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EXECUTIVE SUMMARY ________________________________________________________________________________ Overview Over the past few years there has been a drive by the Irish Government to ensure that breastfeeding becomes a social norm and efforts are being made to increase both initiation and duration rates. Despite the advantages of breastfeeding, both for the mother and baby, being highlighted, rates of breastfeeding in Ireland still remain the lowest in Europe. Forum theatre is a form of interactive theatre whereby scenes, based on real-life stories are acted out and members of the audience are then asked for ideas on how the situations depicted in the scenes could be improved. The audience members are invited to act out the scene as they would like to see it, enabling them to change it and empowering them to deal with the situation. This evaluation examined the role of forum theatre in creating an increased awareness of breastfeeding. The evaluation is based on the performance of the play with four different audiences, a Youthreach group (a training programme for unemployed young early school leavers aged 15-20 years), a traveller training centre, a college of further education and a maternity hospital. Data was collected before, during and after the performances of the play. This data was collected from interviews (with viewers of the play and with those involved in the production and management of the play), observations and a brief survey. The study employed both qualitative and quantitative methods. Results The play was performed in front of approximately 160 people, the majority of whom were from 1630 years of age. Overall feedback on the play was very positive and all audiences responded well to the play and to the concept of forum theatre. Nearly all of those that responded to the postcard survey thought that the play was enjoyable. In addition, the majority thought that it was interesting, informative and professional. Ninety five percent thought that the play was a good way of discussing breastfeeding. The main reasons given for this were based on the play being different to the usual methods of health promotion, it being informal and a fun way of highlighting issues around breastfeeding and it being real and shedding light on the situation. It was also considered thought provoking, informative and afforded the opportunity to give one’s own opinion. 1 Words which participants from all groups used to describe the play included ‘fantastic’, ‘brilliant’, ‘enjoyable’, ‘interesting’, ‘very well done’, ‘great way of educating people’ and ‘excellent’. Participants commented on the fact that they felt that the play was very realistic. Other people commented on the fact that the play brought the reality of breastfeeding to life more than a leaflet would and this made it more enjoyable to watch. Participants that have worked with disadvantaged groups commented on the fact that the play was ‘literacy friendly’. While in general participants felt that the play would not change people’s minds as to whether they would breastfeed or not it was felt that the play would create a general awareness around breastfeeding which was felt to be very positive in the promotion of breastfeeding. Many people commented on how they enjoyed the fact that the audience had to participate in the play giving them the opportunity to give their own opinion about different aspects of the play. The only criticism that some people had regarding the play was that it ‘pushed’ breastfeeding too much, in their opinion. The majority of people, however, felt that the play was balanced in its approach to breastfeeding and bottle feeding. Another criticism was that the role of the father of the baby in the play was not developed enough and that his role should have been given greater emphasis. Having seen the play some participants were much more communicative in the focus groups compared with their communication prior to watching the play. This was particularly obvious in one group where participants had initially been quite hesitant to talk but after seeing the play they spoke more openly and freely. Some respondents also discussed how they had talked to friends and family about the play. This had encouraged discussion about breastfeeding. One traveller woman said that she would not normally have talked to her daughter about the subject because she hadn’t breastfed herself but had spoken to her about the play and breastfeeding. A lot of people felt that the play had raised awareness about breastfeeding and this was in regards to helping people be more accepting of it, being more prepared in the future if they ever had a baby themselves, knowing that the law protects a woman from discrimination if she is breastfeeding in public and also giving an awareness of various issues that breastfeeding women can come up against. In addition to the play being received positively by the audiences, those involved in the management and production of the play also had a positive experience. Some of the actors discussed how they had gained in their own personal development as a result of participating in the play. On the production side of this play there was collaboration between the HSE, the drama facilitator and Blue 2 Drum. As the play was a pilot project it provided a learning experience for all involved. Overall, the collaboration was successful in that the end product, the play, was commended by all. Conclusion This project was novel in so far as it aimed to get people, both young and old, discussing and debating breastfeeding through the use of drama. This evaluation shows that this aim was achieved. It also presented breastfeeding in many different guises and so did not only present the benefits of breastfeeding but also presented the stories of real women who had experienced both breastfeeding and bottle feeding, hence drawing a more realistic picture that the audience could connect with and believe in. Because the play was presented in the form of forum theatre the audience had the opportunity to change scenes in the play and to discuss and debate the different issues that arose. The evaluation shows that this was appreciated by the audience members. The play proved to be a useful tool to create awareness around breastfeeding in a ‘literacy friendly’ way. Although the play was performed in front of four diverse groups, each audience engaged well with the play and the concept of forum theatre, all getting involved in the intervention part of the play. Thus, feedback was very positive and the play can only be built upon for future use in the promotion of breastfeeding to a diversity of subgroups in the population. 3 RECOMMENDATIONS ________________________________________________________________________________ Production of play Meetings should be held regularly between project managers, drama facilitator, actors and any other important stakeholders to ensure vital communication about any aspects of the play’s production, to provide a forum for people to air their views and to ensure transparency in the process. From the beginning role definition needs to be clearly communicated. Contracts should be drawn up where appropriate. A clear decision should be made as to whether people are working in a voluntary capacity or for payment and this should be communicated to all parties involved. There should be collaboration between the drama facilitator and venue organiser so that the drama facilitator will know the audience in front of whom the play will be performed in order to allow him/her to be more prepared for the intervention part of the play. Performances The interventions that are suggested by the members of the audience should be recorded and communicated back to the Breastfeeding Steering Committee where there is potential for them to be acted upon, especially if they are at a level that is above that of the individual, such as where change is needed in an organisation or at a policy level. Consideration needs to be made as to how groups can be further engaged on the topic of breastfeeding especially where they have questions about breastfeeding and they are not answered through the forum theatre. A structured approach needs to be sought to identify whether improved outcomes associated with breastfeeding, amongst those that see the play, should continue to be built upon. Either as part of an ongoing programme of work or developing culture within the organisation. Future development and research Decisions need to be made as to what audiences the play should be performed in front of and clear guidelines should be drawn up as to how this should be done. Such performances should 4 be monitored/evaluated closely in the initial stages to ensure that the desired outcomes are being achieved with all groups. The HSE should consider further applications for using forum theatre in health promotion to engage young people and diverse audiences. 5 INTRODUCTION ________________________________________________________________________________ Breastfeeding and the National Policy Context The benefits of breastfeeding for infants are widely recognised and they include, immunological protection, a lower risk of suffering from type 1 and 2 diabetes and better cognitive development (Howie et al., 1990; Dewey et al., 1995; Wright et al., 1995; McKinney et al., 1999; Fewtrell, 2004; Oddy et al., 2003). There is also increasing evidence that breastfeeding provides a protective effect against obesity in childhood (von Kries et al., 1999; Arenz et al., 2004; Mayer-Davis et al., 2006). Breastfeeding confers benefits on mothers too with evidence for those who breastfeed having increased weight loss postpartum, a decreased incidence of ovarian cancer and premenopausal breast cancer (Rosenblatt & Thomas 1993; Newcomb et al., 1994; Marcus et al., 1999; Kac et al., 2004; Danforth et al., 2007). Although there are clear advantages to breastfeeding, rates in Ireland remain one of the lowest in Europe. The most recent perinatal statistics show exclusive breastfeeding rates of 44% at discharge from hospital (Department of Health and Children, 2008). These statistics also, however, indicate a strong socio-economic divide between those breastfeeding at discharge from hospital with 66% of mothers from higher professional occupations breastfeeding at hospital discharge compared with only 33% of semi-skilled manual workers. Over the past few years there has been a drive by the Irish Government to ensure that breastfeeding becomes a social norm and efforts are being made to increase both initiation and duration rates. A Five Year Strategic Action Plan for Breastfeeding in Ireland (Department of Health and Children, 2005) was published in October 2005. The Mission statement of this document is ‘To improve the nation’s health by ensuring that breastfeeding is the norm for infants and young children in Ireland’. Two of the goals of this action plan are that ‘all families have the knowledge, skills and support to make and carry out informed infant feeding decisions, particularly those least likely to breastfeed’ and that ‘Irish society recognises and facilitates breastfeeding as the optimal method of feeding infants and young children’ 6 Forum Theatre Forum theatre is a form of interactive theatre whereby sketches, based on real-life stories are acted out and members of the audience are then asked for ideas on how the situations depicted in the sketches could be improved. The audience members are invited to act out the sketch as they would like to see it, enabling them to change the sketch and empowering them to deal with the situation. Forum theatre has been identified as a ‘powerful agent for positive change’ in both industrialised and developing countries alike (Seguin & Rancuort, 1996). Forum theatre has been used successfully in different settings, dealing with a variety of issues. Sequin and Rancourt (1996) described its use in Mali whereby issues around family planning, the menopause and healthy lifestyles were dealt with. In addition they described its use in Canada, dealing with mental disorders and also with women’s exposure to the risk of HIV infection. It has been used in the education of student nurses and was found to be a successful tool as it was found that learning amongst the students was enhanced and that students were more engaged and more likely to remember (McClimens and Scott, 2007). It has also been used, with successful outcomes, in the United Kingdom (UK) with issues such as sexual health and racism (Orme et al., 2006; Camillin, 2006) Forum Theatre originated with Augusto Boal over thirty years ago in Brazil. He aimed to transform theatre from a ‘monologue’ as seen in a traditional performance into a ‘dialogue’ between the audience and the stage. Boal coined the word ‘spectactor’ to describe the audience members such that they would become empowered and would play a part in the drama in a ‘real and meaningful way’ (McClimens and Scott, 2007). The scenes played out in forum theatre are expected to resonate strongly with the usual experience of the audience such that they are transformed from passive spectators to engaged spectactors (Sullivan et al., 2008). Jackson (in Boal, 2004) described forum theatre as a ‘theatrical game in which a problem is shown in an unsolved form, to which the audience (spect-actors) is invited to suggest and enact solutions’. After the play has been played in full length the audience is then asked to decide which scene/scenes they would like to replay and change. The scene is then replayed and a member of the audience shouts ‘stop’ at the part they want changed. They then take the place of the protagonist and try to defeat the ‘oppressor’. The play and audience interaction are presided over by the ‘Joker’ (facilitator) whose job it is to engage the audience and encourage participation ensuring the audience understands their role. In a single forum many different solutions can be enacted and this results in a merging of ‘knowledge, tactics and experience’, in what Boal has described a ‘rehearsal for reality’ (Jackson, in Boal 2004). The aim of 7 such theatre us to ‘stimulate debate (in the form of action, not just words) and to show alternatives to enable people to become the protagonists of their own lives’ (Jackson, in Boal 2004). Merging the concept of forum theatre with the topic of breastfeeding, the Health Service Executive (HSE) Dublin Mid-Leinster along with the area Breastfeeding Steering Committee commissioned Marie McNamara to develop and facilitate a forum theatre production which was entitled ‘Milk It! Much Ado about Nothing?’