Stakeholder engagement in developing a father-inclusive early life obesity prevention intervention: First Heroes

Background Although paternal involvement in the perinatal period is associated with benefits for maternal-child health and reduced obesity risk, fathers are seldom included in perinatal or obesity prevention efforts. Engaging community leaders and fathers as stakeholders in intervention development is a critical step in designing a father-inclusive intervention that is efficacious and responsive to their needs. Methods We conducted a structured engagement study, including community stakeholder engagement and qualitative interviews with new fathers, to inform the development of a prospective randomized controlled trial that includes mothers and fathers as equal partners in infant obesity prevention. We interpreted stakeholder feedback through the Consolidated Framework for Implementation Research (CFIR) framework. Results Between September 2019 and April 2020, we held a Community Engagement meeting, formed a Community Advisory Board, and conducted 16 qualitative interviews with new fathers. Stakeholder engagement revealed insights across CFIR domains including intervention characteristics (relative advantage, complexity, design quality & packaging), outer setting factors (cosmopolitanism and culture), individual characteristics (including self-efficacy, state of change, identification with the organization) and process (engagement and adaptation). Stakeholders discussed the diverse challenges and rewards of fatherhood, as well as the intrinsic paternal motivation to be a loving, supportive father and partner. Both community leaders and fathers emphasized the importance of tailoring program delivery and content to meet specific parental needs, including a focus on the social-emotional needs of new parents. Conclusions A structured process of multidimensional stakeholder engagement was successful in improving the design of a father-inclusive perinatal obesity prevention interventions. Father engagement was instrumental in both reinforcing community ties and increasing our understanding of fathers’ needs, resulting in improvements to program values, delivery strategies, personnel, and content. This study provides a practical approach for investigators looking to involve key stakeholders in the pre-implementation phase of intervention development. Trial registration ClinicalTrials.gov, NCT04477577. Registered 20 July 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04759-z.


Introduction
Childhood obesity is a major public health concern, with over 10% of two-to-five-year-old children in the United States meeting criteria for obesity and higher rates among children from racial/ethnic minorities and lowincome families [1,2]. Disparities in obesity prevalence originate before birth and are exacerbated by risk factors during infancy and early childhood, which influence health outcomes across the life course [3]. While early life obesity interventions are a promising strategy for obesity prevention [4], the majority target mothers and largely ignore the important role of fathers [5,6].
Paternal engagement in early life is associated with positive maternal-infant health outcomes [7][8][9][10] and overall child well-being [11,12]. Increasing evidence also highlights the important role of fathers in relation to childhood obesity risk [13,14]. A father's own obesity status and health behaviors are associated with a child's risk of obesity, independent of maternal factors [14][15][16]. This may occur through several mechanisms. Fathers influence their child's nutrition, in relation to early childhood feeding practices [17], food and beverage intake [18][19][20], and overall food parenting practices (i.e. access to healthy foods, modeling healthy behaviors) [9,21]. Although less research exists specifically related to fathers and physical activity [22], there is a strong argument for a critical role for father in physical activity promotion [23,24].
Despite this importance, barriers at multiple levels prevent adequate outreach and engagement of fathers in both early life [9,25,26] and obesity prevention programming [27]. These barriers include both inner setting factors, such as lack of conceptual engagement, inadequate father-focused materials and programs, and lack of trained staff to work with fathers [28], as well as outer setting factors, such as insufficient funding and lack of established best practices. On a larger scale, there is also the need for a cultural shift in recognizing the importance of fathers as partners in parenting [29]. To overcome these obstacles and meaningfully involve fathers in early life interventions, engaging key stakeholders-especially fathers-is a critical strategy to inform the design and implementation of an efficacious program that are responsive to their unique needs, perspectives, and experiences [30,31].
The purpose of this engagement study was to engage both fathers and community stakeholders to inform the adaptation of the "First 1,000 Days" intervention, an evidence-based, systems-level obesity prevention program that originally targeted the mother-infant dyad, to fully involve fathers [32]. The "First 1,000 Days" program included universal screening of social and behavioral needs early in pregnancy and after birth, clinician/staff training on health promotion, multimedia educational materials supporting health behavior change and social needs, and individualized health coaching for women at high risk of obesity or depression. Program participation was associated with reduced risk of gestational weight gain [33], improved health behaviors and psychosocial outcomes during pregnancy [34], and improvements in both infant weight status and maternal postpartum care at 12 months of age [35].
Our goal was to engage fathers and apply their lived experiences to identify and dismantle traditional barriers preventing father engagement in the perinatal period. Through strengthening our program to meet the needs of fathers, our long-term aim is to empower fathers in promoting strategies for preventing childhood obesity. Advancing the development of informed father-inclusive perinatal programs, we hope our program can serve as a practical model for other groups that seek to incorporate both parents equally in traditionally maternally oriented spaces [36]. This manuscript describes the process and results of our stakeholder engagement.

