Parenting is always an experiment so why not collect the data?
Question Mark Dot

How to do research? A Q&A with Dr Petra Boynton (part 2)

Petra BoyntonWe’re very excited to welcome back Petra Boynton, author of The Research Companion, and a very talented social science researcher. Hopefully she’s going to help us lick our research ideas into shape.

Petra is a Social Psychologist who’s worked in International Health Research for over 20 years. She’s also an Agony Aunt and spends a lot of her time now supporting organisations, charities, and universities to do research ethically, effectively and enjoyably. She’s a mum to two boys aged 10 and 6.

This is the second and final part of our “How to do research?” Q&As with Petra – you may want to catch up with part one before reading this.


Petra Boynton: I hope all of you have survived Snowmageddon and/or World Book Day! Last week we were focusing more generally around what research can entail, this week we’ll be building on that and looking and your specific research question(s), what method(s) are open to investigating said question(s), and what outcomes/impact you’d like to have. There’ll be fewer threads than last time, but more focus on getting you agreed on your research question.

As you’ll know, your area of interest is to explore the experiences of breastfeeding mums with health care professionals (HCPs).

Last week we discussed a lot of possible research questions/issues that could be covered under this banner. This week we’re going to be much more focused and we will:

  1. Identify possible research question(s)
  2. Consider what methods would suit those questions
  3. Think about how you’ll share your findings/make an impact.

If you missed last week it might help to read the transcript of our discussion so we don’t go off-piste with more general discussions of what research can mean and possible study issues.


Question 1

Let’s get started! Given you’re interested in the experiences of breastfeeding mums with healthcare professionals, what question would you like to see answered?

I’ll drop into the thread with additional prompts and ideas for structuring/refining the questions further.

PSG A: What HCP actions are the most helpful / detrimental to continuation of breastfeeding?

PSG B: And what factors facilitate or act as barriers to the provision of HCPs support for breastfeeding?

PSG C: What are the most common myths/misinformation being perpetuated by HCPs?

PSG C: How effectively are HCPs able to separate their own perceptions and experiences of infant feeding from their practice?

PSG A: our top voted areas are:

  • HCP interactions in the early days of breastfeeding.
  • HCP interactions relating to longer term breastfeeding
  • And HCP interactions relating to breastfeeding and sleep.

PSG C: How many mothers have had HCPs recommend using a specific brand of formula? Out of scope I know but I’d personally like to know 😆

Petra: I’m going to be strict this evening and focus us on research questions rather than experiences, so can you rephrase that as something you could test/explore please? 🙂

PSG C: Self reporting survey diffused to breastfeeding groups with the following questions

  • Has a healthcare professional ever recommended using formula while you were exclusively breastfeeding? Yes/no
  • What kind of healthcare professional?
  • In what context: routine appointment including developmental checks and weigh in, experiencing feeding difficulties, maternal health problem requiring treatment, concerns about sleep, other
  • Did they recommend a specific brand? Yes/no
  • If yes which (tick box but I’m not giving them the guts here)
  • How did this make you feel about your breastfeeding experience?
  • How did this make you feel about the HCP?

PSG D: One of the top topics voted as most popular was sleep. People were interested in how advice on infant sleep affects breastfeeding (e.g. no cosleeping, encouraging the idea of that babies should all sleep through, etc)

PSG E: I suspect this is one of the key factors that affects breastfeeding relationship, people’s expectations and cultural beliefs would be a rich area to explore

PSG E: Parents and health professionals need to reconcile breastfeeding with safe co-sleeping.


Sophia Collins: What kinds of things do HCPs say or do that could damage people’s breastfeeding journeys?

PSG D: I think this is fundamental. How often do HCPs end breastfeeding relationships unnecessarily, possibly without even realising it?

PSG G: and can this be broken down by type of HCPs e.g. GPs, paediatricians, health visitors, dentists, etc

PSG F: Yes I think this is key too but often the mother might not realise that led to the end of their journey or was bad advice

Sophia: Yes, I think it would be very hard to say exactly what ended someone’s breastfeeding journey – often it must be a combination of factors. And just hard to survey anyway. Whereas documenting the kind of things that HCPs sometimes do that are unhelpful, feels a bit easier.

PSG H: If one of the major goals is the increase breastfeeding rates then perhaps focusing in question 1; early experiences with breastfeeding and HCPs would be the most useful?

PSG G: I’d like to just make people aware of how HCPs thwart breastfeeding – to expose it like everyday sexism or #metoo have done with sexism and abuse. But not sure if that counts as research.

PSG I: Yes, there are plenty of instances of bad advice/bad interactions but we mainly hear them from mums who continue to breastfeeding as have done their own research etc so not sure how we’d capture those that have stopped because of the bad advice as they may not realise it was bad advice so would never report it as such.

PSG C: In my experience when debriefing breastfeeding problems or previous breastfeeding experiences mothers often mention comments from HCPs that sow seeds of doubt and then cause them to take unhelpful actions like spacing out feeds or offering a bottle or dummy, even if the advice wasn’t to do that. So know what the HCP said but also the impact on the mother and their future actions are both important.

PSG D: Sometimes GPs do directly tell mothers to stop breastfeeding to take medication though, often unnecessarily had the GP been better informed. Not sure how that fits with our research! Possibly a different project entirely! But it would be possible to do.

PSG C: Not just GPs. There are midwives who tell nursing mothers they can’t breastfeeding through pregnancy.

PSG G: If we’re asking parents to self-report non-evidence based advice from HCPs then you would be relying on the parents to know that the advice wasn’t evidence-based. But you could do something different where you interview a mother at various points in her journey and then the interviewer could judge whether the advice the mother had received was evidence-based or not. Just thinking there might be a way around the fact that mothers don’t always know if they’ve received good advice.

