Men's health and fatherhood in the urban Midwestern United States.
Article Type: Report
Subject: Fatherhood (Influence)
Fatherhood (Health aspects)
Fathers (Surveys)
Fathers (Health aspects)
Health behavior (Surveys)
Health promotion (Management)
Men (Health aspects)
Men (Research)
Authors: Garfield, Craig F.
Isacco, Anthony
Bartlo, Wendy D.
Pub Date: 09/22/2010
Publication: Name: International Journal of Men's Health Publisher: Men's Studies Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Men's Studies Press ISSN: 1532-6306
Issue: Date: Fall, 2010 Source Volume: 9 Source Issue: 3
Topic: Event Code: 310 Science & research; 200 Management dynamics Canadian Subject Form: Health behaviour Computer Subject: Company business management
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 241277013
Full Text: A sample of U.S. urban fathers was studied using in-depth qualitative interviews to better understand how having children might influence the fathers' health and health behaviors. Over three-quarters of the men reported positive changes to their health behaviors since becoming fathers. The specific examples cited as positive changes by fathers included; positive changes in diet, increased frequency of exercise and physical activity, taking better care of themselves in general, decreased alcohol use, and less risk-taking behavior. A key shift is also identified in men's perspectives around the transition to fatherhood. Recommendations are provided to clinicians who seek to design interventions that reengage men in the health care system and caring for their health.

Keywords: fathers; qualitative; men's health

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Men's health has the potential to be influenced by the transition to fatherhood and the presence of children in their lives. We interviewed a diverse sample of urban American men in order to better understand how having children might influence their health and health behaviors. By determining if the birth of a child is a catalyst for men to modify existing health behaviors or adopt new ones, healthcare providers and researchers can identify opportunities to improve men's health by developing properly timed and developmentally appropriate interventions with new fathers.

Of the 108 million adult men in America, 66.3 million are fathers (U.S. Bureau of the Census, 2007) and the overwhelming majority of men under age 55 have children in their homes (U.S. Bureau of the Census, 2005). Becoming a father is a major event for men with respect to their development with implications for motivations for change, psychological well-being, and roles in the family (Bozett, 1985; Cowan, 1988; Daniels & Weingarten, 1988; Palkovitz, 2002; Paikovitz, Copes, & Woolfolk, 2001; Strauss & Goldberg, 1999). The changes that occur for men who become fathers can be "jolting" or, alternatively, may result in "settling down" (Palkovitz, 2002; Palkovitz et al., 2001). Becoming a father may signal a shift away from individualism and lead to an elimination of negative behaviors, assuming more responsibilities, an increased perception of maturity, and self reflection that instigates positive behavior modifications. Capitalizing on this developmental event to encourage men to think of their health as one of their responsibilities to their family and child may be a key to reacquainting them with the healthcare system and emphasizing the importance of their own health.

FATHERHOOD IN THE CONTEXT OF MEN'S HEALTH IN THE UNITED STATES

There exists a growing disparity between men and women's health in the United States. Men are at a greater risk for death in every age group compared to women, with 1.6 times more mortality for all causes (Centers for Disease Control and Prevention & National Center for Health Statistics, 2006). While in 1920 men in the United States were dying one year before women, in 2005 the life expectancy gender gap had grown to 5.2 years with men living on average to 75.7 years (Kung, Hoyert, Xu, & Murphy, 2008). These health disparities are even worse for men of color, with life expectancy for African American men at 69.5 years (Kung et al.). Additionally, men of color face the most barriers to accessing healthcare (Satcher, 2003).

While biology plays some part in the disparities between men's and women's life expectancies, some argue that the ability of biological factors to predict gender differences in morbidity or mortality is relatively small compared to gender-specific behaviors (Courtenay, 2005). Men are less likely than women to seek healthcare or do self-exams (testicular), have healthy sleep habits, have healthy dietary habits, wear seat belts or helmets, or have a large support network; they are more likely to smoke, drink alcohol, drive recklessly, engage in early sex, have multiple sex partners, or engage in criminal activity (Bjornson et al., 1995; Courtenay, 2000a, 2000b; Garfield, Isacco, & Rogers, 2008; Gritz, Thompson, Emmons, Ockene, McLerran, & Nielsen, 1998; Harnett, Herring, Thom, & Kelly, 1999; Holmila & Raitasalo, 2005; Ogden, Carroll, Curtin, McDowell, Tabak, & Flegal, 2006; Wilsnack, Vogeltanz, Wilsnack, & Harris, 2000). Some of these behaviors--tobacco use, poor diet, physical inactivity and alcohol consumption--represent the leading actual causes of death between 1990 and 2000. Those actual causes of death are considered to be modifiable and preventable health behaviors (Mokdad, Marks, Stroup, & Gerberding, 2004). To address these issues, researchers and clinicians seek to identify windows of opportunity to improve men's health; fatherhood may be one such avenue worthy of further exploration. In this study we seek to qualitatively examine and document from the perspective of urban fathers, how having a child has affected their health.