. Overview of ‘Milk It! Much ado about nothing?’ In line with a forum theatre production, ‘Milk it! Much ado about nothing?’ was developed from women’s true stories of their experiences around infant feeding. These stories were collected by the project managers and the drama facilitator from interviews with women attending breastfeeding support groups, phone interviews and staff in a civic office. They were collated by the drama facilitator and organised into main themes. The process of story collection and organisation into themes ran concurrently and story collection continued until there was saturation of themes. In total stories were collected from 20-30 women, a few of whom had bottle-fed their babies. The main themes that emerged from these discussions were as follows: From those women that had bottle-fed their babies issues that were discussed: A lack of help at home and in the hospital. A lack of knowledge and thought about breastfeeding. Having to consider giving up drinking alcohol and smoking if breastfeeding A lack of information antenatally - not understanding ‘the basics’. Embarrassment around breastfeeding in public and in front of male relatives/friends at home. For those women that had breastfed their babies issues that were discussed: Health professionals ‘pushing’ breastfeeding was off putting. The antenatal class was technical and didn’t go into the benefits of breastfeeding apart from the nutritional benefits. A desire to have been more informed about breastfeeding from the beginning. 8 A lack of information and practical advice after birth. A lack of encouragement in hospital not to ‘give up’. Not wanting to be difficult and insist on help. Conflicting information in hospital Difficulty and frustration with feeding in first three weeks. Partner not understanding the motivation for wanting to breastfeed and family ‘dying for you to give up’. Feeding in public and considering how other people feel. Not feeling it is a social norm and acceptable. Not wanting to cause offence. (Themes were given courtesy of Marie McNamara) Once the stories were collected workshops were held weekly for ten weeks and the process of developing the stories into a play began. In total six actors (five women, one man) were involved with the play, three of whom were women who had relayed their stories in the initial process and were on maternity leave at that time. Two of the actors were got from an advertisement on an actor’s forum web page and one of the actors, a health professional, became involved due to her interest in the area of the promotion of breastfeeding. Three of the actors had babies and were breastfeeding them at the time of the workshops. One of the actors did not have children and she played the role of a young woman who had just found out that she was pregnant and had no information about pregnancy or breastfeeding. The workshops followed several stages with the first four weeks involving Marie McNamara, the drama facilitator, introducing the actors to forum theatre. A long with developing the group, it was also essential that trust was developed between them and this was done through games and exercises. Story development followed on from these workshops. The stories which had been collected originally were further developed by the actors and drama facilitator, into short sketches. This resulted in the development of the script by the seventh week. The actors drew from their own experiences which for some involved having breastfed and for others not. In order that the play remained ‘loyal’ to the stories that had been collected, three protagonists were written into the play as opposed to just one, which is the norm for forum theatre. This along with the fact that two professional actors performed in the play with four ‘non-actors’ were the only concessions made to Boal’s model of Forum Theatre. 9 The three protagonists were: Lizzie, a young woman of 18-20 years who was pregnant. She hadn’t planned the pregnancy and was quite clueless as to what to expect. She had not put any thought into how she would feed her baby. Heather, a woman in her early thirties who was very excited about being pregnant and was really looking forward to breastfeeding for all the benefits that it would incur on her and the baby and for the bonding that it would establish between them. She planned to breastfeed for six months. A midwife who worked in a busy maternity hospital and who was frustrated that she did not have enough time to help and support women. Some of the issues raised in the play included: Breastfeeding not being a social norm Lack of information on breastfeeding and bottle feeding antenatally Positive and negative attitudes to breastfeeding Lack of support for breastfeeding women from health professionals and family members Midwives having insufficient time to support women 10 METHODOLOGY ________________________________________________________________________________ The aim of this evaluation was to examine the role of forum theatre in creating an increased awareness of breastfeeding. The specific objectives of the evaluation were as follows. To assess the outcome of using drama to engage young people in discussion and debate about breastfeeding, to promote breastfeeding as the norm rather than the exception and to allow participants develop solutions to identified barriers to breastfeeding. To determine the experience and attitudes of the project team (project leaders, drama facilitator, drama participants and project manager) in developing the forum theatre production. Data was collected before, during and after the performances of the play. This data was collected from interviews, observations and a brief survey. Both a qualitative and quantitative approach were taken in the design of the study. The qualitative approach was in the form of interviews which were carried out with a sample of the viewers of the play, where possible both before and after watching the performance. In addition interviews were carried out with all of those involved in the play. These included those that commissioned the project, the drama facilitator, the actors, a community arts support agency and members of the South Dublin/Wicklow Breastfeeding Steering Committee. The quantitative methods comprised a postcard survey which was used to determine the opinions of those that saw the play. Each performance was also observed and information regarding the venue, audience, their participation and the changes that they made to the play, was collected. Sampling Research participants were identified through the organisations in which the play was performed. These organisations were a Youthreach group, Traveller Training Centre, A College of Further Education and a Maternity Hospital. In the case of the project team, all of those that were involved in the play were invited to take part in the evaluation. The evaluation was explained to all participants and they were given information about the study and a consent form (Appendix 1). For those with reading difficulties the information was read aloud. 11 All participants were assured that they were under no obligation to take part in the study and that they could withdraw from the study at any time. Research Methods Views of the audience: Some viewers of the play were interviewed before watching the play and again after. This was to ascertain if their attitudes and awareness towards breastfeeding had changed. In some cases viewers were interviewed a week before the play while in others they were interviewed on the day of the play. After watching the play, they were interviewed again and this was from a few days to five weeks after seeing the performance. The views of additional audience members were also sought after seeing the play and this was to ensure that a range of views had been got. Interviews were in the form of individual and group discussions. Observations: Each performance was observed and details of each were recorded under the following headings: organisation, venue, description of the audience, reception and engagement of the audience, a description of the audiences’ interventions. Postcard survey: After watching the play viewers were invited to fill out a short postcard survey (Appendix 2). This survey was similar to that used by Orme et al., (2006) and was written taking into consideration National Adult Literacy Agency (NALA) guidelines. If people had difficulty reading or filling out the survey help was available. The survey aimed to gather information regarding people’s opinion towards the play, the main message of the play and the role of drama in discussing breastfeeding. The postcard was piloted amongst a group of women (n=20) who watched a rehearsal of the play and their feedback was sought on the content of the postcard. Overall feedback was positive and so no changes were made to the postcard. Views of project team: Individual and group interviews were carried out amongst the project managers, the drama facilitator, a member of the community arts support agency Blue Drum which was commissioned to support the drama facilitator, the actors in the play, and members of the breastfeeding steering committee for South Dublin/Wicklow. Data was collected from audio taped, semi-structured interviews. Interview guides (questions which could be used in the interviews) were developed in order to provide a framework around which the interviews could be done. These were developed from the aims of the research and reading the literature of other studies which used drama in health promotion. All interviews except for one were 12 face-to-face. One interview had to be done over the phone as this was the most convenient for the interviewee. Interviews were recorded except for the phone interview and one other interview where the person did not want her voice recorded. In these two cases notes were made during the interview and were written up as soon as possible afterwards. Data Analysis All interviews were transcribed and were then analysed for themes and sub-themes. The computer software NVivo 8 was used to help in the analysis of the data. NVivo is a specialist package developed solely as a computer aided qualitative data analysis system (CAQDAS). NVivo aided in organising the data into themes and sub-themes. In addition memos were written and stored in NVivo alongside coding to explain the rationale for choosing different codes and also to record the researcher’s train of thought while coding. Qualitative data from the postcard survey was also transcribed and analysed for themes. Quantitative data from the postcard survey was analysed using descriptive statistics in Statistical Package for the Social Sciences (SPSS) 15.0. Ethical Considerations Permission for this study was granted by Dublin Institute of Technology, Research Ethics Committee. All participants were given the opportunity to ask questions prior to participating in the study. In addition written and verbal assurance of confidentiality was given and also assurance that they could withdraw from the study at any stage was given. All of the names of those that participated in the study were changed and so quotations can not be identified to a particular person. In the case of the actors and steering committee members, the interviews were coded by a number and only the researcher could identify the identity of the participant. In the case of the drama facilitator, project managers and member of the community arts support facilitator, their titles were used as opposed to their names. 