Including Men in Prenatal Health: The Potential of e-Health to Improve Birth Outcomes

Abstract

Background: The U.S. infant mortality rate is the highest in the developed world, and disparity impacts underserved populations. Traditional maternal health focuses on women, excluding men from information affecting family health. Scholars advocate including men in prenatal health to reduce infant mortality, a proven strategy in developing nations. This study explored the role of U.S. men in prenatal health, barriers to involvement, and the use of e-health. Special attention was given to health literacy; research indicates e-health is effective in educating low health-literate audiences. Materials and Methods: This study interviewed men with an average age of 33 years (n=32). The sample was 38% Hispanic, 28% African American, 28% white, and 6% multiracial. Participants were asked about pregnancy health and used a pregnancy-related e-health application on a tablet computer. Participants provided opinions on content, ease of use of the tablet, and willingness to use similar applications. Results: Men believe it is important to be involved in pregnancy to help ensure healthy births. Most use mobile devices and computers for health information and found the application to be useful and interesting. Most concluded they would use a similar application to learn about pregnancy. Health literacy had minimal impact on participants' use of the tablet and information. Conclusions: This study explored the role men play in prenatal health, a promising avenue toward better birth outcomes. Using e-health is an opportune approach—it can reach men unavailable to attend prenatal programs because of work or feeling unwelcome at programs deemed “only for women.”

Introduction

Pregnancy outcomes in the United States rank among the worst of all developed nations, with the most recent vital statistics report estimating 6.15 infant deaths per 1,000 live births.^1,2 The leading causes of infant death in the United States are birth defects and preterm birth (<37 weeks).^2,3 Poor birth outcomes in the United States are more pronounced among minorities, particularly in non-Hispanic blacks, Native Americans, and certain populations of Hispanic Americans. These populations are disproportionately impacted by negative pregnancy outcomes such as low birth weight,^4,5 and they also tend to have risks associated with inadequate health literacy, such as low socioeconomic status.⁶ Improving pregnancy outcomes is one of the goals of the Healthy People 2020 initiative.³ Healthcare and support during the prenatal/perinatal phases can reduce the risks associated with factors that drive infant mortality, such as preterm birth.³ Examples of this include health education programs, nutritional assessments, immunizations, and mental health screenings, among others.^3,7

Research has demonstrated that health communication campaigns using mass media can be effective in promoting the use of healthcare services and can lead to healthier behaviors.^8
–10 The interpersonal communication that arises from these mass-mediated campaigns has been shown to play an important role in adopting healthier behaviors as well.^11,12 In the context of prenatal/perinatal health, campaigns have been beneficial in promoting healthcare visits,⁸ increasing birth preparedness and recognizing emergencies,^9,13 taking measures to prevent maternal–child human immunodeficiency virus transmission,¹⁴ and, perhaps most notably, reducing sudden infant death syndrome with the help of the “Back to Sleep” campaign.¹⁵

Although mass media campaigns have complemented public health initiatives and medical advancements, research indicates these interventions have been almost entirely targeted toward women,^16

–19 leaving men outside of a defined role in prenatal care and pregnancy outcomes. Despite research that including men in these initiatives can improve outcomes, pregnancy is dominated by women and is often a domain where men feel “invisible” or “unwelcome.”^20,21 Other barriers to being involved in prenatal health include having to work (no time) and expenses.^16,21 Given these barriers, the potential of e-health to reach men and motivate them to be more involved in prenatal health is promising. E-health has the ability to educate difficult-to-reach audiences, such as men, and to target and tailor information in ways that could resonate better than existing programs designed for women. Applications on hand-held/mobile devices present even more convenient access to health information.

The goal of this research was to explore the perceived role of men in prenatal health and the potential of e-health to reach men. Health literacy was given special attention as populations with negative birth outcomes are often at risk for low health literacy.^22,23

Health Literacy

Health literacy is defined as an individual's ability to obtain, process, act, and communicate about health information.^6,23,24 Individuals who are low in health literacy face a range of issues when trying to understand health information, and this can lead to poor health outcomes.^25,26 Research indicates between one-third and one-half of adults in the United States face challenges understanding patient brochures and following medication instructions.²⁷ Factors such as age, low socioeconomic status, and being part of a minority or immigrant population can impair health literacy.^23,22

Low health literacy places a considerable financial burden on the U.S. healthcare system. It is estimated the U.S. healthcare system incurs $106–$230 billion annually in problems associated with low health literacy, such as revisits to healthcare professionals and longer in-patient hospital stays.²⁸ Effectively communicating with low health-literate audiences is imperative for improving outcomes and reducing costs. When developing health communication interventions, it is crucial to understand the needs of individuals with low health literacy.