THEORETICAL FRAMEWORK

Research on health and behaviors over the lifespan has highlighted gateways and barriers to optimal health. The Life Course Health Development (LCHD) framework explains how health trajectories develop over a person's life, acknowledging the contributions of biopsychosocial and contextual determinants to health (Halfon & Hochstein, 2002). Halfon uses this framework to suggest that a focus on early risk factors and protective factors leads to more effective preventative strategies and interventions to maximize health over time (Halfon & Hochstein). Lu and Halfon (2003) compliment the LCHD framework by further showing the importance of properly timed interventions on improving health outcomes along a developmental continuum. This framework highlights the potential influences of the transition to fatherhood on health, health behavior, and healthcare utilization, suggesting that becoming a father affects these domains of men's health over time and intervening during this transition can positively affect men's health behaviors and health.

LITERATURE REVIEW FOR FATHER'S HEALTH

The health benefits of becoming a father have usually been studied vis-a-vis the health benefits of being married, with little study of non-married men as fathers and even less of non-married men of color as fathers. Overall, compared to single men, men who are married have more proactive health beliefs related to health behaviors and outcomes (Markey, Markey, Schneider, & Brownlee, 2005), may gain health benefits from increased monitoring of health behaviors (Umberson, 1987, 1992), and gain psychological benefits through social support (Aneshensel, Rutter, & Lachenbruch, 1991; Phillipson, 1997). In the Panel Study of Income Dynamics, researchers found lower mortality risk in husbands with more children over a 20 year period (Smith & Zick, 1994). In this paper, we seek to expand the literature by examining a sample of primarily non-married, minority men who are fathers in order to better understand the relationship between children and men's health.

The relationship between men who are fathers and their health is a relatively recent research focus and the direct effects are uncertain. Previous research indicates the transition to fatherhood may have varied effects on men's health, from negative, to positive, to neutral. There are a limited number of studies that suggest becoming a father could potentially be detrimental to male health. For fathers in one study the transition to fatherhood was associated with small declines in men's feelings of well-being (Nomaguchi & Milkie, 2003). Another study of men during the first year of parenthood found a significant decrease in general health (Ferketich & Mercer, 1989). Recent research suggests 10% of fathers will experience depression around the time of their partner's pregnancy and postpartum (Paulson & Bazemore, 2010). Qualitative research describes the father-to-be as often unprepared, anxious, and experiencing role strain (Barclay & Lupton, 1999; Bartlett, 2004; Marks & Lovestone, 1995). One Australian prospective study found similar levels of stress during pregnancy and the first year of the child's life for first-time fathers (Condon, Boyce, & Corkindale, 2004).

Still others have found that men who are fathers experience neither benefits nor risks to their health. In the U.S., the Alameda County Study found no difference in 18-year mortality risk for men by either presence or number of children (Kotler & Wingard, 1989). Another 15-year prospective follow-up cohort of men in an HMO found that time spent with children, degree of worry about their children, and satisfaction with their parental role had no influence on men's subsequent risk of death or diagnosis of heart disease, stroke, or cancer (Hibbard & Pope, 1993).

In addition to inconclusive evidence as to the effect of being a father on men's health, the existing research in the area of men's health and the transition to fatherhood has several other limitations. Research on fatherhood and health lags behind studies on maternal health and has created a gap in family research and theory (Barclay & Lupton, 1999; Bartlett, 2004). Furthermore, research on fatherhood and men's health in the United States is underexplored when compared with research conducted on fathers in Canada, Britain, and Australia (Dudley, Roy, Kelk, & Bernhardt, 2001; Gough, 2007; Gough & Conner, 2006; Matthey, Morgan, Healey, Barnett, Kavanagh, & Howie, 2002; Steinberg, Kruckman, & Steinberg, 2000). Empirically supported interventions designed to facilitate health and well-being for men are limited or non-existent (Bartlett, 2004; Chalmers & Meyer, 1996). Studies that have examined men's experiences related to fatherhood typically use small samples and rely on homogenous populations consisting of predominately White, married, well-educated, and middle-to-high socioeconomic status participants (Anderson, Kohler, & Letiecq, 2002; Coley, 2001; Felix-Aaron, Moy, Kang, Patel, Chesley, & Clancy, 2005; Goodman, 2005). Our objective, therefore, was to qualitatively investigate the relationship between the transition to fatherhood and men's health with a group of urban, primarily non-married, low-income and minority men in the United States. In doing so, we strive to enhance the limited existing literature on paternal health and health behaviors and to inform practitioners about a possible window of opportunity to reengage men with the healthcare system and to promote healthier behaviors.

