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Evaluation of an Evidence-based and Community-responsive Fatherhood Training Program: Providers’ Perspective

Background And Objectives: Studies on male involvement and pregnancy outcomes have often not incorporated the providers’ perspectives, which are potentially critical to understanding program context, evolution, perceived impact, and sustainability. We sought to evaluate the 24/7 Dad® program from the viewpoint of the program providers. Methods: We conducted purposive sampling of 24/7 Dad program facilitators and administrators who were involved in recruitment, training, and follow up of program participants within a federal Healthy Start program (REACHUP) in Tampa, Florida, USA. Using a snowballing approach, we recruited six key informants who had administered the program for at least four years. We elicited and evaluated factors impacting the performance of the father involvement program using content analysis. Results: Under program participation and perceived impact, most providers thought that the program had created a safe space previously unavailable for men in the community. The most useful recruitment strategy was building partnerships with other organizations. The key informants noted an important evolutionary trend in the father involvement program over time as well as the nature of linkages to partner organizations within the area. Threats to program sustainability included the continued reluctance and scepticism to invest funds to address male issues, sub-optimal retention of participants who were living transient lives as well as geographical/transportation barriers. Conclusion and Global Health Implications: The involvement of fathers during pregnancy has significant implications for healthy babies. Our study results provide a clarion call to augment capacity and infuse more resources to improve paternal involvement in order to attain the United Nations Sustainable Goal (2015-2030) of ensuring healthy lives and the promotion of well-being for all at all ages.


Background of the Study
Male/fatherhood involvement in a child's life enhances child well-being. 1 Evidence from the literature suggests that fatherhood involvement positively impacts the social, behavioral, emotional, psychological and cognitive outcomes of children. [2][3][4] Children with positive male influence in their lives are more likely to be well adjusted for life, 5,6 making them suitably equipped to forge better friendships, achieve academic success, experience fewer behavioral problems, have high self-esteem and enhanced life satisfaction outcomes. 1,2,5-7 These positive expectations have been shown to persist from infancy to adulthood even after controlling for maternal involvement. 4,5,8 Over the period of time from 1960 to 2016, children living in father-absent homes tripled from 8% to 23%. 9 In 2010, black children had disproportionately high rates of living in fatherabsent homes (48.5%) compared to 26.3% and 18.3% among Hispanic and white children, respectively. 10 Children from father-absent homes are at increased risk of negative outcomes in mental health, physical health, social behavior and development, economic mobility, poverty, greater risk of infant mortality, teenage pregnancy, incarceration, alcohol and drug abuse, child abuse and neglect, behavioral problems as well as low educational attainment. 4,[11][12][13][14][15] These effects have a more long lasting impact if father absence begins earlier in childhood.
Consequently, there has been an increased focus in Maternal and Child Health (MCH) research, practice and policy to strategize the most effective ways to sufficiently involve men in a child's life. 1 However, one of the biggest challenges to developing a program is the dynamic nature of what fatherhood and father involvement mean. The conceptualization of fatherhood as a construct has evolved over time but is also deeply embedded into cultural and local spaces which means it can vary from one community to another. 2,5,16 Evolution in the construction of fatherhood and masculinity has changed the way that men view and embrace fatherhood and family such that there has been a shift in the perception of what a father's role should be. 16,17 As a result of the shift, we now witness an emergent paternal identity where the father is more nurturing, being both emotionally present and expressive with their children. 16 Several theories have been put forward to conceptualize fatherhood but they all converge around engagement, accessibility and responsibility as the pillars of positive fatherhood involvement. 2,5,18,19 The National Fatherhood Initiative (NFI) was formed as a response to increasing reports of father absence in America. 3,20 The aim of NFI was to use evidence-based programs to address the underlying issues that impede fatherhood involvement. 3 The 24/7 Dad® program from NFI aims for fathers to be involved, responsible and committed around the clock. [20][21][22] The program is built around five components: (1) self-awareness, (2) fathering skills, (3) parenting skills, (4) relationship skills, and (5) selfcare. The program is delivered in two hours a week over a twelve-week period and has been found to be effective in improving fatherhood knowledge and skills. 21,22 In the Tampa Bay region, Florida, U.S.A., REACHUP Incorporated, a community-based organization whose aim is to provide equality in healthcare and positive health for families, offers the 24/7 Dad® curriculum in addition to other male engagement programs. REACHUP has been offering the evidence-based 24/7 Dad® curriculum since 2013. 20 It is estimated that the target area for REACHUP programs has a population of about 102,181 inhabitants, 23,24 which include 60% blacks, 18.3% whites, 12.1% Hispanic and 9.6% are other racial/ethnic groups. 25 Around 56.0% of all births was to black mothers who are typically young, unmarried, undereducated, and Medicaid-eligible. 25,26 Compared to the rest of the Hillsborough county, families in the project area tend to be poorer, with half the county median income and double the unemployment rate. 26