Overview
In planning for a new, father-inclusive intervention, we conducted a structured multilevel engagement study to identify strategies to recruit, retain, and influence fathers in perinatal and obesity prevention programs. We used the Consolidated Framework for Implementation Research (CFIR), an evidence-based framework that identifies multi-level intervention factors that influence implementation effectiveness, to interpret stakeholder feedback [37]. Over an 8-month period (September 2019 -May 2020), we engaged a broad range of stakeholders in the adaptation of the First 1,000 Days program to be father-inclusive. Our engagement efforts informed the design of a prospective randomized controlled trial enrolling the mother-father-infant triad beginning in pregnancy and continuing throughout the first year of life ( Fig. 1).
Our engagement plan consisted of two components: community stakeholder engagement and qualitative interviews with new fathers. We chose each component Keywords: Fatherhood, Stakeholder engagement, Community engagement, Obesity prevention, Social determinants of health, Maternal-child health, Perinatal health, Infancy to provide unique perspectives relating to issues such as father receptivity to program participation, study design, and intervention structure and content. Based on our prior work with First 1,000 Days, we also recognized that embedding our intervention within the larger community and gaining institutional support is critical for increasing the likelihood of intervention success [32].

Setting
We directed our engagement efforts to include fathers and clinical leaders who receive and provide care at obstetric and pediatric practices affiliated with Massachusetts General Hospital (MGH) in Boston, Massachusetts. MGH includes hospital-and community-based care locations and serves a diverse population, with over 40% of delivering mothers identifying as a racial or ethnic minority. We aimed for our engagement sample to reflect this diversity. We also engaged community leaders with experience in engaging new parents, especially fathers, in early life interventions and connecting families with community resources.

Community stakeholder engagement
We conducted a two-stage process of community engagement. We held the open Community Engagement Meeting (CEM) to introduce the study to community stakeholders. Following the meeting, we invited interested attendees to participate in a Community Advisory Board (CAB) to provide ongoing input on study design and father engagement.

Community Engagement Meeting (CEM)
We held an open CEM in September 2019 to guide the initial formative stages of intervention adaptation. In identifying meeting invitees, we leveraged existing community connections from the First 1,000 Days, as well as solicited requests from these connections to identify any other key stakeholders we may have overlooked. We systematically created an invite list, including MGH obstetric and pediatric clinicians providing care in the perinatal period, care providers from community home visiting programs, leaders of father advocacy groups, and local fathers. During this meeting, we provided an update on results from First 1,000 Days, explained our rationale in extending the program to include fathers, and described the current proposed intervention structure ( Table 1). The initial intervention design was the product of an extensive literature review of effective obesity prevention and father-inclusive perinatal interventions targeting the first year of life [4,38]. The research team collaboratively reviewed the current literature relation to existing First 1,000 Days intervention content to develop our proposed intervention structure.

Community Advisory Board (CAB)
We invited CEM attendees to provide ongoing feedback through participation in our CAB. We informed potential members that responsibilities would include (1) attending quarterly meetings and (2) providing feedback on intervention design and content. We asked members to identify other stakeholders within the fatherhood community for invitation. The first CAB meeting was held in January 2020. The meeting agenda addressed program  modifications based on initial feedback, recruitment plans, and study educational materials. Board members received all study materials prior to the meeting for their review, with opportunities for feedback provided within the meeting as well as through follow-up phone conversations or written communication. The first meeting was held via video conference. To minimize the burden on our advisory board members during the COVID pandemic, we provided ongoing updates through email (Spring-Summer 2020), with resumption of the quarterly meeting schedule in Fall 2020.

