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Parents reasons for not attending parental

education groups in antenatal and child health

care: A qualitative study

Karin Forslund Frykedal, Mia Barimani, Michael Rosander and Anita Berlin

The self-archived postprint version of this journal article is available at Linköping University Institutional Repository (DiVA):

http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-160159

N.B.: When citing this work, cite the original publication.

Forslund Frykedal, K., Barimani, M., Rosander, M., Berlin, A., (2019), Parents reasons for not

attending parental education groups in antenatal and child health care: A qualitative study, Journal of

Clinical Nursing, 28(17-18), 3330-3338. https://doi.org/10.1111/jocn.14912

Original publication available at:

https://doi.org/10.1111/jocn.14912

Copyright: Wiley (12 months)

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Parents’ reasons for not attending parental education (PE) groups in

antenatal and child healthcare: A qualitative study

Karin Forslund Frykedal*1,2, Mia Barimani3, Michael Rosander1 & Anita Berlin4

1Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden 2 Department of Social and Behavioural Studies, University West, Trollhättan, Sweden

3 Department of Learning, Informatics, Management and Ethics, Karolinska Institute, Stockholm, Sweden 4 Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden

Aims and objectives. To explore expectant and new parents’ reasons not to participate in parental education (PE) groups in antenatal care or child healthcare.

Background. In Sweden, expectant and new parents are offered PE groups in antenatal care and in child healthcare. Although many parents feel unprepared for parenthood, an urgent task is to attract parents to attend the PE groups.

Design. 915 parents with children aged 0 to 21 months answered a web questionnaire with open questions about (a) reasons not to participate; (b) anything that could change their mind; and (c) parenting support instead of PE groups. This was analysed using content analysis. The study following the SRQR guidelines.

Results. Parents expressed private reasons for not attending PE groups. Some parents also asked for more heterogeneity regarding content and methods, as well as accommodation of parents’ different interests. Other parents asked for like-minded individuals who were in similar situation to themselves. Lack of information or invitations from antenatal care or child healthcare, or that PE groups were unavailable, were additional reasons for not participating in groups.

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Conclusions. Reasons for not attending PE groups were multifaceted from personal, self-interested and norm-critical reasons, to that the groups were not available or that the parents were not aware of their existence.

Relevance to clinical practice. Parents of today are a diverse group with different interests and needs. Nevertheless, all parents need to feel included in a way that makes participation in PE groups relevant for them. Thus, it is important for leaders to be aware of structures and norms, and to be able to create a group climate and a pedagogy of acceptance were group members value each other’s differences. However, to attract parents to participate in PE groups, it is necessary for clinical practice to work on individual, group and organisational levels.

KEYWORDS

children’s nurse, education, family care, leadership, midwifery, parenting, qualitative study

What does this paper contribute to the wider global clinical community?

• Parents’ differences and interests must be accommodated within the PE group. • The importance of PE group leaders to be aware of social structures and norm

constructions, and to be able to create a group climate and a pedagogy of acceptance were group members value each other’s differences.

To attract parents to participate in PE groups, awareness and changes are needed at the individual, group and organisational levels.

1. INTRODUCTION

Pregnancy and the time nearest childbirth is an important part of the transition to parenthood, and parents are very receptive to advice and information during this time (Barimani, Vikström,

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Rosander, Forslund Frykedal & Berlin, 2017). Expectant and new parents are in many countries offered early parenting support in PE groups as a way to prepare parents for childbirth and to support their transition to parenthood (Barlow, Smailgagic, Husband, Roloff & Bennet, 2012; Gagnon & Sandall, 2007). When parenthood, as a topic, is in focus in PE groups, parenthood is strengthened (Ahldén, Göransson, Josefsson & Alehagen, 2012; Asenhed, Kilstam, Alehagen & Baggens, 2014; Barimani, Vikström, Rosander, Forslund Frykedal & Berlin, 2017; Barimani, Forslund Frykedal, Rosander & Berlin, 2018; Berlin Törnkvist & Barimani, 2016; Schrader McMillan, Barlow & Redshaw, 2009; Svensson Barclay & Cooke, 2009). Better relationships between parents by, for example, information about co-parenting and an interactive learning approach are also reported (Pinquart & Teubert, 2010; Schrader McMillan, Barlow & Redshaw, 2009; Svensson et al., 2009). Furthermore, improved maternal self-efficacy when the focus was on increasing baby-care competence has also been reported (Svensson et al., 2009).

