We’re Doing our Best
Final Report: Summary ‘We’re Doing our Best’: African-Caribbean Fathers’ Views and Experiences of Fatherhood, Health, and Preventive Primary Care Services.
March 2009. Authors: Dr Robert Williams. Dr Alistair Hewison.
University of Birmingham. School of Health and Population Sciences. 52 Pritchatts Rd, Edgbaston, Birmingham. B15 2TT.
Acknowledgements.This study was commissioned by Heart of Birmingham (Teaching) Primary Care Trust.
We are extremely grateful to the men who took part in the study, and to Dorel Carty and David Oliver who helped with the planning of the study and made suggestions for reporting the findings.
Thanks are also due to those people who helped us make the contacts to recruit fathers to the study. Those who gave assistance were: Amanda Smith, Caroline Oliver, Tony Roots, Bishop Richards, Angela Knight-Jackson, Kathy Senessie, Christine Wint, Herman Wheeler, Rehana Ahmed and Pastor Bryan Scott.
This is a shortened report which explains why and how the study was undertaken. It summarises the findings, implications, and recommendations of the project. The full report is available from Robert Williams (contact details below).
Fathers can make a positive contribution to family health, yet how this happens for African Caribbean fathers, has not been studied to any great extent in the UK. It is important that such research be done so that we know what the health needs of this group of men and their families are. This report describes a qualitative research project which was carried out to learn more about African-Caribbean men’s views about, and experiences of being a father. It was commissioned by Heart of Birmingham Teaching Primary Care Trust (HOBtPCT) and was conducted between April 2008 and February 2009. Aim and Research Questions
The aim of the study was to investigate African-Caribbean fathers’ health experiences and their views about preventive primary care services delivered by the Heart of Birmingham Teaching Primary Care Trust, in order to identify implications for practice, policy, and future research.
To meet this aim the following research questions were addressed:
• What are African-Caribbean fathers’ views about the roles of fathers within families?
• What do African-Caribbean fathers’ believe about health?
• Does being a father influence health beliefs and practices?
• Do fathers use preventive health services in the HOBTPCT area?
• What do fathers’ think about the acceptability and accessibility of preventive primary care services offered by HOBTPCT?
Nine in-depth, semi-structured group interviews were undertaken. Forty six African- Caribbean fathers, and 2 respondents who were not fathers, took part in the interviews. The interview schedule was developed based on the findings from previous research and the help of the advisory panel, which was convened to guide the study. Qualitative group interviews were used as this was the best way to get those involved to talk about the issues of being a father and family health. They encourage discussion and analysis of shared concerns and meanings in social groups and help build understanding of the issues from the group’s point of view. They are also a good way to involve local people in research.
The interviews were digitally recorded and transcribed word for word. The written records of the interviews were then subject to thematic analysis.
Six themes were found in the interviews which reflect the views and experiences of African-Caribbean fathers who took part in the interviews. These were:
• African-Caribbean fatherhood as a complex set of responsibilities.
• Fatherhood within communities and a hard social world
• Dynamic, changing forms of fatherhood.
• Fathers’ beliefs and practices for children’s mental well being.
• Interdependence of fathers’ and children’s health habits and lifestyles.
• The limited significance of preventive health services in fathers’ lives: barriers and future opportunities.
These represent the areas of concern and interest the fathers discussed. Each of the themes is summarised below, and some examples of what the fathers said are included. However, this is a summary and only includes brief extracts from sometimes lengthy conversations. The depth and wealth of the experiences and stories shared in the interviews are best appreciated by reading the full study report.
Theme one. African-Caribbean fatherhood as a complex set of responsibilities. The central part fatherhood plays in the identity of the men was a consistent theme in the interviews. This identity is made up of a range of responsibilities. These included different level of involvement, sometimes referred to as ‘being there’, dependent on whether fathers were living with or separate from their children’s mothers, and the extent of other obligations such as employment. Fathers reported providing practical help, doing domestic tasks, giving physical care, comfort, emotional support, and being an economic provider. They also emphasised the importance of protecting their children from social hazards, giving them opportunities (for example education), and providing guidance, leadership and healthy values. For example:
…it’s a strange thing, when my son was born and that. …everybody must know what that feels like [laughter], its just an amazing feeling. You think to yourself well it’s a lot of joy…but at the same time you feel, feel scared. I’ve got this little kid that is gonna look to me until he’s 18 and I’ve gotta look after him. He’s got no one else to depend on but me and his mum, and its an awesome sense of responsibility hits you at that time andâ€¦you start thinking about your lifestyle and how you’re gonna live your life, you can’t carry on as you were because you need to be there for this kid.(Group 6, Father No 37)
Promoting good health and mental-well being were also important areas of responsibility. Fatherhood was seen as enjoyable, yet challenging, creating anxiety, and conflict. The challenges arose from wider structural influences and obstacles that African-Caribbean fathers and their children face.