Qualitative interviews Study design
We conducted 16 semi-structured qualitative interviews (November 2019-April 2020) with fathers of children under 1 year old to investigate the acceptability and feasibility of the proposed intervention. We identified fathers for participation through review of well-child visits with pediatric practices at MGH, including both hospitaland community-based locations. Fathers were eligible to participate if they were at least 18 years old, had a child receiving care at a MGH pediatric primary care site, were English proficient, were first time fathers, and had a child 0-12 months without significant medical comorbidities that would affect growth, development, and feeding. This study was approved by the MassGeneral Brigham Institutional Review Board.

Interview procedures
Study staff mailed recruitment letters to eligible fathers describing the engagement study. One week after the letters were mailed, study staff contacted fathers by phone to explain the study, answer questions, and enroll fathers who chose to participate. Three phone call attempts were made to reach each eligible father who received a letter. We called 137 fathers; 83 did not answer the phone, 17 declined, 21 were ineligible (n = 8 due to language barriers, n = 2 due to medical comorbidities, n = 3 due to child age > 12 months, n = 2 due to moving out of state, and n = 6 due to not being a first-time father), and 16 consented to participation. Participants received a $25 gift card upon interview completion. After providing informed consent, fathers participated in semi-structured, in-depth interviews. The development of the interview guide was informed by a review of prior studies exploring early life obesity prevention strategies [4] and literature review of relevant methodological considerations regarding father engagement [25,27,38,39] as well as CFIR constructs [37]. The interview guide included core and probing questions to elicit discussion of relevant topics, such as fathers' information and resource needs, perceptions of their roles and experiences, and preferences for intervention content and modalities (see Supplemental File). Each semi-structured 30-min phone interview was audiotaped and transcribed by an independent company for analysis. We reached thematic saturation with a total of 16 interviews, as review of transcripts revealed reinforcement of previously identified themes and no new themes were generated.

Data analysis
We used the CFIR domains to organize feedback from community stakeholders as well as our thematic analysis of qualitative father interviews [37]. Two team members (RW, SS) organized stakeholder perceptions into relevant CFIR domains, including (1) characteristics of the intervention, relating to intervention advantages versus alternative solutions (relative advantage), potential implementation difficulties (complexity), and intervention design (design quality and packaging), (2) "outer setting" factors, relating to connections with other organizations (cosmopolitanism), (3) "inner setting" characteristics of the organization implementing the intervention, including norms and values (culture), and (4) characteristics of individuals involved in the intervention, including progress towards sustained intervention use (state of change), commitment to the program (identification), beliefs that they are capable of executing the intervention (self-efficacy), and other personal traits of both intervention participants and intervention staff (other attributes).

Community stakeholder meetings
At both the CEM and AB meeting, a research team member transcribed detailed notes of all feedback provided by meeting attendees. We reviewed findings in detail in group debrief meetings following both stakeholder meetings. We categorized transcribed notes into CFIR domains using a deductive approach.

Qualitative interview
We used an iterative immersion-crystallization inductive approach to conduct content analysis through repeated cycles of reading and discussing transcripts to identify predominant themes [40]. The full analysis team (HFM, RW, GK, MK, ET) individually read nine transcripts indepth in sets of three before discussing as a group. Based on our initial list of themes, three team members (HFM, RW, GK) independently coded interview content line-byline, collating codes into an Excel spreadsheet to generate a preliminary codebook. We reviewed independent coding for consensus between coders. We revised and reviewed the codebook after each set of three interviews. After in-depth review of nine interviews with the full analysis team, we noted overall repetition of themes.
We reviewed the codebook at this time, reorganizing all codes under relevant corresponding themes that had been identified through group discussion. Two coders (SS, RW) independently coded the next two interviews using the revised codebook, with agreement > 85%. The final five interviews were independently coded, with no new themes emerging from content review and discussion. We sorted codes within CFIR domains using a deductive approach.

