1. How Children Affect Fathers’ Health and Health Behaviors Craig Garfield, MD, MAPP Assistant Professor of Pediatrics Section of Child and Family Health Studies

2. Background: Men’s Health  There are 86 million men ages 18-65 in the United States (31% of the entire population); the health of men is generally worse than that of women 1 In 1920, male life expectancy was one year shorter than female; by 2005, male life expectancy was 5.2 years behind 2  Minority male life expectancy is significantly lower than White, male life expectancy, and ranges from 66.1-74.5 years 3  Men are at a greater risk of death in every age group compared to women with a 1.6x higher mortality rate 4

3.  Compared to their female counterparts, men engage in greater risky behaviors and fewer protective ones such as: Failing to wear seat belts or helmets 5 Poor sleep and dietary habits 6 Smoking and alchol use and abuse 7 Failing to complete self-exams (i.e. testicular) and/or get healthcare 8  Many of these behaviors--including poor diet, tobacco use, and alcohol consumption--are considered modifiable health behaviors and preventable causes of death 9 Male Risk-taking Behaviors

4.  Adolescent males exit pediatric care with limited ties to the healthcare system, despite recommendations for regular preventive visits and screenings 10  Men are less likely to have a regular doctor and attend regular doctor visits 33% men have no regular physician 11 24% men have not seen a physician in the past year 12  Women attend doctor visits for annual or preventive services (i.e. - non-illness related) at a rate of 100% higher than men, after controlling for age and pregnancy- related visits 12 Men and the Healthcare System

5. Men’s Health and Marriage  Marriage has been associated with increased men’s health Marriage seems to serve as a protective factor for men’s health 13  Assumes long-term contract, sharing of resources, economies of scale, and social support Compared to unmarried fathers, married fathers are:  more educated  have higher incomes  more physically and mentally healthy 14  Yet the number of unmarried couples having children and cohabiting has increased and continues to rise. 14

6.  Fatherhood may be an important influence on men’s health 66.3 out of 108 million American men are fathers 15 Fathers’ time and involvement with children has grown  Likelihood that fathers may not only affect their children’s health, but children may affect their father’s health 16 Whether children have a beneficial, detrimental, or neutral impact on men’s health remains to be explored. 17 Men’s Health and Fatherhood 15- U.S. Census Bureau, 2006; 16-Coleman & Garfield, 2004 ;17- Bartlett, 2004; Chalmers, 1996

7. T o better understand how children influence fathers’ health and health behaviors through qualitative interviews with a diverse sample of urban fathers Objective

8. go Time, Love, and Cash in Couples With Chidren (TLC3) Methods - Sample Fragile Families and Child Wellbeing Study (FFCWB) Randomly sampled hospital births of 3800 unmarried couples and 1200 married couples nationally representative of large U.S. cities 75 New York, Chicago, and Milwaukee low- to moderate-income married, cohabiting, or romantically involved couples at time of child’s birth. Fathers and Healthcare 33 fathers of 3 year olds from TLC3 living in Chicago or Milwaukee

9. Methods: Qualitative Methodology Interview protocol:  1.5 hr face-to-face, open-ended, semi-structured interviews  Focusing on father involvement in the health and healthcare of the child and changes and experiences around becoming a father Data analysis:  Verbatim interview transcription  Inductive and deductive coding with team triangulation, consensus  Content and narrative analysis to identify emerging and recurring themes  Frequencies tabulated from FHC, FFCWB

10. Results: Sample 31/ 33 fathers from the TLC3 study in Chicago and Milwaukee participated (adjusted response rate: 94%) Sample (N=31)N (%) Mean age of Father (Years) 31 African American Hispanic White/Non-Hispanic 17 (55) 9 (29) 5 (16) HS graduate or equivalent Some HS or less Some college or technical training College degree or higher 10 (32) 9 (29) 10 (32) 2 (6) Non-married 17(55) First-time father 7 (22) Income 34,999 or less 15(48) Resident 18(58) Employed 26 (84)

