Men’s perceptions of the supportive use of health communication tools during the ante-and postnatal period

). Abstract. In the contemporary approach to ante-and postnatal care, where men are anticipated to participate more, men themselves also wish to be more included. Even though national health policy presents person-centred care as a central goal, it is not clear if and how it manifests itself for some, as men continue to feel excluded from the ante-and postnatal care process. The aim of this research was to identify the information sources that men in Estonia currently rely upon regarding the ante-and postnatal period in order to both understand the possible areas of development and the potential application of health communication tools to support men in ante-and postnatal care. The research, which was part of a master’s thesis, was a qualitative study conducted with 13 men who were fathers or were about to become fathers. The results indicate that despite the new standards in health policy, there is a lack of targeted support systems to address men’s information needs during the ante-and postnatal period in Estonia – a problem further intensified by the COVID-19 pandemic. The current results show that adequate information access requires advanced skills in source criticality, languages, health and digital literacy. The study found that the issue can be resolved through conscious use of health communication tools, which need to be in a person-centred format – easily found, user-friendly and logically structured. A systemic approach needs to be developed to further support men. Health communication strategies can mediate such an approach by being able to accommodate a wider range of skills and preferences.


INTRODUCTION
What distinguishes maternity care from other areas in medicine is that most often care provision deals with people who are going through a fully physiological and natural life event [1]. However, in order to ensure a standard of quality, maternity care has become tightly connected to healthcare service provision [1]. These characteristics allow maternity care to be a unique vessel of person-centred care, as providers of these services have always understood that both pregnancy and birth are an experience far from being only a set of procedures or a diagnosis needing a cure [2,3]. Alongside focusing on the woman, the familial elements of maternity care also create a forum for involving family members [4].
In theory, family-centred perinatal care clearly focuses on the need to engage men [5,6], but in reality, improvements are needed to secure family-centredness [5]. As described in the national guidelines for family-centred maternity and newborn care in Canada [6] and in works by Daniele [7] and Panter-Brick et al. [8], men's participation has seen an increase during the ante-and postnatal period but is met with limited resources and assistance on how to adapt to their new role and position [9]. A review by Steen  Men's perceptions of the supportive use of health communication tools during the ante-and postnatal period they cannot be considered a patient or merely a visitor [10], indicating that person-and family-centred care in maternity services, even if applied, currently caters to mothers but could have the potential to support the needs of both women and men in equal measure. Regarding the availability of services which would facilitate creating a kind of support system for men, an inventory listing the services provided for men found that only 13% (N = 78/613) offered tailored support [11]. It was noted that several institutions use the term 'parent' to make services appear to be inclusive, with the final product still being focused on women [12]. The lack of directed guidance has acted as an incentive for many to turn to the Internet for answers [13,14]. Though helpful in some cases, users often find themselves riddled with more questions and worries rather than answers [14]. Now, with the ongoing COVID-19 pandemic, the issue of limited engagement and information availability for men is being highlighted more than ever, as men have felt more isolated because of the restrictions imposed on maternity care provision [15]. Thus, when searching for ways on how to better engage men and provide care which is person-centred, health communication tools and digital solutions should be regarded as a significant medium to harness and develop. Health communication tools such as hospital webpages, the forum Perekool.ee, family school lessons, though being available, currently lack the service design and focus to actually be considered inclusive and family-centred to all counterparts of maternity care.
The Estonian Ministry of Social Affairs has identified person-centredness and adaptation of innovative approaches as cornerstones in implementing the Public Health Development Plan for 2020-2030 [16]. Though, as stated by the OECD (Organisation for Economic Co-operation and Development), even though digital solutions can make access to health information easier and people more active in decision-making, that alone will not make care models more person-centred if health related in formation continues to be difficult to navigate [17]. For person-centred care models to work, attention has to be drawn to the necessity of developing both people's health and digital literacy skills [17], as well as to the im plementation of innovative user-friendly solutions to tackle current health care challenges [16]. Therefore, understanding people's experiences can help create change in service provision and how healthcare services are designed to be more person-centred in nature [15]. The aim of this research was to identify the information sources that men in Estonia currently rely upon regarding the ante-and postnatal period, to both understand the possible areas of development and the potential improved application of health communication tools to support them.