Stakeholder characteristics
For the Community Engagement Meeting (CEM), we invited 46 individuals to attend, representing MGH obstetric, pediatric, and research leadership (n = 18), obstetric and pediatric clinical champions (n = 4), local community and state programs focused on fatherhood or early childhood health (n = 17), community outreach/home visiting programs (n = 3), and fathers who were community leaders (n = 4). Ultimately, 22 invitees planned to attend and 11 attended; of those unable to attend, the primary reason was scheduling conflicts. Our CAB was primarily drawn from CEM attendees and was composed of 12 members, including representatives from pediatrics and obstetrics (n = 2), academic public health research (n = 1), community outreach/home visiting (n = 2), local family and community organizations (n = 4), state public health infrastructure (n = 1), and a national child health organization (n = 1) as well as a local father advocate (n = 1).
A total of 16 fathers completed the qualitative interview, with 8/16 receiving pediatric care at a community health center. Of participating fathers, 10/16 identified as white, 3/16 identified as Hispanic/Latino, and 3/16 identified as "other". The majority of fathers had a college education or higher (10/16); the remainder had either completed high school/GED (n = 2) or some college (n = 4). The median age of participating fathers was 35 years (IQR: 32, 39).

Stakeholder feedback
We present results through the five CFIR domains (intervention characteristics, outer setting, inner setting, individual characteristics, and process). Within each of these domains, we organize findings from community stakeholder meetings and qualitative interviews by mapping emerging themes to relevant CFIR constructs.

Intervention characteristics: key intervention attributes that influence implementation effectiveness
Relative advantage: perceived advantages of intervention relative to alternatives At the CEM, attend-ees highlighted advantages that are unique to our intervention, including program initiation during pregnancy, specific outreach to fathers, and aim to empower both parents. Within the qualitative interviews, fathers identified several relative advantages of our proposed intervention, including convenient access to father-specific intervention content that was delivered directly to them as opposed to them seeking out on their own (Table 2).
Complexity: perceived difficulty of implementation CEM attendees and CAB members reflected on ways in which the intervention must address the more complex sociocultural needs of a socioeconomically and racially diverse patient population such as through accommodating busy work schedules and training interventional personnel on cultural sensitivities and mandatory reporting (Table 1). Fathers identified several potential implementation barriers related to program delivery and content, such as scheduling conflicts, disagreement with content, technological difficulties, and intrusiveness of home visits ( Table 2).
Design quality and packaging: how well the intervention is presented, bundled, and assembled To brand the program in a way that immediately engages fathers, CEM attendees suggested an inclusive name for the program, with an emphasis on the theme of parents as 'heroes. ' With regards to visit modality and delivery mode, both CAB members and fathers preferred home visits to virtual visits and recommended presenting intervention content in 'bite-sized' summaries before and after visits (Tables 1  and 2). CAB members suggested that key intervention messages be packaged in brief videos, text messages, or short summaries, while fathers expressed interest a "summary sheet of the key takeaways" with each visit. Both groups also recommended a degree of customization depending on dyads' preferences.
Though we initially designed the visit structure and timing to align with critical developmental time points during the prenatal and postnatal periods, there were mixed attitudes amongst interviewees regarding the timing of each visit with respect to the pregnancy and child's age as well as the overall structure of the proposed intervention (Table 1). CEM attendees, CAB members, and father interviewees generally supported the proposed intervention content. Stakeholders also proposed key content areas that they felt were important to include and highlight in the program curriculum, such as infant growth and development, as well as parental support for social connectedness, relationships, and mental health ( Table 1).  iv. List of intervention topics are appropriate, with a highlighted need for information on healthy eating, sleeping, and activity for babies and parents i. "I'm definitely the kind of person who want to receive the material ahead of time, I could actually read it, digest it, and ask questions instead of trying to absorb it during the visit. "; "If there's a summary sheet of the key takeaways or key things to look out for, it's always helpful. " ii. "One visit is probably not enough and two is-yeah I think that's a perfect amount. "; "Maybe the first two visits are more closely scheduled, like we'll say 4 weeks, and then at 7 weeks, and then another one at 18 to 20 weeks. " iii. "I like videos, absolutely, and a web page. Maybe even a quick text with someone on the other line. "; "I would say printed information is good, but also maybe a link to the same type of information online would be helpful as well. " iv. "You're hitting the nail on the head with every issue and period of the child's growth that I think parents fear…Any way you can prepare parents with information before that will definitely put their mind at ease. "

Outer setting: factors external to the organization implementing the intervention
Cosmopolitanism: the overall connectedness with other organizations To take advantage of existing resources that support new parents,, CEM attendees recommended connecting participants with local parenting, fatherhood, and child abuse prevention programs. Similarly, CAB members provided recommendations to relevant parenting and child development resources from national organizations, such as the National Institute for Children's Health Quality [41], and local organizations, such as Boston Basics [42].