13 RESULTS ________________________________________________________________________________ DELIVERY OF THE PLAY AND OBSERVATIONS The play was performed in four different venues. These venues included a maternity hospital, a college of further education, a youth training centre and a traveller training centre. The audiences ranged from teenagers to those in their fifties and included both students and professionals. Below is a description of each performance explaining the organisation, venue, audience, reception and engagement of the audience and the interventions that were put in place. The descriptions show the different ways in which the audiences intervened in the scenes and also their level of engagement with the play. Overall feedback was very positive and all audiences responded well to the play and to the concept of forum theatre. Organisation Youthreach: This is a training programme for unemployed young early school leavers aged 15-20 years. The performance was held in a large room with just enough space for everyone. Venue The acoustics were good and the play could be seen and heard without difficulty. Female: 16 Audience Male: 5 (Spect-actors) Eighteen of whom were students and three teachers. Sixteen were aged between 15-20 years, three were 21-30 years and one was 31-40 years. Three people from the HSE also attended along with a member of the breastfeeding steering committee. The audience were attentive and laughed at funny scenes. Some moved position to Reception and have a better look at the play and also some sat forward which would indicate 14 engagement of interest in what was happening. The audience responded really well. They got the audience particularly animated when their friends in the audience got up and participated in the drama. 1. The hospital scene: A young man said that the scene in the hospital could be Interventions changed. He got up and introduced a new character, Heather’s husband/partner and called her on her mobile just at the point where she was beginning to despair over not being able to feed and not getting the support from the midwife. He supported Heather in two ways. First on the phone he offered her support and then in the hospital he said to the midwife that she wanted to breastfeed and needed help. This in turn empowered Heather to ask if she could see the lactation midwife. 2. The café scene: One young woman said that the old person was from a generation where breastfeeding was the norm and so this was not her fault that she found it disgusting. However, with a little encouragement she got up and took the part of the waitress and told the young people who were laughing that they were ‘gobshites’ and should have more respect and that they could lump it or leave. She then turned to Heather and asked her if she was ok and showed her support. 3. Booking clinic: One woman from the HSE got up for the booking clinic scene and she took on the part of Lizzy. She insisted on getting information about breastfeeding from the midwife and the midwife then gave her a little more time. By asking for help this empowered Heather and Sally and they responded that they would like information too. Additional Information 4. During the intervention part of the play the issue of respect came up in the discussion and the idea of respect for both bottle and breastfeeding was discussed. 5. At the end of the play a young man said that he had found the performance really good as it gave him knowledge about breastfeeding and made him think about it and gave him a respect for it. He thanked the group for coming in and performing. 15 Organisation College of Further Education: This college is run by one of the Vocational Education Committees and offers a diverse range of courses for Post Leaving Certificate and mature students. The performance was held in the school gymnasium. It was a large hall. The Venue performance was on the floor at the top of the hall. This made it difficult for some people to see, however, acoustics were great and there was no difficulty in hearing what was being said. Female: ~55 Audience Male: ~10 (Spect-actors) The vast majority of those that attended were students, most of whom were under thirty years of age. The students came from childcare, performing arts and social studies. Two people from the HSE also attended along with a member of the breastfeeding steering committee and the National Breastfeeding co-ordinator of Ireland. The audience received the play well. There was complete silence in the room Reception and during the play. They laughed at the following parts engagement of In the booking clinic the audience The comment about being like cows in a barn milking Mermaid pose comment during the yoga scene Breastfeeding together like cows (in yoga scene) The nightclub scene The reaction of the friend to breastfeeding, in the nightclub The audience also showed interest by craning their necks to see what was happening in the yoga scene, and café scene. 16 Interventions 1. Café scene: Almost immediately when the drama facilitator asked how things could be changed a woman said that the café scene had happened to her a few years before. She got up and played the part of Heather. When the granny was admiring the baby and suddenly looked shocked the woman said I am breastfeeding her why, it is perfectly normal. The granny said ‘well not in my day dear’. And the woman replied well you can have your opinion. The waitress then asked her to leave and said that she would put a brownie in a bag for her. She said that she didn’t want a brownie in a bag and then she asked to see the manager. The audience laughed at her persistence. Someone in the audience commented how breastfeeding should be a cultural norm and the drama facilitator asked how this could be. One woman said that support was needed. A young woman said that she was 17 years when she had a baby and that there were no support groups for young people. She said that the group near her was attended by older women and so didn’t suit her. A woman from the HSE said that there are support groups but they are universal and drop in. There was a suggestion that there should be support groups for young people. The National Breastfeeding co-ordinator of Ireland then made the point that it was against the law to ask a woman to stop breastfeeding in public and that it was the proprietor’s responsibility to protect the woman from discrimination. The audience didn’t know this. 2. Hospital Scene: A young woman took the role of Heather while the midwife was hurriedly trying to advise her how to breastfeed. She went to leave her and the young woman said ‘oh hang on, I’ve never done this before, please can you just hang on?’. The midwife then suggested giving a bottle and the woman said no, that she wasn’t giving her a bottle. The midwife suggested getting the lactation consultant. The woman was still not happy and asked if there were any other mothers who were breastfeeding that she could talk to. The midwife said yes there were. The woman was happier. Someone from the audience said that mother could have been more prepared and 17 could have researched things before the baby was born and this might have prepared her more for breastfeeding . 3. Heather at home: A member of the audience took on the role of Heather’s husband. Heather wanted to talk to him about her experience earlier in the hospital and was exhausted. The husband was on his way out to football and the young woman from the audience playing the part of the husband explained that he needed some time with his mates and suggested that Heather ring her friends from the booking clinic. Heather decided to ring Sally and they chatted and Sally offered support – they decided to meet the following day and joked about going back to the café the next day and breastfeeding together. The drama facilitator asked them how it felt playing the new scene and Heather said much better. 4. There was a brief discussion about the booking clinic and the idea of having support by other mothers at the initial appointment at the booking clinic. One of the actresses mentioned that there already was La Leche League and Cuidiu volunteers but a woman in the audience got up and said that they were only volunteers and that they would love to be going into hospitals but that they didn’t have the resources. 5. Booking clinic scene: A woman from the HSE took on the role of Lizzie and asked for the information on breastfeeding to be explained to her. She said ‘you can’t just give me stuff like this’. She asked questions like where the support groups etc. were and the midwife showed her at the back of the booklet where they were listed. She got her questions answered, however, in a very hurried fashion. She then asked for information on bottle feeding and the midwife went and got her some. Additional After the performance some people came up and said how much they had enjoyed Information the performance and they thanked the actors for the play. 18 Organisation Traveller Training Centre: This centre provides education for women aged 15 years and upwards. Venue The performance was held in a family resource centre, in a small brightly lit room. There was sufficient room for everyone to be seated and everyone had a good view of the performance. Audience Female: 22 (Spect-actors) Sixteen of whom were students, one a tutor and five public health nurses. Members of the audience ranged from 16-60 years. Two people from the HSE also attended the performance. The reception from the audience was really good. They laughed at the following Reception and parts: engagement of At the beginning with Lizzie screaming and then the baby coming out. the audience Some people got out of their seat to get a better view of what was happening. Laughing at baby hugging Susan and Lizzie. Get baby out of my arse comment Laughing at being like a cow comment Laughing at nightclub scene Laughing at young people in café scene Laugh at 10lbs – ouch! The audience engaged well with the play. They responded quickly once the drama facilitator opened it up to the audience as to what Lizzie was going to do and what her dilemma was. Interventions 1. Lizzie and her mother scene: A woman in the audience asked if there was any 19 midwife that could explain things to Lizzie individually. She said how Lizzie was a young girl and that the midwife should have taken her in and explained the different feeds to her. The girl’s mother could also have explained to her, her different options and how to ask for advice. With some persuasion she got up and played the role of Lizzie’s mother. She told Lizzie that when she goes to the booking clinic, to ask the midwife if she could speak to her in confidence and she told her to ask her what she should drink and eat, and how to control her weight and she asked her if she would like her to go with her to the booking clinic. Lizzie said that she would. 2. The Booking clinic scene: Another woman then took over the role of Lizzie’s mother in the booking clinic. She was slow to ask the midwife for information but then did interrupt her and ask her. The midwife said how busy she was and the woman asked if they could talk in private. The midwife said it wouldn’t be possible as she was too busy. She persisted and finally the midwife agreed that she would see her at the end of the clinic when it was a little quieter. The drama facilitator asked them if it was ok for them to wait. They said yes but then the mother said maybe it would be better to go to their family doctor about it instead as the hospital was so busy. The drama facilitator asked Lizzie how she felt about the change in the scene and she said how she really liked getting the support from her mother. 3. The yoga scene: There was a discussion about yoga as a woman in the audience asked what it was. Two of the actors discussed how good it was during their pregnancy and they explained how relaxing it is. One woman in the audience joked about how the actors didn’t looked so relaxed playing the yoga scene and there was laughter. A public health nurse got up from the audience and played the role of Lizzie. The yoga scene was repeated and she took over as Lizzie. She asked about the antenatal class and makes specific arrangements with Sally to meet her at the Dart station the following week and they will go together to the class. Sally said that she would call her the day before they go to finalise arrangements. 