MATERIALS AND METHODS
The study was conducted in Estonia, between September 2021 and May 2022. Men who met the pre-set inclusion criteria were recruited to take part in this qualitative study. The use of a qualitative approach allowed to better understand people's personal experiences by giving access to their versatile stories and points of view [18]. The use of semi-structured interviews as a data collection method allowed for a more thorough understanding of the topic which until now had not been studied in Estonia. This study was granted approval by the Research Ethics Committee of the National Institute for Health Development on 2 December (Research No. 2316, Decision No. 972).
The participants for the semi-structured interviews were recruited through study invitations which were shared through the National Institute for Health Development's Facebook page, in different pregnancyrelated Facebook groups and on the Facebook page of Hanna-Maria Trei, the author conducting the study. Confidentiality of the participants was guaranteed so that all identifiable information was separated from the person and the answers they gave. Each participant was given a sequence number, which was used in the interview transcripts and data analysis. All the participants' personal data, along with the recordings, were stored on a password-protected institutional server and deleted im mediately after the transcription process. A total of 13 participants met the inclusion criteria and were included in the study ( Table 1).
The inclusion criteria were chosen and created based on the topic of the study and relied upon previously conducted studies on similar topics. Situations that deviate from the ordinary or are pathological in nature entail a more specific need for information and counselling [19]. Therefore, the exclusion criteria of the study were set to ensure that participants included in the study were experiencing what is considered a normal ante-and postnatal period. Each participant was given an overview of the aim of the study, after which consent forms were signed digitally by both counterparts.
For data collection, semi-structured in-depth interviews were used. Due to the COVID-19 pandemic, interviews were conducted via Microsoft Teams or on a phone call. The interviewees were first asked questions concerning their background data, after which the interview agenda was followed. Other themes covered by questions were men's information needs during the anteand postnatal period, information availability and reliability, digital information sources for men. In addition, men were inquired about the influence of the COVID-19 pandemic on their engagement in the ante-or postnatal process because of the changes it brought to maternity care provision. The interviews were thereafter transcribed and analysed. For data analysis, thematic textual analysis with the combination of deductive and inductive methods was used.

RESULTS
Based on the performed data analysis, different codes with three main categories evolved (Fig. 1). -Partner is at least 28 weeks pregnant, and the pregnancy is without complications.
-The man has become a father within the last 5 years, the child was born after the 37th week of pregnancy vaginally, did not need additional medical attention after birth and is healthy.
First-time father and/or already has children: -Partner is less than 28 weeks pregnant and/or the pregnancy is high-risk.
-The man became a father more than 5 years ago, and/or the baby was born before the 37th week of pregnancy and/or the birth process was pathological and/or the baby needed medical attention after birth.

