Digital Parenting Interventions for Fathers of Infants From Conception to the Age of 12 Months: Systematic Review of Mixed Methods Studies

Introduction

Background

Fathers play an important role within families during the transition to parenthood. Father involvement during the perinatal period (ie, from conception to 1 year following birth) and fathers’ access to knowledge about the transition to parenthood are important for perinatal mental health, improved adjustment to parenthood, and the provision of support from fathers to families [1]. New and expecting fathers are at risk of psychological distress in the perinatal period (eg, depression [2]), and these difficulties are associated with maternal postpartum depression [3,4], less and poorer quality of paternal involvement with their children’s development [5,6], and unhealthy lifestyle behaviors (eg, substance use [7]). Increased father involvement is associated with lower levels of depressive symptoms for fathers themselves [8]; better prenatal health behaviors, including decreased smoking and attaining prenatal care [9]; and early breastfeeding practices for mothers [10], as well as better neurodevelopment [11] and sleep duration and quality for infants [12,13]. Although all parenting partners and coparents play an important parenting role in the family, the World Health Organization has identified the importance of exploring effective strategies to increase the involvement of fathers in the process of pregnancy and childbirth to support mothers and their children, and there has been increasing recognition of the benefits of coparenting [14,15].

Research that aimed to investigate the needs and experiences of parents during the transition to parenthood found that fathers tend to report a lack of or inaccessible parenting information and supports specifically for fathers, as well as feelings of frustration about this lack of information in the antenatal period [16,17]. Resources targeted primarily toward mothers without being adapted for fathers can be ineffective as fathers’ needs can differ from those of mothers during the transition to parenthood [18,19]. Fathers have identified inflexible working practices, gaps in service, sleep deprivation, a lack of infant care skills, and feeling excluded by health professionals as specific barriers to receiving health information during the transition to parenthood [1,20]. Fathers have expressed the need and desire for access to relevant, accurate, and up-to-date information on infant care and challenges associated with new parenthood as well as the availability of support services [1,21]. Specifically, first-time fathers have described the need for more information on the demands of fatherhood shortly after birth, as well as how to recognize when to reach out for mental health supports [1]. In a video-modeled play intervention, fathers supported that 4 months postpartum was the right time to start the program, with some expressing interest in a higher frequency of home visits (ie, monthly) and having the intervention extended to a 1-year duration [21]. Moreover, the pandemic has been particularly burdensome for individuals in the transition to parenthood as it has unexpectedly altered the standard approaches to pregnancy and childbirth care, with many countries restricting access for fathers (ie, primary caregivers who are individuals who identify as male) and parenting partners (ie, any individual who supports the birthing parent) to attend medical appointments before and after the birth of their children [22]. Visitor restriction policies in hospitals were also found to be disproportionately harmful to racially diverse communities [23]. Thus, the pandemic has weakened the support offered to fathers, who have historically been less involved.

eHealth, which is the use of technology in the provision of health services [24,25], has become increasingly popular [26]. Extending eHealth to intervention delivery (referred to as digital interventions hereafter) helps address some of the common barriers associated with engaging with traditional health care services, such as accessibility, costs, availability, and time [1,27,28]. A key advantage of digital health interventions is their potential for scalability. During the COVID-19 pandemic, factors such as social and public health protections paired with additional childcare responsibilities for families and economic uncertainty contributed to increasingly challenging access to in-person services worldwide [29,30]. Parents often seek both information and support on the internet [31,32], and meta-analyses have shown that digital programs designed for parents are effective in improving parenting skills and child outcomes [33-35]. As such, complete or partial digital delivery of interventions has become increasingly beneficial during this time [36,37] and holds great potential for supporting fathers.

Although digital interventions exist for parents, they are often oriented toward mothers (ie, birthing parents or primary caregivers who are individuals who identify as female) rather than fathers and parenting partners or coparents [38,39], who have historically been underrepresented and excluded from parenting research [15]. For example, a recent systematic review of studies examining the efficacy of mobile interventions from conception to 1 year postpartum included fathers. In total, 3 of 12 studies including fathers were identified. Although the results suggested that both mothers and fathers benefited from the mobile interventions, the lack of data prevented the ability to draw conclusions regarding the relative mobile app effectiveness, and the authors suggested that future studies including fathers are needed [40]. In contrast to the growing popularity and promising findings of digital programs for mothers in the perinatal period [41-45], the authors of this review are not aware of any other reviews that have examined digital interventions (including any digital modalities) for fathers of young children.