2. BACKGROUND

The social context that PE groups can provide in terms of interaction between parents, exchanging parenting-related information and expanding the parents’ social network is important (Asenhed et al., 2014: Barimani et al., 2017; Barimani et al., 2018; Berlin et al., 2016; Fabian et al., 2005; Forslund Frykedal & Rosander, 2015; Murphy Tighe, 2010; Nolan, 2009; Norling-Gustafsson, Skaghammar, & Adolfsson, 2011; Schrader McMillan et al., 2009; Svensson, et al., 2006; Svensson, Barclay & Cooke, 2008). However, parents attending PE groups have different expectations of the content and the methods of delivery of content (Andersson, Christensson & Hildingsson, 2012; Berlin, et al., 2016; Forslund Frykedal & Rosander, 2015). In a study by Berlin and colleagues (2016) parents expressed both satisfaction and dissatisfaction with PE groups and the leader’s role. Several studies have shown that parents want leaders who can create interactive and participative learning environments instead of a

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more directive or lecture-type approach (Andersson et al., 2012; Petersson, Petersson & Håkansson, 2004; Schrader McMillan et al., 2009). Parents also expect balanced health information (Hjälmhult, Glavin, Okland & Tveiten, 2014) and a greater focus on topics such as parenting, sex and relationships (Barimani, et al., 2018; Lefèvre, Lundqvist, Drevenhorn & Hallström, 2016). Larger groups and a didactic mode of teaching, that is, lecturing and minimal interaction between the participants, can even inhibit learning (Ho & Holroyd, 2002).

Today, many parents feel unprepared for parenthood, and an urgent task for the future is to find ways to reach groups in need of support but not attending PE groups (Petersson, Petersson & Håkansson, 2003). As Lefèvre and colleagues (2016) have concluded, there is a need for leaders to develop PE groups to attract those parents who currently choose not to participate. To gain more knowledge about parents’ non-attendance in PE groups, we have, in this study, investigated parents' reasons for not attending PE groups in antenatal care and child healthcare.

2.2 The aim of the study

The aim of this study was to explore expectant and new parents’ reasons for not participating in PE groups.

3. METHODS

3.1 Settings

Sweden is one of the countries that offer PE groups both during pregnancy (in antenatal care service) and after childbirth (in child healthcare service) to first-time parents. The leaders of PE groups are primarily midwives or child healthcare nurses. Expectant and new parents’ participation in PE groups varies depending on, for example, sex, country of birth and education

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(Lefèvre, Pålsson & Köhler, 2018; National Quality Register for Maternity Service, 2016). Between 50–70% of first-time parents attend PE groups during pregnancy; however, after delivery, fewer partners attend the groups (Blennow et al., 2013; Lefèvre, et al., 2018; National Quality Register for Maternity Service, 2016). Women participate to a greater extent in PE groups than men, and men often perceive that they are more focused on supporting women (Petersson, et al., 2003).

3.2 Data collection

A web questionnaire containing both closed- and open-ended questions was distributed by the organization “Föräldravrålet” (a non-profit organization in Sweden based on people working for safer childbirth care from a parental perspective). The organization mailed a link to the questionnaire to its 7,000 members and also published the link on its website (www.foraldravralet.se) and on the social forum on Facebook. Parents who were not members of the organization were also given the opportunity to participate in the study because the study and the link were shared on Facebook. An inclusion criterion for the study was that a participant’s latest child had been born within the last 21 months. The web questionnaire was open for six weeks from the last week of April 2017.

3.3 Participants

A total of 915 parents from Sweden, who have recently become parents to a child (having a child between 0 and 21 months old), participated in the study. The mean age was 32.7 years (SD = 4.29), ranging from 21 to 47 years. 97.4% of the parents lived in a relationship with a partner. 95.2% were born in Sweden and 85.9% worked for a living, although most of them were probably on maternal leave at the time of the study (in Sweden parents are entitled to 480 days of parental leave). 77.2% had a university degree or were studying at university. About

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half of the participants lived in larger cities (with more than 250,000 inhabitants), and the other half were evenly spread over smaller cities and towns of varying sizes throughout Sweden. A majority were primiparae (61.9%): about one-third had given birth once before, and the rest (about 10%) had more than two children.