METHODS

Men in our study were sampled from a nested qualitative study (i.e., Time, Love, and Cash in Couples With Children-TLC3) within the national, randomly-sampled Fragile Families and Child Well-being Study of 3800 non-married couples and 1200 married couples of birth cohort in large U.S. cities (Princeton University & Columbia University, 2005). TLC3 recruitment criteria included: (1) mother's household income <$60 000 a year, (2) geographic accessibility (e.g., neither mother nor father living out of state or in jail), (3) child living with mother or father, and (4) both parents English speaking. Participants in our study were eligible if they were still enrolled in the parent studies and lived in Chicago, Illinois or Milwaukee, Wisconsin, two urban U.S. centers. As was standard for the TLC3 study, fathers were given $50 for their participation. Our Institutional Review Board approved the study. All participants consented to participate in the interview process, and were given pseudonyms to protect their identities.

We conducted semi-structured, in-depth qualitative interviews with 33 urban fathers as part of a broader study examining father involvement in the health and healthcare of their families. A section of this longer interview focused on fathers' involvement in the family, health, health care of the child, and changes and experiences around the birth of the child, and is analyzed here.

Data Collection and Analysis

Participants were interviewed at home for approximately 1.5 hours when their child was approximately 3 years old. The construction of the qualitative interview questions were based on literature review, previous qualitative interview protocols in the TLC3 study, and pilot interviews with fathers who were not in the study. All questions were deliberately open-ended to allow the fathers to provide detailed accounts and personal stories. Fathers were asked to describe their overall health status, experiences with medical care, anal any health and health-behavior related changes that occurred since the birth of their child.

The interviews were conducted by professional interviewers with extensive experience interviewing in minority communities. Interviewers were trained in the interview protocols via mock interviews and monitored by reviews of audio-taped interviews. All interviews were taped, transcribed verbatim, and analyzed using Atlas.ti.5.2. We used open coding to interpret interview narratives using little inference, which lead to the establishment of new codes, distinct themes, and an evolving codebook through team discussions anal investigator triangulation. Once coded, we used content and narrative analysis to examine all codes and themes related to fathers' health, health attitudes, and health behaviors that could be attributed to having a child. The content analysis focused specifically on counting the frequency of themes, while the narrative analysis examined that nuances of the emerging themes (Elo & Kyngas, 2008; Hsieh & Shannnon, 2005; Lyons & Coyle, 2007; Ryan & Bernard, 2003).

Participant Characteristics

Of the 33 fathers from the TLC3 study in Chicago and Milwaukee, one father declined to participate and one interview tape was damaged leaving 31 fathers in the study (adjusted response rate: 94%). At the time of the interviews, participants in our sample had a mean age of 31 years, 41% had an income of $34,999 of less, 61% obtained less than of equivalent to a high school diploma, and 84% were employed. Forty-eight percent of the fathers resided in Chicago and 52% lived in Milwaukee. Fifty-five percent of the fathers were African-American, 29% were Hispanic, and 16% were White, nonHispanic. The focal child was the first child for the couple, and the child was approximately 3 years old when the father was interviewed. At the time of the focal child's birth the fathers had the following relationships with the mothers: 45% of the fathers were married, 26% were not married, not cohabitating, and not romantically involved, 13% were divorced, 10% were non-married, but cohabitating, and 6% were non- married, not cohabitating, but romantically involved with the mother of the focal child. Twenty-six percent of fathers interviewed did not have custody of their child. Participant characteristics are detailed in Table 1.

RESULTS

Positive Changes to Father's Health

Over three-quarters of the men reported positive changes to their health behaviors since becoming fathers. The overall sentiment is summed up best by Jerry, an African-American father from Chicago: "I think I take care of my health [better now]. I think that I always did, but [the child] made it better." The specific examples cited as positive changes by fathers, in order of frequency, included: positive changes in diet, increased frequency of exercise and physical activity, taking better care of themselves in general, decreased alcohol use, and less risk-taking behavior. These positive changes in behavior are discussed in detail below and summarized in Table 2.