Technology is widely used by new and expecting fathers as a source of parenting information, with fathers showing a strong interest in using internet-delivered strategies for mental health and parenting supports during the transition to fatherhood [46,47]. Although traditional health services, monitoring, and psychoeducation provided by health care clinicians are often key aspects of prenatal care [48], many fathers turn to digital technology to support them during their transition to fatherhood. For instance, fathers report enjoying and benefiting from listening to the stories of other fathers who have gone through similar experiences [49]. Web-based father support groups are being increasingly used by fathers, and as such, these are an important resource [47,50]. Although these types of informal support groups are valuable, evidence-based interventions that have been evaluated in controlled clinical trials with fathers specifically are crucial in ensuring effective support for fathers and, in turn, families in the transition to parenthood.

Objectives

Father-targeted digital interventions are a promising avenue for promoting the health of families. The perinatal period is critical and time sensitive, wherein more paternal involvement and less maternal parenting stress can positively influence infant development [51]. Digital interventions offer a unique opportunity to re-examine how interventions can be more inclusive of fathers throughout the perinatal period to promote and maximize the benefits of father involvement. Therefore, this systematic review aimed to describe the digital interventions that exist or are currently being developed for fathers of infants—from conception to 12 months postpartum—to provide the foundation for future development, testing, and implementation of digital interventions for fathers. For the purpose of this review, digital intervention is defined as an intervention in which the digital component is crucial to program delivery (ie, the intervention could not have been delivered in an alternate format or an in-person portion was not substantial enough to be the only component of the intervention). In recognition of the unique roles and experiences of fathers [1,16,17,20], this review is focused on the term fathers rather than parenting partners.

Methods

Eligibility Criteria

This systematic review was conducted and reported in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [52]. The articles had to describe a digital intervention that targeted fathers of fetuses and infants up to the age of 12 months. The inclusion and exclusion criteria for the papers are presented in Textbox 1.

Search Strategy

The MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials, Embase (using Ovid), and CINAHL (using EBSCO) databases were used to identify studies from database inception to June 2022. The original search was conducted from April 2020 to May 2020 and identified 1614 studies, and the updated search from May 2022 to June 2022 identified the remaining 395 articles. Table 1 presents an example of the search strategy used, and Tables S1-S4 in Multimedia Appendix 1 present the search strategies for all other databases, which were drafted in consultation with an academic librarian. Following this search, a team of researchers—a PhD (EK), a PhD student (EBX), a Master of Sciences student (JWJ), and an undergraduate student (JK)—independently screened all titles and abstracts and full-text articles. In total, 2 researchers independently reviewed all abstracts and full texts, and additional authors (KMB and LTM; PhD) reviewed and resolved all conflicts that arose. Before extraction, protocol papers and trial registrations underwent a forward reference review by JWJ and JK to identify whether there was a subsequent published article following the protocol paper or trial registration. No backward reference review was conducted. Of the 39 studies included, 4 (10%) were added following the forward reference review (in lieu of the protocol or clinical trial registration that preceded it).

Data Extraction and Synthesis

Extracted data for each intervention were tabulated according to the year of publication to assist in understanding any changes in intervention characteristics over time. Extracted data on study characteristics and the results of each study were tabulated according to the intervention’s primary topic of interest. Results were synthesized narratively. To assist with the synthesis of both qualitative and quantitative data, we used a parallel results convergent synthesis design, which consists of independent syntheses of quantitative and qualitative evidence with an interpretation of the results in the Discussion section [53,54]. Consistent with this approach, we analyzed and described the findings separately with some integration in the discussion because of limited qualitative research. For the qualitative studies with data on acceptability, feasibility, and usability, we used a textual narrative synthesis that involved dividing the studies into homogeneous groups and comparing similarities and differences across the studies [54]. Quantifiable data were tabulated, and frequency and percentages were calculated. Owing to the heterogeneity of the study designs, measures, and outcomes, we were unable to conduct inferential statistics. However, to understand the potential trends of the intervention characteristics on intervention effect, we further examined studies that used a randomized controlled trial (RCT) design by calculating the proportion of studies with particular intervention characteristics (ie, exclusively eHealth, digital or in-person human contact, and type of technology used) within studies that demonstrated significant intervention effects. This approach allowed the researchers to summarize a wide range of interventions and diverse study outcomes in a systematic way.

