Fatherhood group sessions: A descriptive and summative qualitative study

Abstract The aim of this qualitative study of fatherhood group sessions offered as part of child health care services for new parents was to examine the activities, roles, and topics initiated by the leader and describe fathers' participation. Eight new fathers took part in three audio‐ and video‐recorded sessions led by a male leader. Three qualitative content analysis approaches were used to analyze the data. The analysis showed that the group leader took on four leadership roles, mainly that of discussion leader, but also expert, friend, and organizer. When the group leader acted as discussion leader, fathers participated by discussing challenges and changes in their new situation. Challenges were related to raising the child, partner relationships, everyday life, and gender equality. Fathers also discussed changes in their partner relationships and an increased focus on practicalities in daily life. Fatherhood groups can help new fathers form social networks and can create space for fathers to work through challenging topics, such as gender equality in parenting. The discussion leader's choice of role is crucial to creating the space for such discussions.


| INTRODUCTION
Becoming a father is a life-changing event that causes a mixture of positive and challenging emotions (Kowlessar, Fox, & Wittkowski, 2015;Ngai & Lam, 2020;Sansiriphun, Kantaruksa, Klunklin, Baosuang, & Liamtrirat, 2015). Qualitative studies that give new fathers a voice have revealed that many go through emotional challenges throughout the transition to parenthood, including feeling detached from their partner's pregnancy experience and questioning their role (Åsenhed, Kilstam, Alehagen, & Baggens, 2014;Kowlessar et al., 2015). In the early days after the birth, men can experience fatherhood as a period of trial and error and helplessness (Kowlessar et al., 2015). Additionally, Swedish fathers have reported difficulty managing the demands of fatherhood, poor emotional health, and a lack of time for their partner, child, friends, and personal interests (Johansson, Thomas, Hildingsson, & Haines, 2016). In fact, many Swedish fathers feel that having a baby was in some ways less than a positive experience (Johansson et al., 2016). Additionally, more than a third of 827 fathers surveyed reported financial and health worries, concerns about achieving balance in their new situation, and apprehension about raising a child (Johansson et al., 2016). Swedish fathers described the postnatal period as a "roller coaster" of emotion that includes both stress and feelings of great joy (Åsenhed et al., 2014, p. 1309).
2 | BACKGROUND Support can help reduce worries and anxiety during the transition to parenthood (Barimani, Vikström, Rosander, Forslund Frykedal, & Berlin, 2017;Bryanton, Beck, & Montelpare, 2013). Group-based parental training or parental education groups (hereafter PE groups) are one way to provide support and prepare expectant and new parents for childbirth and parenting (Barimani et al., 2017;Gagnon & Sandall, 2007). Parents who attend such groups often find it reassuring to meet others in similar circumstances and satisfying to have the opportunity to establish social networks (Berlin, Törnkvist, & Barimani, 2016). However, they can feel dissatisfied with PE groups' primary focus on childbirth and lack of discussion about parenting and changes in partner relationships (Berlin et al., 2016). Moreover, a lack of group activities means that parents' wishes to interact with other parents are not always fulfilled (Berlin et al., 2016;Forslund Frykedal & Rosander, 2015). When group leaders take on the role of experts and give lectures, it also leaves little time for parents to actively participate and interact (Berlin, Rosander, Forslund Frykedal, & Barimani, 2018).

PE groups in Sweden typically include both mothers and fathers
(National Handbook of Child Health Services, 2020a) and are led by midwives or nurses in child health care services (hereafter CHC services), most of whom are women (Barimani et al., 2017). A higher percentage of women than men participate in PE groups (Hallberg, Beckman, & Håkansson, 2010;Petersson, Petersson, & Håkansson, 2003), and men often perceive that support is primarily focused on women (Petersson et al., 2003). Fathers attending mixedgender PE groups may feel "invisible, disregarded and insulted" (Salzmann-Erikson & Eriksson, 2013, p. 381) and that the content preserves traditional gender roles (Berlin et al., 2016). Fathers can also find it difficult to know what questions to ask during PE groups (Erlandsson & Häggström-Nordin, 2010).
As part of health care services for new parents, CHC services have started to offer fatherhood group sessions at some centers.
However, these remain less frequent than mixed-gender sessions.
There is thus a shortage of studies examining what fatherhood group sessions can offer fathers. This is an important question, as traditional PE groups seem to fail to provide support for new fathers (Kowlessar et al., 2015) and it is children's right to have equally prepared and supported parents (Eklund & Lundqvist, 2018).
We had the unusual opportunity to observe and record several fatherhood group sessions that were offered through CHC services and held by a male leader. In this qualitative study, we aimed to observe and describe (i) the activities, roles, and topics initiated by the leader; and (ii) new fathers' participation in the sessions.
The analysis focused on information that could answer the fol- The study had a qualitative, descriptive, and summative design as outlined by Hsieh and Shannon (2005) and used audio and video recordings and observations. We chose this design to obtain access to the phenomenon under study (fatherhood groups) in a naturalistic setting (CHC services). Such access is difficult for approaches that rely on qualitative interviews and/or quantitative methods (Salmon, 2015).

