Survey on Elderly Policy in Hong KongPDF... · 2015.A8.030.16A.A6 Project Title : 項目名稱： Association Among Father Involvement in Pregnancy and Childbirth, Pregnancy Violence

PUBLIC POLICY RESEARCH FUNDING SCHEME

公共政策研究資助計劃 Project Number : 項目編號：

2015.A8.030.16A.A6

Project Title : 項目名稱：

Association Among Father Involvement in Pregnancy and Childbirth, Pregnancy Violence and Health Outcomes: Does It Help Promote Good Health Among Newborns, Mothers, and Fathers? 父親在懷孕及嬰兒出生期間的參與能否促進嬰兒、母親

及父親健康？

Principal Investigator : 首席研究員：

Professor CHAN Ko Ling Edward 陳高凌教授

Institution/Think Tank : 院校／智庫：

The Hong Kong Polytechnic University 香港理工大學

Project Duration (Month): 推行期 (月) ：

12

Funding (HK$) : 總金額 (HK$)：

649,035.00

This research report is uploaded onto the Policy Innovation and Co-ordination Office’s

(PICO’s) website for public reference. The views expressed in this report are those of the Research Team of this project and do not represent the views of PICO and/or the Assessment Panel. PICO and/or the Assessment Panel do not guarantee the accuracy of the data included in this report.

Please observe the “Intellectual Property Rights & Use of Project Data” as stipulated in

the Guidance Notes of the Public Policy Research Funding Scheme. A suitable acknowledgement of the funding from PICO should be included in any

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The English version shall prevail whenever there is any discrepancy between the

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Association Among Father Involvement in Pregnancy

and Childbirth, Pregnancy Violence and Health

Outcomes: Does It Help Promote Good Health Among

Newborns, Mothers, and Fathers?

PUBLIC POLICY RESEARCH FUNDING SCHEME

Final Report

Submitted by Professor CHAN, Ko Ling Edward

Department of Applied Social Sciences,

The Hong Kong Polytechnic University

December 2017

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Principal Investigator Prof. CHAN, Ko Ling Edward Department of Applied Social Sciences The Hong Kong Polytechnic University C-Investigators FONG, Daniel Yee Tak

Associate Professor (Non-clinical)

School of Nursing, LKS Faculty of Medicine, The University of Hong Kong

FUNG, Tak Yuen

Chief of Service Department of Obstetrics and Gynaecology, Hong Kong Baptist Hospital

IP, Patrick Clinical Associate Professor

Department of Paediatrics & Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong

LEUNG, Wing Cheong

Chief of Service Department of Obstetrics & Gynaecology, Kwong Wah Hospital

TIWARI, Agnes Fung Yee

Professor and Head

School of Nursing, Hong Kong Sanatorium & Hospital

TOLMAN, Richard M.

Professor School of Social Work, University of Michigan, Ann Arbor, USA

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Table of Content

Abstract ...................................................................................................... 6 I Introduction ....................................................................................... 9

1. Introduction ................................................................................................... 9 Key issues and problems ............................................................................... 9 Conceptualization and operationalization of father involvement ................. 9 Father involvement and the health of fathers, mothers, and newborns ...... 10 Possible mechanisms of father involvement and health .............................. 11

2. Research questions and hypotheses ............................................................. 14 Relevant work done by investigators ........................................................... 15

II Research Methodology ................................................................... 16

3. Research methods ........................................................................................ 16 Sample and sampling procedures of the cohort study ................................. 16 Inclusion and exclusion criteria .................................................................. 16 Data collection procedures.......................................................................... 17

4. Summary of Objectives addressed .............................................................. 18 III Research Findings ........................................................................... 20

5. Demographic characteristics ....................................................................... 20 Age, educational attainment and marital status .......................................... 20 Chronic illness and diagnosed mental illness ............................................. 21 Economic characteristics ............................................................................ 22

6. Planned pregnancy ...................................................................................... 23 Proportions of planned pregnancy .............................................................. 23 Planned pregnancy by age, educational attainment and marital status ..... 24 Planned Pregnancy by Chronic health conditions and diagnosed mental illness ........................................................................................................... 25 Planned pregnancy by economic characteristics ........................................ 26

7. Prevalence and patterns of father involvement ........................................... 27 Father involvement on daily housework and emotional support ................ 27 Father involvement during pregnancy or after delivery ............................. 28

8. Health outcomes .......................................................................................... 29 Chinese Edinburgh Postnatal Depression Scale (CEPDS) and Depression Anxiety Stress Scales (DASS) ...................................................................... 29

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9. Association between father involvement and health outcomes ................... 31 Depression Anxiety Stress Scales (DASS) – Stress ...................................... 31 Depression Anxiety Stress Scales (DASS) – Anxiety ................................... 33 Chinese Edinburgh Postnatal Depression Scale (CEPDS) ......................... 34

IV Conclusion ....................................................................................... 36

10. Policy implications and recommendations .................................................. 36 Policy implications ...................................................................................... 36 Recommendations ........................................................................................ 36

11. Dissemination of findings ........................................................................... 38 Publications ................................................................................................. 38 Conferences in which Papers Related to this Research Project were Delivered ..................................................................................................... 38

References ................................................................................................ 41

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List of Tables

Table 5.1: Age, educational attainment and marital status (%) .................................... 20 Table 5.2: Chronic illness and diagnosed mental illness (%) ...................................... 21 Table 5.3: Economic characteristics (%) ..................................................................... 22 Table 6.1: Planned pregnancy (%) ............................................................................... 23 Table 6.2: Planned pregnancy by age, educational attainment and marital status (%) 24 Table 6.3: Planned pregnancy by Chronic health conditions and diagnosed mental

illness (%) ................................................................................................. 25 Table 6.4: Planned pregnancy by economic characteristics (%) .................................. 26 Table 7.1: Father involvement on daily houseworks and emotional support reported by

mothers (%) ............................................................................................... 27 Table 7.2: Father involvement on daily houseworks and emotional support by planned

pregnancy (%) ........................................................................................... 27 Table 7.3: Father involvement during pregnancy or after delivery (%) ...................... 28 Table 7.4: Father involvement during pregnancy or after delivery (times and days) .. 28 Table 8.1: CEPDS and DASS by planned pregnancy (%) ........................................... 29 Table 8.2: CEPDS and DASS scores by planned pregnancy ....................................... 30 Table 9.1: Hierarchical regression analysis for DASS - Stress .................................... 32 Table 9.2: Hierarchical regression analysis for DASS - Anxiety ................................. 33 Table 9.3: Hierarchical regression analysis for CEPDS .............................................. 35

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Abstract

(English)

Association Among Father Involvement in Pregnancy and Childbirth, Pregnancy Violence and Health Outcomes: Does It Help Promote Good Health Among Newborns, Mothers, and Fathers?