Pilot extraction was performed for reliability, and then extraction was completed independently by EK, EBX, JWJ, and JK. Data on study design, study aim, target population, intervention period, sample size, and study outcomes (eg, infant feeding, parenting knowledge, parenting self-efficacy, child outcomes, and parental mental health) were extracted and tabulated according to the primary intervention topic. Intervention descriptions were extracted and then characterized based on whether they were exclusively eHealth, meaning they were “stand-alone” and did not have a component that depended on an in-person interaction with a human provider, or a blended intervention, meaning that they had both digital and in-person components (eg, paper handouts, handbooks, newsletters, in-person parenting classes and parent support groups, and home visits by and discussions with health care professionals). Interventions were also categorized based on whether the intervention could be personalized to the participant’s needs and context or if it was standardized. Data on the types of digital modalities (eg, website, mobile app, SMS text messaging, social media, online video, email, or videoconference) that were included in each intervention were also tabulated. The favorability of the interventions was assessed and determined based on the reported acceptability, satisfaction and usability of the intervention or the rate of participant adherence and engagement. Interventions were categorized as favorable if there was an adherence or engagement rate of >60% or if >60% of the participants identified satisfaction, acceptability, or usability of the intervention. For studies with quantitative data on intervention effectiveness, statistically significant intervention effects were categorized based on P values (<.05).

Quality appraisals of each included article were conducted by the research team (EBX, JWJ, and JK) and verified by EK or KMB using the Mixed Methods Appraisal Tool (MMAT) [55]. The MMAT includes 2 screening questions (ie, whether there are clear research questions and whether the data allow for addressing the research question) and 5 quality criteria for each type of study design (ie, qualitative, quantitative RCT, quantitative nonrandomized, quantitative descriptive, and mixed methods). The questions in each domain are answered with “yes,” “no,” or “cannot tell.” The MMAT has been shown to be a reliable tool for reviews that incorporate diverse study designs [56] and provides overall methodological scores calculated as a percentage, from 0 (poor quality) to 100 (high quality). As in other reviews, scores were calculated as percentages based on the number of criteria met [57,58] to inform the quality of the studies and gauge the level of confidence in the study results. Mixed methods studies included both qualitative and the appropriate quantitative scores in their final MMAT score calculation.

Results

Overview

The search strategy retrieved 2816 articles, 803 (28.52%) of which were identified as duplicates, leaving the remaining 2013 (71.48%) titles and abstracts that were screened for eligibility. At the title and abstract screening stage, 93.39% (1880/2013) of the articles were excluded as irrelevant. Another 94 articles were excluded at full-text review, leaving the remaining 39 (29%) of the 133 studies that met the inclusion criteria and were included. Notably, 35% (33/94) of the articles were excluded from this review because the digital component was very minor, such as the use of DVDs, PowerPoint presentations, or videotape feedback that were reviewed in face-to-face sessions or phone calls (eg, [59-66]). Another 2% (2/94) of the articles were excluded because of the small percentage of fathers who were included in studies targeting couples (ie, 8.8% and 0.09% fathers; Figure 1) [67,68].

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Study Characteristics

Of the 39 peer-reviewed articles included, 1 (3%) described a protocol only; 1 (3%) described the development of the intervention as well as a study protocol; 9 (23%) described the development of the intervention only (ie, the intervention development was in progress); and 28 (72%) described the testing of the usability, satisfaction, or effect of an intervention. The studies included 29 unique interventions that were developed or tested in Canada (n=4, 14%), Brazil (n=1, 3%), the United States (n=7, 24%), Finland (n=1, 3%), China (n=2, 7%), Australia (n=6, 21%), Iran (n=2, 7%), Singapore (n=1, 3%), Turkey (n=1, 3%), South Korea (n=1, 3%), Denmark (n=1, 3%), Italy (n=1, 3%), and the Netherlands (n=1, 3%) between 2003 and 2022. The most common study designs were RCTs (14/39, 36%; 2/14, 14% of which were proposed studies) followed by quantitative nonrandomized studies (7/39, 18%). Table 2 provides more detailed descriptions of the study designs.