3.4 Open-ended questions in the questionnaire

This study focused on the six open-ended questions in the questionnaire (see Table 1).

Table 1. Questions in the questionnaire and number of answers.

Questions Answers

What was the reason for not participating in a PE group in antenatal care? 472 Is there anything that could have changed your mind about the PE group in antenatal care? 417 What parenting support did you have instead of a PE group in antenatal care? 433 What was the reason for not participate or plan to participate at PE group in antenatal care 238 Is there anything that could have changed your mind about the PE group in child healthcare? 223 What sort of parenting support do you have instead of a PE group in child healthcare? 223

The length of the answers to the open-ended questions varied from one word to several sentences. A total of 2006 answers were collected (1322 answers related to antenatal care and 684 answers related to child healthcare). Of the 915 parents answering the whole questionnaire, 555 answered at least one of the open-ended questions.

3.5 Analyses

To analyse the answers to the open-ended questions, we used a qualitative content analysis (Elo & Kyngäs, 2007; Graneheim & Lundman, 2003; Hsie & Shannon, 2005). It was performed in two waves, each including several phases. The first wave started with an open coding using

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MAXQDA12 (software, MAXQDA 2014), resulting in 2027 codes being constructed, that is, an inductive content analysis approach (Elo & Kyngäs, 2007). Each code was connected to a meaning unit of varying length in the empirical data (Graneheim & Lundman, 2003). The shortest consisted of one word (e.g. “no”, “yes”), others of a few words (e.g. “I don’t think so”, “don’t know”) and longer units consisting of one or more sentences (e.g. “If there had been a PE group near where I lived, I would have met parents nearby. But we live in the countryside”). After the open coding was completed, the codes were compared based on their differences and similarities and organised into clusters containing repeated patterns from the data set and sorted into twenty-six content areas (Granheim & Lundman, 2003) using MAXQDA12. Examples of content areas are “group for multiparae”,” support from family and friends”, “more available alternative” and “arguments for participation”. Since the content areas contain many codes sharing a commonality, they are referred to as sub-categories.

In the second wave, we used a comparative analysis on the twenty-six sub-categories resulting in the construction of ten categories. Each category included 2–5 of the constructed sub-categories. When defining and naming the categories, a pattern of reasons for not participating in PE at the personal, group and organisational levels emerged, and the categories were sorted into these three themes. In the study, the levels (personal, group and organisational) form the basis for three themes. Each theme included 3–4 categories. According to Elo and Kyngäs (2007), creating categories and themes provides a means of describing the studied phenomenon in a more abstract way. Unlike the analyses in the first wave, which involved sorting codes and sub-categories, the process in the second wave was more interpretative, resulting in the ten categories and the three themes. For an illustrative picture of the analysis process from codes to a theme, see Table 2.

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Codes Sub-categories Categories Themes

Don’t like new groups

Feel pressure

Private factors

Personal reasons for not attending PE groups Uncomfortable Premature The baby Fear of infection Germany Living abroad Structural factors Denmark

Just feeling to sick, to old, to unequal

Age Perhaps, if I was younger…

Dads are excluded and minimized

More norm-critical

Contents in PE

groups Norm-critical1 and self-interested reasons for not participating in PE groups More heterogeneity

More openness Discussions

More interactions Methods in PE-groups Exchange experiences

Different view than mine

Does not fit in Relevance of PE groups

They were much younger than me

No information Mediocre information Information from

antenatal or child

healthcare Unavailability and being uninformed as reasons for not participating in PE groups Knowing about it

Difficulties to sign up

Private antenatal car No invitation

Invitation to PE group

Switched the AC

No group available for multiparae

Holiday period Staff shortage PE groups were

not available Cancelled

Vaccination period

Resource shortage Lack of money

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Granheim and Lundman (2003) argued that a category is a group of codes that shares a communality and refers mainly to a descriptive level and an answer to the question “What?”. A theme, on the other hand, is considered to include an underlying meaning through codes, code content and categories on an interpretative level, which makes it possible for a theme to answer the question “How?”. The study following the SRQR guidelines (O’Brien, Harris & Beckman, 2014).