20 4. Disco Scene: One woman said that the disco would be too noisy for the baby. Someone else said that Lizzy was responsible in not drinking alcohol and instead having water. Someone said that she needed more support and the drama facilitator asked how could she get support for herself. Someone said she could talk to her friends and go to dinner instead of the nightclub. She could bring a book with her to show her friends at dinner. A telephone conversation was then acted with two members of the audience, one playing Lizzie and the other her friend. The friend asked Lizzie if she was going out for a drink and Lizzie said that she didn’t know as she was pregnant. With a little persuasion from her friend she agreed. The scene was replayed again, however, this time Lizzie said that she would like to go for a quiet meal instead of going for a drink and her friend agreed. 5. There was a brief discussion then about breastfeeding rates in Ireland and how they had decreased since the 1920s. One woman in the audience said that it had not been encouraged and that everything was hidden. 6. Hospital scene: When Heather was having difficulty in the hospital one woman in the audience suggested that she call one of her friends from the yoga class. The woman played the role of Sally and Heather called her, telling her how difficult she was finding it. Sally asked if there was any nurse she could ask and she told Heather to insist that she needed help. She offered her support. Additional At the end of the play two women came up and said how much they had enjoyed Information it. They asked for their feedback to be written on the postcards as they couldn’t themselves. One of the women said it was very important that she had seen it as her daughter was pregnant and she could tell her things after seeing it. She also marvelled over the yoga as she hadn’t been aware of it. 21 Organisation Maternity Hospital: Dublin City Centre Venue The performance was held in a small lecture theatre in the hospital. The play could be viewed and heard easily. Audience Female: 44 (Spect-actors) Male: 4 Two people from the HSE also attended along with two members of the breastfeeding steering committee and the National Breastfeeding co-ordinator of Ireland. The audience was a mixture of dietitians, administration staff, engineers, midwives, student nurses, members of voluntary breastfeeding organisations, healthcare assistants and other. They ranged in age from 20-60 years of age. The audience received the play very well. They smiled and laughed and were Reception and attentive throughout. engagement of The audience laughed at the following parts the audience the baby’s entrance and his dialogue people smiled knowingly at the booking clinic scene being like a cow and imitation of milking out of my arse comment yoga scene: will it make my tits bigger comment mermaid pose nightclub scene – baby in the background – complaining about friends – laughing hospital with Heather and midwife: laughing at midwife saying we are very busy, I won’t be able to stay the midwife suggesting a top-up 22 café scene the scene with Heather and her husband and she says about having to go up stairs when his mum calls Interventions 1. Lizzie and her mother scene: One woman in the audience said that the mother could have said that she would help her daughter with the baby. (instead in the play the mother said how she would help with the baby and that she could help with the bottle feeds). The woman got up and the scene was replayed. She said to Lizzie that herself and her husband would help with everything and she also mentioned about breastfeeding. The drama facilitator asked the audience if that worked better and they agreed. 2. Booking clinic scene: Someone in the audience said that Lizzie’s feelings could have been acknowledged and the drama facilitator asked who could have done that? Someone said that an introduction could have been made to the young mum. A woman gets up from the audience and immediately stopped the scene when the midwife asked very hurriedly for the urine samples. She took over the role of the midwife and came out less rushed, politely and in a friendly manner asking for the urine sample and said that she would get someone to talk to the women because it was their first time. Someone in the audience mentioned how it would be great to have one nurse whose job is specifically to support breastfeeding. The drama facilitator asked if that was a realistic solution and asked the midwives in the audience. One person said they do a team clinic and they can tailor, to some degree, support for women. Someone else mentioned that because that week was National Breastfeeding week, voluntary counsellors were invited into the antenatal clinics to speak to women. The drama facilitator asked if that could happen again and someone said that they were going to look into it. One woman from a voluntary breastfeeding organisation said that she had done a stand that morning and 23 she felt there was a great need for such a thing and that people needed information in a non-threatening way. She said that there was something awful about the way in which Lizzie had just been handed leaflets about breastfeeding by the midwife in the booking clinic. 3. Booking clinic scene: This was replayed again, this time with a woman from the audience playing the role of a member of a voluntary breastfeeding organisation. She approached the three women (Lizzie, Heather and Sally) in the booking clinic and said that she was from a voluntary organisation and that the women were welcome to come along to a breastfeeding support group and that they could come along when they were pregnant. 4. Someone from the audience made the point that balance was needed about feeding and that while breast is best a little more is needed on bottle feeding. 5. A member of the audience asked Lizzie if a buddy system would have worked in supporting her. 6. Booking clinic scene: a care assistant said that she would like to redo the booking clinic. She plays the role of someone walking around and talking to the women and she asks them if they had considered breastfeeding. She said that breastfeeding was good and that there were breastfeeding midwives to help and that if they couldn’t breastfeed they couldn’t but that they should at least give it a try. She introduced herself and said that she was always there and she would help the women and make time for them. She made the point that if the care assistants had more knowledge they could help and said that training in breastfeeding would help them. She felt that care assistants could be good to help with antenatal care and in getting mothers together as support for each other. 24 FINDINGS FROM THE POSTCARD SURVEY In total approximately 160 people watched a performance of the play. One hundred and ten people responded to the postcard survey which was a response rate of approximately 69%. The demographic details by venue of those that responded to the survey are described in Table 1. Table 1: Demographic information by venue of those that participated in the postcard survey ________________________________________________________________________________ Youthreach (n = 21) College of FE* (n = 33) Traveller training centre (n = 16) Maternity hospital (n = 40) % (n) ___________________________________________________________________ Age (Years) ≤ 20 76 (16) 49 (16) 13 (2) 8 (3) 21-30 14 (3) 30 (10) 25 (4) 33 (13) 31-40 5 (1) 3 (1) 31 (5) 18 (7) 41-50 - 12 (4) 51-60 - - Missing 5 (1) Male Female - 18 (7) 25 (4) 10 (4) 6 (2) 6 (1) 15 (6) 24 (5) 12 (4) - 10 (4) 76 (16) 88 (29) 100 (16) 90 (36) 86 (18) 85 (28) 69 (11) 28 (11) 25 (4) 35 (14) Sex Profession Student Health professional - - Administration - - - 8 (3) Engineer - - - 5 (2) 14 (3) 6 (2) 6 (1) 20 (8) - 9 (3) - 5 (2) Other Missing ________________________________________________________________________________ * College of FE is College of Further Education 25 Nearly all of those that saw the play thought that it was enjoyable. In addition the majority thought that it was interesting, informative and professional (Table 2). Table 2: Views of the performance (n=110) ________________________________________________________________________________ Yes % (n) No % (n) No response % (n) _______________________________________________ Did you enjoy the play? 98 (108) - 2 (2) Interesting 95 (104) - 5 (6) Informative 91 (100) 1 (1) 8 (9) Professional 85 (93) 4 (5) 11 (12) 78 (86) 16 (18) 6 (6) 95 (105) 2 (2) 3 (3) Did you think the play was: Did you think the things discussed in the play are relevant to you? Did you think the play was a good way of discussing breastfeeding? ________________________________________________________________________________ Seventy eight percent (n=86) of those that filled out the postcard survey thought that the things discussed in the play were relevant to them. Ninety five percent thought that the play was a good way of discussing breastfeeding. The main message of the play Comments regarding what people felt was the main message of the play were divided under four themes. The need for information and support The importance of breastfeeding and the need to encourage it 26 Challenging attitudes to breastfeeding Highlighting the obstacles that exist around breastfeeding The need for information and support Interestingly, most of those that commented on the main message being related to the need for information and support saw the play in the maternity hospital. Some people felt that the main message of the play centred on there being a need for information and support for women before and after pregnancy. ‘New mothers need to be provided with a lot of support and knowledge to help them to make the right choices for their baby’ (Student nurse, Maternity hospital) ‘Need extra staff, more support for women, more time spent educating, listening and supporting women’ (Midwife, Maternity hospital) ‘Better information around breastfeeding infants is needed (patient focused)’ (Dietitian, Maternity hospital) Others felt that the play highlighted the lack of information and support available to women. ‘It shows the lack of support for breastfeeding in the community and that midwives are sometimes too busy to help expectant mothers’ (Student nurse, Maternity hospital) ‘Lack of support /info. for mums – to be particularly around the area of breastfeeding’ (Dietitian, Maternity hospital) ‘The play highlighted the lack of information and support and practical help available to mothers who wish to breastfeed their babies’ (member of a voluntary breastfeeding organisation, Maternity hospital). ‘Not enough information’ (Student, Traveller Training Centre) Two students in the College of Further Education mentioned the importance of women informing themselves about breastfeeding so that they would be prepared and also having a support system ready. They acknowledged the fact that the information is there if people looked for it. 27 ‘Self education and informing yourself is very important. It’s not all going to be there on a plate’ (Student, College of Further Education) ‘That breastfeeding can be difficult but there is support and information available if you look for it’ (Student, College of Further Education) ‘If you want to breastfeed don’t be turned off by others. Have a support system’ (Student, College of Further Education) The importance of breastfeeding and the need to encourage it Some people felt that the main message of the play was to highlight the importance of breastfeeding and the need to encourage it. ‘It is ok to breastfeed and it should be encouraged’ (Engineer, Maternity hospital) ‘Promotion of breastfeeding’ (Student midwife, Maternity hospital) ‘Breast is best’ (Administration staff, Maternity hospital) ‘That breastfeeding is an ok thing to do’ (Student, College of Further Education) ‘That breastfeeding is good’ (Student, College of Further Education) ‘Breastfeeding should be acceptable’ (Student, College of Further Education) ‘The message was to tell you that breastfeeding is the best start to your baby’s life and there is lots of good advantages’ (Student, Youthreach) Some others felt that the main message was that breast is best but that changes need to be made at the level of society in order for the message to be appreciated. ‘Breast is best but changes need to be made by all members of the community. Social change is the key to promoting breastfeeding’ (Student, Maternity hospital) 28 ‘To emphasise the importance of breastfeeding. The different types of support that is available. That breastfeeding should be seen as ‘normal’’ (Student, Maternity hospital) Challenging attitudes to breastfeeding It was felt by some that the play challenged attitudes to breastfeeding and cultural norms. ‘Cultural change in attitude to breastfeeding. Midwives need more time to educate’ (Midwife, Maternity hospital) ‘Breast is best. The idea that breastfeeding is not as readily accepted in Ireland as it could be’ (Student, Maternity hospital) ‘That breastfeeding should be treated like a normal everyday thing in Irish society and not frowned upon’ (Student, College of Further