Intervention Characteristics

In total, 31% (9/29) of the interventions clearly described a guiding theory (eg, self-efficacy theory or social cognitive theory) underlying intervention development or testing. Of the 29 different interventions, fathers appeared to have been involved in co-designing less than half (n=10, 34%). Co-design techniques included strategies such as father involvement in focus groups and interviews during app development (ie, the Milk Man app) [90,91,103], surveys of fathers on their information needs and factors associated with the decision to visit a father-focused website [46], and the incorporation of feedback from fathers during SMS text message development (ie, SMS4Dads) [77].

Most of the interventions (22/29, 76%) were exclusively digital. The remaining 24% (7/29) were blended interventions. The most commonly used digital component across the interventions was a website or web-based portal (14/29, 48%). Other digital technologies that were used included SMS text messages (7/29, 24%), mobile apps (7/29, 24%), digital videos (5/29, 17%), email (4/29, 14%), videoconferencing (4/29, 14%), and social media (1/29, 3%). Notably, the 14% (4/29) of interventions using videoconferencing modalities were recent, with publication dates of 2021 and 2022 [87,102,103,105]. Some interventions (11/29, 38%) included more than one type of eHealth component, such as the use of websites and email communication (3/29, 10%), SMS text messages, website resources and modules (2/29, 7%), or a mobile app and website links (2/29, 7%). A total of 3% (1/29) of the interventions used 4 digital modalities: SMS text messaging, web-based videos, email, and videoconferencing [103]. Multimedia Appendix 2 [39,46,69-114] provides more detailed intervention descriptions.

More than half (22/39, 56%) of the articles described an intervention that targeted couples together (eg, both mothers and fathers or coparents). Only 26% (10/39) of the studies targeted fathers exclusively, 3% (1/39) targeted men only, and the remaining 15% (6/39) included both mothers and fathers. Just over half (21/39, 54%) of the articles described an intervention that was designed to be delivered from pregnancy through the postpartum period, whereas 33% (13/39) targeted the postpartum period only, and 13% (5/39) targeted the prenatal period only.

Quantitative Data Synthesis

When reviewing the study characteristics of interventions that had an effect (RCT design only; 13/29, 45%), 62% (8/13) detected intervention effects on a broad range of outcomes, including parenting knowledge, attitudes and confidence, parental mental health and perceived child sadness, father or partner prenatal engagement and presence during the birth, smoking cessation and exposure to secondhand smoke, and parent-child interaction quality. Of the 8 interventions that had significant results on the outcome of interest, 5 (62%) were exclusively eHealth (ie, were not part of a blended intervention with an in-person component) and 4 (50%) had a human intervention component (digital or in person). In terms of digital components, 60% (3/5) of the interventions that included a website had a significant effect, 75% (3/4) of the interventions that included SMS text messaging had a significant effect, 50% (2/4) of the interventions that included a mobile app had a significant effect, and only 33% (1/3) of those that used a web-based video had a significant effect. Of the 4 interventions that included more than one type of digital component, only 2 (50%) demonstrated a significant effect.

In terms of primary outcomes of the included studies, approximately half (21/39, 54%) had a primary outcome related to acceptability, usability, or satisfaction with the intervention. Of these 21 studies, 11 (52%) were examined for perceived favorability, with 8 (73%) being considered favorable by the review team and 3 (27%) being perceived to have unfavorable outcomes (see Table 3 for outcome summaries). The studies also evaluated intervention effects on outcomes such as coping, parental satisfaction, and parenting self-efficacy (12/39, 31%); coparenting (6/39, 15%); paternal mental well-being (6/39, 15%); parent-child relationship (5/39, 13%); infant feeding or breastfeeding (4/39, 10%); injury prevention (smoking cessation; 1/39, 3%); and infant physical health (weight gain; 1/39, 3%). Of the 18 studies primarily examining efficacy outcomes (ie, how effective the intervention was across various outcomes), 13 (72%) reported a statistically significant intervention effect. Statistically significant intervention effects were reported for father-child attachment and interaction [99,101,102]; knowledge about and attitudes toward participation in perinatal care [70]; smoking cessation and mothers’ secondhand smoking exposure [96]; parenting self-efficacy and satisfaction [72,74,104]; breastfeeding self-efficacy, knowledge, and infant feeding attitudes [89,92]; parental depression and child sadness [75]; and parental anxiety, depression, and quality of life [98].