11. Results: Fathers’ Health Status Self-report health status (N=31) N(%) Excellent Very Good Good Fair Poor 5 (16) 8 (26) 14 (45) 4 (13) 0

12. Perceived Changes to Fathers’ Health Percentage of Respondent Fathers Perceived Change to Health 24 (77%) 4 (13%) 3 (10%)

13. Results: Positive Changes to Health Behaviors Health Behavior N (%) Better Eating Habits 11 (35) Exercise More 9 (29) Decrease Alcohol Use 6 (19) Take Better Care of Self 4 (13) Less Risk Taking 3 (10)

14. “I need to eat whatever he’s going to eat. So, it’s more healthy, like vegetables and stuff like that. I can say that I used to eat a lot of junk food before, I quit just because of my son.” Positive Changes: Better Eating Habits [n=11 (35%)] “Before I didn’t drink a lot of water, now I drink a lot of water. I’m not eating a lot of steak or drink pop. I eat a lot of fish and drink orange juice.”

15. “Me taking him to his doctor for his checkup has kept me in shape and exercising, walking, running. [Without my child]. I would be more lazy. Kids keep me moving.” Positive Changes: Exercise More [n=9 (29%)] “I do a little bit more exercising now. He’s riding bikes, he likes to run, likes to go outside and play. So I go do all of that stuff.”

16. “I went from going out every night to now I go probably once a month. I don’t drink [alcohol], I just have a soda. And that’s about it.” Positive Changes: Decrease Alcohol Use [n=6 (19%)] “Well, I’m not an alcoholic any more [after having a child]. I’ll come home have one or two beers instead of a case or two cases. So he’s helped me.”

17. “I think I take care of my health [better now]. I think that I always did, but [child] made it better.” Positive Changes: Take Better Care of Self [n=4 (13%)] “I know that I have to take care of myself so that I can run and play baseball with [child]. I realized that if I’m going to keep up with him, I have to keep myself in shape.”

18. “I don’t party anymore like I used to, and I’m a responsible father, try to spend time with him.” Positive Changes: Less Risk Taking [n=3 (10%)] “I don’t put my health in as stressful or dangerous situations as I probably would. For instance, I don’t hang out with friends who may not be in the most safe of situations.”

19.  Among the 10% attributing negative changes to their health on account of becoming a father, the common themes include: Decreases in exercise and sleep Increases or decreases in eating Increases in stress and smoking Negative Changes

20. Attitudes and Behavioral Changes Results: Attitudinal Changes Attitudinal changes attributed to becoming a father N (%) Being There for the Child 6 (19) Putting Family First 5 (16) Adjusting to Real Consequences 3 (10) Being a Good Role Model 2 (6)

21. “I want her to be there with me when she gets through kindergarten. When she gets into 8th grade I want to be there, go through that. I wanna live a long time so I can see those things, see her graduate from college, see how her life turns out. ” Attitude: Being There to Take Care of the Child [n=6 (19%)]

22. “Yeah, yeah, it’s not about me. It’s about the life of your child, so I have to keep myself together to make sure I’m here for him. So I’d say my whole entire attitude to health is that it’s not just about me anymore, it’s about us.” Attitude: Putting Family First [n=5 (16%)]

23. “I like to try to stay healthy, because if I’m not healthy I can’t work, and if I can’t work, we don’t eat. And then we have real health problems. ” Attitude: Adjusting to Real Consequences [n=3 (10%)]

24. “Yeah, I do more vegetables, I eat better, I drink more milk now at the dinner table. I don’t drink as much beer now, because, unfortunately, ‘monkey see, monkey do’. So if I do things correctly, then he automatically thinks that’s the right thing to do. So I try to be a little bit better now I guess, health wise. ” Attitude: Being A Good Role Model [n=2 (6%)]