Objectives of the Study
This paper presents the results of the evaluation of the 24/7 Dad® involvement program offered by REACHUP in the Tampa Bay region from the provider's perspective. Stakeholder engagement as a component of program evaluation includes the www.mchandaids.org | © 2020 Global Health and Education Projects, Inc.
people served by the program and the providers or people running the operations. 27 Existing evaluations of 24/7 Dad® are limited to program participants only; the first evaluation was performed by Janet Olshansky in 2006 using the in-built pretest/post-test questionnaire, 21 and the second in 2015 by Lewin-Bizan, who in addition to the inbuilt questionnaire, did follow-up surveys with participants post-program. 21,22

Specific Aims and Hypothesis
The providers' perspectives are key to designing targeted programs that respond to the needs of a community. 28 Moreover, there has been a call for evaluation practice of evidence-based programs to include multiple perspectives, 29 especially the perspectives of those who implement the program to fully understand the relationship between the inputs and the outputs. 30 It has further been demonstrated, specifically for father involvement programs, that the providers' perspectives are vital to understanding program context, evolution, perceived impact, and sustainability. 1 To our knowledge, this will be the first study that evaluates the 24/7 Dad® program from the perspective of the program providers.

Study Variables
Sample REACHUP Inc. has been offering male engagement programs in the Tampa Bay area for more than four years. We conducted purposive sampling of 24/7 Dad program facilitators and administrators who were involved in recruitment, training, and follow up of the participants. After the first two key informants were recruited from REACHUP, we used snowballing techniques to connect us to other facilitators affiliated with REACHUP. We had six key informants, three male and three females. The sample represented the entire facilitator/ administrator population involved specifically with this program at REACHUP. Two of the informants were administrators, three were facilitators who provided the training and one informant was a community gatekeeper who transitioned into the role of a facilitator. All the informants had been working with the REACHUP male involvement program for more than four years.

Questionnaire Development
A semi-structured open-ended questionnaire was developed as an interview guide based on the structure used by the Early Head Start Fatherhood demonstration project to evaluate the contextual factors impacting the performance of those programs. 1 Questions were modelled to gather information around four main topics: (1) the context of the program (i.e. the recruitment strategies and program components), (2) the evolution of program practices over time, (3) perceived program impact, and (4) program continuity/sustainability from the providers' perspectives. Table 1 outlines the questionnaire and the resulting specific probing questions.

The Interviews
All the interviews were conducted in person by the researchers at REACHUP between September and November of 2017. After a brief scripted introduction and request for consent, the interview began following the order in which the questions were written. Each researcher, however, was free to use additional probes (i.e. repeating the question, silence) to obtain more information or reword the questions to make it suitable for each specific informant. The interviews lasted 30-60 minutes for each participant, and were recorded and transcribed verbatim. The transcriptions were reviewed with the audio for accuracy and clarity, and all errors corrected before being entered in the data matrix. Extensive notes were then typed, checked for clarity and reviewed by other researchers before being added to the data matrix.

Data Analysis
Content analysis was used to identify common themes occurring within the pre-identified topics for each interview transcript. Open coding was employed to create a coding dictionary complete with definitions of themes and key emergent concepts. Chunks of data and phrases were utilized at different points to ensure that the coding dictionary was comprehensive and fully saturated for all themes appearing in the data. The coding dictionary was then applied in another coding pass-through covering the full set of transcripts to identify the frequency of themes and outline the relationship among concepts. Significant statements and themes attached to the codes were used for the identification/characterization of perceived program impact/barriers by facilitators and administrators.

Ethical Approval
This project was reviewed and approved by the Institutional Review Board at the University of South Florida. Table 2 shows the results of the most-common occurring themes under each main topic addressed.