PSG H: I’m just wondering how we would differentiate between what information the HCP gave and what the mother understood she was being told…or is only the latter relevant?

PSG C: I would want to see both sides of that coin! Perception and understanding is just as relevant as the information itself. If there’s a problem with delivery of information then it will have a negative impact on the mother.

Sophia: PSG H: That’s a really good point. We may only be able to find out what the patient heard. But it may not be what the HCP said.

PSG J: Sophia and perhaps what HCPs have done or said to enable, support, and empower mothers to breastfeed.

PSG C: That would probably be more useful to increase breastfeeding rates 😉

PSG J: We should consider the humanity of HCPs working within a pressured environment in this. We want them on side.


PSG K: What is the correlation between negative HCP interaction and breastfeeding rates long term compared to positive HCP interaction

Petra: that’s an interesting one. Thanks!

Your challenge here would be to unpack ‘negative interaction’ and ‘positive interaction’ (so how might you define it), and then breastfeeding rates (what time periods would you consider, would you want breastfeeding only or mixed feeding), who would you ask – parents or practitioners or both, and how can you be sure you’re able to correlate the two?

All of it’s possible but as we discussed last week there needs to be a focus on skills, time, etc to undertake a study. Tonight we’ll be looking at all your great ideas to see what could be done in the time you all have.


PSG A: What do people actually talk to their HV about?
I never spoke to mine about sleeping arrangements, for example.

PSG L: I do think PSG A has a point at what points in their breast feeding journeys do mothers have the most interaction with HCPs and will this have a bearing on what we decide. After the early days I have had no real interaction with HCPs over anything breastfeeding related


Petra: These are all great questions.

One thing that may help you is to narrow down is what PSG G has mentioned above – you could include HCPs as a very broad group, but that increases who you’ll be studying. So it might be you prefer to focus on a specific group (e.g. GPs, nurses, health visitors, health care assistants etc).

PSG I: I think there is poor advice across all of the HCPs but is it better to focus on one group and then spread it wider once we’ve covered one?

PSG A: I’m not sure this is the most helpful way to narrow, but I understand why you are suggesting it.Perhaps another way is to define a time period e.g. within first 6 months.

Petra: PSG I that would make sense to me. Remember last week we were talking about things needing to be small, focused and feasible. So realistically you need to have parameters.

You can decide what they are so it might be profession, or as PSG A says it might be time period. What is going to help you is to have a question that is clear and you know you can answer.

PSG C: I’m not sure narrowing would be helpful, and it may feel like we’re picking on one group. Unless we work with an existing network like the GPIFN to do very focused research on GPs, for example. But sometimes problems start because the midwife said one thinking and the health visitor said another…

Sophia: I sort of want to know *which* HCPs people are most likely to have problems with though. e.g. we know that HVs should get a lot more training on breastfeeding. Whereas GPs get very little. Does this mean that many GPs give bad advice? That could help to show a need for more breastfeeding training for them. Whereas if actually a lot of problems are coming from HVs, then something else is going on.

PSG D: If we narrowed by time, then it could be all professionals within that time.

PSG D: Many HVs give shocking advice too though! Some are great but some are very anti breastfeeding

PSG C: HVs are problematic because you have 2 pools (identified by WTBi) – those with the UNICEF training and those without.

PSG G: One interesting question would be when do mothers feel they receive conflicting advice about breastfeeding? Mothers might not be able to say which advice is evidence-based, but they can say when they’ve been told things that aren’t consistent or create tension.

PSG C: I like that idea, PSG G. That way we aren’t relying on mothers being able to differentiate the quality of the advice and we’re working the perception angle.

PSG L: I think it also depends on what stage or area of breastfeeding we want to go with eg early days will probably be midwives and health visitors, sleep – health visitors and older breastfeed children – GPs

PSG I: Good point, much more interaction with HV and MW initially as you get so many visits in the very early days.

PSG B: I guess the question for me is whose voices/experiences do we want to capture. HCPs, mothers or both? If it is mother’s voices then we don’t need to narrow the type of HCP as the research can explore quality and quantity of interactions with different HCPs around breastfeeding.

If it is HCP voices then narrowing may or may not prove useful… again it depends on methodology chosen, time and funds available for research and designing a sampling framework that best captures the range of HCPS women are likely to have contact with during x time period.

Petra: This all works – so alongside potentially studying HCPs, and with a specific time period, you might also want to study mothers. All of this is fine but again you need to think about where you feel your energies are best centred. Remember last week we were talking about how as a group you’ve an amazing insight into the experiences of mothers. So it might be one sub group looks at this, then another looks at ways of finding out more about HCPs.

 

PSG C, Good points. My question would be how much of this work has already been done? Mother’s experiences regarding breastfeeding has been studied a lot – it doesn’t mean you can’t also ask about it but it can sometimes help to either look at what’s already been done and find a new angle. Or to say ‘we know the answers to this pretty well from the evidence but we *don’t* know xyz, so we’ll be addressing that because we want to make abc happen’


Petra: Another tip is if you’ve got a question, run it through scholar.google.co.uk or www.ncbi.nlm.nih.gov/pubmed/ you may well find someone’s already explored what you’re interested in.

Which is fine, you can build on existing work, or shift from it, or use it to review what’s been done to ask why said work isn’t necessarily implemented or followed.

Just as a quick example this is what you find if you use a very basic search of “physicians AND breastfeeding”


PSG M: Impact of HV interactions (key visits) on improvement of breastfeeding rates?

PSG N: Surveying women’s experiences with HCP’s relating to breastfeeding. Looking for positive and negative topics
What are most commonly reported
Then could that guide future work on what/how to improve interactions

Petra: Did you mean most commonly reported experiences? I’m guessing you’d want to cover good and bad ones here?