Most of the included studies (31/39, 79%) used a convenience sample (ie, from clinics or health services, either self-selected or during a certain period, or a general convenience sample). In terms of study quality, MMAT scores ranged from 20% to 100%, with only 42% (15/36) of the articles meeting ≥80% of the MMAT criteria. In total, 25% (9/36) of the articles met all domain criteria, 17% (6/36) met 80% of the criteria, 28% (10/36) met 60% of the criteria, 19% (7/36) met 40% to 50% of the criteria, and 11% (4/36) met 20% of the criteria. A total of 8% (3/39) of the articles could not be appraised as they described protocols or processes [71,86,103]. Articles examining primary outcomes related to parent-child relationships, father mental health and well-being, injury prevention, and coparenting or partner support appeared to have slightly higher MMAT scores, with all scoring ≥60%. Articles examining primary outcomes related to parenting coping, satisfaction, self-efficacy, neonatal intensive care unit care, and parenting involvement appeared to have lower MMAT scores, with all scoring ≤60%. Articles examining primary outcomes related to infant feeding or breastfeeding and parenting skills and knowledge had a wider range of quality. Overall, a moderate level of confidence is expected from the results based on the quality of the studies included in the review, as indicated by the MMAT scores (Tables S1-S5 in Multimedia Appendix 3 [39,46,70,72-75,77,79,81-85,87-102,104,105,111]).

Qualitative Data Synthesis

The qualitative studies that were part of the review examined outcomes related to feasibility and usability as well as identifying findings related to user experience. Most articles (4/6, 67%) discussed interventions related to parenting skills and knowledge. In total, 50% (3/6) of the articles were on the SMS4Dads intervention, an intervention designed to deliver parenting skills and knowledge through SMS text messages and sometimes links to helpful websites [83-85]. The mixed methods articles similarly involved interventions targeting parenting skills and knowledge as well as infant feeding or breastfeeding. Most studies (4/5, 80%) examined outcomes related to the acceptability and feasibility of the intervention, with the exception of 20% (1/5) of the articles, which reported on intervention efficacy outcomes related to breastfeeding. All mixed methods studies included in this review involved interventions with a website component.

Overall, 40% (2/5) of the mixed methods articles described the aforementioned SMS4Dads intervention [77,78]. A common qualitative finding was the importance of providing support to partners during pregnancy and the postpartum period [77,80,84,90]. Another common qualitative finding involved the intervention helping fathers better understand their role and become more confident in their parenting [83,85,87]. A third common finding was the normalization of stress and fathers’ feelings of social connectedness in the intervention [83,84,90].

Of the studies that included a qualitative component (including the mixed methods studies), 55% (6/11) identified feedback from participants on their digital interventions. Participants generally reported having a positive experience with the digital interventions [77,78,92]. A total of 33% (2/6) of the articles similarly mentioned the importance of usability on mobile devices [69,92]. There was some discrepancy between the studies in terms of content. Participants in 17% (1/6) of the studies suggested simplifying the content included in the intervention [69], whereas participants in other studies reported wanting more specific solutions to specific problems [92] and suggested the inclusion of an additional tutorial [39]. Specific challenges with the digital interventions were also highlighted, such as the text being too small, wanting to personalize avatars, and content loading slowly, and a recommendation was made to make the intervention available during the prenatal period [39,92]. Finally, perceived barriers to father involvement included a lack of time and available resources [80,92]. Participants from 1 (17%) of these 6 studies suggested that making the intervention available during the prenatal period would provide fathers with more time compared with during the postpartum period [92].

In terms of MMAT quality ratings, the qualitative studies were of high quality, with 83% (5/6) of the articles meeting all criteria and 17% (1/6) that did not have an interpretation sufficiently substantiated by the data. For the mixed methods studies, 60% (3/5) did appear to have mixed methods designs but did not include an adequate rationale for using a mixed methods design to answer their research questions. No mixed methods studies included in this review met all the individual criteria for the quantitative and qualitative components involved in their methodology, which future mixed methods studies should consider in their study designs. These ratings suggest that we can have a high level of confidence in the findings of the qualitative studies. However, there is less confidence in the findings of the mixed methods studies.

Discussion

Principal Findings

To our knowledge, this is the first systematic review to describe studies on digital interventions (including any modalities) for fathers during the perinatal period. During the search, 39 articles were included that described 29 different interventions either under development or being tested across 13 different countries. There was a variety of digital components included in these interventions, classified into 7 distinct categories: web-based programs and websites, mobile apps, SMS text messages, digital videos, email, social media, and videoconferencing. On the basis of the MMAT appraisal, the articles included in this review demonstrated a range of quality levels (20%-100%), with a moderate quality level overall.