Sociodemographic Characterisitcs Results
Program modifications to make the program fatherfriendly and suitable for the community served were the main points under program evolution. Under program participation and perceived impact, most providers thought that the program had created a safe space previously unavailable for men in this community. The biggest challenge for program continuity was financial.

Context of the Program
Of all the key informants, the administrators found it easier to fully respond to this topic. A call for proposals on programs focusing on men was put out by the Children's Board of Hillsborough County, Florida. To be funded, it had to be evidence-based. The choice of a training program was crucial to its success based on the demographics of the communities that frequently receive services from REACHUP.
"we had to look for an evidence-based program, something that we could work with across age, across cultural lines, across socioeconomic lines. We found that the 24/7 Dad program at that time was a promising practice. They were working on moving it into evidence-based, which it is currently" (Key Informant 2) "So, we were looking for a model that would have some flexibility for us in our community and hence why it uhm, it appealed to me-the 24/7 Dad program" (Key Informant 1).
As described by both informants, the program had to be evidence-based to be funded. Additionally, for the facilitators at REACHUP, it also had to be community-responsive. This meant that the program had to be flexible and fully modifiable to suit the needs of the community.
Most of the program participants were involved in other REACHUP programs to try to get their lives together. Data from other facilitators confirmed that some of the participants had been incarcerated. Recruitment strategies included fliers, radio and word of mouth from program participants. The most useful recruitment strategy was building partnerships with other organizations working on male involvement issues as well as key persons who served as community gatekeepers. As one of our key informants noted, it was through partnerships that most participants were recruited.

Evolution of Program Practices
Over the four years that 24/7 Dad had been offered at REACHUP, it had gone through several modifications while maintaining the integrity of the curriculum as it was designed. This was possible because of the choice of the program and because the administrators worked together with NFI to make ensure the program still maintained its original integrity despite modifications. The modifications included: 1) change of mode of delivery-original program had been designed with a workbook for each participant. Due to literacy challenges among most of the participants, the facilitators created a visual using PowerPoint and delivered the training as lecture; and 2) change of duration of delivery -original program had been designed to be delivered over two hours every week for 12 weeks. The new version consisted of six-week program training, weekend retreats or one-on-one sessions. In this community, most participants were living in transition, job search, sharing childcare duties et cetera and would be unable to commit to a twelveweek program.

"I like the curriculum" but it is "not perfect"; "We lose fathers [participants] if the curriculum is too long… "We've been doing one-on-one's". Saying to the guys "give me 2-3 hours of your day…It's been working" (Key Informant 3).
In this excerpt, that facilitator noted that even though the curriculum was good, when they tried delivering it over the original time-frame, they lost many participants to follow-up. Using creativity, facilitators created (a) a weekend retreat; (b) intergenerational monthly mentorship groups; (c) one-on-one programs; and (d) 4-hr Saturday programs to condense the curriculum into shorter durations. This modified, intense but shorter duration curriculum was found to be more acceptable. REACHUP also partnered with other organizations to provide legal services and child care services support to participants while attending the training. Resulting themes that emerged from analysis of questionnaire answers for each topic.

Male Participation Patterns and Perceived Program Impact
The consensus among the providers was that there had been an increase in the number of participants over the years. However, providers noted different changes on the characteristics of the population. One provider observed that they were attracting more non-fathers (uncles, teenage men, grandfathers), another one proffered that the population was becoming increasingly diverse in terms of race and education, yet another provider stated that the program was seeing more men in blended families i.e. step-dads. Mentorship component of the program was considered the most beneficial. Mentorship relationships both from the facilitators and fellow participants provided a vital support system especially for the teenage men. Facilitators could count examples of program graduates who ended up becoming custodial parents of their minor children: "But when he started with in 24/7 Dad he got involved with the mentoring piece and intergenerational mentoring piece was doing really well with (his) girls. uhm he really demonstrated how important it was to affirm that they were dads that was getting it right and step up to the plate and take leadership and so he was one of the success stories that I think about" (Key Informant 1).
The providers felt that the program not only impacted the men's parenting skills but also helped reassess their relationships with the co-parents and take up responsibility to better their lives. One provider noted that the impact of the program was indescribable.
"You can't see it… it is not tangible… you have to look at their faces when they are receiving their certificates… some with fears are glad they came" (Key Informant 3). "Huge impact, dads do not typically feel that there is a program for them -they are part of the family too" (Key Informant 5).