25. Specific behavior: Doctor’s Visits Have a regular doctor 21 (68%) Last visit to doctor 0-12 months14 (45) 1-2 years8 (26) >2 years5 (16) Don’t know2 (6)

26. Results: Attitudes about Doctor Visits Fathers’ attitudes about visiting a Doctor’s N (%) Importance of visit 16 (52) Delay going 10 (32) Dislike doctor 8 (26) Fear results 2 (6)

27. Doctor visits: Importance of visit [n=16 (52%)] “In general, I don’t mind. I wanna find out what’s going on with myself too. It’s very important for me to be healthy because I want to live to see my grandchildren.” “I think it’s very important now, because I’m getting older and my body’s not as young as it used to be. So I think it’s very near the top of the list to go see a doctor.”

28. “It’s just a big hassle. The insurance is never good enough, or they screw up the billing. I don’t go unless I have to. My wife forces me to go even if I have to go. ” Doctor visits: Delay visits [n=10 (32%)] “I have to be very sick before I go. Like I cut my eye open and I was gonna sew it up myself, but my wife didn’t want me to do it, so I just let it heal on its own.”

29. “I think you should stay as far away from [doctors] as you can. I really don’t enjoy doctors or hospitals.” Doctor visits: Dislike visits [n=8 (26%)] “I hate it. I’m supposed to always be strong, and maybe that sounds crazy to you, but I’m supposed to be the person who’s always ready to go at any point, and I know that going to the doctor will help keep me that way, but I still don’t like it for me.”

30. “I don’t find that it’s necessary, and I just feel uncomfortable. I always feel like if I go there they might find something that’s wrong anyway. Hospitals just give me a feeling of you’re gonna get old one day, you’re gonna have to go here.” Doctor visits: Fear results [n=2 (6%)]

31.  In this demographically and SES diverse sample, the majority of fathers (77%) attribute positive changes to their health by having a child, such as:  better eating habits  increased exercise  decreased alcohol consumption  Fewer (10%) reported negative health consequences since the birth of their child including:  Decreased exercise and sleep  Increased or decreased food intake  Increased stress and smoking  No changes were reported by 13% Discussion

32. The attitudinal shifts that may be behind the positive behavioral changes include: desire “to be around” for their child’s future to “put my family first” the realization that their unhealthy behaviors had “real consequences” for themselves and their children the importance of “modeling” positive health behaviors But not all modeling is positive; avoidance of doctor visits and continued risk behaviors can also be observed and adopted by children Men in this sample credit becoming a father with making lifestyle changes, generally for the better Discussion

33.  Fatherhood is a defining and transformative moment for men, as well as a touch-point for their health  Early fatherhood, a time when men are re-examining their priorities and responsibilities--including health--is also a time when men are least likely to be in the healthcare system  How can the transition to fatherhood be more effectively used to improve men’s health within the current healthcare framework? Discussion - Implications

34.  Healthcare system modifications- Welcome and acknowledge men in the healthcare system Educate fathers on the importance of their health for themselves, families Explain how fathers model behaviors for children Use the transition to fatherhood as a lever for positive lifestyle change Re-evaluating the delivery of healthcare for men  Nursery clinics, partner/child chaperones Discussion - Implications

35. Fathers and Healthcare http://www.youtube.com/watch?v=NmhIhlHC-9k

36.  Future research must include pre- and post- fatherhood, longitudinal studies designed to examine the bidirectional affect that father and child health have on one another  If there are truly health benefits (or detriments), uncovering the biological mechanisms responsible is essential Alterations in biomarkers, hormones, allostatic load? Implications - Future Research

37. Acknowledgements  Father Involvement Research Alliance  Anthony Isacco and Fathers and Health Care (FHC) Research Team  FHC participants  Section of Child and Family Health Studies, Evanston Hospital  Northwestern University TLC3 : Kathy Edin, Paula England, and Greg Duncan

38. Thank you Craig Garfield, MD, MAPP Assistant Professor of Pediatrics Northwestern University Craig.garfield@gmail.com