3.6 Ethical considerations

Throughout the study, we adhered to the four ethical principles of the British Psychology Society (2014): (a) respect; (b) competence; (c) responsibility; and (d) integrity. By answering the questionnaire, the parents gave informed consent for participate in the study. The study was approved by the regional Research and Ethics Committee at Linköping University, Sweden (# 2017/202-31).

4. RESULTS

Almost half of the parents who answered the questionnaire had attended some form of PE group prior to giving birth (47%), and of the primiparae, 56% had attended. Almost three out of four (73%) had experience or planned to get experience from a PE group after giving birth (50% had participated previously, 17% were currently participating and 6% were going to attend). There were also parents who had chosen not to attend a PE group for different reasons. We asked for their reasons for not attending a PE group, and if there was anything that could have changed their mind. Additionally, we also asked what sort of parenting support they have instead of a PE group. When analysing the parents’ answers, a pattern of reasons at the

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individual, group and organizational levels emerged. From these patterns, the following three themes where constructed: (a) personal reasons not to participate in a PE group; (b) norm-critical and self-interest reasons not to participate in a PE group; and (c) unavailability or being uninformed about reasons not to participate in a PE group.

4.1 Personal reasons for not participating in a PE group

This theme is about parents’ personal reasons not to participate in a PE group based on the categories private, structural, or organizational factors or other form of support. The parents’ ages ranged from 21 to 47 years, and they lived in cities or towns of varying sizes. Private factors, such as not being interested or feelings of not being related to anyone else in the PE group, were expressed as: “if I have had a friend in the group” or “if my partner would have come along with me”. These were reasons for not participating. Additional reasons for not participating that were connected to private factors were illness, such as “being on sick leave”, “depression” or in need of “specialist antenatal care”. Others included a fear that the baby may get infections; as one parent expressed it: “We have a baby with a heart defect, so we avoid all public environments, and just see people who are healthy”. Having a baby with special needs or a premature baby are additional examples of private factors in this theme.

Living abroad, living in the countryside, the size of the income, being young as a parent or being an older parent are all structural factors, which were expressed as reasons not to participate in a PE group. One older parent expressed it as “just feeling too sick, too old, and too unequal”. Expressions like, for example, “if it was closer to home” and “we have moved abroad” were other factors used as explanations for not participating in the groups. Having a profession as midwife or child healthcare nurse or working with babies in other ways were

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further examples of structural factors that parents expressed as personal reasons for not participating in a group.

Insufficient time was a common reason for not participating, for example, having a “heavy workload”, “older siblings” or “other activities”. The absence of a group for multiparae or possibilities for older siblings to participate in the parent education group were all examples of organisational factors in the theme of personal reasons for not participating in a PE group.

The parents also communicated that they had other forms of support. This support could be, for example, their own earlier experiences, support from relatives or friends, personal support at antenatal care, child healthcare or from other professionals or support from books and the Internet. Earlier experience could involve siblings or nephews, but some parents also expressed “common sense” as a reason for not participating in a PE group. Support from relatives or friends could include, for example, a “partner”, their “own mother”, “sister”, “mother in law” or “colleagues”. To be “psychologist”, “curator” or “paediatrician” as own profession and individual support from a “midwife or child healthcare nurse” in antenatal care or child healthcare were additional reasons that the parents expressed for not taking part in a PE group. Additional examples of ways in which the parents got support in their parenthood included searching for support on websites, “Facebook groups”, “motherhood blogs”, “internet forums” and “reading books about pregnancy and children’s development”.

4.2 Norm-critical2 and self-interest reasons for not participating in a PE group

This theme is about the parents’ expressions of relevance and judgements of the content and methods in PE groups. They asked for more heterogeneity and openness regarding both the

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groups’ content and methods, so that parents’ differences and interests could be accommodated within the group. Their conceptions about or experiences of PE groups were the basis for judging if the groups were relevant or otherwise; as one parent expressed it: “I feel a disinterest for, what I believe, a PE group means”. Additionally, different forms of word-of-mouth from people that are close to them also seem to affect their judgements.