Nutrition and Diet

More than a third of the fathers reported positive changes in their eating habits since their child's birth. These changes included increases in healthy foods and beverages and decreases in junk food, red meat, and soda. Michael, an African-American father from Chicago, summarized modifications in his diet as, "Before I didn't drink a lot of water, now I drink a lot of water. I'm not eating a lot of steak or drink[ing] pop. I eat a lot of fish and drink orange juice." Juan, a Hispanic father from Milwaukee, confirmed that his son was the catalyst for his dietary changes. "I need to eat whatever he's going to eat. So, it's more healthy [sic], like vegetables and stuff like that. I can say that I used to eat a lot of junk food before, I quit just because of my son."

Physical Activity and Exercise

Fathers described efforts to maintain physical fitness, keeping active by caring for children, and engaging in physical activities for recreation with their children. An increase in exercise was reported by almost a third of fathers since the birth of their child. Lenny, an African American father from Milwaukee, said, "Me taking him to his doctor for his checkup has kept me in shape and exercising, walking, running. [Without my child] I would be more lazy [sic]. Kids keep me moving." Thomas, a father from Milwaukee, explained how spending time with his son resulted in increased physical activity; "I do a little bit more exercising now. He's riding bikes, he likes to run, likes to go outside and play. So I got to do all of that stuff." Richard, an African-American father from Chicago, described his motivations for staying active; "I know that I have to take care of myself so that I can run and play baseball with [child]. I realized that if I'm going to keep up with him, I have to keep myself in shape." These quotes demonstrate how the presence of children motivates these men to participate in physical activities and serves as an incentive for many men to stay active.

Decreased Risky Behavior

The transition to fatherhood appears to encourage men to reassess their priorities and the consequences of their actions. Several of the men reported that since becoming fathers they engaged in fewer risky behaviors. Changes included decreased alcohol usage, less "partying," and avoidance of dangerous situations and friends since having a child. Donnie, a Caucasian father from Milwaukee, said this about the influence that his child had on his alcohol consumption; "Well, I'm not an alcoholic any more [because of having a child]. I'll come home and have one or two beers instead of a case or two cases. So he's helped me." Sanchez, a Hispanic father from Milwaukee, explained his changed socializing and drinking habits. "I went from going out every night to now I go probably once a month. I don't drink [alcohol], now I just have a soda. And that's about it." In addition to consuming less alcohol, fathers reported less risk taking overall since becoming fathers. "I don't put my health in as stressful or dangerous situations as I probably would. For instance, I don't hang out with friends who may not be in the most safe [sic] of situations," said Joe, an African American father from Milwaukee. Bobby, an African American father from Chicago, described how he socialized less and spent more time with his child. "I don't party anymore like I used to, and I'm a responsible father, try to spend time with him."

POSITIVE SHIFTS IN FATHERS' ATTITUDES ABOUT HEALTH AND FAMILY

Perceived changes in mind-set and viewpoints were also attributed to becoming fathers. Fathers described "being there" for their children as an important motivation for changes to lifestyle or health behavior. "I want her to be there with me when she gets through kindergarten. When she gets into 8th grade I want to be there, go through that. I wanna live a long time so I can see those things, see her graduate from college, see how her life tunas out," said Michael, an African-American father from Chicago.

Several men explained how their families and children took precedence over themselves as individuals. Some of the fathers said that they now put their family first, before their individual needs. "Yeah, yeah, it's not about me. It's about the life of your child, so I have to keep myself together to make sure I'm here for him. So I'd say my whole entire attitude to health is that it's not just about me anymore, it's about us," said Michael, an African American father from Chicago. Several of the men reported an increase in their responsibilities since becoming fathers and a need to adjust to the "real consequences" associated with not fulfilling their parenting and family responsibilities. Paul, a Caucasian father from Milwaukee, explained his need to stay healthy in order to provide for his family. "I like to try to stay healthy, because if I'm not healthy I can't work, and if I can't work, we don't eat. And then we have real health problems."