Education) ‘That breastfeeding is seen as an unnatural thing to the general public, this should not be the way’ (Student, College of Further Education) ‘That breastfeeding is normal and should be considered so, and that it is the best for the baby’ (Student, College of Further Education) ‘That breastfeeding should be a natural process and should not be looked down on’ (Student, College of Further Education) ‘How society is ignorant when it comes to the most natural and healthy way to feed your child. And also how there is a lack of information given to women about feeding’ (Student, Youthreach) ‘That breastfeeding is more beneficial for the baby and that society are so dumb when it comes to breastfeeding’ (Student, Youthreach) 29 ‘That breastfeeding is the best way to feed your baby, and that peoples views on breastfeeding are wrong when they think it’s bad’ (Student, Youthreach) Highlighting the obstacles that exist around breastfeeding A few people mentioned that the play highlighted the obstacles that can exist around breastfeeding and the importance of being prepared for these. ‘Very interesting and informative – highlighted many issues relating to breastfeeding and mothers i.e. being unaware of its benefits for both mum and baby, wanting to do it and not succeeding – the trials and tribulations associated with it - also it showed how midwives may not necessarily have the time to discuss the different methods of feeding and its benefits’ (Student nurse, Maternity hospital) ‘The main message is to promote breastfeeding as a positive thing to do. Also to realise that there will be obstacles along the way but to get advice, information and ask questions’ (Administration staff, Maternity hospital) ‘To promote awareness around breastfeeding and how rude some people can be’ (Tutor, Youthreach) The play being a good way of discussing breastfeeding Ninety five percent (n=105) of those who answered the postcard survey thought that the play was a good way of discussing breastfeeding. Two percent (n=2) did not think it was a good way of discussing breastfeeding and three percent (3%) did not answer the question. Only one of those that did not think it was a good way of discussing breastfeeding wrote why and the reason given was that ‘It didn’t explain why it is being frowned upon in society at the moment i.e. why there is a need for this play’ (Manager, College of Further Education) Of those that thought the play was a good way of discussing breastfeeding, their reasons were broken down into themes and these were as follows: The play being different to other ways of promoting health Informal and fun way of highlighting issues around breastfeeding It was real and shed light on the reality 30 Thought provoking Opportunity to give own opinion Informative The play being different to other ways of promoting health Respondents mentioned the difference between the play and other ways of promoting health such as receiving lectures and leaflets. It was felt that the play was a more effective medium through which the message could be transmitted and it was more engaging for the audience than a lecture. ‘It brings a reality to it that reading a leaflet never would. It was a very good portrayal of the benefits and problems with it’ (Student nurse, Maternity hospital) ‘It’s visual, interactive, captivating, funny, imaginative’ (Student dietitian, maternity hospital) ‘People start thinking about it. The play showed real life situations. It’s easier to send a message with this than just a letter. Well done!’ (Student, College of Further Education) ‘Because it’s showing people how good breastfeeding is instead of giving out boring leaflets’ (Student, College of Further Education) Informal and fun way of highlighting issues around breastfeeding The fact that the play was fun and informal was mentioned by a few people and they felt this aided in their enjoying the play and in being attentive to what was happening in the play. It also encouraged thought about the issue and this was in a friendly non-threatening environment. ‘Encourages thought about the issue. Great fun way of providing information’ (Midwife, Maternity hospital) ‘Informal, basic, funny, approach to a very important topic in women’s health and childcare’ (Midwife, Maternity hospital) 31 ‘It was fun as well as informative. If it was boring nobody would have paid attention. Getting the crowd involved was a good idea’ (Student, Youthreach) ‘Cause they do it in a way that you wanna watch it’ (Student, Youthreach) ‘A great way to be able to discuss breastfeeding. An interesting and friendly way to discuss. You have put on a very good play’ (Student, Traveller Training Centre) It was real and shed light on the reality Many respondents appreciated the fact that the play depicted real situations. Some mentioned the fact that by being ‘real’ the audience could understand breastfeeding and different situations related to it better than just reading about them and that they could relate better to a breastfeeding woman after watching the play. ‘It shows different women from different walks of life going through the same problems. Women who are breastfeeding might relate to the characters and realise they’re not the only ones experiencing these problems’ (Student nurse, Maternity hospital) ‘It is easier to relate to these women when their real lives are acted out in the play’ (Student, College of Further Education) ‘Because it showed real life situations as they would happen; situations that might be hard to put into words in a verbal description of situations that could arise’ (Student, College of Further Education) ‘It makes people feel involved and they can visualise it’ (Student, College of Further Education) ‘Because it was what happens in real life. It was very good’ (Student, Traveller Training Centre) ‘Real situations and discussions’ (PHN, Traveller Training Centre) 32 Respondents from the maternity hospital felt that the play shed light on the reality of what can happen when a woman is breastfeeding and it was felt that this aided in their understanding of what goes on outside of the hospital and the experiences that women can have in society. ‘Gives us a good idea what is going on out there in the public’ (Midwife, Maternity hospital) ‘Using all senses helped. Seeing life from the other side of the fence. The importance of words/actions in our interactions with women/clients’ (Administration, Maternity hospital) ‘Because during the play you get to really see it like in practical we do not realise it’ (Health care assistant, Maternity hospital) One respondent felt that the play should be shown to managers in order to show them the reality of hospital life and breastfeeding. ‘It is known there’s a baby boom and lack of time and staff in hospitals. Just brings it to light. Should be shown to managers and masters and make them aware how women are treated’ (Student midwife, Maternity hospital) Thought provoking Some respondents felt that the play was thought provoking and in the case of some health professionals it encouraged self reflection with regards to their own practice. For others the play provided the opportunity to have an ‘insider’ look into situations that can arise around breastfeeding. ‘It made you think about why people breastfeed and why they may give up too soon’ (Administration, Maternity hospital) ‘Need to avail of lots of opportunities to inform and discuss with antenatals’ (Midwife, Maternity hospital) ‘Promotes discussion and self reflection re ways of supporting breastfeeding. Highlights negative influences on breastfeeding’ (Unknown, Maternity hospital) 33 ‘It highlights different issues e.g. social perception of breastfeeding, family support that all affect breastfeeding’ (Student, College of Further Education) ‘Opens up about and gives us more of an inside look on it’ (Student, Youthreach) Opportunity to give own opinion Some of the students from the College of Further Education, Youthreach and the Traveller Training Centre commented on the fact that the play provided the opportunity for people to give their opinion about breastfeeding and to be involved in the different scenes of the play. They appreciated this aspect of the play. Cos everyone got a chance to talk and say what they thought’ (Student, College of Further Education) ‘Because everyone got a chance to express their opinions on breastfeeding’ (Student, College of Further Education) ‘Because it shows you different inputs of different people and their opinions and reactions rather than just your own’ (Student, Youthreach) ‘I thought it was very good because you could discuss your opinions and also alter the play itself. Thank you!’ (Student, Youthreach) ‘Discussion with people’ (Student, Traveller Training Centre) Informative Some of the students in Youthreach commented on the fact that the play gave information about breastfeeding and they learned some things from it. ‘Because I got a lot of information on breastfeeding’ (Student, Youthreach) ‘It is because it explains a lot on breastfeeding and a lot of things I didn’t know and it’s a fun way of explaining it’ (Student, Youthreach) 34 FINDINGS FROM THE INTERVIEWS Interviews prior to participants watching the play A focus group discussion was held with some of the members of the audience, in each of the venues prior to the participants seeing the play. In most cases the focus group was held the week prior to the play and in some it was held on the day of the production. In the case of the maternity hospital two focus groups were held and one individual interview. The focus groups and interviews lasted an average of twenty five minutes. Table 3 shows the number of people in each group for each organisation, their age range and occupation. Table 3 The organisation, sex, occupation and age range of those that participated in the interview Organisation Sex and occupation of participants Age range Youthreach Females = 14 ≤ 20 years = 8 Nine students and 5 tutors 21-30 years = 3 ≥ 31 years = 3 College of Further Females = 13 ≤ 20 years = 3 Education All students 21-30 years = 2 ≥ 31 years = 3 Missing = 5 Traveller Training Females = 3 ≤ 20 years = 1 Centre All students ≥ 31 years = 2 Maternity Hospital Focus group 1: Females = 4 Males = 2 One engineer, two administration staff, one manager, one maternity care assistant and one nurse 35 Missing Table 3 Contd. Focus Group 2: Females = 5 ≤ 20 years = 3 Two student general nurses, three 21-30 years = 1 student paediatric nurses ≥ 31 years = 1 Individual interview: Male = 1 (Engineer) 21-30 years = 1 Six themes emerged from the semi-structured interviews that sought to determine the participants’ awareness and experience of breastfeeding and their attitudes and opinions about breastfeeding. These themes which are explained in detail below were as follows: Advantages and Disadvantages of breastfeeding Embarrassment about breastfeeding Opinions about breastfeeding Attitude to people breastfeeding in public Asking questions about breastfeeding The media and breastfeeding Advantages and Disadvantages of breastfeeding The students in the College of Further Education, the Traveller Training Centre and Youthreach had some knowledge of breastfeeding and all groups mentioned some of the advantages and disadvantages. They were all studying childcare courses and breastfeeding was part of the curriculum for the courses. Some of the advantages which were mentioned by students in all three groups included: It creates a bond between the mother and the baby It provides nutrients It is convenient as you don’t have to sterilise and make up bottles It’s good for the baby’s immune system It helps the mother to return to her normal weight It’s healthier for the child 36 Some of the disadvantages which were discussed included: No-one else can feed the baby It can be sore to breastfeed at the beginning You don’t know how much milk the baby is getting People can look at women who breastfeed in public strangely Embarrassment about breastfeeding In the focus groups which were carried out prior to participants seeing the play embarrassment about breastfeeding was a theme that came up especially among those with very little exposure to breastfeeding, namely in the focus groups in Youthreach and the Traveller Training Centre. Some women felt that it would be embarrassing to breastfeed and they wondered about what their partners along with other people would think if they did it. ‘A lot of people think what will the people think like’ (Mary, student, Traveller Training Centre) ‘I think that’s probably what it is, it does seem a bit embarrassing doesn’t it’ (Sharon, student, Youthreach) ‘But I think like if you had your partner with you or if you had a partner, they’d just get embarrassed like and probably tell you to cop on. They would like, they’d probably say what are you doing like making a show of me’ (Sharon, student, Youthreach) Opinions about breastfeeding When asked what people’s views