Some of the parents asked for a more norm-critical approach in the PE group and a “more modern approach to parenting”. They claimed that much of the focus was on the normality around pregnancy, childbirth/delivery, the mother, breast-feeding and children’s development, among other issues. These aspects often constitute the norms in the groups, which create imbalances and exclusions of individuals who experience that they do not “fit” in the group or just “want to be a parent in their own way”. Expressions such as “dads are excluded and minimized” or “acceptance of the fact that women want to give birth in different ways” are examples from parents who wanted more norm-critical perspectives in the group. These parents asked for more openness to the fact that not everything is normal, and instead, they meant that there should be a greater variation in the views of everything covered in a PE group. They wanted more openness to the fact that babies are different, stating that: “not all babies are calm and fall asleep in their arms”. The parents questioned why “everything is about the ‘normal’ [in the groups]” and claimed that “it is when it feels abnormal you need more knowledge and support”.

The parents also gave other reasons than norm awareness for wanting heterogeneity in a group. In some of the answers, you could discern a more self-interested perspective, including statements such as: “[If there were] mothers, who were at my age”, “possibilities to log in to the net to see who has sign up” and “individuals in the group who would be interesting to

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associate with”, or if there had been “the right mix of people, I would have wanted to participate in the group”. Unlike the norm-critical answers, these answers did not contain significant levels of norm awareness; instead, they probably could have contributed to the fact that the norms and structures in the PE groups may have been strengthened. Additionally, some answers were about the methods used in the groups and a desire to have more variation in how the group content was treated. However, there was no clear conformity in the answers, and some wanted “more facts and information from different perspectives” or “research about baby food”, while others wanted “more discussion” or “to change experience between the parents”. The parents also asked for alternative forms of methods and content, which differed from what the parents expressed were usually covered in the groups, including, for example, “yoga”, “meditation”, “mental preparation” and “massage”.

4.3 Unavailability and being uninformed about reasons for not participating in a PE group

This theme is about availability of and information about PE groups. The parents described how their reasons for not participating in a PE group depended on the way antenatal care and child healthcare services handled information, but also on whether there were enough staff or financial resources available to carry out PE groups. The parents expressed reasons in three areas regarding the group organization for not participating in a PE group. These were: Information from antenatal care or child healthcare, Invitation to PE groups and PE groups were not available.

For different reasons, the information about the PE group, how to sign up and when it starts were not clearly presented. This type of poor information from the antenatal care and child healthcare services was a reason not to attend. Statements like “I didn’t know there was one”,

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“no invitation”, “no offer”, “no information”, “hardly know what it is” and “hard to sign up” were characteristic examples. In some cases, a midwife or child healthcare nurse also forgot to inform or invite the parents.

Some of the parents were asking for more information and engagement from the midwife or the child healthcare nurse around the importance of participating in the group. They wanted arguments for why it is important for them to participate and what support on a group level they could provide that the individual support from a midwife or child healthcare nurse could not. They also wanted information on the purpose and contents of the group. Regarding something that would have changed one’s mind about PE groups, one parent stated: “yes, greater commitment from the midwife regarding the importance of participating in a parent education group”.

For a number of parents, there were no PE groups available or the group was cancelled due to the fact that too few participants had signed up. The antenatal care and child healthcare services’ explanations for not providing a PE group included staff shortages or insufficient financial resources. Common explanations from the parents were that there were no groups available because “it was a holiday period”, “there were large groups of refugees who needed support” or “the staff had to prioritize vaccinations against the flu”. For some, there were no groups available for multiparae, which implied that parents who already had had one or more children were not included in the PE groups.

5. DISCUSSION

In this study, we explored expectant and new parents’ reasons for not participating in a PE group. The results showed that parents have reasons for not participating on individual, group

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and organizational levels. The reasons given were multifaceted, ranging from personal reasons, self-interest reasons and norm-critical reasons, to reasons involving the fact that a group was not available or that the parents were uninformed. Some parents gave reasons on a personal level for not participating in a PE group, but, at the same time, indicated a need of group support from the child healthcare services. As Lefèvre and colleagues (2016) concluded, there is a necessity to develop PE groups to attract the parents who currently choose not to participate, but obviously need it.