PSG D: This is one of the things the GPIFN said they could use – mothers’ top issues with HCPs and breastfeeding advice (they didn’t mention format).


PSG M: Parents perceptions of HV advice on sleep?

PSG A: On that link Petra posted, this US paper looks interesting:

Do Perceived Attitudes of Physicians and Hospital Staff Affect Breastfeeding…

PSG A: Many women did not report receiving positive breastfeeding messages from their health caregivers and hospital staff. A perceived neutral attitude from the hospital staff is related to not breastfeeding beyond 6 weeks, especially among mothers who prenatally intended to breastfeed for only a short time.

PSG C: So HCP attitudes are key to maternal success…


Petra: You may well find there are a number of studies on key areas – for example the practitioners and breastfeeding issues (and what advice they give – good or bad). See also women talking about breastfeeding experiences and journeys (particularly with focus groups and surveys).

There’s also the existing guidance for practitioners on breastfeeding advice, plus somewhere there’ll be records of what they’re taught in medical education/continued professional development.

It can take time to go and find this stuff but a. it’ll build your case to strengthen other work and b. it means you can use it for lobbying and/or to discount a particular research question (because it’s already been done but you can spot something that hasn’t)

PSG C: For pre registration training WTBi UK has an excellent summary.

 

Petra: thanks, that’s very useful. Please tell me if I’m repeating things you’ve already done, but it might be helpful if you create a database where you can archive all these resources – guidance, support/lobbying networks and any literature they’ve produced, plus papers you find that will help you.

Remember if you see a paper and it’s paywalled (so you need institutional access to get it, someone in your group might be able to help – or email the author direct and ask for a copy – I promise they’ll be delighted! People don’t often ask for papers!)


PSG O: I agree with the above comment that often it’s different HCPs or them contradicting each other, so the idea of focussing on a timeframe such as babies 0-6 months could be more helpful rather than limiting to just one HCP grouping which isn’t necessarily the worst/most influential. If mums can be supported to feed until 6 months, that would be HUGE compared to the current situation, & no doubt gradually the cultural perceptions of feeding in public & of feeding older babies would gradually be impacted by this too as those mums gain confidence & extend their initial goals…

PSG F: We all acknowledge that the early days are important but seem to me to be harder to access – these mums won’t always know that what they’re being told is bad or unhelpful and harder to track down women who stop early from our networks.

One of the other questions was around interactions from longer term breastfeeders with HCPs. This might be easier in that we come from these groups but also many of these know bullshit advice when they hear it so can pinpoint it more easily. Also, if that advice is being given to them, it’s probably also being given to people in the early days. It might also help to ‘normalise’ longer term breastfeeding so you don’t get lots of mums told at 6m or 12m to just stop now cos there’s no more benefit to it

Petra: This is very helpful – lots of good ideas here and we’re already way more focused than in our chat last week. I don’t think you’re at a point to pick one question at this time, and it might be you pick a few that you cover in smaller sub groups. After tonight you’ll need to decide to pick a specific question, commit to it and move it forward. It’s common to have this in the early stages of research that there’s a lot of things you WANT to do. Your challenge is to pick what hasn’t already been covered, that is meaningful (as in will bring findings others can use), and what all of you can do given the time you’ve got and that for most of you this will be the first time you’ve had a go at running a social research project.

PSG P: What ‘incorrect’ advice have breastfeeding mums received from their HCPs?

What we’d do in the group is brainstorm a list of incorrect advice that we’ve heard of then implement a survey beyond the group to find out which pieces of perceived incorrect advice are most common and by which HCPs Eg:

  • been told to stop breastfeeding for a short period
  • been told to wean unecessarily
  • been told to night wean to improve sleep
  • been denied over the counter medication
  • been told breastfeeding beyond X months has no value
  • been told night feeds will cause cavities
  • etc

I’ve put incorrect in quotations for a few reasons: in case the advice is in some sort of grey area (opinion, unproven etc); in case the advice isn’t incorrect (there’s a pharmacist in the group whose intro mentioned not being able to sell something due to their license, in which they’re not in the wrong)

PSG K: I’m also wondering if there is a postcode lottery when it comes to HCPs and breastfeeding rates, do certain areas provide more support?

PSG P: It’s known that breastfeeding rates vary across the country, maybe from the discontinued infant feeding survey. I wonder if that could be cross-referenced to levels of support?

PSG O: Where I grew up almost all my friends gave up by day 5….

PSG C: By support do we mean just HCPs or also organisations like La Leche League (LLL)? We know that mother to mother support increases breastfeeding rates and most support organisations have more volunteers in affluent areas than economically deprived ones which also correlates with breastfeeding rates. It’s a chicken and egg scenario but I think the presence of voluntary mother to mother support could be a confounding variable.

PSG K: I would suggest just HCPs. When I had my first I had never heard of LLL until I joined a social media group

Petra: PSG Pauditing existing data is another option and worth thinking about. There may be secondary datasets you can work with – area codes and breastfeeding rates is one topic.
You might also find variance by mother’s age, ethnicity etc. Younger parents, those from ethnic minorities, low income areas in general do worse (although not always) so it’s worth exploring what’s going on – and how you could then support parents/HCPs.

PSG C: There isn’t just LLL though, there are active areas and places where there is no Leader – a lot of breastfeeding drop ins at children’s centre are actually run by voluntary organisations, independently or in conjunction with HCP. In order to evaluate the effectiveness of HCPs I think the provision of that support may also need to be accounted for somehow in the statistics.

