We conducted three focus groups amongst men (n=15), and 12 telephone interviews and one mini focus group (n=3) amongst women (n=15). The focus groups lasted between 45 and 91 minutes (averaging 72 minutes), and the telephone interviews between 22 and 43 minutes (averaging 32 minutes).
Participant characteristics
Participant characteristics are summarised in Table 1. Men in the sample were aged 27-44 years (mean 35 years) and of varying ethnicities (5 were Black, 5 were White, 4 were Asian and one was mixed ethnicity). None of the men had post-school qualifications and 5 respondents had no educational qualifications. All of the men were first time fathers/fathers-to-be. Nine of the men lived in London or the South East and 6 lived in the Midlands or North England.
Women in the sample were aged 18-39 years (mean 31 years), and ethnicity-wise, 9 were White, 3 Asian and 3 Black. Seven women had no post school qualifications and one declined to answer. Five women were multiparous. The women in the sample were geographically spread across the UK (excluding Northern Ireland).
Table 1: Participant characteristics
|
Men
|
Women
|
Total (%)
|
Age (years)
|
|
|
|
<20
|
0
|
1
|
1 (3)
|
20-29
|
2
|
5
|
7 (23)
|
30-39
|
10
|
9
|
19 (63)
|
40+
|
3
|
0
|
3 (10)
|
Ethnicity
|
|
|
|
White
|
5
|
9
|
14 (47)
|
Black
|
5
|
3
|
8 (27)
|
Asian
|
4
|
3
|
7 (23)
|
Mixed
|
1
|
0
|
1 (3)
|
Education (highest qualifications)
|
|
|
|
None
|
3
|
1
|
4 (13)
|
GCSE
|
7
|
5
|
12 (40)
|
A level
|
5
|
1
|
6 (20)
|
Graduate
|
0
|
5
|
5 (17)
|
Post-graduate
|
0
|
2
|
2 (7)
|
Not stated
|
0
|
1
|
1 (3)
|
Pregnancy/baby status
|
|
|
|
First pregnancy/baby
|
15
|
10
|
25 (83)
|
Second+ pregnancy/baby
|
0
|
5
|
5 (17)
|
Last trimester
|
0
|
2
|
2 (7)
|
Baby< 6 months
|
7
|
6
|
13 (43)
|
Baby 6-12 months
|
3
|
7
|
10 (33)
|
Baby 13-18 months
|
5
|
0
|
5 (17)
|
Themes
Four themes relating to partners’ role in energy balance behaviours in pregnancy were identified; partner involvement and support; partner understanding of good energy balance behaviours; concordance of energy balance behaviours in couples; partner influence on her energy balance behaviours. These themes provide a context for understanding barriers and facilitators to participating as a couple in a healthy eating and physical activity intervention during pregnancy.
Partner involvement and support
Experiences and attitudes of both men and women in our sample suggested a continuum of partner involvement and support in pregnancy, with three broad typologies of expectant fathers emerging:
Our baby, her pregnancy: The least involved expectant fathers were characterised by their view of the pregnancy being their partner’s. They perceived pregnancy to be a ‘woman’s thing’ and often talked about the active involvement of other female relatives in their partner’s pregnancy. As they saw it, their role as fathers began only when their baby was born. For some respondents these gender-stereotypical roles were rooted in family or cultural beliefs.
When we visited my in-laws, there was lots of questions …. mostly aimed at my wife….I did feel that I was on the outskirts, I wasn't shocked, as such…. I'd be sitting there watching football with the beers. (Male,#2)
Whilst they were happy to support their partner in any way she wanted, they tended to adopt a reactive approach, taking the lead from her. Similarly whilst they were receptive to information, advice and guidance from their partner, other family members and healthcare practitioners (HCPs), they rarely sought it themselves.
I think it's widely known in the medical world and even outside of the medical world, that the expectation for self-educating yourself in pregnancy is the woman's role. (Male, #10)
Women whose partners conformed to this typology tended to criticise the men for not understanding pregnancy and not being more proactive in supporting them.
