights how aspects of public (social) stigma drive experiences of self-stigma in men across the lifespan (McKenzie et al., 2022). Moreover, the men in this study were able to articulate and locate their resistance to help-seeking in the pressure they felt to uphold hegemonic ideals of masculinity. Morrow et al. (2020) suggest that steps should be taken to enable groups of ethnic minority men to join together and consciously acknowledge the impact of stigma on help seeking, as well as benefit from the positive impact of exposure to each other to reduce self and social stigma.

Recommendations

As this was a service evaluation project, specific recommendations were provided. There is a need for clearer information sharing about the role of neonatal psychologists as tripartite: to support the baby’s development, containing and supporting the family system around the baby (with a focus on the father’s role in this), as well as providing support to the staff team who subsequently support the family system. Emphasis on support provision for fathers is also necessary; a strengths-based approach targeting building resilience and providing coping strategies for fathers may challenge perceptions of psychology as a threat.

It is crucial that staff hold stigma in mind in all interactions with fathers. Focusing on support for the family system and encouraging fathers to engage in non-specific conversations may distance the offer of support from associated stigma. When approaching fathers directly, doing so in private spaces or offering the option to email or telephone the service may soften fears of feeling and being seen as vulnerable on the unit. Units may also benefit from a ‘Father’s Room’ as a space for fathers to feel safe, build a shared identity, and seek support from each other.

More information on other relevant culture or faith-based perceptions and norms related to having a baby on a NCU is needed. Psychologists may play a key role in this through developing resources (which should be available in multiple languages), teaching, and consultation with staff around cultural barriers. Knowing families in relation to their contexts including shared values, group ideas and identities will facilitate an understanding of needs and barriers, and subsequently may enable fathers to access support. This process of enquiry is one that should be adopted by the entire NCU staff team and will contribute to more sensitive and holistic care.

Limitations

Given the tendency of the homogenisation of ethnic minority people’s experiences, it is important to recognise that this project speaks to the experiences of a small number of fathers, on a specific neonatal unit, without acknowledging nuanced differences in culture, faith, or language. Further information is needed on how non-English speaking parents experience the NCU environment as only one non-English speaking father participated in this study through an interpreter.

Conclusion

Ultimately, these findings add to previous literature which emphasise the need for NCUs to be inclusive of fathers in support provision, as well as a need to understand factors relevant to being from an ethnic minority background for insight into additional sources of burden, as well as coping. Health services must consider the intersectionality of culture and gender to be more aware of the barriers to access.

Availability of data and materials

The datasets analysed during the current study are available from the corresponding author on reasonable request.

Consent for publication

All participants consented to publication of anonymous data.

Ethics approval and consent to participate

This manuscript includes a statement explaining why ethical approval was not required, as well as a statement on participants’ consent to participate.

Acknowledgments

We would like to thank all the fathers who generously shared their stories with us for this project. We would also like to thank Dr Rebecca Knowles Bevis for her support with the early stages of this work.

Disclosure statement

No potential conflict of interest was reported by the author(s).