Men care too: a qualitative study examining women’s perceptions of fathers’ engagement in early childhood development (ECD) during an ECD program for HIV-positive mothers in Malawi

Objectives Integrated early childhood development (ECD) and prevention of mother-to-child transmission (PMTCT) interventions rarely target fathers, a missed opportunity given existing research demonstrating that father involvement improves maternal and child outcomes. We aimed to explore mother’s perceptions of fathers’ buy-in to an integrated PMTCT-ECD programme, any impact the programme had on couple dynamics, and perceived barriers to fathers’ involvement in ECD activities. Design Qualitative study using individual in-depth interviews with mothers participating in a PMTCT-ECD programme. Interviews assessed mothers’ perceptions of father buy-in and engagement in the programme and ECD activities. Data were coded using inductive and deductive strategies and analysed using constant comparison methods in Atlas.ti V.1.6. Setting Four health facilities in Malawi where PMTCT services were provided. Participants Study participants were mothers infected with HIV who were enrolled in the PMTCT-ECD programme for >6 months. Interventions The PMTCT-ECD intervention provided ECD education and counselling sessions during routine PMTCT visits for mothers infected with HIV and their infants (infant age 1.5-24 months). The intervention did not target fathers, but mothers were encouraged to share information with them. Results Interviews were conducted with 29 mothers. Almost all mothers discussed the PMTCT-ECD intervention with male partners. Most mothers reported that fathers viewed ECD as valuable and practised ECD activities at home. Several reported improved partner relationships and increased communication due to the intervention. However, most mothers believed fathers would not attend the PMTCT-ECD intervention due to concerns regarding HIV-related stigma at PMTCT clinics, time required to attend and perceptions that the intervention was intended for women. Conclusions Fathers were interested in an integrated PMTCT-ECD programme and actively practised ECD activities at home, but felt uncomfortable visiting PMTCT clinics. Interventions should consider direct community outreach or implementing ECD programmes at facility entry points where men frequent, such as outpatient departments. The primary objectives of this study were to use qualitative interviews to evaluate mothers’ perceptions of male partners’ experiences with and perceptions of an integrated PMTCT-ECD intervention in Malawi. A detailed description of the PMTCT–ECD intervention can be found elsewhere.17 In brief, we conducted an integrated PMTCT–ECD intervention for mothers infected with HIV and their young children (aged 1.5–24 months) in six health facilities in central Malawi. Facilities varied in size, type (district hospital, mission hospital, health centre) and district (Lilongwe, Kasungu, Nkhotakota). Mothers who were infected with HIV, enrolled in PMTCT programmes at participating facilities and whose youngest child was <8 weeks of age, were recruited to participate in the integrated PMTCT–ECD programme. Enrolled mothers received an interactive ECD skills development session during every PMTCT visit (every 1–3 months, depending on mothers’ time since ART initiation and ART adherence measures) until they graduated from the PMTCT programme when their child reached 24 months of age. Mothers could also access ECD sessions anytime they attended a facility, whether for PMTCT services or not. ECD sessions were offered while mothers waited for routine health services, so participation did not require additional time or resources from the mothers. ECD sessions followed the WHO-UNICEF ‘Care for Child Development’ package that sensitises mothers to the developing cognitive, emotional and communication needs of their infants, and reinforces caregiving sensitivity and responsivity through support and simple play activities.18 Mothers are trained through interactive lessons, play and demonstrated scenarios to talk and sing with infants at an early age, make eye contact, mimic infant vocalisations, and recognise and respond to their infant’s developmental milestones. All sessions were implemented by trained ECD counsellors who were ‘Expert Clients’, a Malawi cadre of HIV-positive community members who volunteer for a small monthly stipend to provide HIV counselling and support to infected individuals.19 This was a qualitative study using individual in-depth interviews with mothers who had participated in the PMTCT–ECD intervention for >6 months. Given the relative lack of research in this specific area, we used a grounded theory approach.20 Individual in-depth interviews were used instead of focus group discussions in order to emphasise the experiences of individual participants and investigate the unique effects of the programme within individual family units. Mothers participating in the PMTCT–ECD programme were eligible for study participation if they had been enrolled in the programme for >6 months in order to ensure exposure to the majority of the ECD curriculum. Participants were selected randomly in order to avoid biases in sample selection. Thirty-two mothers were randomly selected using a computer-generated random sequence of mothers and were stratified by health facility (eight participants selected from each of four facilities) to ensure representation of all districts and facility types. Participants were invited by study staff for an in-depth interview at the health facility. Written informed consent was obtained from each participant prior to study participation. The interview guide was developed based on the existing literature and previous experiences with the PMTCT–ECD programme and pilot.21 22 Interview guides assessed mothers’ ECD knowledge, practice and male caregiver involvement in ECD. Specifically, with regard to male caregivers, mothers were asked to describe their perceptions of their male partners’ attitudes towards the programme, involvement in ECD activities at home, any indirect effects of the programme on couple and family dynamics, and potential barriers to male caregivers’ direct involvement with the PMTCT–ECD programme at the health facilities. The interview guide was reviewed and edited by local study staff to ensure cultural humility and acceptability. Guides were piloted among three women to ensure comprehensibility and refined based on feedback. In-depth interviews were conducted from June to July 2019 with a random subset of 29 mothers enrolled in the PMTCT–ECD programme across four implementing facilities for ≥6 months. Data collection was stopped after 29 interviews as thematic saturation had been reached. Interviews were conducted in the local language (Chichewa) by a trained, local female research assistant in private spaces in the health facilities. Interviews ranged in duration from 30 to 50 min and were audio recorded. Women were compensated 4000 Malawi Kwacha (approximately US$5) for their transportation costs to attend the interview. Audio recordings were translated and transcribed to English for analysis. For this paper, we only include interviews with women who report that the father of their youngest child was present in the child’s daily life. Interviews with women who reported absent fathers were omitted from this analysis, since absent fathers would not have been exposed to ECD sessions nor would they have a chance to practise ECD activities with the child. A preliminary codebook was generated using a combination of deductive and inductive approaches. Using deductive coding, we developed an a priori codebook based on an initial version of the interview guide and themes found in the existing literature. Additional codes were added using inductive coding from pilot interviews, which allowed additional themes and theories to emerge from the preliminary data. Two investigators (TT and PK) coded the same five transcripts separately using Atlas.ti, compared codes and resolved differences. One investigator was a Malawian researcher with extensive qualitative research experience. The other investigator was a US medical student with training in qualitative research. An additional two transcripts were simultaneously coded with similar codes between investigators. The final codebook was used by the same two investigators to code all remaining transcripts. Data were analysed using constant comparison methods. Below, we present dominant themes related to male engagement and fathers’ understanding and interest in PMTCT–ECD programmes. Patients or the public were not involved in the design, conduct, reporting or dissemination plans of our research.