| Study setting
Swedish family policy has a critical influence on parenthood and on the topics discussed in PE groups; it is therefore an important aspect of the study setting. In Sweden, gender equality goals are emphasized in national, government-led, public health awareness programs

| Participants
To recruit participants, we provided the administrative office of a county council in an urban area with verbal and written information about the study. We arranged meetings with health care developers at the Department of CHC services to find a fatherhood group leader and obtain his or her contact information. The health care developers provided information on a leader, and one of the authors contacted him by email. He was a father who had previously led fatherhood group sessions in urban areas in Sweden.
After receiving verbal and written information about the study, the group leader and eight fathers agreed to participate. Some fathers brought their infants (age range 7 weeks to 6 months) to the sessions.   Table 1). The video recording helped capture how the leader behaved when performing different activities but could only be used at one session for practical and ethical reasons.

| Data collection
Two researchers attended each group session and sat at the back of the room with the intention of causing as little disturbance as possible. One researcher was responsible for the audio and video recorders and the other took field notes throughout the sessions to complement the recorded material. The notes focused on the number of participants, activities in the room, topics presented, and questions asked.

| Data analysis
We used three approaches to qualitative content analysis outlined

| Ethical considerations
Throughout the study, we adhered to the ethical principles of the British Psychological Society (2014): respect, competence, responsibility, and integrity. We obtained written informed consent from the group leader and the fathers. All participants could decline to be video and/or audio recorded. One father declined to be video recorded but accepted audio recording, so when he was present, the cameras were shut off (see Table 1). The research project was approved by the regional Research and Ethics Committee at Linköping University, Sweden (reference # 2013/401-31).

| Leader activities and roles
In the analysis of audio and video recordings, we identified leader behaviors and activities that characterized four roles: discussion leader, expert, friend, and organizer ( Table 2). The leader engaged in each role to a different degree.

| Discussion leader
The leader assessed expectations, initiated discussions on agreedupon topics and homework assignments, evaluated fathers' opinions, and strove to create intragroup trust by stressing the importance of confidentiality: "What's said here stays in the group!" In addition, the leader asked reflective questions and encouraged the fathers to listen to each other and share their experiences. For instance, he said, "It's good that we listen to each other and share our experiences. It's a give and take!"

| Expert
The leader referred to science when talking about worries and difficulties that women and men experience during parenthood. He contributed expert knowledge related to scientific studies, such as national and international statistics about the length and gender distribution of parental leave: "The

| Organizer
In this role, the leader dealt with practical matters such as scheduling (e.g. opening and closing each session, planning for coffee breaks). He offered a list of contact information to participants, gave homework assignments, and initiated planning for independent group meetings: "Does the group intended to continue meeting? Is one of you willing to be responsible for that?"

| Distribution of leader activity and participant time
In the first and the last group sessions, the leader spent most of his time -35% to 50%in his role as discussion leader. The fathers had the opportunity to speak between half and two-thirds of the total time at these sessions (see Table 3).

| Leader role, topics initiated, and fathers' response
The agreed-upon topics that the leader initiated at each session were: Session ranged from quiet listening to active participation via discussing, reflecting, making statements, and asking questions (Table 4).

| The content of fathers' verbal responses
In their verbal responses to topics initiated by the leader, fathers took up perceived challenges and changes (Table 5).

| Challenges
Fathers discussed several challenges, such as how to manage and raise their child, how to handle their relationship with their partner, everyday life, and aspects of gender equality.

| Managing and raising a child
Challenges that fathers brought up included how to provide the best care for their child, how to raise their child, and how to interpret and understand their child's personality. The fathers discussed the anxiety they felt about their child's overall health and well-being when the child was not eating or sleeping properly. They asked questions such as the following during the discussion: "How is it possible to manage everything when you have a second child?" (Father 1), and "How is it possible to raise a baby girl to become a strong and independent individual?" (Father 2).