They don’t understand anything, the sleeping problems the sitting problems. Because my husband doesn’t understand- I do see it more of my pregnancy but our baby if that makes sense. (Female, #15)
Our pregnancy, her body: Sitting midway along a dimension of involvement, another group of respondents expressed a view that whilst they felt pregnancy was a shared event, the physicality of the experience belonged to the woman. Expectant fathers in this group recognised their important role in providing practical and emotional support to their partner, but ultimately felt the pregnancy was their partner’s. For some this created a dissatisfying sense of being a side-player or worse, excluded.
I see it my role… is like a supportive role, like an auxiliary role, where you can't obviously take the main role, so you basically work like a mix between a waiter … and being someone who's there for her. (Male, #6)
Sometimes men can feel a bit left out of the whole pregnancy because the woman goes through all the changes and has these massive mood swings…I felt like a bit of a spare part to be honest. (Male, #13)
For this group and for the previous group, men’s experience of pregnancy support services and HCPs could reinforce their views on their role in pregnancy.
I felt that it (NCT) was that was very much geared towards the woman and in fact, I made the point that is there any point of me being here? (Male, #10)
Our pregnancy: The most involved expectant fathers in our sample were characterised by their belief that their role as fathers had already begun during pregnancy.
When we’re talking about the baby he’s always talking about our son, he’s very much going to be part of the child’s life, he wants to be part of it now. He talks to the bump. (Female, #5)
As such they were fully involved in all aspects of the pregnancy and made sure that HCPs understood and respected this. In addition to providing practical and emotional support to their partners, these expectant fathers took steps to inform and educate themselves about pregnancy. Some had downloaded pregnancy apps or joined social media groups for expectant dads.
It was definitely a team effort. Guys in the 21st century are a lot more on it. You look at the apps and you help where you can. (Male, #7)
I made myself be involved – I wanted to know everything that was going on. So I wasn’t going to wait - I was in first, asking them (HCPs) everything (Male, #14)
Most women in our sample whose partners conformed to this typology supported their partners’ view of seeing pregnancy as a shared adventure. They welcomed the level of support they received and were often aware of their partner’s need for support too.
It was our pregnancy - it was our baby. We were pregnant – not just me. (Female, #7)
He’s very hands on. He’s come to all my (antenatal) appointments ... As we’ve had more children he has looked after them so I can go and do something …it’s divide and conquer…very involved in every aspect. (Female, #12)
However, one respondent voiced a concern about her partner’s involvement bordering on controlling or ‘policing’ behaviour.
It's a little bit like he was policing me, but then again it goes back to this is our pregnancy, not mine - it was because he cared for me and baby. (Female, #7)
Partner understanding of good energy balance behaviours
Levels of understanding regarding the importance of good energy balance behaviour in pregnancy varied in both men and women. Apart from the most involved expectant fathers, most relied on their pregnant partner as their main source of information on this matter. Most men were aware of the relationship between maternal diet and baby’s health and development and talked about ‘healthy eating’. However few understood the risks to maternal and foetal health of poor energy balance behaviours. Awareness of conditions like gestational diabetes was largely limited to those who had experience of it. Likewise, partners’ knowledge of what is a healthy diet in pregnancy varied considerably. More health conscious men and those who were more involved in the pregnancy talked about the value of specific food groups (typically fruit and vegetables) and nutrients. Others were more vague, often referring to a ‘normal’ or balanced diet or simply highlighting dietary changes she had made.
I think we just kept it as normal cos we was (sic) already eating quite nutritious diet…as long as they're having these Pregnacare tablets, then that covers most of it. (Male, #6)
She had a craving for double cheeseburgers from Mac Donald’s, but she was making sure she was taking Pregnacare and Folic acid. (Male, #9)
Understanding of the importance of exercise for maternal and foetal health was limited. Typically only those who already were quite committed to exercise knew of its benefits in pregnancy. Others were unsure what type or amount of exercise was safe in pregnancy, tending to believe it was safer to avoid exercise apart from walking.