When we designed the study and started the exploratory analysis, the focus was not on norm criticism/awareness. However, in the inductive analysis procedure the creation of norms and social structures in the PE-groups became apparent by parents’ expression of how they experienced the leaders’ more or less unconscious approaches. Thus, as the results about norms and structures were constructed from the empirical data, the concepts “norm-critical” and “norm-awareness” needs some elaboration. In this article we look upon norm criticisms/awareness as a way to analyse and understand current norms and social structures as a tool for challenging or dismantling them. Actions, values and norms are involved in tutorial/teaching, such as in PE groups. For this reason, it is important for PE leaders to be aware of how unequal relationships are created and sustained at different levels in society and in PE groups (Boutain, 2005). Such knowledge can help leaders to counteract oppressing structures in the PE groups. Unconsciously, leaders convey their own norms and values in the PE groups. To be aware of one’s own preconceptions and normative values is a first step towards a norm-critical approach (Johansson & Theodorsson, 2013). By using norm criticism leaders can raise awareness of the privileges, power imbalances and exclusion that some norms create. It is also a way to challenge social structures and combating marginalisation of individuals and groups in society (Tengelin & Dahlborg-Lyckhage, 2016).

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Some parents protested against the fact that the content in the PE groups was focused so much on normality, regarding motherhood, pregnancy and childbirth. These findings are in line with results in a study by Erlandsson and Häggström-Nordin (2010), in which fathers described how PE groups emphasize the importance of a normal birth, avoiding the complicated births and preserving traditional gender roles. The parents in our study also expressed the fact that fathers in PE groups are “excluded and minimized”, and similar results have been found in a study by Salzmann-Erikson and Eriksson (2013), where fathers revealed that they felt “invisible, disregarded and insulted” (p. 381). Parents in our study asked for a more norm-critical perspective in PE groups. According to Kristjönudóttir Jónsdóttir, Kovacs and Jojsimovic´(2015), when using norm criticism, one can raise awareness of the power imbalances and exclusion that norms could create. If nurses have norm-critical competence, and an awareness of one’s own taken-for-granted norms, prejudices and stereotypical beliefs, then they could analyse and understand norms and power structures (Tengelin & Dahlberg-Lyckhage, 2016). There were parents who wanted more diversity in the groups. Despite different approaches to or attitudes about, for example, delivery, breast feeding and parenting, or different requests regarding content and methods in the groups, all parents should be able to feel included in such a way that it would be relevant for them to participate. On the other hand, other parents wanted more like-minded individuals or individuals who were in a similar situation as themselves. Given that parents express so many diverse reasons for not attending PE, it will be a real challenge for the leaders to manage and meet all the parents’ needs and interests. A lack of norm awareness creates an implicit bias that seems to be correlated with a lower quality of care (FitzGerald & Hurst, 2017), and this risks negatively affecting the nurse-patient relationship (Tengelin & Dahlberg-Lyckhage, 2016). To support parents’ preparation for parenthood, it is instead important for leaders to create a norm-critical approach in the PE

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groups and thereby avoid lowering the quality of care (Tengelin & Dahlberg-Lyckhage’s, 2016; FitzGerald & Hurst’s, 2017) – not least because of the fact that today many parents feel unprepared for parenthood, but at the same time, they are very receptive to advice and information about becoming or being a new parent (Barimani, et al., 2017).