(Chinese) 父親在懷孕及嬰兒出生期間的參與能否促進嬰兒、母親及父親健康？

Project No.: 2015.A8.030.16A.A6 Background

1. Father involvement during pregnancy and labor, as well as after the child is

born, is believed to have positive impacts on the health of fathers, mothers, and newborns. Evidence is needed to show how father involvement can be promoted, and how it affects public health in Hong Kong. Yet among researchers there is no consensus on the operationalization of the concept, making it difficult to compare between studies as well as to confirm the effectiveness of father involvement. This study aims at (a) exploring a holistic operationalization of father involvement during pregnancy and childbirth, (b) examining whether paternity leave and flexible working arrangement among fathers are useful for promoting father involvement, and (c) investigating how father involvement is associated with the health of father, mother, and newborn.

Methods 2. The study comprised 2 phases: the validation study and the population-based

prospective cohort study. In the validation study, a measure for the assessment of father involvement was developed and validated with a sample of 200 mothers. A total of 2,479 (originally planned sample size was 2,260) expectant fathers and mothers attending antenatal clinics in local public and private hospitals were successfully recruited, representing 78.3% successful response rate. Eligible couples were approached during weeks 32-36 of pregnancy and invited to participate in a survey to be conducted after childbirth. Structured questionnaires were employed to guide the participants’

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reporting on different aspects of father involvement, paternity leave, flexible working arrangement of father, health-related variables, pregnancy violence, and demographic characteristics. Descriptive statistics, multiple regressions and structural equation modeling techniques were conducted to address the study objectives. The high-quality dataset has allowed us to achieve all project objectives with good reliability.

Contributions 3. This study provides supportive evidence for the potential effectiveness of

father involvement during pregnancy and childbirth on the health of parents and the newborn in Hong Kong. Its findings inform policy related to paternity leave, flexible working arrangement, and the development of effective parenting programs for fathers. As one of the first studies to operationalize the concept of father involvement with both objective measures of time and resource commitment and subjective measures of emotional support perceived by mothers, this study provides insights for future research. Specifically, it facilitates investigation into the effects of various kinds of father involvement on the health of different family members. Furthermore, this study provides one of the first pieces of evidence on the effect of father involvement on the health outcomes of fathers, mothers, and newborns in Hong Kong.

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背景 1. 本研究旨在（a）探索對「父親在懷孕及嬰兒出生期間的參與」較全面的

界定與操作，（b）調查侍產假及彈性工作制度能否促進父親參與，及（c）研究父親、母親及初生嬰兒健康與父親參與的關係。

研究方法 2. 我們於第一階段邀請 200 位母親參與設計及驗證一份有關「父親參與」的

問卷。於第二階段，我們成功邀請 2,479 位 (原定計劃邀請 2,260) 在本港

醫院產前檢查的準父母作詳細問卷調查，成功率達 78.3%。合資格的準父

母於懷孕 32-36 週受邀參加本研究。問卷涵蓋父親參與、侍產假及彈

性工作安排、各成員健康、懷孕暴力及背景資料。我們使用複迴歸分析

及結構方程模式等方法分析研究數據。我們預計能夠達到全部目標。研究貢獻 3. 本研究針對分析父親在懷孕及嬰兒出生期間的參與對本地家庭及其成

員的影響，並調查侍產假與彈性工作安排能否促進父親參與。研究結果

有助政府關於侍產假及彈性工作制度的政策制訂，亦有助有關機構設計

更有效的父親教育課程。本研究為父親參與訂立一個較為全面的定義，

將有利於未來有關父親參與的研究。

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I Introduction

1. Introduction Key issues and problems

1.1 The effects of engaging fathers during pregnancy and labor, as well as after

a child is born, have attracted increasing research interest globally. Research shows such father involvement is associated with better physical and psychological health for mothers, newborns, and even fathers themselves (e.g., Bottorff et al., 2009; Dudgeon & Inhorn, 2004; Gungor & Beji, 2007; Platin, Olukoya, & Ny, 2011).

1.2 Hong Kong recently saw public interest in the impacts of father involvement

in pregnancy and childbirth rise when the government began providing statutory paternity leave under the Employment (Amendment) Ordinance 2014. However, there has been a debate on whether the provision of this benefit is useful to foster a supporting environment for the mothers and newborns, and whether the length of the leave matters. Evidence is urgently needed to determine whether paternity leave, flexible working arrangements for expectant fathers, and father involvement has positive impacts on health outcomes in Hong Kong.

Conceptualization and operationalization of father involvement 1.3 The involvement of men in reproductive health is receiving increasing

attention worldwide. Father involvement milestones which have been identified include men’s participation in parenting classes and during childbirth, and caring for newborns (Platin et al., 2011). In recent decades, there has been a growing amount of research on the effects of father involvement. However, studies often operationalize father involvement differently, making comparison of research findings difficult. Some studies operationalize father involvement as fathers’ participation in parental preparation classes and antenatal consultations and checkups (e.g., Madsen et al., 2002), whereas others investigate such involvement by assessing fa-thers’ presence and active participation during labor (Sullivan 1999), as well

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as their presence for ultrasound scans undertaken throughout pregnancy (Draper, 2002). Still others measure the concept by looking at fathers’ involvement in the care of newborns and mothers following birth (Sarkadi, Oberklaid, & Bremberg, 2008; Yogman, Kindlon, & Earls, 1995). Even more common is the use of level of emotional/psychological support afforded mothers during pregnancy and delivery and after birth (e.g., Gungor & Beji, 2007).

