Parental involvement for infants admitted to the neonatal intensive care unit (NICU) encapsulates the earliest, critical moments of interaction with a child, yet can be accompanied with stress, anxiety, and uncertainty [1]. Parents who speak languages other than English are at increased risk of disrupted communication, stress, and suboptimal care [2]. NICU fathers who are from minority racial and ethnic groups have higher rates of depression and anxiety than fathers who are not [3,4], in part due to ineffective communication and targeted support/resources, resulting in feeling undervalued [3,5,6].

Various interventions have been implemented to support the well-being and involvement of NICU fathers including psychosocial support [7], written materials [8], enhanced nursing support [9], narrative writing [10], skin-to-skin, and increased physical interaction [11,12]. Despite being inexpensive and distributable, there is a paucity of video-based interventions [12] targeting Spanish-speaking NICU fathers. Prior work demonstrates that NICU fathers find staff education, particularly from nurses, pivotal in overcoming low knowledge and uncertainty, leading to improved confidence and overall NICU experience [13]. Thus, a video-based, educational intervention for Spanish-speaking fathers would provide an opportunity to better support fathers and the child-father relationship at its earliest stages.

The Bronfenbrenner’s ecological systems theory posits an individual’s health and development is shaped by varying layers of environmental and social relations from the micro to macro scale [14]. Over the course of a lifetime, an individual’s development evolves through shared, increasingly complex interactions between the individual and their environment. This project aimed to support the early child-father relationship to improve fathers’ knowledge and confidence such that the reciprocal, foundational nature of their relationship may flourish.

We performed a single-arm intervention feasibility study using short videos on high-yield NICU topics. Our objective was to assess whether the intervention “Los Padres de los Pajaritos” (“the fathers of little birds”) would be feasible and acceptable to Spanish-speaking NICU fathers to assess improved knowledge and confidence, decreased anxiety, and improved parenting competency to lay the groundwork for future, larger-scale efficacy trials.

A total of 42 fathers met inclusion criteria; 27 [2] were approached and 21 (78%) were enrolled; 13 (62%) completed all study procedures (Figure 1). Demographics and clinical variables are reported in Table 1.

All fathers viewed at least 2 videos; 85% (11/13) viewed all videos. The Nursing Care video was most informative, while the Lactation Support video was the least watched. Likert scores on video feedback, including understandability, length, and quality, were all greater than 4.5 (Table 2). Confidence in caring for their infant showed a significant increase from 4.2 (95% CI 3.66-4.74) to 4.8 (95% CI 4.51-5.09), P=.02, while knowledge increased (not significantly) from 4.09 (95% CI 3.46-4.72) to 4.69 (95% CI 4.29-4.97), P=.08. The average GAD-7 and PSOC scores did not change significantly (GAD-7: 4.75, 95% CI 2.56-6.92 and 3.33, 95% CI 1.49-5.17; P=.07; PSOC: 68.5, 95% CI 60.48-76.52 and 77.2, 95% CI 64.16-76.5; P=.31). Select comments were positive (Table 3). Qualitative video feedback included the following: “I found all the videos very interesting and educational,” “The videos speak very clearly and precisely...it is very important to know who you are dealing with and the trust that one places in them,” “I’m looking forward to seeing more videos,” and “Don’t stop sharing them because they are very important and you really do learn a lot.”

We performed an open-label pilot study evaluating the feasibility and acceptability of videos to increase knowledge and confidence, decrease anxiety, and increase parenting competency of Spanish-speaking fathers of NICU infants. Enrollment feasibility was good (21/27, 78%), but completion of study material could be improved upon (13/21, 62%). Based on high Likert scales on video feedback, the project was accessible and well-accepted. Confidence increased significantly following the intervention, but not anxiety or parenting competence. Reasons for suboptimal study recruitment/retention could include fathers preferring alternative means of communication or poor digital literacy. Ways to improve completion rates of study material include greater incentivization and repeated follow-up (phone calls, emails) [18].

This study has several strengths. The project targets a vulnerable population that is undersupported [2]. We sought an intervention that was portable, flexible, accessible, and did not require NICU presence as fathers visit less than mothers [19,20]. The intervention was low-cost (a couple thousand dollars) and is reproducible for other units, languages, and topics. Fathers gave positive feedback on the videos and suggested other topics as well. This affirmative feedback to improve knowledge is consistent with other data on videos administered in a hospital-based setting that have had significant positive effects on outcomes including knowledge and emotional and behavioral outcomes [21].

The study has several limitations. First, the study sample size was small; significance may have been overestimated and the study was underpowered to detect changes in GAD-7 and PSOC scores or associations between outcomes while controlling for generalized anxiety and clinical characteristics. Second, the study lacked a control group and depended on precomparisons and postcomparisons, making it difficult to establish causality. Second, Latinos are a heterogeneous group and cultural differences may exist that impact study engagement or benefit. Of great importance, multiple factors affect the knowledge, confidence, anxiety, and competence of a father in the NICU; perhaps a single intervention will not influence these factors and a multifactorial approach is necessary. Additionally, the utilized Likert scales were not validated Spanish tools and recall bias may have influenced outcomes. Given this was a feasibility study to elucidate procedures for larger trials, future work will include a control group to allow for external validity. Lastly, fathers self-reported the timing of video watching and number of videos watched; future interventions can confirm videos were watched entirely in a consistent manner.

This preliminary work lends itself to future steps, including improving retention and follow-up through the exploration of barriers to enrollment and retention, as well as a larger, randomized controlled trial powered to assess longer-term changes in outcomes. Due to staffing limitations, we were unable to recruit at all times. Tailoring recruitment during visitation, particularly given that fathers visit less frequently [20], could improve recruitment feasibility and will be included in future work. Finally, the perspective of fathers on their preferred mode of receiving information and support is unknown; we are surveying fathers on their preferred means of communication and content to better target their needs.