were about breastfeeding, responses were mixed with some being very positive and supportive of breastfeeding. ‘I think it’s brilliant, it’s cheap and it’s healthy, I don’t have any experience of it, any family or anything doing it but I think it’s a good idea to consider it’ (Michelle, care assistant, Maternity hospital) ‘I have read the benefits of it on lets say the information that the hospital gives out and it makes sense to me really to breastfeed or for women to breastfeed you know’ (Paul, engineer, Maternity hospital) 37 Some people felt that breastfeeding is an individual choice and a decision that should be made by the mother with no guilt being put on her. ‘I think it’s an individual choice and I don’t think women should be made feel bad if they don’t or made feel whatever if they do. I think it’s really up to the mam, she knows best really for her children or what’s best for her if she’s happy with the bottle why not and if she’s happy with the breast why not too’ (Karen, student, College of Further Education) Others felt that breastfeeding was something they felt they would like to try if they had a baby however they would be open to how long they would continue doing it. ‘I probably would try it I’d say. I wouldn’t mind like anyone looking at me or whatever, it wouldn’t bother me. But I’d say I probably would try just to see and then I wouldn’t do it for the long term’ (Susan, student, College of Further Education) The importance of being shown how to breastfeed when a woman is pregnant was highlighted by one respondent as she felt that many women do not understand what it means to breastfeed and so can’t make an educated decision about whether to do it or not. ‘I think that you should be shown when you’re pregnant how to breastfeed, if you want that like. Like they just say do you want breastfeeding and you say no and it’s like how do you know what you want when you’re not shown’ (Mary, student, Traveller Training Centre) One woman reflected on the fact that although breastfeeding would be better for her child, it never came into her mind to breastfeed her baby, it was something that she simply had not considered. ‘It never came into me mind to breastfeed. I just didn’t see meself breastfeeding. If I had to just like you know use the pump like but I wouldn’t actually breastfeed. I don’t know I just wouldn’t. It’d be better for the child alright but I just I don’t know, it never came into me mind like to breastfeed. I went straight to formula’ (Sharon, student, Youthreach) It was obvious from the group discussions that some groups had much more exposure to breastfeeding than others. Of course those in the Maternity hospital had plenty of exposure, however, those in the College of Further Education could also elaborate on their own personal 38 experience of breastfeeding or that of someone close to them. This was not the case with those in the Youthreach group or the Traveller training centre although one of the traveller women had tried to breastfeed her son because her grandmother had encouraged her to. Discussion around breastfeeding was more limited in the Youthreach group because of the lack of exposure to breastfeeding. Interestingly some of the stories that people told during the interviews prior to seeing the play were reflected in the scenes of the play. This showed that the play was real to life. People discussed how busy the hospital can be and the lack of time that midwives have to support women. ‘Some nurses or midwives don’t actually have the time to be going around to everybody and they might only just show them once, but once may not be enough. They might find they did it once and then kind of maybe if they got the wrong position the second time and there is no midwife there, I think that’s an issue as well’ (Paula, student nurse, Maternity hospital) ‘She said anyway that they (the midwives) just landed the baby on her and they just said well you do this and more or less left her to her own devices. I know probably most women would probably prefer the privacy anyway to do it but if you can’t manage it and you really want to do it, you do need somebody to more or less show you’ (Karen, student, College of Further Education) Attitude to people breastfeeding in public Generally amongst those in Youthreach there was a feeling that it was unacceptable to breastfeed in public although some people did say that if the mother covered up then it was ok. One woman described seeing a woman in a café breastfeeding a few weeks earlier and was unsure about whether she felt it was ok to do that. ‘It’s just like all of a sudden I looked and there she was breastfeeding like. It didn’t bother me as such but I’m sure like it probably bothered a few other people. I don’t know. The child’s hungry she has to be fed but I don’t know, I don’t know’ (Sharon, student, Youthreach) It was suggested that a woman could express the milk and then give the baby a bottle in public. One young woman showed disgust at the idea of breastfeeding in public and someone in the group asked her ‘What if your child was hungry and you were breastfeeding?’ and she replied ‘Put it in a pump 39 and bring it in a bottle’ (Louise, student, Youthreach) Those in the Maternity hospital and the College of Further Education supported women that breastfed in public and did not have any issue with it. ‘People are more accepting of it and people are more aware of the benefits of it. Men as well, they’re not as judgmental’ (Susie, student nurse, Maternity hospital) ‘It wouldn’t bother me to see someone breastfeed their baby, I think it would be ok’ (Elizabeth, student, College of Further Education) ‘I think it’s kind of an encouraging thing because if more and more women are willing to breastfeed in public other women would see them doing it and if you see someone doing something you kind of think ah sure there’s nothing wrong with that. It might encourage them to do it themselves, you know. I wouldn’t look the other way’ (Paul, engineer, Maternity hospital) Asking questions about breastfeeding Throughout the group discussion students in the Youthreach and the traveller group asked some questions about breastfeeding. This showed their interest in the subject and that the discussion got them thinking about different aspects. Questions related to what age a baby should be when a mother would stop breastfeeding, whether you can drink and smoke when breastfeeding, whether breastfed children are more intelligent, whether it was true that ‘if you breastfeed you loose weight better and get your figure back quicker’. One young woman also enquired as to whether it would be possible to start breastfeeding a baby a month after having the baby if up until then the baby had been given formula. ‘Say if you were in the hospital and you had your child and you were at home and you were going our and you were somewhere and you forgot a bottle and you weren’t planning on breastfeeding. Could you just do it there and then like? Like say if the child was on formula for a month and you went out and you had no bottle and the child was going mad for a bottle, could you breastfeed there like?’ (Sarah, student, Youthreach) 40 The media and breastfeeding Students in Youthreach, the Traveller Training Centre and the College of Further Education all related stories about breastfeeding which they had picked up in the media through television programmes and new stories. Some of the stories were the same across all three groups and related to women breastfeeding different babies and not just their own. ‘And is it dangerous for them to be breastfed by some other woman. Did you ever see the way they’re doing that nowadays. They had a programme about that on the telly. It was weird. I think that’s disgusting, I really do. There’d be a sitting room and all these mothers and they’d just swap the child’ (Sarah, student, Youthreach) The stories also related to women expressing breastmilk and selling it. ‘It was mostly based in the States wasn’t it and where women who had had children expressed their milk if they had too much and you could buy it from them and give it to your own’ (Elaine, student, College of Further Education) Someone also discussed that formula had been taken off the shelves in England a few months earlier because of a scare. ‘In England there a while back there was scares with the formula, in May I think it was, it was taken off the shelves. At least with breastfeeding you know what’s going in’ (Mary, student, Traveller Training Centre) Conclusion The groups in which the focus groups took place were quite diverse and hence the discussions were equally diverse. Common themes were however found between some or all of the groups. Participants in different groups were of different ages and backgrounds however all could give their opinion about breastfeeding and could relate either personal stories or those from family, friends or the media. All participants showed an interest in the subject and all were interested in seeing the forum theatre production. 41 Interviews with participants after seeing the play Focus groups and individual interviews were held following the forum theatre performances. Those that had been interviewed previously were again interviewed however unfortunately in some of the groups some or all of those that had been interviewed could not be interviewed again. This was due to them not attending the play or not being available for interview after the play. In addition some people were only interviewed after the play to get their thoughts and opinions on it. Some people were interviewed a few days after seeing the play and others up to five weeks after. Table 4 describes the people that were interviewed after the play and shows those that were part of the original interviews prior to watching the play and those that were only interviewed after watching the play. Table 4 The organisation, sex, occupation, age range and summary of whether interviewee attended interview prior to play Organisation Sex and occupation of Age range participants Youthreach Attended focus group/interview prior to play? Female = 15 ≤ 20 years = 9 Yes (all but one student attended 10 students and five tutors 21-30 years = 3 the second group interview along ≥ 31 years = 3 with two other new students) College of Further Female = 10 ≤ 20 years = 3 Yes (eight students from the first Education All students 21-30 years = 4 group attended the second ≥ 31 years = 3 interview along with two new students) Focus Group 1: Traveller Training Female = 6 Centre All students Missing No Missing No Missing No Focus Group2: Female = 2 Two public health nurses Individual Interview: Female = 1 Public health nurse 42 Table 4 Contd. Organisation Sex and occupation of Age range participants Attended focus group/interview prior to play? Focus Group 1: Male = 2 21-30 years = 1 Two Engineers ≥ 31 years = 1 Yes Focus Group 2: Maternity Hospital Female = 4 ≤ 20 years = 2 One student general nurse 21-30 years = 1 and three student paediatric ≥ 31 years = 1 Yes nurses ≤ 20 years = 1 Individual Interview 1: Female = 1 Yes Student general nurse Missing Individual Interview 2: Female = 1 No Midwife manager Individual Interview 3: Female = 1 Missing Yes 21-30 years = 1 Yes ≥31 years = 1 No Administration staff Individual Interview 4: Female = 1 Maternal care assistant Individual Interview 5: Female = 1 Dietitian Individual Interview 6: Female = 2 ≤ 20 years = 1 Student Dietitians 21-30 years = 1 No On the whole most of those that were interviewed were extremely positive about the play and were very happy to have had the opportunity to see it. Five themes emerged from the semi-structured interviews that sought to determine the participants’ views on the play and also the change, if any, in their attitude and awareness of breastfeeding. 