It's taken us, it took us a long time to get to this point and we didn't want to throw it away for the sake of doing you know, one gym session a week, or running or, or even fast walking. (Male, #10)
I see some pregnant women doing push ups and running and I stand there in amazement thinking is it really worth taking that risk? (Male, #7)
Concordance of energy balance behaviours in couples
The majority of respondents reported a high degree of concordance of dietary behaviours with their partner, and since many women had made changes to their diet during pregnancy, many expectant fathers had, by default, done so too. Generally these had been healthier changes, such as increasing fruit and vegetable intake or decreasing snack foods and takeaways. However respondents also reported worsening dietary behaviours.
So whatever made her sick is basically what we what we stopped eating. (Male, #1)
I think my wife’s diet sort of lapsed or relaxed….I think that why a lot of guys like me put on weight during pregnancy because my wife’s lifestyle choices meant she didn’t have the energy to cook and therefore it was easy for me to pick up the phone and ring for a pizza or whatever. (Male, #10)
He put on a bit of sympathy weight during pregnancies…. I was getting hungry and I think he just started to eat more as well….bigger portions at mealtimes. (Female, #10)
For the majority, concordance in dietary behaviours was driven by convenience of preparing one meal rather than a view that expectant fathers should also make dietary changes. Indeed men generally did not feel the need to sacrifice their own preferences.
She tried to eat a lot more healthy, like vegetables which she wouldn’t normally do. I tried but I must admit I don’t like salads and that. (Male, #11)
However, for a small minority of more involved expectant fathers, concordance was motivated by a desire to show support and solidarity.
I mean, it's definitely difficult when you will want to get the take-away or something but she can't really eat it. Sometimes you'd have to sacrifice your pleasure. (Male, #4)
Well he actually started to take smoothies as well, and the disgusting vitamins because like, he didn’t want me to feel singled out. (Female, #2)
Unlike in dietary behaviours, respondents rarely reported couple-concordance of physical activity behaviours, either in the type or amount of exercise taken or general activity levels. The only exceptions to this was firstly the tendency for men to share more household duties and secondly couples taking walks together, particularly towards the end of the pregnancy.
….allowing her to not do the things she might have done before, that are a bit strenuous. So kind of taking work away from them. (Male, #6)
Hold her hand and walk with her to the park …because the doctors and the nurses say she has to walk a bit – 100 to 200 meters a day - because she was suffering from diabetes. (Male, #12)
Partner influence on her energy balance behaviours
Only a small number of more health conscious men in our sample actively encouraged their pregnant partners to adopt better energy balance behaviours.
When I was pregnant, he was then cooking more because I was either having a nap or I was tired or whatever. So he would be consciously trying to put veg and stuff like that into my diet. (Female, #3)
Diet-wise, the majority of men felt their role was to concur with her choices. This was particularly apparent in men’s tendency to enable their partner’s cravings.
That’s the best way to placate them – if they say KFC you just go get KFC. If they say Burger King, you just go get it – no opposition no question just get it. (Male, #14)
Indeed some men reported that even when they felt their partner was eating the wrong food or gaining too much weight, they would keep quiet to keep peace.
I’ll tell you what anyone who says they are not going to say let it slide for the day…I’d rather fight the battles I can win. If they are already feeling body conscious, they already know a packet of custard creams isn’t going to do them any good, there’s not point me telling them that and making them feel worse. (Male, #13)
There was evidence of some men unintentionally encouraging unhealthy dietary behaviours, which appeared to be rooted in cultural beliefs.
Everyone kept telling me to eat for two – maybe it’s in our culture - Bangladeshi culture. (Female, #15)
My mother-in-law, even my husband, all my family were saying you’ve got to eat for two. (Female, #13)
Similarly some men were encouraging their partners to avoid exercise or any overly strenuous activity, partly because they felt allowing her to relax and rest was evidence of their support and partly because their belief that it was unsafe in pregnancy.
I don't know what other exercises are acceptable in pregnancy, I have no idea, so we stuck with walking. (Male, #1)
Barriers and facilitators to participating as a couple in an intervention mapped to COM-B and TDF.
Table 2 summarises the identified barriers and facilitators to participating as a couple
in a digital intervention to encourage healthy eating and physical activity in pregnancy. Barriers and facilitators were largely different for men and women, although some were common to both. The most highly populated COM-B domain was Reflective Motivation, with TDF Belief about the Consequences being particularly pertinent to women and Identity, Goals and Intentions to men.