| Handling the couple relationship
Fathers discussed how challenging it was to get communication with their partners to work and described how this difficulty led to conflicts almost every day: "We have disputes about minor things. We never had that many conflicts before!" (Father 3). Fathers could also perceive that their partners had unspoken expectations. It was especially hard to handle these expectations when they and their partners were short on sleep and did not have enough time with each other: "Your partner expects you to be able to interpret thoughts, needs, and feelings!" (Father 3).
One participant said that his partner had gone through a lot of physical challenges during pregnancy and childbirth. He therefore stressed the importance of showing understanding, paying attention, and being gentle.

| Managing aspects of gender equality
Some fathers brought up their belief that there is a difference between mothers and fathers. They described mothers as comforters, the ones who know the routines and what the child needs (clothing and other material goods) and fathers as entertainers, the ones who make funny faces to get the child to laugh.
It was challenging to take equal responsibility for the child and household work. One father stressed the importance of avoiding the traditional man's trap of working longer than normal. The men then discussed the dangers of the traditional woman's trap, taking full responsibility for the child and housework. "I have female friends who are active feminists fighting for equality between women and men," said one participant. "After they had their children, they stayed at home, took most of the responsibility, and used all of the paid parental T A B L E 5 Categories, subcategories, and codes drawn from data gathered during three fatherhood group sessions leave [did not divide the paid parental leave equally with their partners]" (Father 2).
The fathers accepted that given the importance of breastfeeding, it would be hard for them to take the first part of parental leave. However, they stressed the need for parents to make equal use of parental leave in order to spend equal time with their child. They brought up a number of factors outside their immediate control that made it hard to achieve this goal, including social structure, family budget, and salaries. One said, "The way things turn out depends on the social structure in society. It's common for women to take the majority [of parental leave], since in general their salary is lower" (Father 6). The fathers expressed a willingness to continue holding independent fatherhood group meetings since they felt it was good to meet and discuss aspects of fatherhood.

| Changes
Fathers discussed changes that had come with parenthood, such as changes to the couple relationship. The most significant change in the fathers' relationship with their partners was becoming closer and more connected because of their joint parenthood "project." They also explained that their relationship had shifted to focus on everyday practicalities, which they perceived as dominating life. One father stated that his partner had changed. "She's always here and now.
When [the baby] has just fallen asleep, I want to take advantage of it, relax and slow down…. Then she says: lay him down and start making dinner. She's become so practical" (Father 3).
The fathers also described a stronger connection to their immediate and extended families. For example, after becoming parents they regarded meeting and celebrating holidays together with the extended family as more fun. One father said, "With a child, the Christmas celebration will changethere will be more joy and fun.

| DISCUSSION
Audio and video recordings revealed that the leader took on four different roles. When he adopted the role of discussion leader, he cre- Fathers in this study discussed the challenge of gender equality and differences in men's and women's parenting roles. It was clear that they were aware that such inequalities persist despite national and public health programs promoting gender equality. The understanding of gender equality and gender differences in parenting is still in its infancy (Doucet, 2009, p. 117), and this topic deserves further attention from researchers. Another topic for further investigation is how much the gender of the group leader impacts fathers' willingness to discuss their concerns. Previous studies are suggestive but not conclusive on this point. A study of fatherhood-only discussions, led by a man (Pålsson et al., 2017, p. 90), found that these sessions provided fathers with an opportunity to discuss fatherhood. In another study, men leading fatherhood group sessions explained that it was important to them to get fathers to reflect on parenthood and to empower their role in the family (Kerstis, Wells, & Andersson, 2018).
On the other hand, the role that the group leader chooses to assume for example, discussion leader or expertmay be of equal or greater importance (Berlin et al., 2018). Studies comparing fatherhood groups led by men and women could help resolve this question.

| Methodological considerations
To the best of our knowledge, the real-life setting of fatherhood group sessions has not previously been studied using video and/or audio material. The main strength of this method of data collection is direct access to the phenomenon under study, which might be difficult to obtain with qualitative interviews and/or quantitative methods (Salmon, 2015). The concepts of credibility, confirmability, and transferability describe different aspects of trustworthiness (Graneheim & Lundman, 2004). To achieve credibility, the research team discussed the video and audio data, as well as the analysis, until we reached consensus about codes and categories. To attain confirmability, we added quotes to illustrate the descriptions of the group leader's roles and the fathers' responses. Fewer quotes were used to illustrate the group leader's role as friend, as many relevant quotes would have revealed personal information.
We attempted to facilitate transferability by providing a clear description of the study context, data collection, and data analyses.
The structure and goals of fatherhood groups differ between countries, so findings from the Swedish context might not be transferable elsewhere. However, the results about the leader's role seem less context-bound and may therefore be worth further research in other contexts.