Data analysis

It has been suggested that researcher experience and interpretive creativity is implicit in studies underpinned by grounded theory (Scott & Howell, 2008). Guidelines for conducting grounded theory research tend to be attractive to novice researchers and doctoral students (Scott & Howell, 2008). There is wide and substantive discussion of the tradition of grounded theory, yet the procedure for carrying out the actual analysis has remained somewhat vague (Boeije, 2002). However, there are numerous methodological texts and tools that offer suggestions on how to analyse data in the grounded theory tradition (Holton, 2007). Data in this study can be described as being analysed in a manner that is closely aligned to the grounded theory tradition of Glaser & Strauss (1967). It was felt that, as grounded theory was being utilised within a mixed-methods study, it was more appropriate to reflect the analytic techniques rather than to espouse the generation of a grand theory, as one may propose in a purely grounded theory study. During the study, conceptual memos were maintained in longhand diaries alongside a reflexive diary. Much of the researcher’s questioning, and initial thoughts about the nature of the emerging data, was stimulated through these entries, which were maintained throughout the study and served to guide ongoing coding and analysis.

Although analysis in this section is presented in a sequential manner, the reality of the analysis was not linear. Abstraction of the data and the results was achieved by continually moving back and forth through each level of coding.

Open coding

Results were derived initially using open coding, in order to break down the raw data into concepts. Analysis of these concepts took place using the constant comparative method. Words, phrases, lines, sentences and whole paragraphs were searched for concepts which were then compared for contrasts and

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similarities, as suggested by Strauss & Corbin (1990). Related concepts were developed by grouping related dimensions of these categories, and considered judgements were made about the progression of data and its analysis within these categories. Grounded theory can be distinguished from other forms of interpretative analysis by the practice of grouping of categories in this way as they emerge (Strauss & Corbin, 1990). Open coding resulted in the identification of five categories: ‘Motivation to breastfeed’, ‘Antecedents to early cessation’, ‘Cessation of breastfeeding’, and ‘Enduring views of breastfeeding’. A core category, ‘reconciling breastfeeding’, emerged as a result of further abstraction of the data. This category encapsulated and harnessed the essence of the other five categories.

Axial coding

Specific relationships between each of the categories and their relevant subcategories were developed through axial coding, thus adding depth and complexity to the open coding technique (Charmaz, 2006). Axial coding allows the category to be viewed as an axis around which the data fit (Bryant & Charmaz, 2007). A ‘paradigm model’ (Strauss & Corbin, 1990) was selected and used to guide this level of analysis. Application of this procedure, and the strict procedures inherent in grounded theory, has been criticised by Glaser (1992) as being ‘forced conceptualisation’ of data. It was felt, however, that the selective use of the paradigm model as a loose guide to axial coding, as suggested by Strauss & Corbin (1990), enabled the application of a clear strategy of coding at this level. While use of the model is a complex process, clear, contextualised links and relationships between categories were allowed to emerge, rather than being forced.

When examining the open code, the paradigm model specifies consideration of the following: causal conditions, context, actions and interactions resulting from the phenomenon, the intervening conditions and the consequences of the

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actions taken. Some conditions and consequences could be found among the actions and interactions, but actions and interactions were found, predominantly, to provide a link between conditions and consequences.

The fact that the data, in the absence of ‘forcing’, fitted the paradigm in this regard supports the selection of this approach in this study. Table 8 illustrates how the selective application of the model was applied, and further examples are provided in Appendix V.

Table 8: Illustration of Axial coding for the category ‘Motivation’

Context: Before the birth women made the choice to breastfeed their babies

Causal Conditions Actions/Interactions Consequences

• Antenatal preparation: formal/informal • Notions about ease or difficulty of breastfeeding • Desire to breastfeed • Commitment to breastfeeding • Previous experience • Early feeding experiences • Mode of delivery • Social norms • Knowledge, information and confidence • Postnatal support • Perceived pressure to breastfeed • Feeling vulnerable • Lack of confidence in abilities • Confusion (often re information received) • Questioning ability to breastfeed

Intervening Variables: Previous experience, belief in the notion of ‘Breast is Best’

Axial coding uncovered relationships between categories and subcategories, which open coding had not revealed. For example, previous experience of, or exposure to, breastfeeding was found to be a causal condition for confidence in postnatal breastfeeding abilities, with views about ‘breast is best’ serving as an

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intervening variable. Both previous experience and women’s beliefs about whether or not ‘breast is best’ were identified as intervening variables and mediating circumstances, influencing motivation for breastfeeding and sustaining the experience.

Selective coding

Reconciling emerged as a potential core variable fitting the data, and subsequent data collection and coding provided confirmation of this. Although the intention was to utilise grounded theory as a guide to underpin the qualitative element of the study, selective coding ultimately resulted in a category that met many of the essential characteristics of a Basic Social Process (BSP) as described by Glaser (1978). A minimum of two clear phases were evident during ‘reconciling breastfeeding’, which was related to many other categories and their properties, and recurred regularly in the data. Glaser (1978) suggested that a BSP is categorised by a gerund, demonstrating a feeling of ‘process, change and movement over time’ (Glaser, 1978) (p.97). Reconciling demonstrates a clear example of a BSP.

Theoretical saturation

Dey (1999) has questioned the appropriateness of the concept of saturation in naturalistic enquiry. Strauss & Corbin (1998) also suggest that saturation is a ‘matter of degree’ (1998) (p.136). They propose that the longer researchers spend examining and analysing their data, the greater the potential for new data to emerge.