PSG H: Volutary support groups make a huge difference in breastfeeding rates in my experience and varies widely within a small area. In my area there is very little available but just 7 or 8 miles away my friend had a baby café available every day with ibclc’s and trained supporters on hand. I think this would have ti be taken into account when looking at breastfeeding rates in different areas or it just wouldn’t be comparable


PSG L: From mother’s view what issues they had with breastfeeding (if any) and from their point of view which HCP’s helped and which didn’t

e.g. early days – tongue tie midwives didn’t help, infant feeding specialist did.

You could interview mothers or collect stories


Question 2:

Petra: Having thought about your research question (you might want to tweak it slightly now) can you repost it here, but this time saying how you think you could answer it please? Some of you have already started this, mentioning surveys or focus groups. If you don’t know the method but have a sense of what you’d like to try that’s fine, you don’t have to know the name – I can match that for you 🙂

Finally, don’t panic if I don’t reply to each of you on each thread. I’ll be picking up on key points some of you raise that help move our focus on. If you feel you need an answer or want to know from me tag me in and I’ll get on it!

PSG B: If we are studying women’s experiences then qualitative content analysis of written narratives would be the best approach for me as it would be easy to generate the data (no interviewing, just asking women to reflect upon and write up these experiences) but it could have draw backs if looking at why breastfeeding “failed” (for lack of a better word) as it may be harder to gather narratives from women who are not vested in breastfeeding or have strong emotional reactions associated with not being able to feed. In fact, I think that this could be a limitation regardless of the research method chosen.

For HCPs surveys often work best due to time demands but response rates could be poor and the data biased by selection bias (e.g. only those already vested and supportive of breastfeeding respond).

Petra: Those are both good ideas. I agree surveys are time consuming for a low return (and, if we’re honest they’re overused in health research so I don’t know how useful they always are). However you could find ways to get them done via networks and it might be a good plan if you want to reach a lot of HCPs – particularly if they feel the survey is designed to find ways to help them do their job more effectively.

The written narratives is also a good plan – and we talked last week of harnessing this group as a place to gather them. It’s not necessarily representative, but it will generate data easily. You’re right to think about the emotional impacts of research – not just for those talking about experiences that might be upsetting, but those doing analysis.

Thinking of ways to keep everyone supported is a good plan within whatever work you decide to do. As is thinking about the realities of how much work is needed to design a study – be that a survey or gathering narratives – the subsequent data cleaning, analysis etc. It’s all possible but it might be the scaling of this needs to be smaller to allow you to get the work done.

PSG G: We could invite people to submit their stories, like on the everydaysexismproject web site. We could also look for examples from online forums as suggested in a comment below.

PSG G: We could ask for interactions that were undermining of breastfeeding or that made breastfeeding more difficult rather than those that caused breastfeeding to “fail”. Often these experiences may not cause the end of breastfeeding but may make the mother feel uncomfortable or to lose trust in HCPs.


Petra: p.s. just a reminder that in this discussion I may well add more ‘yes, but’ comments.

PLEASE don’t see this as me shutting you down or implying your idea isn’t good. You’ve all suggested brilliant things so far, my job is to gently keep bring you back to research questions you are going to be able to manage to answer.

You want to put your enthusiasm to good use and I don’t want you taking on something that either reinvents the wheel/wastes your time, or is a great topic if you’re in a fully funded research unit with a team of staff but not going to be feasible if you’re a busy mum!

PSG K: Focus groups and surveys.

Sophia: What incorrect or unhelpful pieces of advice do HCPs give to breastfeeding mothers? Researched by examining posts in large breastfeeding groups for mention of interactions with HCPs and then scoring them into categories (ie type of bad advice), age of child, and type of HCP.

Petra: I like this as it’s neat and gives you a clear idea of what you’ll be asking and of who (and how you’ll find them!)

Sophia: I tried to put the advice you’ve been giving us into practice!

PSG P: Similar question to mine!

Petra: Your challenge will be how you code the different kinds of interactions – it’s absolutely do-able but it can take time to a. agree what the different interactions mean and then co-rate them. For example one person’s idea of ‘bad advice’ might be what helps someone else. Take a GP telling a tired mum who’s struggling with breastfeeding to use a bottle. For some that will be interpreted at the time or latterly as ‘bad advice’ because it didn’t encourage breastfeeding support. But others will be empowered by it as it allows them to stop doing something they were finding difficult.

PSG D: I really like this approach

PSG C: I think we could have a matrix that scores the advice relative to our stated goal (increasing breastfeeding rates for example) in which case giving a bottle for the purposes of this study is justified as bad advice.

PSG C: How do we get consent for using this data? Is group admin sufficient or would we need consent from each mother?

We would also need to verify that it was a UK post. BOBAB, for example, is pretty international.

Sophia: We’d need to speak to an ethics expert. My (non-expert!) thinking is that if we copied loads of info from posts that would be too intrusive. But if we just counted how many posts fell into fairly broad categories, that would prob be OK.

PSG C: Given that the groups are closed it could get muddy, but Mumsnet for example is openly available (having previously used data from Mumsnet for research, albeit in linguostics) so less problematic.

Sophia: But I feel like it would be one thing if we were doing it in breastfeeding groups (who we could broadly assume would support our aims). Whereas if we did the same thing to ff groups that would be kind of weird. #notanethicsexpert

PSG G: We could ask for consent from mothers, or invite them to submit their experience on our web site.

PSG L: I think Petra has a point as I have known so many get to the point where they need to give a bottle and that is not bad advice at that time. It would be good if we could identify how they got to that point – painful latch, persistent crying baby, fussy baby, reflux, tongue tie, under weight and why they haven’t managed to overcome these issues up to this point.

PSG B: I also like this idea. If it’s publically available data then my understanding as a researcher is that it is fair to analyse without consent, but closed groups would require consent as they have been set to private for a reason.