1.4 Although there is supportive evidence for the role father involvement plays

in promoting better family health, the positive effects of such involvement are difficult to compare. Without a comprehensive concept of father involvement, it is unclear whether all aspects of father involvement are necessary for better health or whether any one kind is sufficient; whether there is a particularly effective type of involvement (e.g. emotional support, which has been shown to be more preferred by women (Mickelson et al., 2006)); and/or whether the timing of involvement (such as at the antenatal stage, during childbirth, and in the postnatal period) matters. An evidence-based definition encompassing different aspects of involvement or commitment at various stages of pregnancy is clearly needed to improve our understanding of how and to what extent father involvement affects the health of family members and, in turn, guide professionals in developing effective guidelines for better paternal engagement and participation in childbirth. Based on the father involvement and social support literature, three major aspects of paternal involvement are identified: (a) availability of father during pregnancy, labor and after the child’s birth, which includes paternal presence during these periods; (b) emotional support as perceived by mothers; and (c) instrumental support, including the time and resources spent in taking care of mothers and newborns.

Father involvement and the health of fathers, mothers, and newborns 1.5 Father involvement during pregnancy and childbirth is often associated with

better maternal health. For instance, it has been related to a lower maternal mortality rate (Dudgeon & Inhorn, 2004), a shorter labor period (Gungor & Beji, 2007), a reduction in maternal pain, anxiety, and fatigue during labor (Chan & Paterson-Brown, 2002), and an increased partner satisfaction with their relationship (Bobdas-Salonen, 1998).

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1.6 Similarly, positive impacts on newborns’ health can be found in the father involvement literature. For example, paternal engagement decreases the likelihood of preterm birth (Ghosh et al., 2010), death (Dudgeon & Inhorn, 2004), and low birth weight (Teitler, 2000).

1.7 Interestingly, research also shows that father involvement during pregnancy

and childbirth also benefits the health of the fathers themselves (see review by Platin et al., 2011). The possible mechanisms of these beneficial effects include an increased likelihood of positive changes to fathers’ lifestyle that promote their health and well-being, such as smoking cessation or reduction (Bottorff et al., 2009) and an increased sense of maturity and responsibility during their partner’s pregnancy (Finnbogadottir, Crang, & Persson, 2003) that promotes the positive personal development of expectant fathers.

1.8 Although studies seem to agree that father involvement promotes good

outcomes among family members, past research has its limitations. A number of studies use only a small sample of around 50 participants (e.g., Gungor & Beji, 2007; Liamputtong & Naksook, 2003). Another limitation is that the mainstream research in this field has been conducted in Western countries, and relevant studies in the Asian context are scarce. The representativeness of existing findings is therefore questionable. Furthermore, there has been little differentiation between kinds and degrees of father involvement in terms of effectiveness; most studies investigate one kind of father involvement only. Existing studies have provided mixed findings, and some research has shown father involvement to have non-significant effects on maternal health. For example, two studies found no difference in obstetric indicators such as the use of painkillers and obstetric intervention during delivery between mothers who felt supported by their partners and those who did not (Draper, 2002; Ip, 2000).

Possible mechanisms of father involvement and health 1.9 Due to the lack of systematic and comprehensive empirical studies on father

involvement and health, the mechanisms underlying the associations between them remain inconclusive. Some preliminary research has suggested several possible pathways. For example, father involvement during and beyond pregnancy may promote paternal health by facilitating development of positive paternal health behaviors, such as cessation of smoking, alcohol consumption, or drug use (Bottorff et al., 2009;

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Finnbogadottir et al., 2003). These positive health behaviors among fathers do not only promote paternal health; they have been demonstrated to also facilitate both maternal and child health, possibly serving as a protective factor against poor pregnancy and obstetric outcomes, such as preterm birth and low birth weight (Huang et al., 2014).

1.10 Father involvement in childrearing has often been linked with marital

satisfaction between parents (Galovan et al., 2013). Research has shown that the level of a father’s involvement is positively correlated with his partner’s satisfaction with their relationship and, in turn, leads to a higher level of marital quality and stability (Kalmijn, 1999). The association between father involvement on and marital satisfaction may not be simply one-way. Past research has indicated that more marital satisfaction also helps initiate and sustain high father involvement (Kalil, Ziol-Guest, & Coley, 2005).

1.11 Violence against women during pregnancy is commonly found to affect the

health of mothers and newborns. It has been linked to poorer maternal psychological health (Tiwari et al., 2009), including pregnancy depression (Chambliss, 2008; Martin et al., 2006), postpartum depression (Tiwari et al., 2008), high stress levels (Valladares et al., 2002), as well as poor health behaviors such as increased use of tobacco, alcohol, and/or illicit drugs (Datner et al., 2007; Pallitto, et al., 2005). Partner violence has also been found to be a factor associated with decline in women’s perceived level of marital satisfaction (Stith et al., 2008).

1.12 Father involvement may interact with health behaviors, marital satisfaction,

and pregnancy violence to affect the health of fathers, mothers and newborns. As stated in the previous section, father involvement is very likely to be correlated with marital satisfaction (Galovan et al., 2013; Kalil et al., 2005). Seeing that pregnancy violence is also associated with health behaviors, marital satisfaction and health outcomes, it would not be far-fetched to link them together. However, empirical studies on underlying mechanisms are lacking, and there is insufficient evidence on how these variables interact. On one hand, it is possible that more satisfaction in marital relationships, which helps promote health, is found among mothers with highly involved and non-abusive spouses. On the other hand, it is equally possible that high marital satisfaction facilitates paternal involvement and reduces pregnancy violence, which in turn promotes better paternal, maternal and child health. Although the specific pathways of how

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father involvement, pregnancy violence and marital satisfaction interact to affect health are still unknown, one could expect a protective effect of father involvement on pregnancy violence and risks of negative health outcomes.

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2. Research questions and hypotheses 2.1 The shortcomings of the existing literature warrant a comprehensive study on

paternal involvement which: (a) cautiously conceptualizes and operationalizes father involvement during and beyond pregnancy; (b) systematically investigates various aspects of father involvement; (c) carefully tests the factors promoting father involvement, such as the availability of paternity leave and flexible working arrangements, and (d) empirically explores the possible mechanisms of father involvement and health among fathers, mothers, and newborns. Despite current efforts to investigate the health effects of father involvement in the whole childbirth process, a clear concept of such involvement that encompasses its various aspects is lacking. This study aimed at filling this research gap by conceptualizing father involvement in childbirth with the various aspects of father support and engagement included in the literature, and investigating the associations between those aspects and the various health outcomes of fathers, mothers, and newborns. Since paternity leave and flexible working arrangements would provide expectant fathers more available time, we made our first hypothesis as: 1. Paternity leave and flexible working arrangements would be positively associated with the level of father involvement.