Table 2: COM-B and TDF mapping of barriers and facilitators to participating as a couple in a digital healthy eating and physical activity intervention.
COM-B
|
TDF Domain
|
Barriers
|
Facilitators
|
Capability Psychological
|
Knowledge
|
|
Understand the importance of good energy balance behaviours to mother’s and baby’s health (Partner)
Understand the importance of partner support in her achieving healthy energy balance behaviours (Partner)
|
Capability Physical
|
|
|
|
Opportunity Social
|
Social influences
Social norms
|
‘Her pregnancy’ and cultural/family gender stereotyping (Both)
|
HCP recommended (Both)
‘Our pregnancy’ – partners today are involved (Both)
|
Opportunity Physical
|
Context and resources
|
Cost and time of participating together (Both)
|
Existing concordance in energy balance behaviours (Both)
|
Motivation Reflective
|
Identity/goals
Beliefs about consequences
Intentions
|
‘Her pregnancy’ -fatherhood begins at baby’s birth (Partner)
Potential conflict/controlling behaviours (Pregnant woman)
|
‘Our pregnancy’ (Both)
Being a fit and healthy father (Partner)
Being a supportive partner (Partner)
Being a good role model to child (Both)
Increase commitment and hence improve success rates (Pregnant woman)
Give partner (more of ) a role in pregnancy (Both)
Positively impact relationship (bonding) (Both)
Improve partner knowledge and hence support (Pregnant woman)
Commitment to be a supportive partner during pregnancy (Partner)
|
Motivation Automatic
|
Emotions
|
|
Feeling supported (Pregnant woman)
Feeling included (Partner)
|
Reflective Motivation
Identity, goals and intention
A key motivation for men to participate in the intervention was their desire both to be a supportive partner and to have a role within the pregnancy. Whilst some regarded participating in the intervention to be evidence of their existing commitment to their partner and their pregnancy, others saw it as a way of increasing their involvement and support. Women too recognised their partner’s intention to be supportive as a facilitator to his participation in the intervention.
To have something that is partner oriented for the two of you, that would really help. A lot of guys want to be involved now, it would appeal to so many people. (Male, #9)
He would definitely cut down on KFCs if he thought it was better for me and the baby … anything to make it work and support me with this.(Female, 4)
The opposite of this was the belief, alluded to rather than explicitly identified as a barrier to participation, that a man’s role as a father does not begin until the baby is born.
At my early stages I didn’t get much attention but now he can see the bump I get more attention. (Female, #14)
At risk of sounding uncaring, I didn't really have to change much to be honest….I think she more or less had it under control. I didn't really have to do anything. (Male, #1)
A desire to be a fit and healthy parent and a good role model for their child was a facilitator, for men especially. Even those who subscribed to the ‘her pregnancy’ point of view could be motivated by the potential benefits to themselves of jointly engaging in a healthy eating and physical activity intervention.
I don’t want to be a fat unhealthy dad…I want to be healthy into my old age. (Male, #3)
I’m not gonna lie – come that sports day when they go to primary school, I don’t want to be the last dad! (Male, #10)
You don’t want to be a lazy dad sitting on the sofa (Male, #11)
Beliefs and consequences
Particularly motivating to women was a belief that working together as a team would increase the likelihood of success of adhering to the chosen health behaviour.
I think it's a good idea because mutual support is the best way to make changes. It's almost impossible to make a change to your diet if one of you is doing it and one of you isn't. (Female, #5)
Some women recognised their need to be accountable to someone else in order to stick to commitments.
As soon as I have told somebody it’s like I’ve committed to it, but if I've only kept that to myself. Then I can say to myself well I didn’t really want to do it or I'll find an excuse not to. (Female, #6)
Women also recognised the benefit to their partners of participating jointly in that this would create a tangible role for partners and help them to feel involved.
Because partners I think, like, males are the other partner that isn’t pregnant, like some of them don’t feel like very included but if they had the app as well, they would probably feel more involved as well. (Female, #2)
More broadly, both men and women also identified the potentially beneficial consequences on the partner relationship of working towards goals together. The opportunity to bond through a shared goal was particularly appealing both to those who found pregnancy a bonding experience and those who had struggled more with the changes it had brought to their relationship.