Petra: Ethics wise if it’s an open group or forum it’s *technically* considered open data – so you could analyse it much in the same way you could analyse what’s in a newspaper or magazine.

However, not everyone agrees with this and I suspect lots of people asking for help from a group are not expecting their words to be analysed. I would seek advice on this and also use some personal reflections – how would you feel if your discussions about feeding were used by researchers without asking? Some of you would be okay but not everyone.

You might be better off either working with groups/asking permission, collecting/analysing your own stories, or as Hannah says, ask people to send you their stories. Your only downside with that is if you get loads of stories (and you very well might) how do you process all that data?

PSG L: I filled in quite a few online surveys that come through my local breastfeeding facebook page. Would we be able to gather this sort of information in a quantitative survey? Would we be able to deal with a large amount of quantitative data?

Petra: You could, although the only drawback is people may not reply as they’re overburdened with calls for surveys. However if the survey is the best way to reach your participants do it. You’ll need to think about finding and reviewing existing similar surveys, designing your own, piloting both the survey and the means of disseminating it, and then how you’ll analyse your data. Surveys are sneaky, people always think they’ll be easy but they’ve got lots of hidden aspects that can add to time/workload – they’re very easy to do badly (although I’m sure nobody here will do that!) 🙂

PSG P: In terms of workload, I haven’t done this type of analysis, but analysing lots of textual data can be time consuming. Even if using specialised software to analyse the posts, it’s still time consuming (I’ve used specialised software but not on online discussion). I’ve suggested a survey for the same topic. It has the risk of low response rates, but online surveys collect responses for you. A survey also partially answers the questions of ethics as the particpants willingly and knowingly consent to their experience being used. Could start with a small number of fb posts to inform a survey.

PSG E: Me too i would be concerned that the coding done by researchers would be discredited as subjective, it will be difficult to design a clear coding method that would be convincingly justified.

Petra: PSG P: and PSG E: coding is time consuming but there are ways you can reduce subjectivities. For example you can use clear ideas of what is good/bad practice, you can get things cross checked with people who’re not coming from the same position as you, and you can co-rate (so more than one person codes the data).

I wouldn’t assume surveys are quicker or easier, as you’ll see above they’re often just as complicated. Whatever you pick it’ll need time to learn the method and do it right – which you can be supported to do – but it’s another reason that whatever you do you keep it small and focused so you’re not swimming in data.


PSG K: Survey both exclusively breastfed and combination feeding

PSG P: What “incorrect” advice have breastfeeding mums been given by their healthcare providers?

What we’d do in the group is brainstorm a list of incorrect advice that we’ve heard of then implement a survey beyond the group to find out which pieces of perceived incorrect advice are most common and by which HCPs. Could also ask the survey participants if the advice negatively impacted their breastfeeding journey.

At some point we’d run this list past HCPs and put together a summary of why each peice of advice is incorrect, actually correct or in a grey zone (eg opinion of HCP).

Petra: You could do that (see my comments to Sophia above about how you define – you may well find making a list very useful as you’ll see even as a group with a lot of consensus some of the ‘bad’ advice won’t always be seen that way).

You may also want to think about your potential participants and how they’d react to research. HCPs already feel overworked and underappreciated, so having to respond to something that shows how ‘wrong’ they are may leave them feeling upset or not inclined to participate. You can do it, but it’ll need some tact. And I very much like your idea of working with them to note what is good/bad advice and the ‘grey zone’.

PSG P: Ha, yes, this is how we’d phrase the questions for ourselves, but externally we’d use more neutral language. And i was thinking of asking the HCPs participating in this group as they are interested and motivated. Maybe broaden to include what advice was helpful.


PSG D: How advice on infant sleep affects breastfeeding (e.g. no cosleeping, encouraging the idea of that babies should all sleep through, etc)

Interviews with a manageable number of mothers on their perceptions of what normal infant sleep “should be”, do they co sleep, how’s breastfeeding going / what age did they breastfeeding to. etc

Then follow up with a larger survey (with questions structured so it’s no too time consuming for us to analyse) based on what we’ve learnt from the interviews.

We should get loads of responses to a survey in our breastfeeding networks.

Petra: that’s useful – I suspect you’ll find there’s lots of evidence on sleep already but it may not necessarily be from what parents think is okay (it’ll be more measuring against guidance/collecting experiential stories).

PSG D: Good point! We have several sleep labs who are our partners as it happens! I wonder if they could advise if there are gaps in the research of if they’ve got it covered.

I know Helen Ball has done lots of research to do with sleep and breastfeeding.

Did we ask her where the gaps in the research are when she did our first ever Q&A I wonder? (I’ll just check … )

Petra: That’s a good idea – when you as a group decide on your question and method you may want to approach researchers who’ve also worked on related areas to see if they can recommend areas they think need looking at (noting you all have a lot of skills in this area already). They can also give you some ideas about what *not* to do – as in they’ll know where they struggled with particular methods, topics, participant groups etc and can give some straight talking insights into where you might need more support or redirect your energies 😉

PSG D: (We didn’t ask her about the gaps, damn!)

PSG O: Dealing with the sleep issue would broaden it to dealing with two cultural taboos – both breastfeeding (at all, in public, exclusively until 6 months, & continuing to 2 years or beyond) & co-sleeping require huge mindset shifts and information sharing (benefits of breastfeeding/risks of formula & correct support/advice, & safe co-sleeping guidelines versus SIDS fears).

In my group of friends where I grew up, most started off trying to breastfeed but almost all had given up by day 5 – what can we do that will get them through the first couple of weeks, so that things like sleep down the line are even still a breastfeeding-related issue?!

PSG M: Impact of HV interactions (key visits) on improvement of breastfeeding rates? – Cohort study?