Inner setting: characteristics of the organization implementing the intervention
Culture: the organization's norms, values, and assumptions CEM attendees urged us to promote an internal culture that expects dads to be involved, thereby motivating fathers to participate in the intervention. Intervention activities should reinforce the value that dads are important in their children's lives. CEM attendees also suggested including ways to show new fathers that they are not alone, such as through testimonials from other fathers and/or connecting fathers in support groups.

Characteristics of Individuals: qualities of individuals involved in the program Participants
Individual State of Change: individuals' progress towards enthusiastic and sustained use of the intervention CEM attendees cautioned that many of our potential participants may not yet fully understand what it means to be a parent and may have lacked parenting role models within their own lives. As such, a goal of our project is to empower new parents in understanding their roles, moving them into a higher "state of readiness" to prepare to meet the needs of being a parent.
Identification with the organization: individuals' relationship and commitment to an organization CEM attendees highlighted the importance of building genuine relationships between the coaching team and parents. Strong relationships between the health coach and fathers will cultivate trust and keep the father engaged throughout the intervention.
Knowledge/beliefs about the intervention: individuals' value placed on intervention Father interviewees recognized a need for the proposed intervention and expressed they would like to be included with mothers when receiving information about parenting and infants (Table 3). Despite the diverse sources that dads-to-be draw on for support and advice, including family, clinicians, friends, and published information, the information they receive is often unclear, contradictory, and explicitly directed at mothers. Consequently, fathers discussed feeling largely unprepared with the information and skills necessary to support their babies and partners. Sleep disturbance and constant work were cited as the most physically draining aspects of being a new father. Emotionally draining challenges included the uncertainty and novelty of fatherhood, feeling of helplessness, relationship strain with the mother, and baby colic.
Self-efficacy: individuals' belief in capacity to achieve implementation goals CEM attendees spoke to the importance of messaging that fathers can make a difference in their children's health. Supporting this theme, attendees framed fathers as "heroes", suggesting that "all men want to be heroes to their child…if you include them, they will rise to this level. " Fathers bolstered the notion of self-efficacy, emphasizing the intrinsic motivation to provide for their child and partner (Table 3).
Personal attributes: traits of participating individuals Within the CEM, attendees raised concern about the intervention inadvertently excluding certain demographic groups (Table 1). Fathers discussed ways in which the physical and mental strain of fatherhood adversely affect their personal health and the difficulties they faced in maintaining healthy self-care habits during the postnatal period. Highly relevant to the intervention and addressing these challenges is fathers' perceptions regarding their main parenting roles and the importance of these roles (Table 3).

Intervention Personnel
Personal attributes CEM attendees and CAB members provided suggestions on optimal skills and credentials we should seek in intervention staff, including sociodemographic diversity and a balance of social skills and personality traits with appropriate educational background, training, and supervision (Table 1). However, CAB members cautioned against too stringent educational requirements, as this may be a barrier for finding well-suited candidates from the community. Fathers were generally open to a variety of intervention staff delivering intervention content related to their child's health, being a father, and their own health (Table 1).