2.2 Findings of previous research suggest that father involvement in childbirth

can be divided into three major categories: (a) fathers’ availability and accessibility during pregnancy, childbirth, and the postnatal stage; (b) emotional/psychological support; and (c) instrumental support in the form of shared responsibility for newborns. Accordingly, we had the second hypothesis as below: 2. Father involvement in childbirth, including availability, emotional support and instrumental support, would be positively associated with better health outcomes of fathers, mothers, and newborns.

2.3 Further, considering the individual relationships of father involvement with

health behaviors, marital satisfaction and pregnancy violence, as well as the individual associations of health outcomes of fathers, mothers, and newborns with the latter three variables (e.g., Galovan et al., 2013; Huang et al., 2014; Platin et al., 2011; Tiwari et al., 2009), we reached our third hypothesis: 3. The association between father involvement and health outcomes of fathers, mothers and newborns would be mediated by health behaviors (e.g. smoking, alcohol dependence and drug abuse), marital satisfaction, and pregnancy violence.

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Relevant work done by investigators 2.4 Our multidisciplinary team’s demonstrated expertise in managing large-scale

projects involving children, pregnant women and domestic violence has been the key to the successful completion of the proposed study. We have worked together on various related projects for about 10 years.

2.5 In 2005-2006, the research team completed the first territory-wide survey of

intimate partner violence (IPV) against pregnant women. A total of 3,245 pregnant women were sampled from the seven obstetrics and gynecology units of the Hospital Authority (HA). A number of papers have been published on the basis of the findings (e.g., Chan et al., 2009; Tiwari et al., 2007, 2008, 2009). In 2010, our team received RGC Public Policy Research Funding to conduct a longitudinal study tracking the effect of IPV against pregnant women on child abuse within the family.

2.6 One of the Co-Is (Tolman) is a pioneer in research into interventions that

engage fathers in order to prevent violence against women (e.g., Kimball et al., in press) and to protect children (e.g., Scourfield et al., 2012), and his work has informed the design of intervention programs for new fathers to prevent family violence. In particular, his participation in international investigations on the effect of men’s involvement on preventing violence against women has significantly contributed to the study (e.g., Casey et al., 2013).

2.7 Our team is also experienced in conducting population-based research on the

family. For example, the PI was in charge of a population study of child victimization in China in 2011 (Chan, 2013; Chan, Yan, Brownridge, & Ip, 2013; Chan, Yan, Fong, Tiwari, & Leung, 2013). A multi-stage stratified sampling procedure was adopted to identify eligible participants from Hong Kong and five cities in mainland China. To assess the experience of child victimization among Chinese adolescents, face-to-face interviews were conducted with 8,945 parents, 3,321 children, and 18,341 students. The PI also conducted the first population-based household survey on child maltreatment and spouse battering in Hong Kong. More than 8,000 participants were recruited, and the response rate was over 70% (Chan, 2005).

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II Research Methodology

3. Research methods Sample and sampling procedures of the cohort study 3.1 Expectant parents were considered a suitable target group for this study for

two major reasons. First, the use of this sample allowed prospective tracking. For example, their health, perceived support, and involvement during the antenatal and postnatal stages could be assessed separately in different phases of the study, which should reduce recall bias and errors that could confound the findings. Second, expectant parents were believed to be a very good target for violence prevention and intervention. As shown in a previous study by the research team (Chan et al., 2012), child maltreatment prevention may start as early as during pregnancy.

3.2 Recruitment was population-based. During the study period, pregnant women attending an antenatal clinic at any local hospital were randomly selected. Their spouse or partner, i.e., the father of the expected child, were also included. The birth order of the newborn, which has shown mixed effects of the time and quality of paternal involvement in past research (e.g. Price, 2006; Volker, 2014), was not a selection criterion in the proposed study, although it was recorded and controlled.

Inclusion and exclusion criteria 3.3 During the study period, all expectant mothers during 32 to 36 weeks of

pregnancy and their partners were eligible for inclusion. This stage of pregnancy was considered the most suitable entry point because: (a) the more stable conditions of the mothers and their babies could increase participation rates in a survey that requires about 15 minutes to complete; and (b) the shorter time period between the two surveys could reduce drop-out rates. Our team’s past experiences in similar settings had proven this kind of recruitment successful (Chan et al., 2009; Tiwari et al., 2009). To ensure the representativeness of the sample, no limit on expectant parents’ ethnicity or

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nationality was set. Expectant parents were excluded only if they did not understand Chinese (Cantonese or Mandarin) or English, which were the main languages used in the surveys. We estimated that fewer than 1% of the sample will be excluded based on this criterion. Participants were also excluded if they were under 18, if they were unable to give informed consent or communicate with the interviewers, or if their spouse/partner refused to participate.

Data collection procedures 3.4 Informed consent was sought from both expectant fathers and mothers prior

to study commencement. The pregnant women recruited were asked to report relevant information at the prenatal stage (between 32 and 36 weeks of pregnancy). Participants were asked for their contact details and expected delivery date, and to indicate their preferred means of completing the second survey (i.e., via phone, mail, e-mail, or face-to-face).

3.5 Within one to two weeks of the delivery date, the fathers and mothers of

newborns were given a structured questionnaire to guide their reporting of relevant information. They were encouraged to complete the questionnaire by themselves, although trained interviewers were available for help if needed. In case of a phone survey, trained interviewers read the questions to the participants and record their responses. Chinese (traditional and simplified) and English versions of all questionnaires, consent forms, and information sheets were available.

3.6 Both father and mother versions of the questionnaires were administered. In

the Phase 2 survey, mothers and fathers were asked to complete the questionnaires separately to ensure privacy. Participants were informed of the purpose of the proposed study and their right to refuse participation, to terminate the interview, and to ignore any item either verbally or in printed form. Anonymity and confidentiality was assured. No incentives were given to the participants.

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4. Summary of Objectives addressed 4.1 Statistical analyses were conducted to address the proposed objectives.

Descriptive statistics were used to characterize the sample and report the prevalence of different aspects of father’s involvement in childbirth, such as availability, emotional support and instrumental support of involvement.

4.2 For the analyses, appropriate statistical tests were conducted, depending on the nature of the variables. T-tests were conducted to study the difference between the mean scores of respondents whether the pregnancy was planned or not; and chi-square tests were used to study the association between pairs of categorical variables.