Petra: cohort studies are great, but they are hugely time consuming and require a lot of skill.

Are you able to see how that might work out given this is going to be largely volunteer based with people who’ve not undertaken research before (this isn’t a no, it’s more a ‘how can this work?’ given everyone’s circumstances) 🙂

PSG M: Petra ah right-I hadn’t grasped that part…or maybe had forgotten 🙂

Petra: You probably blocked it out 😉


PSG M: Parents perceptions of HV advice on sleep? – qualitative study of some sort?

PSG F: If we were to look into the experiences of more experienced breastfeeding mums then we can pool our own stories, look for posts about HCP experiences in our groups and networks or post a question to various forums to get people to share their stories and then analyse these, maybe ask for more detail if needed. We could ask for both good and bad experiences.

Petra: Definitely drawing on what you have is a good plan!

PSG D: About good and bad experiences. I think we may need to just ask for experiences. What people perceive to be a good experience might in fact be the bad advice that undermined their breastfeeding relationship!

e.g. “I’m so grateful the HV explained that I needed to top up because my body just couldn’t make enough milk” may be seen as a positive experience!

PSG B: Playing devils advocate here but we shouldn’t let our own biases of good and bad influence interpreting participants narratives.

If a mother is advised to top up because she believes that she isn’t producing enough and it is adversely affecting her mental health then combination feeding could be seen as a positive outcome given the overwhelming evidence that maternal mental ill health affects attachment and over child outcomes. What we know about the benefits of breastfeeding should be separate from the analysis of data but can inform interpretations.

Petra: Yes, that’s an excellent point. Last week we talked about positioning ourselves within the research – so who are you all in relation to all this work?

Noting you’ll have particular interests and motivations is important – it’s going to drive what you want to study and how you focus on it. It also will influence who’s brought in and who’s left out (which is always good to consider). It’s fine to have particular values, so long as you’re aware of them and transparent about them.

Noting who you all are and how you’re similar and different to other mums is a great plan to keep that focus. And yes, you need sensitivity to yourselves but also those you’re studying – even the title of the study is liable to make people feel included or judged.


PSG D:  It hasn’t been mentioned yet tonight I think, but it’s interesting that we have so many BFing HCPs in this group.

Possibly a side project, but could we do something about how much HCPs advice on BFing changes once they become mothers?

Maybe interviews, pulled together into an article. Or maybe we could do video interviews?

Petra: I’m biased as I love reflexive projects (where you bring your own experiences in) but I think that could be very powerful indeed. You may find if you explore the experiences of the group and can categorise by those who were HCPs before and those that were not there are some interesting differences to focus on). And when it comes to convincing other HCPs having that real world, personal experience really engages them.

PSG C: This is partly why I asked my question about how HCPs separate their personal feelings and experiences from their practice 😉

Petra: I could see these making really powerful teaching examples.

Plus I imagine it’ll be reassuring for other mums because if a HCP needed support, in spite of their existing knowledge, it shows anyone might need help and support with feeding.

PSG Q: This sounds like something that GPIFN might be interested in too


PSG M: If people wanted to look at HV staff impact post BFI training, you could do an interesting study, looking at impact just post training, then 3 months, then 6 months down the line etc, up until their next update?

Again that would be possibly a cohort study?

Harder to put in place because the only person tracking the detail re HV training status would be an IFL like myself 🙂

We already do audits on staff, and of mums, but this would look at the impact on breastfeeding rates, adjusting for confounding factors-if that were possible….

Petra: That’s the worst thing about working with an energised group Annabelle Mackenzie I feel like it’s repeatedly crushing dreams! One thing for all of you to consider is you’ve so many great ideas taking those you don’t have time/capacity for but working with somewhere like James Lind Alliance could allow for other practitioners with more time/money to run a study (which, potentially you could still be involved with).

About Priority Setting Partnerships | James Lind Alliance

PSG M: don’t worry-it’s helping me focus on things I want to write…too! 🙂 so I will probably follow up my suggestions in another way-


PSG C: Reposting this question:  One interesting question would be when do mothers feel they receive conflicting advice about breastfeeding? Mothers might not be able to say which advice is evidence-based, but they can say when they’ve been told things that aren’t consistent or create tension.

This again would be qualitative but rather than a narrative it may be more guided with 2 parts – 1 focusing on what advice was given by whom and 1 about the mothers feelings and perceptions.

Petra: Yes, thanks for the repost! There’s an overlap for a lot of women’s health here where women know something isn’t right but they don’t always have the vocabulary or confidence to raise it – sometimes with terrible results.

You could guide it (as in ask them structured, prompt questions) or you could leave them to tell their story but be on the watch for this as a theme (where they knew they were getting wrong/conflicting advice – and what happened).

We also know that while there’s ‘evidence based’ many HCPs don’t follow it – either because they don’t know about it, or because they don’t agree with it (which can be a good or a bad thing)

PSG M: the advice sometimes can appear conflicting because over time the feeding situation can change a lot. Just mentioning as it’s a factor. The advantage of BFI is it makes discussions a bit more consistent.

PSG C: That’s very true. You only need to look on a FB feeding group to see the unintentional drip feed of information and the seemingly minor detail that can change everything.

PSG C: Tangentially in healthcare complaints (and complaints in general) women are more likely to be dismissed because they lack confidence to clearly express their complaint and couch it in ‘I feel’. There’s potential to use some corpus linguistics analysis here too …


PSG C: ‘what do HCPs say that help mothers breastfeed?’

Collecting reflections from mothers about experiences with HCPs and identifying with ideas and/or specific phraseology/formulations that help.

Being a linguistics geek I would put money on the information/advice dynamic as expressed through modal verbs having a big effect.