E-Health for Low Health-Literate Audiences

E-health can be a powerful tool for engaging lower health-literate audiences—convincing audiences to pay attention and expend the necessary effort to understand a health message and to attempt to integrate the message into their own health behaviors.^29,30 Advances in mobile and Web health promotion are allowing for these messages to be tailored to specific individuals, which research indicates is an effective way of influencing health behavior change.^31
–33

Substantial evidence exists that e-health interventions designed for low health-literate audiences can be effective in delivering health education and are well received by users.^30,34,35 Additionally, interventions designed to meet the needs of lower health-literate audiences are reviewed favorably by more general audiences,³⁶ suggesting best practices to reach low health-literate audiences—simplifying content, matching visuals to textual content, etc.—work for all audiences. The widespread adoption of mobile devices provides ample opportunities for delivering interventions to lower health-literate populations,³⁰ and the proliferation of tablets with larger screens provides additional opportunities to improve these interventions.

Research Questions

This study aimed to investigate the value of an e-health application to educate men about pregnancy-related health information regardless of the men's level of health literacy. Given this aim, the following research questions guided this investigation:

RQ1: How do men describe their perceived role in pregnancy health?

RQ2: What seems to facilitate or impede men's involvement in prenatal health promotion and education?

RQ3: To what extent do e-health applications appear to be a promising avenue for improving men's knowledge of pregnancy-related health information?

RQ4: Are the content and delivery method (mobile, tablet-based) related to levels of health literacy?

Exploring the answers to these questions would lay the foundation for campaigns that encourage men to be positively involved in prenatal health—which has been reported to help improve birth outcomes in communities with few resources. The use of e-health applications would allow the delivery of this information to underserved communities (e.g., rural, those without access to healthcare providers) and may help overcome issues related to low health literacy.

Materials and Methods

Participants

Adult male participants were recruited from two nonprofit organizations in a large Southwestern city. The organizations focus on adult education, General Education Development (GED) attainment, and job readiness training. Participants were given a $25 gift card to a local retailer as compensation. All appropriate Institutional Review Board approvals were obtained. The sample (n=32) had an average age of 33.2 (standard deviation [SD]=15.4) years and consisted of 38% Hispanic, 28% African American, 28% white, and 6% multiracial participants. The majority of participants (75%) reported having at least a high school diploma or GED. The majority of participants (88%) had at least one child or a partner who was pregnant at the time of participation.

All participants completed the Newest Vital Sign (NVS) questionnaire³⁷ at the end of the session to assess health literacy. The NVS is a brief, six-item assessment of health literacy that correlates well with other established health literacy measures. A score of 0–1 on the NVS reflects a 50% or greater chance of limited health literacy, a score of 2–3 suggests the possibility (25%) of limited health literacy, and a score of 4 or greater reflects adequate health literacy. The group's average NVS score was 3.4 (SD=1.7), which broke down to 13.3% of the participant sample having more than a 50% chance of limited health literacy, 30.0% having the possibility of limited health literacy, and 56.6% having adequate levels of health literacy.

Study Procedures and Data Analysis

Participants first had a one-on-one, semistructured interview with a graduate research assistant to discuss issues surrounding the role of men in pregnancy health, attitudes toward prenatal health education, opinions on how to get men more involved in pregnancy health, and their use/nonuse of technology when looking for health information. Interviews and surveys were conducted in English and audio recorded. The overall study procedure was modeled on previous research studying the use of technology by lower health-literate populations.^30,34

The participants then spent 5–7 min navigating through an e-health application, My Pregnancy Today, created by BabyCenter, LLC (San Francisco, CA) on a tablet computer, allowing them to browse at their own pace and explore the application content. This particular application was chosen because of its popularity and ratings—it received more than 100,000 positive votes across Android^® (Google, Mountain View, CA) and iPhone^® (Apple, Cupertino, CA) platforms at the time of the study. Although the application is targeted to women, it may also be downloaded by some expectant fathers. A tablet computer was chosen because of the product's growth in the marketplace as well as prior research already conducted using mobile devices with smaller screens.³⁰

After becoming acquainted with the application, participants were required to navigate through a 39-slide slideshow that detailed fetal development week-by-week. The slideshow used common fruits and vegetables as visuals to illustrate fetal growth. While the participants were browsing and navigating through the application, they were systematically observed to assess general attitudes, actions, navigational issues, and technical trouble. Attitudes while browsing the application could range from “highly engaged” (e.g., taking time to read updates, click and watch videos, and view photos) to “bored/distracted” (e.g., not clicking on videos/photos, skimming through content).