4.3 Multiple regression analysis was conducted to test whether paternity leave

and flexible working arrangements were significant factors for father involvement. Further, the associations between father involvement and the health of mothers were investigated using multi-phase regression analysis, with these health outcomes taken as the dependent variables.

4.4 All of the above statistical analyses were performed with the use of SPSS

23.0. In these analyses, p-values were calculated in order to evaluate the statistical significance of the results, with a p-value of less than .05 (p < .05) being considered statistically significant

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Summary of objectives addressed to date

Project Objectives

Percentage Achieved

1. To explore the prevalence and patterns of different aspects of father involvement, which includes availability at childbirth, emotional support, and instrumental support, in Hong Kong.

100%

2. To examine whether paternity leave and flexible working arrangement of fathers can increase the level of father involvement.

100%

3. To investigate the associations between father involvement and health outcomes of father, mother, and newborn, after controlling for the demographic background and pregnancy violence.

100%

4. To explore the possible mechanisms of the impact of father involvement on health outcomes of father, mother, and newborn.

100%

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III Research Findings

5. Demographic characteristics Age, educational attainment and marital status 5.1 A total of 2,485 mothers and fathers participated in the survey. As shown in

Table 5.1, the average age was 31.9 and 34.1 years for mothers and fathers, respectively. The distribution of educational attainment among mothers and fathers was similar. Over half of mothers (57.9%) and fathers (57.6%) had tertiary education or above. The majority of the participants (89.5%) were married; 3.3% lived as a couple; 5.1% had never been married; and 0.6% were widowed, separated or divorced.

Table 5.1: Age, educational attainment and marital status (%) Mothers (%) Fathers (%) Average age (mean) 31.9 34.1 Educational attainment

Below F.3 8.9 10.7 F.4 to F.6 32.9 31.3 Tertiary – Non- degree 12.8 12.0 Tertiary - Degree 32.4 30.4 Tertiary - Master/Doctor of Philosophy 12.7 15.2 Refused to answer 0.3 0.3

Marital status Never married 5.1 Living as a couple 3.3 Married 89.5 Widow/Separated/Divorced 0.6 Refused to answer 1.6

Total 100.0 100.0

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Chronic illness and diagnosed mental illness 5.2 Table 5.2 shows the health conditions of the participants. A total of 90.9% of

mothers and 91.6% of fathers reported that they did not have chronic illness. On the contrary, about 7.5% of mothers and 6.9% of fathers reported that had chronic illness.

5.3 Regarding mental health, 95.0% of mothers and 95.3% of fathers reported that they had never been diagnosed mental illness; only 0.5% of mothers and 0.1% of fathers were having mental illness at the time of the Phase 1 survey; and 0.7% of mothers and 0.5% of fathers reported that they recovered.

Table 5.2: Chronic illness and diagnosed mental illness (%) Mothers (%) Fathers (%) Chronic health conditions

No 90.9 91.6 Yes 7.5 6.9 Refused to answer 1.6 1.5

Diagnosed mental illness No 95.0 95.3 Yes, but recovered 0.7 0.5 Currently having mental illness 0.5 0.1 Refused to answer 3.7 4.1

Total 100.0 100.0

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Economic characteristics 5.4 As shown in Table 5.3, the majority of fathers (97.0%) were economically

active and about three quarters of mothers (76.1%) were economically active during week 32 to week 36 of pregnancy.

5.5 About 21.4% of the households in the survey had average monthly household incomes under $20,000; 26.6% of the households had household incomes between $20,000 and $39,999; a quarter of the households (25.0%) had household incomes between $40,000 and $59,999; 11.3% of the households had household incomes between $60,000 and $79,999; and 11.9% of the households had household incomes of $80,000 or above.

5.6 About of 3.4% of the households reported that they had received social

security. Table 5.3: Economic characteristics (%) Mothers (%) Fathers (%) Economic activity status

Economically active 76.1 97.0 Economically inactive 23.8 2.6 Refused to answer 0.2 0.4

Average monthly household income Below $20,000 21.4 $20,000 - $39,999 26.6 $40,000 –$59,999 25.0 $60,000 –$79,999 11.3 $80,000 or above 11.9 Refused to answer 3.7

Receiving social security No 94.9 Yes 3.4 Refused to answer 1.7

Total 100.0 100.0

23

6. Planned pregnancy Proportions of planned pregnancy 6.1 As shown in Table 6.1, about 84.5% of mothers reported that the pregnancy

was planned whereas the remaining of mothers (15.5%) reported that the pregnancy was unplanned.

Table 6.1: Planned pregnancy (%) Mother (%) Unplanned pregnancy 15.5 Planned Pregnancy 84.5

24

Planned pregnancy by age, educational attainment and marital status 6.2 Some demographic characteristics were analyzed and compared between

mothers with planned pregnancy and those with unplanned pregnancy. The average age of mothers with unplanned pregnancies was 29.9 years whereas the average age of mothers with planned pregnancies was 32.5 years. The age difference was significant (t = -5.418, p < .001).

6.3 There was a significant difference in the educational attainment between the mothers with planned pregnancy and those with unplanned pregnacy (χ² = 16.963, p = .002). The proportion of mothers who had planned pregnancies had significantly higher level of educational attainment (Tertiary - Degree and above; 49%) than those who had unplanned pregnancies (33.1%).

6.4 There was also a significant association between mothers’ marital status and

whether or not they had planned pregnancies (χ² = 46.455, p < .001). Approximately 95% of the mothers who had planned pregnancies were married; on the other hand, only 77.8% of those who had unplanned pregnancy were married.

Table 6.2: Planned pregnancy by age, educational attainment and marital status (%) Unplanned

pregnancy (15.5%)

Planned Pregnancy (84.5%)

Total t-test/

chi-square p-value

Average age (mean) 29.9 32.5 32.1 -5.418 <0.001 Educational attainment 16.963 0.002

Below F.3 15.4 7.5 8.8 F.4 to F.6 38.2 30.3 31.5 Tertiary – Non- degree 13.2 13.2 13.2 Tertiary - Degree 24.3 34.1 32.5 Tertiary - Master/Doctor of Philosophy

8.8 14.9 14.0

Marital status 46.455 <0.001 Never married 14.8 3.2 5.0 Living as a couple 5.9 2.0 2.6 Married 77.8 94.6 92.0 Widow/Separated/Divorced 1.5 0.1 0.3%

Total 100.0 100.0 100.0

25

Planned Pregnancy by Chronic health conditions and diagnosed mental illness 6.5 There was no statistically significant association between mothers’ chronic

health conditions and whether or not they had planned pregnancies (χ² = 0.009, p = .864), as shown in Table 4.3.