Petra: The beauty of this is if you pick any method where you’ve qualitative data, even if your original question isn’t about more detailed linguistics, the geekier members who like this kind of thing (which is ace) can really explore that data. So as you pick your question and your method you need to be noting analysis wise what skills you already have – or where you might need additional support. Plus, as a big group, where you might want to share out who does what with the data (thinking all the while about confidentiality issues).

Sophia: That sounds interesting PSG C, could you explain a bit about what you mean re modal verbs?

PSG C: So modal verbs of obligation are things like you have to, you must, you should vs possibility (you could, you might).

People tend to go to HCPs for advice so they expect to be told what they should be doing and then do it, which then turns into they then shouldn’t be doing anything else. This gets problematic when the surrounding language is imprecise and ‘you should feed baby every 3 hours’ becomes you should not feed more than every 3 hours. Or you must let youur baby finish the first breast/offer both breasts/change nappy mid feed – when an HCP says that it becomes the law, especially when it’s repeated.

PSG C: It’s also very easy to ‘upgrade’ obligation from should, which is still advice, to must.

PSG Q: so the exact opposite of how breastfeeding counsellors/ LLL Leaders are trained to communicate!


Question 3

Petra:  To finish this week, having thought about possible questions and methods, can you draw those ideas together and think about outcomes and impacts.

If you think of a question, and a way to answer it, what do you want to happen as a consequence? I’ll be jumping in to think about what’s a research outcome and what might be better achieved in other ways.
As with our last thread my feedback’s designed to get you thinking, not suggest anything you’re suggesting isn’t a good idea 🙂

Some of you may have noticed I’ve jumped from research question to method then to outcomes. I’ve deliberately decided not to talk about analysis tonight as I think that’s a separate question we can return to once you’ve agreed your research topic and method (it may be you’ll need additional help with this, or if you’re canny and keep things small and focused you’ll be able to do it all yourself with a bit of instruction).

PSG J: On the personal side, i’m hoping for a PSG team that goes to meetings and conferences to amplify breastfeeders voices about HCP interactions that works and those that don’t work; with suggestions of languages and actions that support breastfeeding.

Petra: I like that and if I recall correctly last week we talked a lot about changing hearts and minds and education. In theory you don’t have to undertake any new research to manage this.

There’s already support and lobby groups, guidance and lots of published research to draw on. If you’re wanting to bring change there’s no reason why some of you can’t work on that now – being an activist researcher is good! I’d prefer to see people USING evidence that’s out there and offering training/support/lobbying rather than running another study that adds to the HCPs pile of ‘will read later’ or ‘not used’ 🙁

PSG J: Thanks 👆👆👆

PSG E: Activist researcher, love it! 👍


PSG M: Packs that would be add ons to people who do the BFI training?

Petra: Yes, that’s a good idea – what might you include in the packs?

PSG M: well depending on what research was done, the outcomes, that could inform what was ‘missing’ in interventions? And could then inform what goes into the packs

PSG J: Helpful and unhelpful words and phrases, breastfeeding organisations and resources to signpost to for antenatal and postnatal breastfeeding support, HCP breastfeeding resources to know about etc

Petra: That’s all good stuff – linked to PSG D’s comments immediately below perhaps another option is to ask HCPs what *they* feel they currently don’t have/what would help them work more effectively and deliver towards that goal – it might be you could ask this before undertaking research as what they want IS out there but they’re just not in the position to find/process it.

PSG Q: I’d like to see some useful nuggets of info/ facts/ skills and language getting into EVERY health profession’s Pre- registration training!

Adding to BFI is a good way, but only reaches a fraction of HPs, and never reaches many specialists (Dieticians, GPs, paediatric nurses, A&E, pharmacists, Maternity Support workers etc etc etc )

(As we found in our WBTi research)

PSG M: yes absolutely

PSG D: I’d like to see us come up with some useful insights into the experiences of breastfeeding mothers, that organisations who provide breastfeeding related training / resources for GPs and HCPs (and maybe even those who have some influence over their curriculum) could use.

PSG G: There’s already a lot of talk about “changing the conversation” in relation to breastfeeding (UNICEF are campaigning on this). I want this project to help with this shift – away from seeing it as about mothers choosing whether to breastfeed or not – and towards an understanding that mothers attempts to breastfeed are being undermined, often by the professionals who are supposed to support them.

I’m hoping this would lead to greater efforts by professional bodies, for example improving training and not taking sponsorship from formula companies etc. I want them to see that they need to take responsibility.

Petra: Those are all important and worthwhile goals – I’m thinking in terms of your energy and insights whether you can channel that to push forward existing work (see the activism/education comments above).

Realistically you’re going to be undertaking a relatively small piece of focused work, and that alone may not bring these bigger changes you all want in your hearts (which ARE important). So noting what is research focused and what’s wider advocacy/activism/engagement is a good plan whatever you all decide to do next.


PSG C: ^^ all of this!

PSG C: In terms of more concrete outcomes, I’d like us to produce evidence that healthcare professionals are undermining women’s attempts to breastfeed.

PSG J: and perhaps, making note of areas where they’re serving breastfeeders well, too.

PSG D: This is the crux isn’t it. We know this is happening. How to package this so it’s not a stick to bash people but something that’s to help them in their jobs.

Sophia: Yes. Often, I’m sure, unintentionally. But if we can name and evidence the problem, then as said above, I’d hope that that would help to convince training bodies that, eg, GPs need more training on breastfeeding.

PSG D: Or to put it another way, how to present the findings so they have the desired effect of (probably overworked, stressed) HCPs feeling they can take on board the comments not just feel under attack.

PSG J: We don’t want folks to feel defensive.