Societal influence on men's participation during the ante-and postnatal period
To adequately understand how to support men's engagement during the ante-and postnatal period, the research had to first establish a baseline of the current situation men face. That involved understanding men's views on their participation during the ante-and postnatal period, as well as topics that they consider to be important, before giving any recommendations on how to best support men. The results of the interviews showed men to be in a complicated position as to how included they felt. The participants referred to the feeling of wanting to be there for their partners, without attributing that need to any type of pressure from the society, but describing their inclusion to be mostly dependent on themselves rather than being encouraged by any form of family-centred care. 'I did not find directly those sources that were supposed to support men or be for men. So, I think there is like no standard to match. It depends more on who you are yourself and what your closest people think -that pressure is there.' (Interview 13) This answer demonstrates how people's attitudes may be based on their own ideals but subconsciously also influenced by generally accepted social norms. With the lack of inclusive care matching women, it is men's task to guide themselves on the path to parenthood. It has to be kept in mind that views on men's participation can vary across cultures and not be applicable to all. However, for some there are general signs of person-and familycentredness becoming more relevant for men's inclusion during the ante-and postnatal period.
'It will take time for things to get better, but the direction is already right in my opinion. /.../ There have been more campaigns at the state level as well, where they encourage more and more /.../.' (Interview 4) Although this demonstrates a shift for the better from previous norms, it is also worth mentioning that participants were asked to elaborate on their experiences of a normal ante-and postnatal period and still they had felt a lack of support. This indicates a more dire situation for families where the ante-and/or postnatal period is considered pathological.
For men who wanted to be involved in the ante-and postnatal period, the topics considered important ranged from early foetal development to the delivery and tips on raising the child. The reasons why men considered these topics important varied as well, but generally included gaining confidence, being able to support their partner and being prepared for what is to come. Knowing what the process looks like in real life helped fathers overcome the stress related to being ready for the birth of their child. Knowledge on how to be prepared brought them inner peace that was necessary for them to feel ready. This also indicates how crucial it is for men to be able to find places where they gain information. Moreover, information that men find important may differ from what women tend to worry about or prepare for, showing the importance of a family-centred care approach which acknowledges the different roles family members have in similar settings.

Men's current use of information sources during the ante-and postnatal period
Having established that men indeed wish to be part of the ante-and postnatal period, it was important to investigate how they currently use available information. Therefore, a better understanding could be attained on how to improve information exchange and engagement of men during the ante-and postnatal period through the possible use of health communication tools.

'I don't know that there was a /…/ a memorable source. But I think that it is rather so that if you have a question, then you google first of all and you use what comes up first there.' (Interview 3)
The main information source men turned to was Google, which gave them access to an array of resources such as forums, hospital websites, blogs. When questioned about specific search results, the participants named none that they were specifically seeking out, although for many the Estonian Perekool.ee forum emerged as the top search result rather than any official source.
Family school courses were considered a good source to gain direct information from specialists in comparison to calling specialists, which was considered more as a last resort.
'The family school courses and the e-courses. Those were good /.../ some we visited together with my partner, some were only for the woman to take part. I just listened in at those as well, because /.../ let's say, two pairs of ears are better than one.' (Interview 4) As the answer indicates, family school courses are considered helpful, as it is a way of learning that one can experience together with the partner. It was noted by the participants who experienced the ante-and postnatal period during the COVID-19 pandemic that their involvement was negatively impacted, as men were not allowed to accompany their partners to hospital visits or on-spot family school courses. This demonstrates how the family-centred approach to sharing information is an important factor in engaging men and making them feel included, even if it currently means joining in at the lessons that are mostly meant for women.
Books and other paperback materials were mentioned as well, but were the choice of the minority. The latter may be due to the fact that most participants preferred digital information sources to non-digital because of the ease of access.
'Rather the digital sources. In that way it is easiest to gain info. You take out your phone or your computer. But you carry your phone with you everywhere, so yes, rather the digital choice.' (Interview 2) However, regarding digital materials, the participants commented that people may get confused by the sheer amount of new information. The main message here is that while easier to access, people need to be smart consumers of digitals sources to discern facts from hearsay. When discussing the use of Estonian sources versus foreign ones, most also turned to foreign webpages, applications and books, referring to wider availability of information.
'/…/ if it (the source) is in English, then there are like one, two, three hundred million people who can use the same app, there you have a better information exchange as well, there is like more of it (in comparison to Estonian sources).' (Interview 10) The downside of using foreign sources was described as the problem of being able to read foreign experiences and general information but finding it hard to place that information into the Estonian context.
'Yes, definitely (looked up) some things (using foreign sources). /…/ In Estonian there are so many translated materials and, well, some of them are well… it can be considered a waste of time and energy that the material has even been translated in the first place. It seems like some of it has already originally been of questionable nature, not wrong /.../. They include the American healthcare system. That is, well, totally inapplicable to us.' (Interview 1) This again indicates the need to provide men with context-specific information, as differences in both cultural and healthcare systems in each country affect the nature of the content, also the level of men's participation. Context specificity is explicitly the cornerstone of offering person-centred care by focusing on the individual's environment and needs. Purely translating the materials into Estonian to boost the amount of information sources is not the key to accessing knowledge, as it may lead to creating more confusion. Generally, when referring to information availability and sufficiency, the participants felt that they can get access to information about the ante-and postnatal period but they do not have access to information created with their experience and engagement as the focal point.
'Well, the amount available to men is likely the same /.../. As to availability, it is the same as for women. But the amount that is focused on men. I think that I cannot currently say that there would be a lot of it (information). /…/.' (Interview 7) The participants described that they were able to cope with the current information made available mainly from the women's point of view, but did mention that they felt better informed and engaged when exposed to information or situations focused on them. Some mentioned the lack of direct content as the reason why some men show modest interest during the ante-and postnatal period. When questioned about the reliability of the sources they use, the participants demonstrated an ability to be aware of the reliability of the sources they used and considered questioning information found on Google to be an elemen tary skill. However, this is mainly indicative of the sample group and cannot be attributed to the general population.
As the study was conducted during the ongoing COVID-19 pandemic, the participants were asked about their experiences of the pandemic, whether it influenced their information access and needs during the ante-and postnatal period.
'/.../ comparing pre-COVID times and now, then I am afraid that there is more confusing information that affects you as well.' (Interview 9) The COVID-19 pandemic has had an impact on men's information needs and sense of engagement because it has influenced information availability, reliability and access to services. Very few of those impacts were positive and the majority were negative. One of the interviewees, who was a medical professional himself, sensed a lack of information when his partner was pregnant with their first child. He was only able to get reliable and adequate information due to his connections in the hospital itself. Therefore, for people with no connections with medical professionals, the sensed lack of information could be significantly more dire. The experience indicated that responsibility does not only lie with the men who seek information, but also with the system that provides the information and support.

