Effect of The HUG (Help-Understanding-Guidance) Program on Stress of Fathers of Preterm Infants and Their Understanding of Preterm Infant Behavior

Reason for research:

Though more than 13 million premature infants are born each year worldwide, country-level data are unavailable for most low- and middle-income countries like Iran. However, in 2004 the United States Census Bureau used international data to extrapolate statistics about preterm births by country. Considering Iran’s population1, it was concluded that there are nearly 109,96 preterm births in Iran annually. Complicated childbirth, the birth of a premature infant, and a Neonatal Intensive Care Unit (NICU) admission are all factors that increase parental stress, alter the expected parental role, and create feelings of separation that may delay parental attachment for both the mother and the father. Studies addressing the needs of parents in a NICU often include a higher percentage of mothers. Though there is some research about a mother’s experience in the NICU, there is inadequate information about a father’s experience in the NICU following the early birth of his child.

Because mothers of NICU babies are experiencing birth complications, fathers in Iran usually see their babies in the NICU sooner than mothers do. However, these fathers are generally not encouraged to be involved with their baby. Typically, no supportive measures are taken to help reduce the father’s stress or to increase the father’s knowledge of their baby. Fathers in such situations in Iran and elsewhere have expressed a need for increased support and guidance. But because the technical aspects of caring for a NICU baby can monopolize the attention of the nurses, attention to the father’s needs is often overlooked. The lack of communication from nurse to fathers, the father’s need to cope with high levels of stress, and the father’s lack of knowledge about infants and their care are three major barriers for fathers in an Iranian NICU.

Today Iranian men are pulled in different directions, resulting in conflict between traditional socialization as breadwinners and cultural expectations of fatherhood that promote the primacy of work. Fathers are often expected to father differently from the way they were fathered, yet they lack practical knowledge and skills to do so.

Because of these issues this study was undertaken to assess a father’s experience in the NICU and to create an intervention program which offers support and education. The goal of this study was to evaluate the effectiveness of The HUG educational program2 to help fathers with premature babies in an Iranian NICU to understand their infant’s behavior, to respond more effectively to their baby, and to experience a reduction in their stress level.

Inclusion/Exclusion Criteria:

Inclusion:
Gestational age (between 32 and 37); Single parity; First experience of prematurity; Fathers more than 18 years old; No major critical medical complications and anomalies threatening infant’s condition; No documented congenital anomalies or conditions necessitating surgery and sedation; No previous NICU experience; No stressful condition in the family like serious disease of another child; Infant’s hospitalization at least one week; Father’s daily visit of infant at least 15 to 30 minutes.

Exclusion:
Father’s refusal to continue being in the study; Any clinical situation which leads to infant’s death or deterioration of infant’s condition; Less than 4 visits with infant during a week.

Location of Study:
This study was done in a tertiary level NICU in “Children’s Medical Center” affiliated with Tehran University of Medical Sciences.

Intervention:
The HUG, a parent educational program created and produced in the USA, is designed to help parents understand newborn behavior in order to prevent and solve problems around a newborn’s eating, sleeping, crying and attachment. With permission from The HUG author3, the HUG’s 20-minute parent education DVD4 was dubbed in Farsi and the parent education handout was translated into Farsi5. 23 fathers in the control groups received routine care in the NICU6. 23 fathers in the intervention group received the same routine care and had a class with the researcher (a nurse who was a Certified HUG Teacher7 through an online program), were shown the dubbed HUG DVD and received the translated HUG handout. The researcher also spent one-on-one time with each father in the intervention group to help him observe his baby’s behavior and to both calm his fussy baby and to explore his baby’s ability to look, listen, and engage with his father.

The Ethical Board of the Tehran University of Medical Sciences reviewed and approved this research. The study had a semi-experimental, double-blind design.

Tools:
With the permission of their authors two standardized tools were used in this study.8

Parent stressor scale (PSS: NICU) questionnaire is an instrument that measures perceived parental stresses9 caused by the physical and psychosocial environment of the NICU.10

The Knowledge of Preterm Infant Behavior (KPIB) scale is a 36 multi-choice questionnaire used to assess the father’s knowledge of a preterm infant’s behavior and to assess the father’s knowledge of the optimal times for interacting with the baby11. (See sample questions regarding a baby’s reflexes12, physical response to stimuli13, motor activity14, sleep-wake cycles, social interaction capacities15, and baby’s self-regulation issues16) These questions were scored and tallied17.

