Challenges Faced

The most significant challenge faced over the course of the study was participant recruitment, and it felt as though there were two main ways in which this felt difficult. I initially had difficulty developing timely and effective service links and later I struggled to find participants who were willing to speak about their experiences in this heavily stigmatised domain.

4.3.1.1 Building Effective Links with Services

The initial process of gaining approval from the National Research Ethics Service’s Research Ethics Committee (NRES REC) was more time consuming than I had

125 expected, but once approval had been granted by the REC and also from the University, I began contacting services to present my research proposal and seek support from parties who could grant me access to potential participants. This was the most challenging part of the research process.

I initially approached senior midwives and heads of service for local midwifery teams and antenatal services, but after repeated non-responses I learned through gatekeepers (receptionists and personal assistants) that these individuals were very busy with day- to-day matters and unlikely to respond to me quickly (or perhaps, at all). In fact, of the nine individuals that I contacted (via telephone and email) I only spoke to one senior midwife, who advised me that she was not, in her role, permitted to make decisions about research involvement. She advised that I should contact the head of midwifery in her Trust, which I did, to no avail.

I went on to approach smoking cessation services, and I received a more favourable response here, perhaps because the focus of my research felt more relevant than it did to midwives and antenatal practitioners, and perhaps because the smoking cessation practitioners had more resources to allow them to engage with research. The smoking cessation service was non-NHS, which meant that I was not required to apply for Research and Development (RandD) group approval, thus avoiding further NHS paperwork-related delays. There was a ‘research steering group’ with whom I liaised prior to commencing recruitment, and they provided me with approval in a fairly straightforward and timely manner. Evidence of all relevant approvals can be found in Appendix A.

My first three couples were recruited via the smoking cessation service, but following the third set of interviews the service was recommissioned and the practitioners with whom I had been liaising were redeployed. I was unable to build relationships that might lead to further recruitment here, so I again made contact with NHS antenatal services

126 and midwifery leads. This was unproductive so I went on to contact my university Clinical Psychology doctorate course team, which comprises a mixture of individuals whose roles involve varying degrees of research and clinical work. My email included a request for advice on recruitment and I also asked recipients to forward my proposal to any services or practitioners who might be interested in supporting my work. I received a response from an Assistant Psychologist who offered to take my proposal to a team meeting at the Children’s Centre within which she was based. At the same time I made a link with the leader of a midwifery team but my liaisons with the Research and Development (R&D) team who gate-keep for this service required extensive liaison and the process took over six months, coming to completion when I was commencing a period of maternity leave. Just prior to my leave, following the support of the Children’s Centre Assistant Psychologist mentioned above, I received interest from the Head of a Children’s Centre, and with her support I recruited my fourth couple.

Following this, I took a maternity break of twelve months and when I returned I was unable to re-establish meaningful contact with the Trust mentioned above, from whom I was seeking R&D approval. The Children’s Centre Head agreed to continue supporting the study following my return, but unfortunately I did not receive any details of potential participants from her. Needing to recruit more couples in order to reach theoretical saturation, I advertised the study using posters in the waiting rooms of non NHS services who had previously agreed to support the study (smoking cessation clinics, antenatal exercise groups, and support groups) and I contacted the head of midwifery for my local NHS Trust, with a plea for support in the final stages of the study. The head of midwifery agreed to support the study and put me in touch with a midwife within her team whose role included a specific duty to facilitate research. She agreed that her midwifery team were well placed to identify couples meeting the study’s inclusion criteria, and so I began the process of gaining NHS R&D approval to link with this site. This took some months, because of delays within my university to review and authorise

127 paperwork, delays within the R&D department, and delays linked with my limited capacity during the final stages of my clinical training. I finally received approval two months before my already extended thesis deadline. I received the details of two potential participant couples in this time but unfortunately, neither one ended up participating. The fifth couple who participated in the study was recruited via a presentation of my research interests at my clinical workplace; a colleague noticed that she matched my inclusion criteria and asked to take part.

4.3.1.2 Finding Pregnant Smokers who were willing to Participate

The other major challenge in conducting this research, beyond the difficulties with finding services to support recruitment, was in finding couples who were willing to speak with me about their smoking behaviours during pregnancy. We know from the literature and from the results of the current study, that smoking during pregnancy is heavily stigmatised. And it is likely that this is one factor that affects the willingness of some pregnant smokers to discuss their smoking behaviour, especially perhaps with someone that they might link with health services and, who they might therefor presume, would not condone their smoking.

The design of this study did not allow for the calculation of the proportion of women who were aware of the study but chose not to speak with the researcher. However, conversation with the research midwife led to the discovery that the last hospital approached for recruitment saw approximately 4,500 women for their ‘booking appointments’ (when the pregnancy is recorded at the hospital and the patient is booked to have their antenatal care and delivery with that hospital) annually, with around 1,000 of those being self-declared smokers. Allowing for some monthly variation, these figures would suggest that the hospital was seeing around 70-90 pregnant smokers at booking appointments each month. But in the two months that midwives were actively recruiting for this study, by describing the research and asking whether couples would like to

128 receive further information, just two women gave preliminary consent. This number is strikingly low, constituting around 2.2%-2.8% of potential participants One of two interested women did not answer or return phone calls about the research, and the other said that her boyfriend refused to take part because “he doesn’t like talking about private stuff with outsiders”.

Other researchers have consistently reported substantial difficulties recruiting this population for research studies (Bottorff et al., 2005; Lopez, Simmons, Quinn, Meade, Chirikos, and Brandon, 2008), and the reactive type of recruitment strategies employed in the current study (poster advertisements and healthcare provider outreach) have previously been found to be less effective than other proactive strategies such as buying telephone numbers from marketing companies and then cold-calling potential participants (Lopez et al., 2008). This latter approach however would not fit within the ethical and resource boundaries of the current study.

An unconnected, and less significant challenge was associated with the processing of study data, once it had been generated. Closeness to the data is important for ensuring that coding, analysis, and the emergent model are grounded in the data (Henwood and Pigeon, 1992), and the grounded theory methodology provides systematic protocols which encourage it. Although I can appreciate the benefits that are associated with data immersion, it also felt rather challenging at times because it was so very time- consuming and interfered with my ability to engage with other non-research related tasks and roles. The periods of transcribing interview data were particularly challenging in this regard, and far more time consuming than I had expected.