Men's expectations regarding information sources
Men did consider it to be important that information be conveyed to them from their point of view. They would be interested in a range of ways of gaining information directed at them about the ante-and postnatal period, indicating the necessity of a multifaceted approach, including the general use of webpages, optimising the use of hospital homepages, family school courses and an increase in unspecified types of materials marketed to men. A one-size-fits-all solution is not the right way to try to support men's information needs during the ante-and postnatal period. One would need different types of sources and information, presented by different stakeholders, to put together the large picture.
'/…/ How to reach those people (the men)? I call Tanel (Padar -an Estonian celebrity), let him speak about his experience, I talk about my experience, 50 men in the room and we talk about things honestly, through dark humour, through jokes. /.../.' (Interview 9) Men wish to get honest, real-life advice, not the watered-down version of how things are during the anteand postnatal period. When questioned about the interest in a patient portal based solution for men, the general response was positive.
'If it (patient portal) were easily /.../ and simply available, then I believe it would be a great help. /…/ It should be made user-friendly and marketed so that men would know of its existence, and it should include all the information available. So, you would not have to search too much, so that it would be included in that particular system, so you would not have to click between different links to finally arrive at the information you need /.../.' (Interview 7) The requirements for a patient portal based solution to be the preferred source for men was that it would be well structured and easily available when searching for information on Google. Without those characteristics, the idea of creating an information source aimed at men would fail to find any users. Also, having all the information put in one place is not a solution itself but depends on the structure of the source. The question is not about whether men are capable of finding information about the ante-and postnatal period, but how a systemic approach is necessary to help them feel supported stepping into the role of a parent. The creation of a patient portal could bring the most important information to men, making the shared knowledge relatable and more widely talked about.