Sophia: As someone suggested on another thread. I think examples of typical interactions that go wrong, and an example of what it might look like gone right (if that makes sense!), could be very useful for HCPs.

Petra: You can ask about difficult issues in sensitive ways. Returning to our previous two threads this evening this is a slightly different take on what you’ve already suggested. And it might be you don’t approach HCPs but instead collate stories from parents, link that into existing evidence and guidance, and feed THAT back to HCPs within a context of both noting where things are going wrong but also offering support to do better (where your ideas of packs/support/training comes in).

Sophia: And I also liked the idea of collecting experiences from HCPs of having their own baby and starting breastfeeding and realising how much they didn’t know. It’s always easiest to hear things from ‘people like you’.

PSG C: Interestingly people when asked for their opinions are more likely to share negative experiences but guidance is more effective when phrased as do rather than don’t. How can we reconcile this?

PSG G: Do we need to be be producing guidance? Isn’t there lots of that already? Isn’t the point that the guidance isn’t being followed? I think I’m hoping we can demonstrate that guidance isn’t being followed, but by demonstrating how widespread this is, I’d like to be able to get across that it’s not because the HCPs are “bad” or don’t care, but rather that there’s a systemic and cultural problem that needs to be addressed – they are struggling in this situation too, not having the training they need, etc. I hope we can communicate this so that we’re demonstrating the seriousness of the problem but not blaming individual practitioners.

Petra: No I don’t think you need to produce guidance, but you can certainly review what is there plus other research to indicate what is technically required – then how that differs from parent’s lived experiences.

PSG C: I agree that if these negative experiences can prove there’s a problem on the ground it may be an impetus for change. We talked last week about communication mismatches between people who do research and w rige guidance and HCPs, who are incredibly busy, and need a 3 point chest sheet rather than a massive manual. It’s the system that needs a adressing but we can do that by recognising that HCPs are part of the system even though it may be their individual words that are under scrutiny.


PSG L: Depending on what we research and the outcomes I would like to get information out to mothers in some form – info sheets, videos etc. I think if we signpost mothers to good information it would help them in their interactions with HCPs and to know who they need to see.

PSG J: The good thing about this is that there are already lots of info sheets and videos available from lots of breastfeeding organisations like ABM and LLL which can be shared with mums.

PSG H: I think it would be really useful for hospitals to give out a comprehensive list of breastfeeding resources in your area so that frazzled new mums aren’t left to try to find the support they need when they’re already under a lot of stress if things aren’t going as they’d like. Just a booklet/sheet with up to date info on numbers to ring and support group whether NHS run or volunteer groups. No research needed for this…would just be really useful!

Petra: This came up last week, talking about HCPs being busy and what might motivate them to read – see also exciting ways to share stories/information with parents. I like PSG L: ‘s ideas of creative methods – sharing in videos (or cartoons or plays!) may work very well depending on who you’re trying to reach.

As PSG J is saying if there is information out there (which there seems to be) looking at who needs it and how better to signpost them to it could be something you consider – which again could be a research question or might just be a subgroup of you finding what’s there and working within your networks to get it more widely known/used (if you wanted to study *that* you could always follow up later to see if more people were discussing/downloading or otherwise utilising materials).

PSG J: Some hospitals give information packs to new mums when they’re discharged, mine does. Also some (if not all) red books have information about local NHS breastfeeding support, as well as the National Breastfeeding helplines, I think.

I wonder who is in charge of what goes into the red books.

PSG L: My thinking is mainly related to the early days as I think for sleep and medication there are already some very good sources that are available in one place eg ISIS, Dbfn. Although there is good information out there on things like tongue tie, reflux and latching it is all over the place and very hard to find as a new mother with no idea about breastfeeding or organisations outside the NHS

PSG C: There s also the underlying issue of mistrust that some HCPs have for anything that isn’t the NHS. Views on mother to mother support or private lactation consultants often change dramatically once HCPs become breastfeeding mothers 😂

PSG H: Ah that’s good to hear, I didn’t get a discharge pack that I recall. I only found out about the lll groups in surrounding areas much later into my breastfeeding journey so was thinking it would have been good to have been sign posted to these earlier.


PSG A: Simple Facebook polls:

  • Who has asked you about breastfeeding?
  • Who have YOU asked about breastfeeding?
  • Who SHOULD have asked about breastfeeding, but didn’t! (eg for prescribing)
  • Have you lied to a HCP about breastfeeding and/or sleeping arrangements (And perhaps why /description in comments.)

This would be simple evidence gathering, perhaps to build a case/background before selecting a more in-depth research question


Petra:  I wanted to say how brilliantly I think you’ve all done this evening. It’s been tougher this week but you’ve all risen to the challenge.

A lot of what you’ve been doing online in these sessions (doubtless in between juggling lots of other jobs) is what many researchers have weeks of time to think about with lots of additional training and support. You should be very proud of all the great ideas you’ve had, and the fact you’re tracking across research questions, to method, to outcomes.

Your next challenge is to pick a specific question, and method. After which we can think more about support/training for you in putting your work into practice, how to use your chosen method, and considering how you’ll recruit participants (if appropriate) and manage/analyse your data. All the while thinking about your longer term goals and wider outcomes.

As you move through this period there’ll doubtless be other questions you have about getting research done and I’m quite happy to share with you resources or tools to read up on that as and when you need them.

If you’ve got any questions based on what we’ve covered last week or this you feel I’ve not addressed please ask them here (you can always come back tomorrow if you’re tired) or ask Sophia or Rebecca to forward them to me.

Remember putting all this effort in at this point in research is invaluable. I know everyone wants to get going but I promise you all this work now will pay off later.

Thanks for all your energy and input these past two weeks, I’ve really enjoyed our conversations and I hope you’ve found them useful as well!

Leave a Reply