Although all first-time parents in Sweden are supposed to get the opportunity to attend a PE group, PE groups are unavailable for some parents, or not all parents receive an invitation to participate. This can be due to a lack of financial recourses or a heavy workload for AC and CHC. Gagnon and Sandall (2007) and Nolan (2009) argued that if there are cutbacks in healthcare, there is a risk that PE groups are dropped from budgets. Thus, antenatal care and child healthcare cannot offer PE groups to the parents. Parents also use other sources for information on delivery and parenthood, such as the web and magazines (Berlin, Törnkvist & Barimani, 2016; Lima-Pereira, Bermudez-Tamayo & Jasienska, 2012). Consequently, not all expectant and new parents in this study realize that PE groups can be beneficial for them, and they asked for arguments from midwifes and child healthcare nurses for why they should participate in a group. Just like Lefèvre and colleagues (2016), we argue that it is crucial for AC and CHC to develop PE groups to attract parents as well as to market the PE groups and give the parents good reasons for attending. However, that would also be an additional task for the leaders who already have heavy workloads. An additional problem is that most of the midwives and child healthcare nurses leading PE groups have no formal education for leading groups (Forslund Frykedal, et al., 2016). An unreflective approach to different structures in society along with health care professionals’ norms and stereotypical values may contribute to a normative leadership in PE groups. Elements of knowledge about and training of both leadership and norm-critical competence, for example, in nursing education programs might contribute to leader’s development of more norm-critical approaches. Dahlborg Lyckhage,

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Brink & Lindahl (2018) proposed a theoretical framework for an emancipatory perspective in nursing care practice to meet the requirements of social justice in health care. This is one example on how formal education can contribute to the development of nurses’ competence concerning norm-criticism.

5.1 Trustworthiness and limitations

Granheim and Lundman (2003) highlighted the importance of describing the analysis process in sufficient detail to give a clear understanding of how the analysis was carried out. In this study, we have been using three concepts of trustworthiness common in qualitative analysis: credibility, dependability and transferability to discuss the research procedures. 915 parents responded to this questionnaire; although far from all answered the six open-ended questions, 555 answered at least one of them, that is, many participants that helped shed light on the reasons for non-attendance from variety of aspects. This contributed to a rich variation of aspects of the phenomenon, which can help in achieving credibility. All six open-ended questions were the same for all parents and thereby strengthened the dependability of the study. The intention has been to describe the entire research processes in a transparent way and thereby facilitate the transferability of the study.

The parents who participated were engaged in, for example, safe childbirth through the organization “Föräldravrålet”, who distributed the questionnaire, and it could be argued that the participants may not be fully representative of all Swedish parents. We can assume that the results probably would have been slightly different if the parents who answered the questionnaire had represented a greater variety of the population. Furthermore, we cannot say with certainty that each individual has answered the questionnaire just once. However, we have not seen anything in the data that indicates multiple answers from the same individual.

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6. CONCLUSION

The reasons for not attending a PE group varied from parents asking for more diversity to parents asking for more homogeneity in the PE groups. Parents with these different perspectives or opinions meet in the groups, and the leaders not only need to manage the group as such, but also need to meet the parents’ needs and interests and lead the groups in a more norm-awareness way. About 70% of the parents in the study had participated in some form of PE group. There were parents who gave reasons for not participating in the PE groups, but still seem to be in need of group support from child healthcare services. Parents also asked for arguments for why they should participate in the PE groups. Taking it together, this emphasizes the necessity to attract all parents, but perhaps foremost the parents who obviously need it.

7. RELEVANCE TO CLINICAL PRACTICE

From earlier research (Forslund Frykedal & Rosander, 2015; Forslund Frykedal et al., 2016; Lefèvre et al., 2016), we know that many leaders of PE groups find it challenging to manage the groups. A challenge the leaders of the PE groups are facing is to be able to address the heterogeneity of the groups so that parents’ differences and interests can be accommodated within the group. Therefore, we think it is important for leaders to reflect upon and to be aware of how norms are constructed, and what the existing norms could be in the PE group. This to be able to meet the requirements in a heterogeneous group and to create a group climate and a pedagogy of acceptance that values each other’s differences. Awareness and a thoughtful approach are important tools for them as leaders when working with PE groups. As Tengelin and Dahlberg-Lyckhage (2016) so clearly expressed, norm criticism needs to be continuously

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reflected upon and discussed, in combination with self-reflections about one’s own privilege and situation. However, this study has shown that to attract parents to participate in PE groups, it is necessary for the clinical practice to work on three levels: the individual, group and organisational levels.

FUNDING

This research was funded by the Swedish Research Council (grant # 2016-03550).

AUTHOR CONTRIBUTIONS

Study design: KFF; data collection: MR, MB, KFF, AB data analysis: KFF and manuscript preparation: KFF, MB, AB, MR

CONFLICTING INTEREST

The authors report no conflicts of interest.

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