The interventions targeted a wide range of outcomes, including broader parenting outcomes (eg, self-efficacy, satisfaction, parent-child interaction, and infant knowledge) and father well-being as well as more specific outcomes related to breastfeeding and smoking cessation. However, most studies (21/39, 54%) focused on evaluating the feasibility, acceptability, and usability of the digital intervention or components of the intervention being developed. The emphasis on evaluating feasibility, acceptability, and usability highlights the growing interest in research on digital interventions for fathers of infants but also indicates the need for more rigorous research designs (ie, RCTs and high-quality mixed methods research designs) to determine if such interventions can result in improved health-related outcomes. With regard to feasibility and acceptability outcomes, of the 21 articles that examined them, just over half (12/21, 57%) provided basic descriptive results with no clear criteria for determining adequate feasibility or acceptability. To help address the lack of standardization in the evaluation of digital health interventions [115], future research on this topic should consider the use of well-established and validated measures such as the System Usability Scale [116]. The System Usability Scale is a 10-item questionnaire that can be used across various digital modalities, allowing for comparisons across interventions.

In studies that used an RCT design to evaluate the effect of the intervention on fathers’ knowledge, attitudes, behaviors, or health outcomes, the intervention topic did not appear to be related to whether the intervention was effective. Similarly, being an exclusively digital intervention or incorporating human interaction did not appear to be related to intervention effectiveness. There was also no clear trend in terms of which digital components were included in effective interventions, although it is notable that 75% (3/4) of the interventions that included SMS text messaging had a measurable impact on an outcome, whereas only 33% (1/3) of the interventions that included a web-based video had an effect. However, it is important to note that these results may not be generalizable because of the relatively small number of articles that could be compared.

The research team was surprised to discover that, despite being a common concern of new parents, there were no digital interventions that primarily targeted fathers’ sleep quality and quantity as study outcomes. This is consistent with a recent review highlighting that the role of fathers and other caretakers in infant sleep has been largely neglected [117]. This is problematic as sleep and mental health are challenges that have been expressed by new and expecting fathers and issues that have been identified as a patient-prioritized research gap from conception to the age of 24 months [118]. Fathers have identified wanting information related to managing sleep improvements [46]. Among the included studies, only 3% (1/29) of the interventions examined secondary father sleep outcomes [97], although there were no significant effects of this intervention on sleep outcomes. The only other studies that examined sleep focused on infant sleep outcomes, and they were also sparse. A total of 3% (1/29) of the interventions included a module on sleep and explored parenting self-efficacy items related to infant sleep; however, this was also nonsignificant [88]. Furthermore, an article that described intervention development examined levels of father self-efficacy related to infant sleep [73], and a protocol paper included safe sleep as a proposed secondary outcome [71]. Moreover, only 5% (2/39) of the studies primarily examined paternal mental health outcomes [97,98], one of which found significant intervention effects on mental health outcomes (parental anxiety and depression) [98]. In total, 5% to 15% of fathers in the perinatal period experience depression or anxiety, and perinatal illness contributes to adverse child and family outcomes, making paternal mental health an important target of intervention [119]. Additional development of digital interventions for fathers focused on mental health, which should include sleep as an important component of mental health, appears to be an underdeveloped area of research.

Few studies included in this review (11/39, 28%) measured or were planning to measure behavior change outcomes among fathers (ie, adjustments in behaviors, such as the implementation of parenting strategies, rather than a reported change in knowledge or attitudes). Although feasibility and fathers’ beliefs and knowledge about infant care are important, they may not necessarily lead to observable behavior change and parenting strategies, which are important for conferring secondary benefits for children and families [120,121]. For instance, Lavin Venegas et al [81] found that, although individuals in an intervention group designed to teach parents effective pain management strategies to use with their infants undergoing painful procedures reported intentions to use or advocate for the use of pain management strategies, there were no significant group differences in the actual use of pain management strategies. Therefore, future research should test interventions that target modifiable behavioral factors.