Process: critical stages of program implementation
Engaging: involving appropriate individuals in the implementation and use of the program Champions (individuals who support program implementation): To support ii. "So many things are geared towards moms. Even when you read books, they are written for moms. It's very clear. And that kind of makes you feel, as a father, like excluded. "; "I think having resources available for dads might make it moremight normalize more that dads are also involved in these decisions about parenting. That might increase dad involvement. " -Additional support for conscious engagement of fathers through program materials -Specific content on importance of fathers Self-efficacy Individual belief in their own capabilities to execute courses of action to achieve implementation goals Fatherhood is a rewarding and empowering experience, instilling a sense of purpose and self-efficacy to provide for the child and partner -"It's been a rewarding new experience watching a little family member grow and mature and flourish. " -"I think the easiest thing is just being able to love my daughter.  ii. "Parenting is a two-person job. Just'cause your wife's breastfeeding doesn't mean you're not involved in the nutrition of your child. Yeah, the earlier you're involved, the happier you'll be. "; "Just making sure that she's healthy, so making sure that she's developing, getting bigger and eating and monitoring to make sure she doesn't have a fever. "; "I do a lot of the day-to-day on the home, everything around the home, cooking, cleaning…Mine's more home and home maintenance, day-to-day maintenance. "; "A lot of it was just being proactive on all sorts of responsibilities more broadly than baby care, doing shifts as night so Mom can get some sleep. " -Supported focus on paternal health behaviors, specifically related to nutrition, sleep, physical activity -Reinforced fathers' role in infant caretaking recruitment efforts in hiring a health coach, CAB members recommended leveraging both local professional and community organizations to advertise the position. Given concern about educational requirements highlighted above, they suggested that using a community health worker (CHW) model may overcome this, as the CHW model recognizes the value of non-clinical skills, including lived experiences and connection with the target community (Table 1) [43]. Innovation participants (individuals who participate in the program): CEM attendees discussed the importance of engaging fathers directly through addressing their backgrounds, "meeting them where they are". They suggested several outreach strategies to achieve this ( Table 1). Fathers recommended a range of additional facilitators to recruitment and engagement maintenance ( Table 1). Fathers also underscored the importance of adaptability (degree to which that an intervention can be modified to individual needs) ( Table 2).

Discussion
In the pre-implementation phase of the First Heroes randomized controlled trial, we used a structured process of multidimensional stakeholder engagement to adapt a mother-focused perinatal obesity prevention intervention to include fathers as equal participants. This process was instrumental in reinforcing community ties and increasing our understanding of fathers' needs, strengthening our intervention to deeply engage fathers throughout the entire process. CFIR provided a framework for understanding and applying our stakeholders' feedback. Our process demonstrated the value of including multiple perspectives when engaging stakeholders, as community leaders and new fathers provided insights that were both unique as well as mutually reinforcing.
While we were open to significant changes in our overall design based on feedback, our stakeholders instead highlighted key areas of focus that strengthened our planned intervention. Both community stakeholders and new fathers had strong support for our approach, citing the advantage of and need for parenting programs that include fathers and begin during pregnancy. Stakeholder input influenced our intervention values, delivery strategies, personnel, and content; we outline specific contributions in each of these domains below. Notably, there were no components of our proposed intervention that were eliminated or deemphasized based on stakeholder feedback.
Our community stakeholders encouraged an inclusive culture that engages fathers from the start. We named our program First Heroes, uniting the preceding First 1,000 Days intervention with themes that arose in the CEM. Community stakeholders strongly believed fathers would rise to the expectations set for them. This was reinforced by the fathers we interviewed who spoke freely and candidly about the rewards and challenges of fatherhood, as well as interest in our program, if it was responsive to their needs.
Stakeholder engagement also influenced our program delivery strategies. We took feedback into account as we decided to allow participant preference to determine both visit type as well as options for receiving materials, as there was a clear interest among fathers for an intervention that could be tailored to their needs. We created materials that could be disseminated through a variety of modalities (e.g. print, email, text messaging). Materials were designed to be easily consumed and not burdensome (i.e. "bite-sized" content), including brief overviews of printed content and short videos summarizing key messages. Of note, based on feedback, we had decided to allow the choice of virtual versus home health coaching visits. However, due to the COVID19 pandemic, home visits were no longer an option and all health coaching visits have been conducted virtually.
Our community stakeholders emphasized essential qualities for the individual delivering our intervention, namely compassion and 'soft' skills that might not be able to be taught. Fathers demonstrated overall flexibility in who they would trust for advice, reinforcing that individual qualities were more important than objective characteristics. We responded to this by creating a health coaching "team, " including a social worker, dietitian, and an experienced health coach, one of whom was male.
Working with stakeholders across multiple dimensions provided unique insights for our intervention content. Community stakeholders were more attuned with 'outer setting' resources to integrate into and support our intervention, as well as the need for awareness of the impact of social determinants of health on infant and parent wellbeing. Fathers were more concrete about their needs, especially related to parenting education, sleep, feeding, development, and sickness. Both agreed on the importance of the social and emotional needs of new parents, which we made a priority in our intervention content.
While the primary aim of our engagement work was to inform the development of an obesity prevention intervention that equally engages mothers and fathers, obesity prevention themes were seldom explicitly discussed among any of our stakeholders. Despite this, targets for obesity prevention were frequent topics of discussion. Fathers identified feeding their child and promoting healthy growth as a key role, which the literature supports as key roles for fathers [17]. Additionally, new fathers endorsed the challenges of maintaining their own healthy sleep, nutrition, and physical activity habits after becoming a father, all of which are potentially obesogenic behaviors. Lastly, community stakeholders emphasized the importance of social determinants of health as a foundational target for our intervention. This resonates with an equity approach to obesity prevention, which requires consideration of basic needs and societal inequities as an essential first step [44]. Our engagement efforts and success in eliciting these priorities represent a model for engaging fathers in the development of perinatal and obesity prevention efforts.
Lastly, our engagement interviews with fathers informed our recruitment strategies, as we recognized the importance of providing additional methods of outreach to mother-father dyads. While we still prioritizing active outreach, we added passive methods to increase study awareness, including printed flyers and posters. Eligible mothers also received messages via the Electronic Health Record that provided an opportunity to initiate the enrollment process online. Additionally, given the relative homogeneity of the interview sample in relation to race/ethnicity and education, we recognized the importance of purposive sampling in identifying eligible dyads to ensure a diverse study sample.