43 The themes which are explained in detail below were as follows: Participants’ views of the play Change in perspective after seeing the play Memorable parts of the play Possible uses for the play Forum theatre as a form of health promotion Participants’ views of the play Words which participants from all groups used to describe the play included ‘fantastic’, ‘brilliant’, ‘enjoyable’, ‘interesting’, ‘very well done’, ‘great way of educating people’ and ‘excellent’. While people generally had a very positive response to the play, their views differed as to their impression of the play and what they liked/disliked about it. Realistic Participants commented on the fact that they felt that the play was very realistic and this surprised some of them as they had expected it to be more idealistic and les typical of what actually happens in real life. ‘It was not what I expected, I was kind of, it seemed to be a bit more kind of on the ground than what I thought. I thought it was going to be, the stories seemed to be a bit more realistic. I was expecting it to be kind of you know like, no waiting times, you know the nurse stops, she spends plenty of time with you, she explains the whole lot, everybody wants to do it as opposed to there being a couple of different stories and I will or I won’t or this woman’s having difficulties or this girl saying oh yeah I’m going to do it anyway. Stuff like that you know. So I thought it was good from the point of view. It was a lot broader than what I was expecting it to be’ (Paul, engineer, Maternity hospital) Other people commented on the fact that the play brought the reality to life more than a leaflet would and this made it more enjoyable to watch. ‘When you’re watching a play it’s like real life because amm it’s just like watching a film there. I know you’d hear about it and you’d see it on a leaflet and all that but it’s not the same thing because when you’re watching a play you kind of like do you know 44 what I mean, you see the girl in the situation and she was there and she didn’t know what to do and all this kind of thing, it looked more like reality, it was very very good now’ (Mary, student, Traveller training centre) ‘I really enjoyed the play. It was very realistic in that you know it was a lot more enjoyable to watch that than to sit and read leaflets and pamphlets on breastfeeding and the different methods and the problems and situations. I thought it was a good portrayal of the benefits and problems associated with breastfeeding’ (Anna, student nurse, Maternity hospital) People also commented on how realistic the hospital was portrayed with the staff being very busy and having little time to spend with mothers. ‘I thought it highlighted the busy-ness in the maternity hospitals where staff haven’t got time to spend with their patients and if patients were given more time at that early stage in the antenatal and more information and more on breastfeeding they certainly would be more focused on it. I thought it was excellent and very well performed’ (Celine, Midwife manager, Maternity hospital) Some people also commented that the play showed two worlds, that of someone who wasn’t at all sure whether she wanted to breastfeed and that of someone who really wanted to breastfeed. ‘You got the best of both you know like from a person who was definitely definitely going to breastfeed to a person who was saying ah sure my mum said she would help me do the night feeds, where it was straight away ahh do bottles’ (Michelle, care assistant, Maternity hospital) Enjoyable and funny Other people commented on the fact that the play brought the reality to life more than a leaflet would and this made it more enjoyable to watch. ‘it was funny, it was entertaining, the message was put out there you know, everyone obviously really put their heart and soul into it and that came across’ (John, engineer, Maternity hospital) ‘Because there is a humour factor in it as well it’s kind of open to all ages in that like if 45 you put a 20 year old mother in there and a 40 year old mother because the humour is in it, it would keep your interest’ (Susie, student nurse, Maternity hospital) Other respondents simply explained that they enjoyed it. They did not elaborate so much as can be seen in the following dialogue between the interviewer and a student from Youthreach. ‘I just liked all of it And anything in particular that you thought was well done? The start of it…It grabbed your attention, I just liked all of it’ And also in the following dialogue between the interviewer and three traveller women. ‘What did the rest of you think? It was very good It was interesting Did you enjoy it? It was very good’ Literacy friendly Some participants that have worked with disadvantaged groups commented on the fact that the play was literacy friendly. ‘I thought it was a great way of educating people or young mothers, particularly those who would be coming from disadvantaged areas who mightn’t have literacy skills and I think it’s a great method because basically many of these people aren’t able to read leaflets or interpret them’ (Jenny, dietitian, Maternity hospital) Promotes awareness about breastfeeding While in general participants felt that the play would not change people’s minds as to whether they would breastfeed or not it was felt that the play would create a general awareness around breastfeeding which was felt to be very positive in the promotion of breastfeeding. ‘Now it didn’t sway me one way or the other, it didn’t sway me because I think, I suppose most people going into that beforehand will kind of know what the plan is you know. I am going to breastfeed but at the same time it didn’t sway me more to it or less to it’ (Helen, administration staff, Maternity hospital) 46 ‘I think in that play I would have come out more with an awareness because it’s not like you are saying or it’s not like the whole drama was saying, these are the benefits of breastfeeding, you’re going to get a flatter stomach and you’re going to lose weight more quickly and your baby’s going to have better health and it’s not like you’re pulling out the statistics. I think it was more just a general breastfeeding awareness’ (Sophie, student nurse, Maternity hospital) This awareness was demonstrated by the fact that one of the traveller women described how she had gone home and told her daughter about the play hence encouraging a discussion about breastfeeding between them. ‘I was just explaining to my daughters and all that. They probably wouldn’t still breastfeed but I was just explaining about how good the play was and everything. And how confused the girl was like, she didn’t know what to do, do you know like, no more than meself now’ (Mary, student, Traveller Training Centre) Some of the participants in the hospital also discussed how the play had made them aware or could make other staff aware of how women are treated in the hospital and also what can happen to them in their normal everyday lives. ‘I think also for the staff it made the midwives more aware of like I think they could see themselves an off time throwing a few leaflets and saying like here it is I’m in too much of a rush. I think it might make them stop and wait and be like ok she’s only 20, she’s a new mother, she does not know what this is and it would be scarey to think of latching a child onto your boob and expect them to feed off it’ (Paula, student nurse, Maternity hospital) ‘I thought that was really strange that you know even her husband wasn’t supporting her decision to breastfeed. It was just a whole load of issues that you know, I suppose I had never kind of thought about before. It certainly kind of made me think oh yeah I guess there are other things out there’ (Shauna, student nurse, Maternity hospital) 47 Audience participation Many people commented on the how they enjoyed that fact that the audience had to participate in the play. ‘I liked the bit where the audience participation, I loved that. I thought that worked really well. I didn’t think it was going to work as well when it started I though Oh God and then it worked really well and you know there were naturals in the audience and it was different every time and it was really really good’ (Sarah, Public health nurse, Traveller Training Centre) Others liked that the audience could participate because it gave them opportunity to give their own opinion. ‘Did you think the interventions done afterwards was good? Yeah that was good because you could give your own opinion’ (Susan, student, Youthreach) In addition one respondent commented on the fact that because the audience was involved it gave them the opportunity to see everyone’s point of view which was more enlightening. ‘That shows like everybody’s, the whole interaction shows everybody’s point of view rather than just the writer of the play so you get everybody’s perspective of it which you wouldn’t do if there wasn’t the interaction at the end’ (Anna, student nurse, Maternity hospital) Another student nurse explained how she felt that the interaction with the audience whereby they had to change scenes and make them as they would like to see them, was empowering and enabled self reflection as to what she herself could do to improve things. ‘The idea of having to think about the play in different ways certainly made me think about the situations in different ways as well because if you were served these situations on a platter and were told this is the way it is and you’re kind of thinking oh ok that’s the way it is and then you’re kind of because we were made to intervene and interact and change things oh here’s the bigger picture, I can actually do something, I can help and it certainly made me look at who I can possibly influence in the picture and who I can help from my own knowledge’ (Shauna, student nurse, Maternity hospital) 48 Criticisms Most of the respondents felt that the play was balanced with regards to its portrayal of bottle and breast feeding. It was not felt that the young woman in the play who was unsure as to whether she would breastfeed was victimised. ‘I didn’t feel like it was against bottle feeding, like no-body actually felt oh my God you’re not breastfeeding’ (Susan, student, College of Further Education) Another respondent explained that she felt the play highlighted the issues that breastfeeding mothers can face and that these would be different to a bottle feeding woman and so naturally that play was more about breastfeeding. ‘when it comes to breastfeeding you do come up against issues about trying to feed here and there and it’s a lot harder to breastfeed than it is to bottle feed and I just think that you know breastfeeding mothers have a lot of problems that need to be addressed and that’s what the forum was doing’ (Shauna, student nurse, Maternity hospital) One respondent felt, however, that the breastfeeding was pushed too much in the play. ‘I personally felt that breastfeeding was being pushed down her throat. I think that, I felt that it wasn’t being very objective, to me I felt it was very much, it’s breastfeeding and nothing else and really I don’t think that’s correct’ (Jenny, dietitian, Maternity hospital) Respondents from some groups commented that they would have liked the father of Lizzie’s baby to have had a part. In the play there had been no mention about the father and they would have liked to have known what had happened. ‘I thought there was no part for the father in the play. He was never really mentioned, so where did this baby come out of. There should have been something, either he dropped her or he didn’t want to be a father or there should have been some little thing there’ (Katherine, public health nurse, Traveller Training Centre) ‘Did she have a fella in it? I thought he should have been there’ (Katherine, student, Traveller Training Centre) It was also felt that if the father had been in the play his role could have been highlighted. ‘and had maybe the dad as well saying, will you express for me cause I’m bringing the 49 baby to the park, cause he’s not involved in it at all so that’s kind of saying it is all about just the mother, you know so there’s not even one thing about the dad, it’s about the baby and herself’ (Michelle, care assistant, Maternity hospital) Change in perspective after seeing the play Having watched the play it was interesting to see how some participants were much more communicative in the group discussions. This was particularly obvious in the Youthreach group where participants had been initially hesitant to talk but after seeing the play they spoke more openly and freely. This change was commented on by one of the tutors in the group and was in reference to a story that one of the students had told about being in a maternity hospital a few days before and a woman in the unit wanting the father of another baby to wait outside while she breastfed her baby. The student had told the story in detail and had said that all the woman had to do was cover herself as nothing would be seen. ‘I think it’s interesting how you have actually changed. Like think about the last time you were scarlet and wouldn’t answer anything and you’re just after saying all she had to do was put a thing over her and before you were saying oh no it’s too embarrassing’ (Lisa, tutor, Youthreach) Respondents also discussed on how they had talked to friends and family about the play. This had encouraged discussion about breastfeeding. One traveller woman said that she would not normally have talked to her daughter about the subject because she hadn’t breastfed herself. This woman also explained that the traveller tradition is very strong and so it would be hard for the play alone to change that however she said that the play would teach people about breastfeeding. ‘You see travellers have a different kind of tradition they don’t, they don’t really breastfeed, they find that disgusting, they wouldn’t really do that but like you would learn a lot from it (the play)’ (Mary, student, Traveller Training Centre) A lot of people felt that the play had raised awareness about