6.6 Also, there was no significant association between mothers’ mental health record and whether or not they had planned pregnancies (χ² = 4.58, p = .101). Generally speaking, the health conditions of mothers with and without planned pregnancies were similar.

Table 6.3: Planned pregnancy by Chronic health conditions and diagnosed mental illness (%) Unplanned

pregnancy (15.5%)


Total t-test/

chi-square p-value

Chronic health conditions 0.009 .864 No 91.8 92.0 92.0 Yes 8.2 8.0 8.0

Diagnosed mental illness 4.58 .101 No 97.1 99.1 98.7 Yes, but recovered 1.5 0.7 0.8 Currently having mental illness

1.5 0.3 0.5

Total 100.0 100.0 100.0

26

Planned pregnancy by economic characteristics 6.7 As shown in Table 4.4, while 79.6% of participants with planned pregnancies

were economically active, only 66.2% of participants with unplanned pregnancies were economically active, demonstrating a significant association between participants’ economic activity status and whether or not they had planned pregnancies (χ² = 11.828, p = .001). There was also a significant association between participants’ average monthly family incomes and whether or not they had planned pregnancies (χ² = 16.994, p = .002). Nearly one third of the participants with unplanned pregnancies had average monthly family incomes below $19,999, but only 17.1% of participants with planned pregnancies had such family incomes. There was no statistically significant association between whether or not the households received social security and whether or not the participants had planned pregnancies (χ² = 1.735, p = .192).

Table 6.4: Planned pregnancy by economic characteristics (%) Unplanned

pregnancy (15.5%)


Total t-test/

chi-square p-value

Economic activity status 11.828 .001 Economically active 66.2 79.6 77.5 Economically inactive 33.8 20.4 22.5

Average monthly family income

16.994 .002

Below $19,999 31.8 17.1 19.3 $20,000 - $39,999 25.6 25.9 25.8 $40,000 –$59,999 24.0 29.3 28.5 $60,000 –$79,999 7.8 13.4 12.6 $80,000 or above 10.9 14.2 13.7

Receiving social security 1.735 .192 No 94.8 97.0 96.7 Yes 5.2 3.0 3.3

Total 100.0 100.0 100.0

27

7. Prevalence and patterns of father involvement Father involvement on daily housework and emotional support 7.1 Table 7.1 shows mother’s reports on father involvement on daily housework

and emotional support given to mothers. Most of the mothers agreed that fathers took care of mothers’ diet and daily life (88.8%), helped with housework (89.1%), took care of children (94.1%), helped replace diapers (86.7%), fed the newborn child (84.5%), and would comfort the mothers when they were unhappy (94.4%). About 68.4% of fathers helped bathe the baby.

Table 7.1: Father involvement on daily housework and emotional support reported by mothers (%) Disagree (%) Agree (%) Taking care of my diet and daily life 11.3 88.8 Helping with housework 10.9 89.1 Taking care of the newborn child 5.9 94.1 Helping replace diapers 13.3 86.7 Feeding the newborn child 15.5 84.5 Helping bathe the newborn child 31.6 68.4 Comforting me when I am unhappy 5.6 94.4 7.2 Each of the seven items above were then given a score of 1 or 0 according to

the responses., and the items scores were summed up to give a total score reflecing mothers’ perception of father involvement on daily housework and emotional support. Table 7.2 shows the total scores of father involvement by planned/unplanned pregnancy. It was found that fathers with planned pregnancies had significantly higher level of involvement (mean score = 22.11) on daily housework and emotional support, compared to fathers without planned pregnancies (mean score = 20.53), t = -4.43, p < .001.

Table 7.2: Father involvement on daily housework and emotional support by planned pregnancy (%) Unplanned

pregnancy (15.5%)


Total t-test/

chi-square p-value

Father involvement 20.53 22.11 21.86 -4.43 <0.001

28

Father involvement during pregnancy or after delivery 7.3 As shown in Table 7.3, 91.4% of fathers attended antenatal checkup with

their wives, 86.3% of fathers saw ultrasound pictures during check-ups with their wives, and 88.0% of fathers took one day-off or more during pregnancy or after delivery. Slightly less than three quarters of fathers (74.1%) accompanied with their wives during delivery. More than half of the fathers (53.9%) attended parent education classes during pregnancy.

Table 7.3: Father involvement during pregnancy or after delivery (%) Yes (%) No (%) Antenatal check-up with his wife 91.4 8.6 Attending parent education classes 53.9 46.1 Seeing ultrasound pictures during check-ups with his wife

86.3 13.8

Had accompanied with his wife during delivery 74.1 25.9 Any day-off during pregnancy or after delivery 88.0 12.0 7.4 As reported by mothers, fathers attended antenatal checkups with their wives

for 6.2 times and had seen ultrasound pictures for 3.7 times on average during pregnancy. Fathers had applied for an average of 8.4 day-off during pregnancy or after delivery. Fathers had attended parent education classes for 2.1 times on average.

Table 7.4: Father involvement during pregnancy or after delivery (times and days) Times/days Frequency of antenatal check-up with his wife 6.2 Frequency of attending parent education classes 2.1 Frequency of seeing ultrasound pictures during check-ups with his wife

3.7

Number of day-off during pregnancy or after delivery

8.4

29

8. Health outcomes Chinese Edinburgh Postnatal Depression Scale (CEPDS) and Depression Anxiety Stress Scales (DASS) 8.1 Table 8.1 shows the proportion of mothers that had postnatal depression,

anxiety and stress presented by whether they had planned the pregnancy or not. About 9.3% of mothers who had planned pregnancies reported postnatal depression whereas 18.4% of mothers who had unplanned pregnancies reported postnatal depression. Besides, 92.1% of mothers with planned pregnancies reported a normal level of anxiety, but relatively fewer mothers (87.5%) with unplanned pregnancies reported the same level of anxiety. With regard to stress level, 92.5% of mothers with planned pregnancies reported a normal level of stress whereas 86.8% of mothers with unplanned pregnancies reported the same level of stress.