Program Sustainability
Providers noted that program challenges included the continued reluctance and skepticism to invest funds into programs that address male issues, retention of participants who were living transient lives and restriction to certain zip-codes.
"Challenges include need for more staff/personnel. We used to have a dedicated person for calling and reminding participants to attend" (Key Informant 4). "one of the challenges… is that, there is no serious investment financially in programs like 24/7 so that's a problem. Not having the resources to promote and to implement programs like 24/7 Dad. That's huge barrier" (Key Informant 1).
This had impeded the goal of expansion, hiring more staff or incentivizing participation. There was a huge gap and need for partnership with other organizations that offered family health services that could be connected to REACHUP for the purposes of recruitment and referrals.

Emerging Themes
Facilitators' training was a key emerging theme in most of the interviews. Because case management was considered part of the male involvement program (i.e. post training follow up), it was important for the facilitators or the trainers not only to know the content of the program, but also to address any personal "Daddy Issues" that might affect their job performance.
"when you are doing, this work around fatherhood piece… you have got to get the staff involved with their Dad issue and male issue … so if we gonna expect for (staff)… to link our dads to our services, then they got to take care of their own stuff and Lord knows they have a lot of stuff…(and) often have not dealt with their absent daddy issues or who don't have real good experiences with men" (Key Informant 1).
As part of the program, REACHUP organizes yearly training for staff to be able to talk through their own issues to effectively deliver the contents program and reach the community that they serve.

Discussion
The focus of this study was to evaluate the 24/7 Dad program provided in the Tampa Bay area from the providers' (facilitators and administrators) perspectives. The evaluation focused on four key www.mchandaids.org | © 2020 Global Health and Education Projects, Inc.
areas: context, content, impact, challenges, and continuity. Results showed that evidence-based nature of the program was key to its continued funding, and its flexibility was key to its acceptance and success in the community. Partnerships with community organizations that provide other services for men and collaboration with community leads remained the key and most useful strategies for recruitment, retention and post-program followup. Providers reported that the program had positive impact on the parenting skills of the participants and also triggered a paradigm shift in the community regarding the importance of engaged fatherhood. The biggest challenge noted by providers was the limited and reluctant funding for male-based programs.
There continued to be a dire need for enhanced practice and interest in research to include fathers and males in MCH programs. Parental involvement is one area that has witnessed a burgeoning number of father involvement programs in recent times. Results from this study revealed that using an evidencebased program (EPB) was key to receiving continued financial support for operation. Methodologically, EBPs are important because they can be evaluated and compared across different contexts. However, similar to previous studies, EBPs that are not modifiable to suit the needs of the community become irrelevant in practice. 30 EBPs should be community-responsive and program operators have the responsibility of maintaining the balance between validated program content and community-specific modifications.
The use of social networks existing within the community to create a social support system for the intergenerational mentorship component of this program was useful in creating a safe space for the participants where they could come and be themselves. Leveraging of existing informal networks or creating additional ones to support the men long after the training ended was a source of considerable strength of the approach. 31 Mentorship group formed as an offshoot of this program proved useful in challenging the persisting perceptions of the role of the father as a provider and a protector rather than a caregiver. This is especially needed for the translation of knowledge gained into practice as men encourage each other to do more than being present because as research indicates presence does not always equate involvement even in dual parental households where fathers still spend less time actively raising children 32 .

Limitations
The results from this evaluation should be interpreted with caution keeping in mind a few limitations of the study. Even though our sample exhausted all possible providers in the program, it was only limited to six people. This means that the results may not be generalizable to the entire population. It is important to note that studies seeking key informants' perspective generally have smaller sample sizes. These limitations, however, do not diminish the importance of provider input.

Conclusion and Global Health Implications
REACHUP Inc. has had a successful male involvement program since 2009 by adhering to the concept of having a holistic EBP approach. This has involved taking an EBP blueprint and modifying it over time to respond to the specific needs of the community being served. The involvement of fathers during pregnancy bears significant implications for healthy babies globally. Our study is a clarion call to augment capacity and infuse more resources to improve paternal involvement in order to attain the United Nations Sustainable Goal (2015-2030) of ensuring healthy lives and the promotion of well-being for all at all ages.

Key Messages
• Committed and responsible fatherhood involvement during pregnancy and childhood has significant impact on growth and development of the child. • There is need for increased funding towards male-focused parenting training programs. • The funding should be directed towards maintaining the sustainability of the training programs.