Limitations
While we attempted to recruit a diverse sample through outreach within the community health centers, we unfortunately were not able to logistically conduct interviews in Spanish due to the costs of translating transcribed interviews. As a result, our sample was relatively homogenous with regard to race/ethnicity and educational background. However, even within this sample, fathers identified a great need for resources and father outreach. Feedback from our community stakeholders was critical in providing a voice for the fathers and families they work with, who we were unable to engage through more traditional research methods.
Given existing literature that highlights struggles with recruiting fathers to participate in research, we used active strategies, as opposed to passive methods, for recruitment. Despite our multifaceted strategy with both mailed and phone outreach, we were unable to reach the majority of eligible fathers. We hypothesize that this does not demonstrate a lack of interest but instead reflects the challenge of identifying effective routes to reach fathers.
Additionally, our engagement efforts highlighted the need for feedback from a more diverse group of fathers. We will continue to prioritize understanding our participants' experiences as we implement our intervention. Implementation science methods, such as CFIR, provide resources for informing the translation of research findings into practice and we intend to continue this participant-engaged approach throughout our work.
Notably, our engagement process overlapped with the early stages of the COVID19 pandemic, which resulted in shifting priorities for new fathers as well as our advisory board members. We had limited success in recruiting fathers for interviews after the onset of the pandemic, and our advisory board members had new responsibilities in responding to the crisis. While we had planned to increase the presence of fathers within our advisory board, as well as the diversity of fathers within our interview sample, our target population included communities who were most impacted by the pandemic at that time. We will continue to prioritize outreach to this group through our continued work.
Given the pandemic, in-person health coach visits were no longer possible, and we moved all interactions (including recruitment) to virtual. Our initial advice from our advisory board to focus on social determinants of health became more salient following COVID19. The challenges associated with COVID19 reinforced our efforts to address social needs in our intervention through appropriate community-based referrals.

Conclusion
Through our engagement process, we identified significant benefits for multidimensional stakeholder involvement. This engagement study gave voice to fathers throughout the design of an intervention in a perinatal health area that does not traditionally include them. Using a structured framework with CFIR allowed us to meaningfully improve our intervention, specifically relating to values, delivery, personnel, and content. Recognizing the value of stakeholder engagement, we will continue talking to and learning from fathers throughout subsequent phases of the First Heroes program in an iterative process that incorporates fathers in the fight against childhood obesity. Our work provides a practical model for other investigators in designing and adapting interventions to new populations, especially those overlooked through traditional research initiatives.