Theme two: Fatherhood within communities and a hard social world Being a responsible father is difficult and more challenging where ‘monochrome’ stereotypical assumptions, expectations, and media representations, influence how others view African-Caribbean people. In the interviews, the men reported that being a father encompassed a broader community responsibility, particularly that of acting as a positive role model for boys, young men and other fathers.
…from the gang cultures, from the criminalsâ€¦so they get confused, they get lost. And so my thing is…I still walk down the road with the kids and … you don’t actually see it that much to be honest. Because I walk everywhere, I don’t drive, you’ve got your car. …and also, cause I stand out,…they always see me with my kids and that is my stance to sort of say: ‘Look, that’s how to be a man. You have your kids, you take them, you show them the way to go’…(Group 4, Father No. 12)
This broader responsibility was seen as important in light of the destructive effects of gangs and racism. This can be regarded as part of a historical legacy which grew from respect for their own fathers’ parenting -and in some cases- ancestral lineage. In addition, for some fathers there was a link between a feeling of responsibility for their own children and a wider sense of legacy for others in the future.
Theme three: Dynamic, changing forms of fatherhood. Fatherhood is changing in a number of ways. For some participants migration from small rural African communities to urban industrial communities, in Birmingham, meant adapting to living with less social support. Generational changes were reflected in new parenting styles based on more communication and give-and-take with children. In the example below two fathers discuss the changes taking place:
Father No. 15:
But when it comes to the crunch and you’re a man, it’s not like whatever I say goes but I have the last wordâ€¦But at least it means an element of leadership and control within the home… [Now]..it becomes confusing who is in charge, but once people know who is in charge then control is easy to run…
Father No 16:
I think, being a real man, for me…I think is every, every ability to be able to communicate. And maintain communication in its good form. What communication is… That’s what being a real man is. That means being able to stand up when you can stand up. And being able to show a vulnerabilityâ€¦sometimes I think man, you know, there’s this macho: ‘I can do all things’ …But being a real man is: ‘Do you know what, when it goes to stumbling I also stumble. So when it goes to actually moving on I also move on’. You know, and I think that’s a real man.
(Group 5, Fathers No. 16 & 15)
Change is also taking place in the context of technological change and evolving gender relations requiring negotiation with increasingly powerful women.
Theme Four: Fathers’ beliefs and practices for children’s mental well being. Although the fathers were not asked specifically about mental well being, they offered their thoughts and views on this. Enabling mental well-being required good communication with children, respect for and nurturing of individual personalities, giving and receiving love and affection, providing social support (particularly emotional support), autonomy and self esteem, and in some cases spiritual wellbeing.
I mean obviously that goes without saying really that self-esteem is importantâ€¦linked into being… a proud father if you like. You try and convey it, you know, be confident, be bold… But on the health aspect of that…I’m very concerned, as we all are, about mental health provision for our community and the issues that we face. So you’re constantly aware of yes they need to have a self esteem but also… just mental sort of calm and, being able to express and sit down and talk and…
(Group 9, Father No. 47)
Mental well-being, linked to self-esteem, was felt to be important as a defence mechanism for children in the face of prejudice, violence and discrimination in wider society.
Theme Five: Interdependence of fathers’ and children’s health habits and lifestyles. Health was reported to be an important issue, as was how health was defined in terms of responsibilities to children. For example:
…emphasise physical and mental wellbeing and…a good diet. Now that sounds like it’s out of a text book. But it kind of is, I mean youâ€¦ say: ‘No, you can’t have those sweets… now you must eat these greens. Let’s go for a walk instead of driving here, let’s walk to school today, I know it’s cold’…
(Group 6, Father No. 38)
Their desire to maintain and improve their children’s health could detract from efforts to manage their own health. Although they were fully aware of what they needed to do with regard to their lifestyle particularly about smoking, alcohol, diet and exercise, they did not always follow the guidance they were familiar with. However there was also a sense that it was possible to look after their own health and it was their responsibility.
Theme Six: The limited significance of preventive health services in fathers’ lives: barriers and future opportunities.
The most important finding to emphasise about local preventive primary care services, is that they are largely insignificant in the lives of the fathers. The men had limited knowledge of and did not use the available services. This is a matter of concern for HOBtPCT as it is a barrier that may hamper the achievement of important public health targets for children and families. Discussion.
The data demonstrate that the men were committed to being fathers and enjoyed the role. However, they found that meeting their range of responsibilities placed great demands on their time. Even so, they were committed to serving as positive role models for other men in order to help create a better image of black fathers. They devoted much time and energy to promoting and maintaining the physical and psychological health of their children. This involved educating them, setting a good example and helping them develop their self-esteem. The mental well-being, on which self-esteem was founded, was believed to be essential as a form of protection for their children against racism, negative stereotypes, and limited opportunities.