In contrast to the current state of the digital intervention literature for mothers in the perinatal period, digital intervention research for fathers lags behind, particularly with a lack of evidence regarding their effectiveness. For mothers, a systematic review suggested the effectiveness of digital tools in maternal health education, with a steady increase in studies in this area, particularly during the prenatal period, in the last decade [41]. Digital interventions have been shown to be effective in improving postpartum depression [42,43], treating insomnia during pregnancy [45], and preventing alcohol consumption [44]. There are mixed findings regarding their effectiveness for other mental health outcomes (eg, anxiety); psychosocial outcomes, including perceived stress, coping, and self-efficacy [42,122,123]; and physical health outcomes [124]. However, past reviews and meta-analyses suggest promising evidence, including cost-effectiveness [125], for the use of digital interventions for mothers during the perinatal period [123]. The focus of the literature on maternal-focused digital interventions seems to be on efficacy testing and implementation, whereas digital interventions for fathers appear to still be in their infancy, with more work being focused on intervention development and the feasibility and acceptability of these novel interventions. Given the effectiveness of digital interventions for mothers, pursuing this work with fathers is likely a worthwhile and promising avenue.

There may be continued challenges related to father recruitment and engagement in digital intervention research during the perinatal period. Only 26% (10/39) of the included studies (3/10, 30% of which tested the SMS4Dads intervention) [78,79,83] specifically recruited fathers, whereas the other studies recruited only couples or both. It is possible that traditional gender roles, such as fathers providing economically for their families and the stereotype that fathers are less involved in interactions with children compared with mothers, contribute to the relative absence of fathers in parenting research and the challenges with father recruitment and engagement [126].

Although there was limited qualitative research included in this review, the limited qualitative findings align with the quantitative results by suggesting that fathers are generally supportive of eHealth interventions and that they find such interventions to show promise in building parenting confidence and knowledge and promoting support toward partners. Qualitative findings also support the need to adapt digital interventions to accommodate father-specific needs and barriers. Suggestions from qualitative studies include mobile compatibility of web-based programs and making programs available during the prenatal period, when fathers may have more time compared with during the postpartum period.

Given the unique needs of fathers and their reported barriers to traditional health services [1,18-20], along with the potential for digital interventions to overcome these barriers, the development of digital interventions could be conducted specifically with fathers in mind. For instance, research can incorporate the use of patient advisory boards to ensure that the needs of patients are being met in a comprehensive way [127]. Past research has found couple-based interventions to be advantageous for parents as they can promote partner support of father involvement [15,128]. Although many of the current interventions are aligned with this as they target partners, future research could explore whether the effectiveness of interventions on fathers differs as a function of whether they are delivered solely to fathers or both partners simultaneously, specifically in a digital context.

Limitations

This review is limited by the lack of data available in the existing literature on the assessment of how digital interventions may be differentially beneficial to various groups (eg, racial minority groups and those of low socioeconomic status). This is problematic as parents who are ethnically diverse and in lower socioeconomic groups tend to experience higher levels of parenting stress and conflict [129]. Furthermore, no studies described interventions for fathers in same-sex relationships or for gender-diverse individuals (with the exception of the study by Abbass-Dick et al [92]), which should be explored in future research and reviews. Additional research is needed to ensure that digital interventions are inclusive of all fathers and diverse family configurations.

Future Directions

There appears to be a growing interest in the feasibility and acceptability of digital interventions for fathers of infants. Interventions for fathers have also been and are being developed to improve broad parenting abilities (eg, coparenting and parenting self-efficacy) and address specific topics (eg, smoking cessation and infant feeding). However, there is a need for more efficacy trial testing and also for interventions that target outcomes such as sleep and fathers’ mental health. Future research should also aim to improve the recruitment and engagement of fathers in perinatal studies as studies specifically examining fathers in parenting research were sparse and studies focusing primarily on mothers do not capture the full parenting picture. Furthermore, future studies should ensure that interventions are developed and tested in representative and generalizable samples. Interventions should aim to target father-identified priorities through direct partnerships with diverse patient populations [130].

Conclusions

Leveraging digital technologies to develop and deliver interventions could help address barriers to traditional health care services that are specific to fathers. However, there seem to be mixed findings regarding the feasibility, acceptability, and efficacy of the existing digital interventions and the interventions under development. Future research on digital intervention development and testing is needed, and strategies to reach more fathers should be explored. Researchers may consider incorporating patient advisory boards to ensure that interventions address the specific needs of new and expecting fathers.