The participants were then asked open-ended questions related to the content of the application and use of the tablet computer, as well as completing a 12-item survey about prenatal health and future use of similar applications; survey items used 7-point Likert scales from 1 (strongly disagree) to 7 (strongly agree). Finally, health literacy was assessed with the NVS.³⁷

A mix of qualitative and quantitative methods was used to analyze the data. Correlations were used to assess the relationship between participants' health literacy and survey questions regarding healthy pregnancy, tablet usage, and application content. Interview audio files, notes, and observations were analyzed by the authors.

Results

Results are organized by the research questions and pertinent themes that emerged during the process of interviewing and observing participants. Results of the 7-point Likert scale items, taken after exposure to the application, are included in Table 1.

Table 1.

Results of the Likert Scale Items After Exposure to the Application

ITEM	POSTAPPLICATION MEAN (SD)	MEDIAN (IQR)
I believe knowing about pregnancy is useful.	6.6 (0.9)	7.0 (0)
It is important to know about things that could hurt your baby during pregnancy.	6.9 (0.4)	7.0 (0)
If I know about things that could hurt my unborn baby, I will try to help my partner avoid them.	6.9 (0.4)	7.0 (0)
I can take a lot of action to ensure my baby is healthy.	6.6 (0.9)	7.0 (0)
I am concerned that my baby will not be healthy.	3.4 (2.1)	3.0 (2.8)
Complications and unhealthiness can be life-threatening to a baby.	6.5 (1.3)	7.0 (0)
Complications and unhealthiness can be life-threatening to a woman.	6.2 (1.4)	7.0 (1.0)
It is hard to make sure my baby is healthy because I am not the one who is pregnant.	4.0 (2.1)	4.0 (3.8)
I found this tablet easy to use.	6.2 (1.3)	7.0 (1.0)
I thought this application easy to use.	6.0 (1.2)	6.0 (1.0)
This application contained useful information.	6.3 (0.8)	7.0 (1.0)
I would use an application like this on my phone or tablet to learn more about pregnancy.	5.8 (1.7)	7.0 (2.0)

IQR, interquartile range; SD, standard deviation.

RQ1: What is the Perceived Role of Men in Pregnancy Health?

Men felt strongly that knowing about pregnancy is useful (mean=6.6, SD=0.9) and that it is important to know about things that could hurt a baby during pregnancy (mean=6.9, SD=0.4). They also believed they could take action to ensure their baby was born healthy (mean=6.6, SD=0.9).

The interviews overwhelmingly suggested the role of a man in pregnancy health is “support.” Nearly every participant (30 of the 32) used the word “support” when asked about the role and responsibility of a man in pregnancy. When the responses were probed to go more in-depth into what “support” meant, they reflected both instrumental support (e.g., tangible offers to help, contributing financially, driving a woman to the doctor) and emotional support (e.g., including empathy, just “being there” for a woman during pregnancy).³⁸ One participant explained: “You have to comfort the mother as best you can. Helping her stay off her feet and being there at any time she needs…make sure I have a stable job and have all my financial priorities taken care of as being the head of household.” The majority of men with children reported having done these supportive behaviors for their wife/partner during their pregnancy.

RQ2: What is the Involvement (or Barriers to) of Men in Prenatal Health Promotion and Education?

Although men reported barriers to being involved in prenatal education itself, the participants strongly felt they could take action to ensure their baby was born healthy (mean=6.6, SD=0.9). Participants were asked whether they had ever been to a prenatal education class at any venue such as a clinic, doctor's office, or church, or if they would consider going if their partner became pregnant. All participants, regardless of if they had children or not, reported they did not attend a prenatal class. Reasons for not attending or not wanting to attend were wide-ranging—from not having the time, to expenses, to having to work, to already knowing how to traverse through pregnancy. One participant's reason for not attending a prenatal class was: “I guess we Hispanic folks grew up taking care of everybody. There's a lot of people. Big families, it's in our genes.” Already having knowledge of pregnancy and children from siblings frequently came up.

When asked whether it was difficult for a man to be involved in pregnancy itself, responses were diverse—some men find it easy to be involved in pregnancies, whereas other men have difficulties. When asked to clarify why this was, men responded factors such as age and relationship status between the man and woman were influential.

RQ3: Are E-Health Applications a Promising Way to Help Improve Men's Knowledge of Pregnancy-Related Health Information?

When asked about the use of a computer, cell phone, tablet, or other electronic device to look up health information, participants generally stated they used these devices to access health information when they or a family member was ill. Google and WebMD were commonly mentioned as sites used, and cell phones and home computers were the most common device used to access these sites.

While participants were browsing the application and navigating through the “Your Baby is as Big As” slideshow, most participants (21 of the 32) were observed as being “engaged” by the application. The most commonly observed action was clicking on videos, but not watching them entirely. No participant used the “Kick Timer” function, which times the baby's kicks. A few participants, mostly older in age, had difficulty navigating through the application, and the graduate research assistant helped when needed. Some accidentally closed the application, whereas others found the navigational arrows on the slideshow too small to use.