DISCUSSION
The results of this study provide a comprehensive insight into how multi-layered the topic of men's support and engagement during the ante-and postnatal period is. The interviewees agreed with the contemporary approach to the ante-and postnatal period, described also in the literature, whereby more and more men are expected to participate actively not only at the birth of their child but also wanting to be part of the whole process [13]. Findings from both this study and previous ones confirmed that despite changed expectations about men's participation, the amount of information and support available to them still ranges from limited to in some ways non-existent [20]. It therefore necessitates investigating how to best support men during the ante-and postnatal period and the methods to provide support, which are person-and familycentred in nature.
The results of this study also showed that men in Estonia mainly use the Internet to find information on the ante-and postnatal period. That does not, however, mean that sources provided by the Internet are somehow the best, mostly it only means that it is currently the best option men have at their disposal. Guidelines that are well defined on paper about integrating men into the care process do not currently find their way into mainstream healthcare practises, indicating a lack of person-centredness from men's perspective. It should be noted, however, that simply creating something aimed at men does not suffice. As stated in previous research on how to improve a person's and family's engagement, service providers have to take into account what the end user actually needs in order to provide adequate support [15]. Be it digital versus non-digital, Estonian versus foreign sources, the results of the present study showed that men with a higher level of education, technical and language skills, and a proficiency in health literacy found themselves in a more favourable position when it came to navigating their participation during the ante-and postnatal period. This corresponds to the 2017 OECD statement that personcentred care cannot be achieved without first developing both people's health literacy and digital literacy skills [17]. Therefore, in order to achieve the goal of person-and family-centredness, the aspects that enable involvement should be developed in parallel.
As for the impact of COVID-19, the extent to which men felt isolated or restricted from access to information depended on whether they were first-time parents or not and whether they had had a childbirth experience before the pandemic began. The result is confirmed by an earlier study which also found that men felt more isolated because of the pandemic rules, referring to previous studies that described men feeling left out already in normal circumstances [21], signalling the negative effect of a healthcare crisis on the regular operations of healthcare service provision [15]. Thus, there is a need for a systemic approach to mitigate the severity of the effects of any possible future crisis on the provision of person-and family-centred care.
If health communication tools were to be used in order to enhance men's support and engagement during the ante-and postnatal period, it has to be noted that the problem of supporting men has not really been whether they manage to find information. Men are currently capable of coping with what they are offered. However, they do expect more and should be offered more support, which is created with them as a focal point, by specifically addressing special concerns seen from men's perspective, as described in the results of this study. Simply sharing information with men created with women in mind is not the solution. Knowing what men consider to be helpful information and solutions is a step in the right direction to make maternity care in Estonia more person-and family-centred.

STRENGTHS AND LIMITATIONS
The study contributes by providing a more comprehensive overview on how to support men during the ante-and postnatal period through means of health communication in a more person-and family-centred manner. As there have been no previous studies on how to support men in Estonia, the current findings offer the first steps in providing supportive services to them. Specialists actually need to know their target audience to create an appropriate service for them [15,22].
The methods used for the selection of the participants did pose a chance that the final sample may not be as diverse and representative of the general population. Although the possibility to make generalisations is limited, discontent in the sample group with the current level of support available during the ante-and postnatal period may indicate that the situation is even more dire for men with a lower skillset of languages, technical skills and health literacy.

CONCLUSIONS
Based on the findings of the study, it was concluded that independent and successful information navigation for men in Estonia during the ante-and postnatal period requires advanced skills in source criticality, as well as digital and health literacy, with few to no sources of information aimed currently at men, referring to a lack of person-and family-centredness. The responsibility to be informed does not only lie with the men who seek information, but also with the institutions and other entities that provide the information, and they must strive to improve information exchange in normal and crisis situations. When designing person-centred services, constant guidance and support from care mediators is mandatory, as men's engagement requires a systemic approach in terms of content as well as format, not a single one-time solution.