However, in doing this the fathers often neglected their own health. They did not use preventive primary care services because they were difficult to access. Barriers and opportunities. The fathers’ views about services indicated that there are significant barriers to service access. These included:
• They did not know what services were available and what they were for, consequently they did not use them;
• Negative views and experiences of NHS services such as GP medical services and hospital services;
• Child health services focus on mothers, rather than both parents;
• Traditional notions of gender dissuaded some African-Caribbean fathers’ from accessing preventive health services;
• Views, experiences and anticipation of cultural misunderstanding, cultural insensitivity, and racial prejudice and discrimination when using the NHS and other services. The study highlights a number of issues relevant to practitioners, policy makers, and researchers with an interest in and/or responsibility for child and family health.
• African-Caribbean fathers are not a ‘hard to reach’ group;
• Fathers are passionate about the health and well-being of their children.
• Fathers work to maintain children’s mental well-being.
• Fostering children’s mental well-being is undertaken to help protect them against wider social and structural difficulties
• Fatherhood was linked to a wider responsibility to support others in African Caribbean, Muslim and Christian communities.
• Fathers are change agents. Fathers’ lives involve migration, changing gender relationships associated with fatherhood, and changes in parenting styles across generations.
• Health messages about diet and physical activity are recognised.
• Fathers have important insights on the way social, structural and material factors affect communities, families, health and well-being. There are opportunities for service development. Effort needs to be directed to ensuring:
• Fathers, their families and their communities are treated fairly and equitably.
• Services recognise fathers are ‘doing their best’ and appreciate the strengths of their families, cultures and communities.
• Good communication between health care professionals and fathers.
• African Caribbean fathers are aware of initiatives to address health problems such as prostate cancer, kidney disease, hypertension, and diabetes.
• Child health services accommodate and build on fathers’ commitment to children’s health and well being by providing services that address fathers’ as well as mothers’ responsibilities and needs in families. Recommendations
• Conduct an audit to review levels of access of the Hotpot by African Caribbean men. This will help determine the extent of HOBtPCT service use by African-Caribbean fathers.
• Consider how the social networks in African Caribbean communities can be accessed to better reflect HOBtPCT’s commitment to increasing community participation in the delivery of child health services. The fathers in this research were committed to doing more to promote and maintain the health of their children. Capitalising on the opportunity this presents represents huge potential for outreach health work with established networks.
• The need for cultural competence and cultural sensitivity in public health work is widely recognised and is reinforced by this study. Continuing the programme of cultural competence and anti-discriminatory practice training in HOBtPCT will help achieve this. • Introduce â€˜Fatherhood Institute’ training for managers and staff in HOBtPCT. Future research: immediate.
(a) The extent to which HOBtPCT models of service delivery and policy are informed by the needs of fathers from different ethnic backgrounds. (b) Conduct a further six group interviews, with fathers from different ethnic backgrounds in order to examine the extent to which the findings presented here reflect common experiences of African-Caribbean fathers. Future research: medium term.
• A larger scale, multi-disciplinary project to investigate the health beliefs and practices of young black men, ‘absent’ African-Caribbean fathers’, and the service provider experience.
• Summary prepared for the fathers who took part, and the people who helped with recruitment from local social networks
• Detailed report submitted to HOBtPCT to inform service development
• Articles reporting the findings will be submitted to professional and scholarly journals for publication. The findings will be presented at local, national and international conferences to share the work with the widest audience possible
• ‘The Fatherhood Institute’, (the leading voluntary organisation in the UK which promotes the needs of fathers), and the ‘Men’s Health Forum’, (the leading UK organisation for promoting men’s health), will help with disseminating findings.
• The HOBtPCT has expressed a willingness to consider hosting a conference focussed on ‘African Caribbean fathers contributions to family and community health’. The findings from the study and other relevant work will be shared with local and national audiences.
Increasingly there is an emphasis in health policy on PCTs engaging fathers in primary health care services. This qualitative exploratory study examined the views and experiences of 46 African Caribbean fathers to find out how effective this has been in HOBtPCT. African Caribbean fathers are not aware of what services exist and make little use of preventive health services in HOBtPCT. There are opportunities for the PCT to improve engagement with local African Caribbean fathers through accessing local networks, staff training, service audit, and further research. HOBtPCT is committed to taking action in all these areas.
For any queries or correspondence regarding this report please contact the principal investigator at the University of Birmingham: Dr Robert Williams. School of Health Sciences. University of Birmingham. Birmingham. B15 2TT. Email: firstname.lastname@example.org Tel: 0121 414 7148 Fax: 0121 414 3158 Published by: School of Health and Population Sciences, University of Birmingham. Â© University of Birmingham. First published 2009.