Table 8.1: CEPDS and DASS by planned pregnancy (%) Unplanned

pregnancy (15.5%)


Total

CEPDS Score No depression 81.6% 90.7% 89.3%

Had depression 18.4% 9.3% 10.7%

DASS Anxiety

Normal 87.5% 92.1% 91.4%

Mild 7.4% 5.5% 5.8% Moderate 2.2% 1.3% 1.5% Severe 2.2% 0.7% 0.9% Extremely Severe 0.7% 0.4% 0.5%

DASS Stress Normal 86.8% 92.5% 91.6% Mild 5.9% 3.8% 4.1% Moderate 5.1% 2.3% 2.7% Severe 2.2% 1.2% 1.4% Extremely Severe 0.0% 0.3% 0.2%

30

8.2 Table 8.2 shows the scores of postnatal depression, anxiety and stress analysed by whether they had planned the pregnancy or not. Mothers with planned pregnancies had significantly lower levels of postnatal depression (mean score = 4.17), compared to those without planned pregnancies (mean score = 5.29, t = 2.34, p = .021). Mothers with planned pregnancies had significantly lower levels of stress (mean score = 2.70), compared to those without planned pregnancies (mean score = 3.36, t = 2.10, p = .037). However, no statistically significant difference was found with regard to maternal anxiety between the two groups of mothers.

Table 8.2: CEPDS and DASS scores by planned pregnancy Unplanned

pregnancy (mean)

Planned Pregnancy

(mean)

Total (mean)

T-test statistics

p-value

CEPDS Score 5.29 4.17 4.35 2.34 0.021

DASS-Anxiety 1.53 1.22 1.27 1.61 0.110

DASS-Stress 3.36 2.70 2.80 2.10 0.037

31

9. Association between father involvement and health

outcomes Depression Anxiety Stress Scales (DASS) – Stress 9.1 Table 9.1 shows the results of a 4-phase hierarchical multiple regression for

maternal stress. In Model 1, being economically inactive (p < .05), having chronic health conditions (p < .01), and having diagnosed mental illness (p < .05) predicted higher level of maternal stress. Whether the participants had planned pregnancies or not was added to Model 2, however, it was not statistically associated with maternal stress. Father involvement on daily housework and emotional support was related to reduced stress as shown in Model 3 (p < .001). Fathers’ frequency of involvement during pregnancy or after delivery were added to Model 4. The frequency of fathers’ attending antenatal checkup with wife was related to reduced stress (p < .01), however, the frequency of attending parent education classes was found to increase maternal stress (p < .05). The frequency of seeing ultrasound pictures with wife, having accompanied with wife during delivery, and the number of day-off were not significant predictors.

9.2 In Model 4, being economically inactive, having chronic health conditions, having diagnosed mental illness, and father involvement were still significantly associated with maternal stress. Model 4 accounts for 7% of the variation in maternal stress.

32

Table 9.1: Hierarchical regression analysis for DASS - Stress Standardized Coefficients Model 1 Model 2 Model 3 Model 4 Age -0.007 0.005 -0.004 -0.004 Education level 0.071 0.076 0.085* 0.067 Employment status 0.085* 0.083* 0.073* 0.072* Chronic health conditions 0.106** 0.105** 0.101** 0.093** Diagnosed mental illness 0.082* 0.077* 0.073* 0.073* Family monthly income -0.004 -0.003 -0.005 -0.007 Family receiving social security 0.014 0.013 0.01 0.007 Planned pregnancy -0.065 -0.046 -0.051 Father involvement (7 aspects)

-0.143*** -0.147***

Frequency of antenatal checkup with his wife -0.101** Frequency of attending parent education classes

0.08*

Frequency of seeing ultrasound pictures during check-ups with his wife

0.036

Had accompanied with his wife during delivery

0.009

Number of day-off during wife's pregnancy or after delivery

0.062

R-square 3% 3% 5% 7% *p<.05 **p<.01 ***p<.001

33

Depression Anxiety Stress Scales (DASS) – Anxiety 9.3 Table 9.2 shows the results of a 4-phase hierarchical multiple regression for

maternal anxiety. Having diagnosed mental illness predicted higher level of anxiety (Model 1, p < .001). Whether or not the participants had planned pregnancies was not associated with anxiety (Model 2). Father involvement on daily housework and emotional support was related to reduced anxiety (Model 3, p < .001). In Model 4, fathers’ frequency of involvement during pregnancy or after delivery were added. Both diagnosed mental illness and father involvement were still significantly associated with maternal anxiety, however, the frequency of fathers’ attending parent education classes was found to increase maternal anxiety. Model 4 accounts for 8% of the variation in maternal anxiety.

Table 9.2: Hierarchical regression analysis for DASS - Anxiety Standardized Coefficients Model 1 Model 2 Model 3 Model 4 Age -0.05 -0.048 -0.059 -0.052 Education level 0.018 0.019 0.028 -0.003 Employment status 0.069 0.068 0.057 0.061 Chronic health conditions 0.054 0.054 0.05 0.05 Diagnosed mental illness 0.119*** 0.117*** 0.113*** 0.113*** Family monthly income -0.023 -0.023 -0.025 -0.009 Family receiving social security 0.041 0.04 0.038 0.033 Planned pregnancy -0.013 0.008 0.01 Father involvement (7 aspects) -0.161*** -0.16*** Frequency of antenatal checkup with his wife -0.061 Frequency of attending parent education classes

0.14***


-0.061


0.007


0.011

R-square 3% 3% 5% 8% *p<.05 **p<.01 ***p<.001

34

Chinese Edinburgh Postnatal Depression Scale (CEPDS) 9.4 Table 9.3 shows the results of a 4-phase hierarchical multiple regression for

postnatal depression. In Model 1, being economically inactive (p < .05), having chronic health conditions (p < .05), and having diagnosed mental illness (p < .01) predicted higher level of postnatal depression. As shown in Model 2, whether or not the participants had planned pregnancies was not significantly associated with postnatal depression. It was found that father involvement was related to reduced postnatal depression (p < .001), and mitigated the effects of being economically inactive and having chronic health conditions after it was added to Model 3. As shown in Model 4, the frequencies of fathers’ attending antenatal checkup with wives, attending parent education classes, and seeing ultrasound pictures were not statistically significantly associated with postnatal depression. Also, having accompanied with wife during delivery or the number of day-off was not significantly associated with postnatal depression. Both diagnosed mental illness and father involvement on daily housework and emotional support were still significantly associated with the outcome. Model 4 accounts for 7% of the variation in postnatal depression.