Men affirmed that their new status as fathers inspired the desire to be a good role model for their children and this was motivation to modify health behaviors. "Yeah, I do more vegetables, I eat better. I drink more milk now at the dinner table. I don't drink as much beer now. So if I do things correctly, then he automatically thinks that's the right thing to do. So I try to be a little bit better now I guess, health wise," said Thomas, a father from Milwaukee. Overall, there was a key shift in the perceptions of these men with regard to their roles as fathers and within their families. They were overtly aware of their potential to influence their children through modeling positive health behaviors. Furthermore, the addition of a child often served as inspiration for men to lead healthier lifestyles in order to participate in activities with their child, remain in good condition to provide for their child, and live a long life to see their child into adulthood.

NEGATIVE CHANGES TO FATHER'S HEALTH

Though the overwhelming majority of fathers in this study noted positive changes to their health, in order to contribute most to this nascent literature we also make note of how fathers perceived negative changes to their health since having a child. In all, only three fathers noted negative changes. These fathers described exercising less, eating less food, sleeping less, feeling more stressed, increasing smoking, and eating more. "Sometimes he [my child] is stressful, so maybe I eat more when I'm stressed," explained Johana, a Hispanic father from Milwaukee. An additional four fathers reported no change in their health as a result of children. Despite these limited instances, the majority of men reported positive changes to their health and health behaviors as a result of having children and provided concrete examples of their changed behaviors.

DISCUSSION

This study is an innovative examination of the relationship between fatherhood and men's health. By examining the perspectives of urban men as fathers, we have identified a key shift in health behaviors that occurs around men's transition to fatherhood. As shown previously in larger quantitative studies, our results support the notion that men frequently adjust their health behaviors and attitudes as they transition to fatherhood and our findings describe these changes in granular detail. From the fathers' perspectives presented above, this adjustment in behaviors occurs out of a desire to live to see their child into adulthood, or with the acute awareness that they are now acting as role models for their children. These results suggest potential implications for clinicians, who may use these alterations in perspective to engage or re-engage men in their own health and to move toward a strength-based perspective on men's health. Clearly, for the men in this sample, the transition to fatherhood represents an important point for intervention.

Previous studies have indicated that becoming a father is a life-altering moment for men, as it relates to their motivations for change and roles in the family (Bozett, 1985; Cowan, 1988; Daniels & Weingarten, 1988; Palkovitz, 2002; Palkovitz et al., 2001; Strauss & Goldberg, 1999). This study expands on previous research and moves beyond merely indicating the changes in mind-set that coincide with fatherhood, to incorporate the relationship between these changes and health behaviors as described by the men. We also have given voice to a primarily minority, non-married group of fathers from a lower socio-economic strata, a population from which there is much to learn. With health disparities greatest and life expectancy lowest among minority men, it is important to understand the drivers for health behavior change and to further seek methods and interventions to engage diverse populations in the health care system.

The Life Course Health Development framework conceives that health behaviors are learned and adapted over an individual's lifetime, and are affected by a wide range of factors that include both biology and environmental context. As suggested by Lu and Haflon (2003), properly timed interventions create an opportunity to intercede in the lives of men at key points in time thereby maximizing the positive impact on health. This study offers important insight into the possibility of timing healthcare interventions for men to coincide with the birth of a child. If the birth of a child is indeed a catalyst for positive health behavior modifications, health providers may seek to construct men's health interventions around the event. Such interventions could take place in the prenatal period along the lines of birth or new parent classes, on the newborn nursery floor, tied to standard pediatric visits, or linked to appropriate infant developmental milestones.

As previous research has shown, men are less likely to get health care, do self exams, (Courtenay, 2000a, 2000b), or seek help from mental health professionals (Addis & Mahalik, 2003; Vessey & Howard, 1993) and there is a need to provide these services to men. Few men in our study reported negative changes to their health (e.g., increased stress, decreased sleep and physical activity). This finding fits into some literature that has detailed the potential negative effects of becoming a father on men's health (Ferketich & Mercer, 1989; Nomaguchi & Milkie, 2003). Whether the ultimate effect is positive or negative, new fathers could benefit from being offered check ups, basic risk/strengths assessments, basic lab screening and connection with a community primary care doctor, who could make referrals to mental health providers if necessary. As our study shows, men describe frequently seeking to modify diet, physical activity, and reduce risky behaviors after the birth of a child. We speculate then that interventions might seek to include visits with a nutritionist or dietician, engagement with a community gym membership or personal trainer, and possibly linking fathers with resources structured to eliminate substance abuse such as counselors, tobacco cessation programs or Alcoholics Anonymous. Approaches like this support a model of salutogenic health care where an individual's health and their social and environmental influences, such as having a new child, are included in a holistic view of men's health and health promotion (Garfield, Clark-Kauffman, & Davis, 2006; Macdonald, 2005).