Saturation of the major codes was achieved, in this study, after eleven interviews. Nevertheless, a further four interviews were conducted in order to add depth to some of the emerging categories. In particular, the experience of pain during breastfeeding, and its actions and interactions, were explored during the later interviews. When subsequently analysed, these four interviews

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confirmed that the initial process had been exhaustive in identifying the pertinent concepts and categories, therefore no further sampling was necessary.

Due to the volume of data in the entire study, a computer-assisted, qualitative data analysis software package (CAQDAS), NVivo version 8 (NVivo qualitative data analysis software, 2008), was used to assist data analysis. Although the researcher was experienced in qualitative analysis, this was the first time she had used the CAQDAS system. Concerns have been expressed that the use of computers in qualitative data analysis may ‘guide’ researchers in a particular direction (Richards, 2009). Initially, the use of the system proved extremely challenging and this prompted a return to a more traditional system of paper copies and coloured pens. However, additional training in the selected package provided the researcher with a better understanding of its functions and capabilities. As a result, fuller use of the software features, combined with the use of paper records, assisted in advancing the conceptualisation of the data. An example of data that have been coded using NVivo are included in Appendix VI to demonstrate the development and density of coding, attributed to each passage of text.

4.5.8 Rigour

The researcher, who is an experienced interviewer, conducted all the interviews and aspired to provide faithful descriptions of women’s experiences and feelings about future infant feeding choices. Prolonged engagement with the data and the subject matter, and determining congruence with the quantitative data available for these women, was also undertaken in order to improve validity and reliability across both data sources. A systematic process of maintaining an audit trail in terms of sequencing, recording, analysing and reporting data is described in the preceding section and also when presenting

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the findings. These elements have been described as the essential components of ensuring a rigorous approach to studies (Peat, 2002).

Mruck & Mey (2007) have highlighted that the particular variant of grounded theory being applied may influence the application of reflexivity in any such study. Traditional grounded theory (Glaser, 1992) rejects the notion of reflexivity, suggesting that investigating the impact of the researcher is only significant when specific issues are seen to emerge directly relating to them. In contrast, the constructivist grounded theory belief is that a reflexive stance and explicit acknowledgement of the conduct and relationship of researcher and participant are intrinsic to the report (Charmaz, 2006).

In this study, reflexivity is viewed as an opportunity to explore and communicate explicitly the process and development of qualitative findings. It is recognised that the sequencing of the quantitative aspect of the study prior to the qualitative element resulted in certain presumptions about the research question being formed in advance of the qualitative stage, and their influence on the reflexive process is acknowledged.

A detailed reflexive research diary was maintained in order to ensure, and provide evidence of, ongoing self-critique. Abstracts from this diary are included in the results chapter. Details of qualitative themes that had emerged were furnished to five of the women who had agreed to review them for validation and confirmation, prior to the final write-up (Perakyla, 2005). Some of the comments made by these women are also presented in the findings for verification purposes.

Samples of the interviews (three) were coded blindly by a colleague with significant experience in qualitative analysis and data interpretation. The purpose of this exercise was to explore whether similar codes and analysis

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would be achieved and to verify the emerging data. This process proved very valuable as the analysis was comparable, but used different terminology and phrasing, prompting the researcher to review and consider the language utilised and its associated meanings.

4.5.9 Consent

Informed consent is a critical component of any healthcare research. It is clear that ethical matters have become integral to conducting all types of research (Sin, 2005). The issue of consent is further compounded in mixed-methods research due to the employment of varying methodological tools in the one study, giving rise to the need to utilise fluent consent procedures at each stage of the process (Creswell & Plano Clark, 2007). Participants in this study were respected throughout the entire process, by placing emphasis on adherence to models of good practice related to recruitment, voluntary inclusion, informed consent, privacy, confidentiality and withdrawal from the study without prejudice (Connolly, 2003).

Local ethical approval for the study was also sought, where necessary, from hospital ethics committees. Access was granted by all 20 units and independent midwives before the commencement of the data collection phase.

In order to protect the mothers’ right to self-determination in this study, the extent of their involvement was clearly stated in all study materials. In planning the study, care was taken to include multiple time points and different methods of presenting information about the study. In Phase 1 of the survey, the participant information sheet was presented as the front cover of the questionnaire thereby ensuring full disclosure of their required involvement in the study. Women also received information about the study in the antenatal clinics and postnatal wards, in the form of posters and leaflets (Appendix VII).

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These included confirmation that the data they provided would be preserved in confidence. In discussions with midwives, care was taken to remind them of their responsibility to ensure that women understood that they were under no obligation to participate in the study and that they were free to decline without prejudice to their care. Completion of the questionnaire by each woman and provision of her contact details was deemed to be consent to take part.

It has been suggested that the ethical and practical issues involved in re- contacting participants in longitudinal studies remain under-documented and are frequently underestimated (Sin, 2005). Thus, in an attempt to apply robust procedures, women were written to again in November 2009 and offered an opportunity to opt out of the interview element of the study if they so wished (Appendix VIII). This was deemed necessary due to the amount of time that had elapsed (one year) between indicating interest and participating in the interviews. In recognition of the need for participants to provide informed consent to the qualitative aspect of the study a participant information leaflet was sent, one week before the interview, to all those who had verbally agreed by telephone (Appendix IX). Informed consent was then sought in written format prior to commencement of the interview. The consent form included the study’s title and purpose and a statement of the rights of the participants (including the freedom to withdraw at any time) (Appendix X).