35

Table 9.3: Hierarchical regression analysis for CEPDS Standardized Coefficients Model 1 Model 2 Model 3 Model 4 Age -0.047 -0.035 -0.048 -0.045 Education level 0.056 0.061 0.072 0.058 Employment status 0.08* 0.078* 0.065 0.067 Chronic health conditions 0.071* 0.07* 0.065 0.066 Diagnosed mental illness 0.093** 0.088* 0.083* 0.083* Family monthly income -0.059 -0.058 -0.061 -0.049 Family receiving social security 0.021 0.019 0.016 0.013 Planned pregnancy -0.061 -0.037 -0.034 Father involvement (7 aspects) -0.185*** -0.18*** Frequency of antenatal checkup with his wife -0.041 Frequency of attending parent education classes

0.069


-0.037


-0.005


-0.003

R-square 3% 3% 7% 7% *p<.05 **p<.01 ***p<.001

36

IV Conclusion

10. Policy implications and recommendations Policy implications 10.1 Recently, the issue on the provision paternity leave and flexible working

arrangements for expectant fathers has attracted increasing attention in Hong Kong. There has been debate over the usefulness of these two benefits on fostering a better environment for the expectant mothers and newborn babies. Unfortunately, there is a lack of concrete and scientific evidence supporting the effectiveness of the two benefits as well as father involvement during pregnancy and childbirth in the local setting, leaving the Government and the private sectors a hard decision on the length of paternity leave and the provision of flexible working arrangements for the male employees.

10.2 This study provides empirical evidence on whether paternity leave and flexible working arrangements can promote father involvement, and whether father involvement during pregnancy, labor, and childbirth, as well as after the child is born, is beneficial to the health of both parents and newborns in Hong Kong. Indeed, this study provides supportive evidence for the positive impacts of father involvement, and provides insight on the need for concerted efforts from relevant institutions to enable fathers to be available for being involved in pregnancy, birth, and baby care and, more importantly, and to neither accept nor inadvertently create barriers to that involvement. Further, the significance of different aspects of expectant fathers’ involvement, including availability at childbirth, emotional support and instrumental support, should also be carefully considered. Fatherhood preparation programs may be evidence supported to guide more effective father involvement and engagement.

Recommendations 10.3 The present findings suggest that promoting higher father involvement may

be an important component of effective health promotion. For this to occur,

37

relevant institutions need to make a concerted effort to enable fathers to be more involved in pregnancy, birth, baby care and, more importantly, to neither accept nor inadvertently create barriers to that involvement. Similarly, to promote gender equality and greater father involvement in childrearing, governments should introduce and implement equal, paid, and non-transferrable parental leave policies in both public and private sectors, as well as other father-friendly policies that allow men’s equal participation in unpaid maternal and child care work.

10.4 To enrich the understanding of father involvement, difficulties and opportunities of father involvement could be examined. The evidence for the effectiveness of intervention promoting higher father involvement should be investigated in future research.

38

11. Dissemination of findings Publications 11.1 A manuscript (Title: “Father Involvement and Its Impacts on Paternal, and

Child Health Outcomes”) has been submitted to Journal of Child and Family Studies (Under review).

Conferences in which Papers Related to this Research Project were Delivered

Date and Place Title Name of Event

Abstract

27th – 28th

April 2017, Philadelphia, USA 20-21 October, 2016 16th – 17th

November 2016, Singapore

Child abuse and maltreatment in China: Involving father in violence prevention Association between father involvement, intimate partner violence, and paternal health Mobilising informal network to the prevention of family violence: Hong Kong experiences

Invited speaker at the conference “Challenges to Children’s Welfare in Contemporary China”, organized by the Penn's Center for the Study of Contemporary China, Philadelphia, USA The Global Scientific Summit organized by Academy on Violence and Abuse, Spartanburg, South Carolina, USA Plenary speaker at the National Family Violence Networking System Conference organized by the Ministry of Social and Family Development (MSF) and the Singapore Police Force (No. of participants: 800)

1 2 3

39

Abstract 1: Inspired by the findings that child poly-victimization were highly associated with other forms of family violence, Chan further developed the concept of family poly-victimization. In Chan’s study (2015), family poly-victimization was defined as the co-occurrence of (a) child maltreatment by parents, (b) IPV between parents, and (c) elder abuse against grandparents. The preliminary findings on family poly-victimization have provided evidence that warrants a holistic approach for future research and violence prevention on family violence to view family as a unit. As pointed out by the World Health Organization (2005), viewing family as a whole for violence prevention and intervention could be effective in some way, as it is very likely for family members to share common experiences and exposures from their immediate settings. To identify the common factors underlying the co-occurrence of multiple forms of family violence could thus be a very important direction for future research to deepen our understanding of the problem and early detection of victimized families. Father involvement for violence prevention and the enhancement of health of family members is considered as a new trend of intervention. Abstract 2: Past research suggested that father involvement could improve maternal and neonatal health but its influence on intimate partner violence (IPV) and paternal health was still poorly understood. The objectives of the study are to investigate the prevalence of father involvement in delivery and childcare, and to explore their associations with intimate partner violence (IPV) against women and paternal health outcomes. Preliminary findings show that father involvement is beneficial in reducing IPV and improving paternal health, more family-friendly policies should be adopted by policy-makers to promote father involvement throughout pregnancy so as to improve family well-beings and child development.

40

Abstract 3: Prof. Chan is the first to develop and apply the concept of family poly-victimization in his research studies. When studying the co-occurring victimization within a family, current literature often focuses on individual violence and fails to cover three forms of violence or more in a family. Prof. Chan’s studies fill the research gap by using families, instead of individuals, as units and investigating the prevalence and patterns of family poly-victimization. While addressing violence in family context and his research on culture-specific interventions, Prof. Chan started exploring the use of informal social control (including bystanders in informal network such as grandparents, relatives and neighbors) for the prevention of family violence. He, together with his research team, has developed intervention programmes using the Asian perspective, particularly those involving father for violence prevention and the enhancement of health of family members. The development of the unique perspective of Asian has led to an approach that allows one to see family as a whole, and to utilize the powerful informal social network to help Asian families build safety support nets for the violence victims.

41

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Survey on Elderly Policy in Hong KongPDF... · 2015.A8.030.16A.A6 Project Title : 項目名稱： Association Among Father Involvement in Pregnancy and Childbirth, Pregnancy Violence