I think it’s a good idea – you can both get involved and it would bring you both together (Male, #9)
And I think people would respond well to having something to do together because there is that feeling that they are bonded together at a time when other things are changing and it can be quite scary. (Female, #6)
Women whose partners were at the least involved end of the spectrum were motivated by the thought that a couple’s intervention could improve their partner’s understanding about pregnancy and thereby lead to him supporting her better.
I think the app will help for the husbands because they will understand more and this way we’d get more support from them, because they’d understand more. (Female, #13)
If someone was to tell him maybe don’t have too much sugar during your pregnancy he might be like you’re not actually meant to have this, give it to me. Because they don’t know all they hear from their mothers is eat for two, eat for two and they probably think they are doing the right thing by feeding me. (Female, #15)
Some men also recognised the opportunity the intervention might offer for self-education around pregnancy and improvement of their skill set.
All the advice that we can get is better because, you know, we can't be expected to know everything. (Male, #6)
The only barrier identified in the context of beliefs about consequences was an anticipation that participation might lead to conflict between couples, particularly if the intervention focussed on weight gain issues.
You would have to have good faith on your partner that they're able to motivate you without it being of a matter of them nagging you - you're putting on weight, dear and you need to be healthier….It would start off nicely and he’d be encouraging and eventually he would grate on me and I’d be saying I'm not doing it. (Female, #11)
One woman was concerned that the intervention might give her partner permission to be overly controlling over her dietary and exercise behaviours.
Automatic Motivation
Emotions
Here, women identified the warm feelings of togetherness and being supported as a facilitator whilst men talked about being included.
I need your support and I want you to do it as well, so I don’t feel like I’m on my own. (Female, #8)
I'd say you'd feel a lot more involved…. my own experience, I felt like I didn't really have any role. (Male, #1)
You need to feel that you and your partner are close together and you are not alone in anything. (Female, #6)
Physical Opportunity
Context and resources
Couples’ concordance of dietary behaviours (and in taking walks) was perceived to be a facilitator in a practical sense of fitting in with existing behaviour and lifestyle patterns.
We cook together we eat together so we're eating the same, the same meals. (Female, #5)
However, the time involved in coordinating activities and the cost of both eating healthier and potentially more expensive foods were occasionally cited as barriers.
I think that the barriers will be maybe time and trying to get organised, (Female, #1)
(He) would have his own rice… white rice and I’d have a wholemeal rice…. When you’re looking after the pennies cos you’ve got a baby on the way it (wholemeal) can be quite an expensive option. (Female, #8)
Social Opportunity
Social norms
Perceiving pregnancy as ‘ours’ - shared experience, albeit one only experienced physically by her - emerged as a facilitator to participating as a couple. Conversely, perceiving pregnancy as ‘hers’, a view that appeared to be propagated by family and cultural gender stereotyping, might be a potential barrier, although this was alluded to rather than openly voiced in our research.
Social influences
HCP endorsement was identified as an important facilitator to participating as a couple. Men in particular claimed that they would be even more likely to participate in the intervention if it was suggested to them by the midwife or GP. Not only would this validate the credibility of the intervention, but also it would confirm the importance of the partner’s role in pregnancy. Similarly women could feel that HCP recommendation would legitimise their desire for greater involvement and support from their partner.
It would be like a stamp of approval from the NHS. When it’s being recommended by a health professional it carries a lot of weight. (Male, #8)
If it was for the father, coming from the midwife makes us be part of the process I would value that because I am being included. (Male, #3)
Psychological capability
Knowledge
Having good understanding of the importance of good energy balance behaviours to maternal and foetal health appeared to be a facilitator for men in that it enabled them to appreciate value of working with their pregnant partner to reduce the risk of adverse health outcomes. Understanding of the potential impact of partner support during pregnancy worked similarly as a facilitator.
It should talk about how it helps your baby and how it helps your relationship rather than just it’s good for you. You hear that message – it’s good for you – all the time. (Male, #13)