Results:
Demographics:

  • There was no difference between the control and intervention group regarding: type of delivery, baby’s gestational age18, weight19, infants’ sex; Apgar scores; addictions issues, desire for child, monthly income; number and health of other children; and fathers’ careers, education, and age.
  • However, there was a significant difference in insurance coverage of the babies20.

Father’s knowledge:

  • In the intervention group there was a significant increase in fathers’ knowledge about preterm infant behavior. See chart21.

Father’s Stress level:

  • Both control and intervention groups reported moderate levels of stress before intervention22.
  • Both control and intervention group experienced a reduction in stress.
  • However, the intervention group experienced a more significant reduction in stress23.
  • The intervention helped fathers better accept their fatherhood role and helped them be more confident in their daily visits with their babies.

Author’s Comments:
In addition to the positive results noted in this intervention project, there were many beautiful behind-the-scenes moments. Here are a few.

  • All intervention fathers completed this project. They seemed interested and committed to this learning process.
  • At the break during The HUG presentation, fathers eagerly spoke with one another about their baby’s well being. They both shared their story and wanted to hear the experiences of the other fathers.
  • Fathers particularly enjoyed helping their baby orient to the sound of a rattle. They noticed a subtle change in the baby’s attention which assured them their baby was engaged in the world.
  • Fathers who participated in The HUG class increased their visits to the NICU.
  • HUG participants were eager to teach their wives about the baby’s body language when the wives were finally able to visit the nursery.
  • Although nurses usually encourage fathers to hold their baby, one intervention father initiated this request. “I didn’t hold my first son during his early days even though he was full term. I was afraid I would hurt him. Now, I really love to hold my baby.”
  • Another father sorted the photos he had taken according to the baby’s Zones and made an album to share with his family.

Our culture and the cultures of the NICU have traditionally supported the involvement of mothers in the care of their newborn. This research has reaffirmed my conviction that how we interact with and teach fathers can be life-changing. Not only can these fathers learn about their baby’s special world, but this type of support may trigger a more meaningful father-child relationship for months and years to come.


  1. Iranian population 67,503,265.
  2. http://www.hugyourbaby.org/
  3. Jan Tedder, BSN, FNP, IBCLC http://www.hugyourbaby.com/about.html
  4. http://www.hugyourbaby.com/skills.html
  5. http://www.hugyourbaby.org/Home/research
  6. A brochure with information on NICU equipment (e.g. ventilator, pulse infusion pumps, phototherapy lights) and interventions (e.g. massage, administration of medications). There is no protocol about what nurses teach parents about the baby’s condition or behavior.
  7. http://www.hugyourbaby.org/Home/hug-training/certified-teacher
  8. A pilot study was completed assessing the translation of the tools and a back translation was done. The tool was translated from English to Farsi. A native Farsi speaker who speaks English confirms that the items in the too carry the same meaning in Farsi. The Farsi tool is translated by another back to English. A native English speaker confirms that the translated Farsi tool has the same meaning as the original English tool.
  9. Stressors include: 1) Sight and sounds in NICU 2) Infant’s behavior and appearance 3) Parental role alteration.
  10. Fathers used a 5-point Likert. A score below 50% was considered mild stress; scores between 50 to 70% were considered moderate, and scores above 70% were considered high stress.
  11. “The best distance for your baby to be able to see your face is…”
  12. “When you push your finger against the inside of your baby’s hand he will…”
  13. “Hiccoughs, spitting up, gagging and grunting are all signs that…”
  14. “When your baby extends her arm as if she is saluting this means…”
  15. “Your baby is telling you that she’s alert and ready to play when she…”
  16. “A common thing premies do to get themselves under control is to…”
  17. Correct answers received 1 point and wrong answers gained no point. D=5 considered as change and progress in fathers’ knowledge of pre-term infant behavior.
  18. The average of GA for control and intervention groups were 34.7 and 34.1 respectively
  19. Average stress score before education for control and intervention group was 66.5 and 71.2 respectively.
  20. 100% of babies in the intervention group had insurance, while 73.9% of babies had insurance in the control group
  21. Chart may be viewed at http://www.hugyourbaby.org/Home/research/results-of-iranian-research
  22. Average stress score before education for control and intervention group was 66.5 and 71.2 respectively.
  23. After education this score changed to 61.2 for the control group and to 55.6 for the intervention group.
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