Men generally stated that the application was easy to use (mean=6.0, SD=1.2), that it contained useful information (mean=6.3, SD=0.8), and that they understood all of the information presented. They also explained they thought the information was accurate and trusted the accuracy because it was on an application specifically for pregnancy. A few men commented the information in the application was the same information given by a doctor to their partners when they were pregnant. In general, participants felt there was “just the right amount of information” presented, and they did not need to click on the videos for more information. A participant explained he was “afraid to click on the video because it might be really graphic.” This sentiment was echoed by other participants, with one stating, “Most guys shy away from [graphic videos of pregnancy].”

The required slideshow detailing the fetal development using photos of commonly known fruits and vegetables was considered by almost every participant to be the most interesting/useful part of the application. Men thought it was quick, straightforward, and to the point. One participant said, “It helped me understand to be careful around a child when they are that little, you know, eight weeks, they are just so small. My baby is a bean at one week and she's an orange at eight weeks.” Another stated, “This is the kind of short information a guy can tune in to, not going too in-depth…it was simple.” A common feeling toward the slideshow was that the use of fruits and vegetables was an easy-to-understand comparison to show fetal development—while at the same time reinforcing the importance of a healthy diet while pregnant.

RQ4: Are the Content and Delivery Method (Mobile, Computer-Based) Affected by Levels of Health Literacy?

A series of correlations to test the potential relationship between the participants' level of health literacy and their evaluation of the application, content, and tablet itself found no evidence that health literacy was related to the participants' reactions to the application, content, or ease of use of the tablet.

Discussion

This study explored the perceived role of men in prenatal health and the possibility of e-health to reach men with prenatal information. Health literacy was taken into account as populations with risk of low health literacy are often at risk for poor birth outcomes.^39,40 A mobile application was used for its convenience and portability, as men indicate time and work schedule are often barriers to attending prenatal classes.^20,21 Overall, the response to the application was positive. The men were engaged, liked the content, felt the slideshow depicting fetal growth was informative, and thought the application and tablet were easy to use. They reported they would use a similar application on their phone or computer to learn more about pregnancy. Health literacy levels did not affect reactions to the application content or tablet.

E-health is a promising approach to communicating effectively with lower health-literate audiences.^34,36 Previous research has demonstrated the utility of e-health applications on small mobile devices for low health-literate audiences,³⁰ and this research extends that work to the larger tablet screen. This is an important advance, as the proliferation of tablet computers—with their increased screen size—presents new opportunities for e-health interventions. Study findings show no relationship between health literacy and usage of the application and tablet computer; this is a promising finding, as the application reflected many best practices for communicating with low health-literate audiences.⁴¹ Well-designed e-health applications can work for users of all health literacy levels.

Future research can build on the findings of this exploratory study by investigating actual usage of such e-health applications and impact on relevant outcomes such as men's involvement in prenatal healthcare visits, quantity and quality of communication with a pregnant partner around relevant prenatal health issues, and ultimately birth outcomes. The application used in this study was not exclusively designed for men, so the development of an e-health intervention targeted specifically to men could further increase their interest in the application and likelihood of active usage. Additional features not considered or studied in this study—such as user-generated content or online discussion groups for expectant fathers—could also be developed and assessed in future projects.

Limitations to this study include a convenience sample taken from local nonprofits that focus on adult education, which may diminish generalizability to other populations. Men expressed their willingness to use a similar application in the future, but this study did not track participants' actual behavior over time. The application and study were done in English, and although 38% of the sample identified as Hispanic, the effectiveness of this application for Spanish speakers cannot be established. Finally, participants' engagement with the application was the assessment of a single investigative team member; although this model has been used in previous research,³⁰ a more rigorous approach might involve several people observing the same application users to assess and agree on engagement.

Despite these limitations, this study presents a unique approach to including men in prenatal health education. It expands on a call from public health officials and scholars to broaden maternal/child health research beyond traditional interventions solely for women, as enhancing paternal involvement in pregnancy has shown to be beneficial in improving birth outcomes.¹⁹ Achieving these important public health goals will require researchers and practitioners to understand the role of men in pregnancy and to find innovative ways to communication with this often difficult-to-reach audience. This particular study demonstrates the potential of e-health on mobile devices to reach men with vital prenatal health information, paving the way for expanded research on men and pregnancy, but also in other health contexts.

Footnotes

Acknowledgments

The authors received financial support for this research from The University of Texas at Austin Moody College of Communication.

Disclosure Statement

No competing financial interests exist.

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