For clinicians this study supports the notion that the birth of the child appears to be a pivotal opening to educate men not only about their own health, but the mental and physical health of their partners (Garfield & Isacco, 2009), the basic care of babies (Garfield & Chung, 2006), and the modeling that inevitably occurs with their own health behaviors. As men make efforts to positively modify their health behaviors, the healthcare system should prepare to meet them half way.

Several limitations exist to this study. As this study serves as exploratory research, our sample size is characteristically small. In small sample qualitative studies, recall bias and social desirability may be present in the data. However, subjects were interviewed using professional interviewers without relations to the healthcare field and were asked to describe in their own words what they felt the effects of having children had on their health while being unaware of the study's objectives. Our sample included a diverse group of urban men; therefore, our findings have a limited generalizability and may not necessarily be related to non-urban, high socio-economic status, or married men. However, the results may still have relevance to interventions designed to promote men's health that capitalize on universal elements of fatherhood and other life-altering events. Finally, as the purpose of our study was to give voice to men who had become fathers, our study does not include the perspectives of the fathers' partners, family members, or other social influences that may or may not corroborate the father's perspectives.

As our findings point to the transition to fatherhood as an important milestone for men and their health, future work in the area is warranted. Such work should include pre- and post fatherhood analyses and longitudinal studies to determine, for example, if changes do remain long-term, for what length of time they remain in place and if the number of children affect the initiation and maintenance of health behaviors. Additionally, further research could determine the interaction of men's health status and their offspring's adoption of health behavior over time. As our study focuses on an urban, primarily minority and low income population, future research should examine how this study might be expanded to other, unique populations. As an exploratory study, we did not delve deeply into the intricacies and complexities of race and ethnicity, and future studies may seek to expand on this. While we have uncovered fatherhood as a pivotal opening for potential interventions, future studies might seek to conduct analyses around other critical moments in an individual's life.

CONCLUSIONS

Men's commitment to their health and their lower life expectancy remains a concern. One force that could be beneficial to increase men's health promotion is the experience of a major life event, such as becoming a father. A majority of the sample of men in this study attribute their transition to fatherhood as having an overall beneficial effect on their health, health behaviors, and health promotion.

DOI: 10.3149/jmh.0903.161

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Craig F. Garfield (a), Anthony Isacco (b), and Wendy D. Bartlo (c)

(a) NorthShore University Health Systems, Section for Child and Family Health and Northwestern University's Feinberg School of Medicine.

(b) Department of Counseling Psychology, Chotham University.

(c) NorthShore University Health Systems, Section for Child and Family Health.

Correspondence concerning this article should be addressed to Craig F. Garfield, NorthShore University HealthSystem Research Institute, 1001 University Place, Evanston, IL 60201. Email: craig.garfield@gmail.com
Table 1
Proportion of Participants Strongly Endorsing * Items on The
Condom Fit and Feel Scale (N = 2350)

Scale items by subscale                                      n (%)

Condoms fit fine

Condoms feel comfortable once I have them on my penis     1433 (68.0)
Condoms fit my penis just fine                            1097 (52.0)

Condoms are too long

Condoms are too long for my penis                          364 (17.3)
I have some unrolled condom left at the base of my penis
  after I unroll it                                        630 (29.9)

Condoms are too short

Condoms are too short for my penis                         294 (13.9)
Condoms will not roll down far enough to cover
  my penis completely                                      350 (16.6)

Condoms feel too tight

Condoms are too tight on my penis                          764 (36.2)
Condoms fee too tight along the shaft of my penis          622 (29.5)
Condoms feel too tight on the head of my penis             492 (23.3)
Condoms feel too tight around the base of my penis         621 (29.5)

Condoms feel too loose

Condoms are too loose on my penis                          175 (8.3)
Condoms feel too loose along the shaft of my penis         169 (8.1)
Condoms feel too loose around the head of my penis         186 (8.8)
Condoms feel too loose around the base of my penis         159 (6.8)

* Proportion of participants responding "often applies or always
applies" to each scale item.

Table 2
Emerging Changes for Fathers since the Birth of their Child

Positive Health Behavior Modifications
  Positive changes in diet
  Increased physical activity
  Decreased alcohol usage
  Decrease in risky behaviors

Changes in Attitudes
  "Being there" for child as motivation
  Recognition of children's needs as taking precedence over father's
    needs
  Desire to be a good role model
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