breastfeeding and this was in regards to helping people be more accepting of it, being more prepared in the future if they ever had a baby themselves, knowing that the law protects a woman from discrimination if she is breastfeeding in public and also giving an awareness of various issues that breastfeeding women can come up against. ‘I think that it made us more publicly aware of somebody that is breastfeeding and to 50 be not so closed and you know ………………. or if you were with someone that did have a problem you’d say listen, it’s only, if you were going out and the person you were with said, God, will you look at your one, you’d be kind of like what are you saying she’s only feeding the baby’ (Susan, student, College of Further Education) ‘I was just going to say you might be more prepared for the situation, like you know you mightn’t realise. I suppose when you’re going into hospital to have a baby you’re just thinking about the baby and you’re not really thinking about afterwards but like if you saw that before hand you know you might be thinking in your head oh maybe I will have to push for information or push for help’ (Kathy, student, College of Further Education) ‘I think it made us very aware of the issues around breastfeeding and I think if you were in a café now you’d be more tolerant. I suppose people would be inclined to have a snigger or talk about it even look at her over there, now I think you’d have a better approach to seeing someone in public doing it’ (Kathleen, tutor, Youthreach) One student nurse, who was very supportive of breastfeeding in the first interview, described how she felt that the play had helped her understand why a woman might give up breastfeeding and she felt that this understanding would enable her to better do her job. ‘I can kind of understand women better now why women give up breastfeeding. So I think you know in that sense because I understand it better I can help the people not to do it now if a situation arose. It was positive for me and I certainly would be more probreastfeeding, well I don’t think I could be more pro-breastfeeding but I’m still probreastfeeding’ (Shauna, student nurse, Maternity hospital) One of the young women in Youthreach, who in the first interview had been unsure as to whether she thought it was ok for a woman to breastfeed in public, had no issue with it at all having seen the play. In response to whether she would care if a woman was feeding in public she said ‘It wouldn’t bother me but I just wouldn’t do it meself like’. This would indicate a change in attitude but also shows that breastfeeding was not something that she would consider herself. This was the case with a lot of respondents. While the play certainly raised awareness and more tolerance towards breastfeeding it didn’t change people’s minds as to whether they would breastfeed themselves. 51 Having seen the play, however, this woman did acknowledge that if she had wanted to breastfeed she could have gotten the support. She had not mentioned this in the first interview and it would indicate that the play had created an awareness that support is available and that it is only a matter of seeking it out. ‘Some of us have kids and we had the option but we just didn’t want to do it like. But we could have done it like and we could have got support but we just didn’t want to’ (Sharon, student, Youthreach) Finally it was felt by one student nurse that the play did make midwives more aware of how women are sometimes treated in hospital and how a little support can really help them. ‘It did reach out to the midwives because I remember going up on the ward the next day and they were discussing it about the whole play and about how the midwives were portrayed in it and how they hand out the leaflets and they were like from their point of view but we don’t have the time and we’re always rushing, you can’t just pick someone out and give them their individual time. They were discussing it and they could see as well, they felt they were portrayed very badly and stuff like that so it definitely did register with them, maybe God like if I do have an extra two seconds just to help this woman or look for the dad or their partner just to inform them and just be like first time, God she really doesn’t know, you know if there, like they had a patient on the ward and she was just about to give up on breastfeeding because the baby wasn’t latching on or whatever like maybe if they gave them that extra minute and said it is latching on, that reassurance (Paula, student nurse, Maternity hospital) Memorable parts of the play Participants could remember the different scenes from the play up to five weeks after the play. They could explain them in detail along with the changes that the audience had made to the play. ‘The initial part of it when she, the young girl arrived in and like seeing the trauma on her face and then the nurse barging in and shouting wanting the urine samples. I think that probably had the most dramatic effect on me. I thought that was absolutely excellent because probably I have worked in hospital and I would appreciate that that is exactly what goes on’ (Jenny, dietitian, Maternity hospital) 52 ‘I think in the coffee shop when the baby was going to breastfeed and the two young ones were kind of going ohh look at that, look at that, you know their attitude and then the woman saying look, it’s not reasonable for you to do it and she goes, what I’m just feeding my baby, you know but yeah she was dong the right thing for the baby but others didn’t see it that way’ (Michelle, care assistant, Maternity hospital) ‘Well I think what I really found was that I hadn’t realised the social side of things. Like I remember doing in class the advantages and disadvantages but I hadn’t realised about say the situation in the café that people would be asked to leave and in hospital like that the staff are too busy to give out information. I hadn’t realised that kind of side of it’ (Maeve, College of Further Education) ‘And you could feel the apprehension and the fear, you could nearly feel it, you could palpate it and you could kind of go oh yeah I’ve been there, I’ve been in a waiting room before and everyone can sort of empathise with that. You’re so nervous and you’re afraid and normally you’d be very outspoken and be able to ask but when you go into a crowded waiting room and someone is really busy, it is that initial thing like oh can I have a little bit of help or I was just wondering about breastfeeding’ (Sarah, public health nurse, Traveller Training Centre) ‘And the part where she went to the disco as well, you know the first scene they done where she went to the disco. She was trying to tell her friends about she can’t drink or anything and that she was pregnant and all this, but they couldn’t hear her, the music was too loud’ (Mary, student, Traveller Training Centre) ‘I think that was actually the best scene out of them all because you could see the ould one whereas she should have been used to people doing that and she probably done it herself, do you know what I mean. That one and the disco part I thought’ (Sharon, student, Youthreach) Drama as a medium for health promotion Those interviewed enjoyed the fact that the play differed from normal health promotion in that it was visual and interactive and kept their attention. Many commented on the fact that it was better to 53 watch the play than read a leaflet. Two students from Youthreach said that ‘I think it’s nicer to have it more as a sketch than having a leaflet. I think it grabs your attention more. Yeah, you took more note of it. Whereas if it was on a piece of paper we probably wouldn’t even bother looking at it’ ‘I think of only myself this very day like how many leaflets were shoved in my door yesterday and today like I put it into the recycling bin. I didn’t even read any of them I just half scanned them at the top so like literature and leaflets there is an awful lot of money wasted and I think that you can do much better things with money, even if it’s only a small amount I think you can spend it in better ways’ (Jenny, dietitian, Maternity hospital) ‘Most people won’t read pamphlets, they don’t really care. It was a really neat way of presenting something and I think it will, if your purpose is to increase awareness with that I think that you definitely hit that’ (Paula, student dietitian, Maternity hospital) One of the tutors in Youthreach really liked the idea of forum theatre and drama to present issues around health promotion, after seeing the play, and asked if there were any more HSE promotions like that as she felt it was a very good way of getting through to people. Possible uses for the play People in all of the interviews made suggestions as to how the play could be used in the future. Many felt that it should be shown to women antenatally and that this would give them an insight into issues around breastfeeding. One woman who was herself pregnant at the time of the interview reflected on the antenatal classes that she had been to and could see a real use for the play in the class. She felt that the play gave an awareness of breastfeeding but did not put pressure on women that it was the only option available to them. ‘I suppose it would be a nice thing at an antenatal class I think. Just to have something a bit different and it still is informative. You know and it’s not in your face, it’s easy going. It’s not pressure that you know you have to breastfeed. You’re more aware of doing it but it wasn’t pressure like this is the thing to do and you have to do it you know 54 it’s very easy going and it wasn’t pressure’ (Helen, administration staff, Maternity hospital) One woman who had a baby felt that the play could also be shown to new mothers in hospital. She felt that it would give women more of an idea about breastfeeding. ‘Do you know when they show you how to bath the baby and then have a little session on, they should put on something like that show in the hospital before you make up your mind about what you want to do. Just to give you more of an idea like, if you wanted to do it you could try it and if you don’t like it, do you know what I mean’ (Sharon, student, Youthreach) Other people felt that it would be important to show the play in schools so that young people would get exposure to breastfeeding and would start thinking about it. Some people felt that it might suit the new Social, Personal and Health Education module in secondary schools. One traveller woman discussed how travellers sometimes get married young and so they should be shown the play, especially because their own mothers would not be able to educate them about breastfeeding as they would not have breastfed themselves. ‘You know the age 14-16 even going around to schools there that’s when they should tell people about things like that because at least they’d have more experience if they did start their families. Especially the traveller generation, they get to marry very very young so they’d be well educated for things like that. And they’d make that decision like do they want to do this or not. Because their mothers don’t know because they weren’t taught by their mothers so they don’t know themselves’ (Mary, student, Traveller Training Centre) 55 Findings from the project team Views from the actors Interviews were conducted with all of the actors in the play. All interviews were conducted individually except for one where two of the actors were interviewed together. The interviews were face-to-face except for one which was conducted over the phone. Experience of the forum theatre production The actors all described their experience of the forum theatre production as being extremely positive. They enjoyed the process of developing the original stories into a play and felt great satisfaction with performing the play and getting positive feedback from the audience. Some of the actors spoke of the positive effect being involved in the play had on their own self development and confidence. They also described how they had learned a lot both about forum theatre and breastfeeding. ‘It was very rewarding to put this issue out there and get positive feedback from people on it’ (Actor 2) ‘It was a really good experience, very good for my own personal development. I thought it was brilliant’ (Actor 5) Even the actors who were breastfeeding mothers felt that they had learned additional things about the subject. ‘I learned lots, I have to say. I breastfed before and I still learned even more stuff that I didn’t know even then and I met so many people and their different stories. I learned lots of new things, all the groups the different things that came up that I had never thought about breastfeeding before’ (Actor 1) Three of the actors were on maternity leave throughout the workshops and the performances of the play. They enjoyed the fact that they were involved in something creative and productive throughout this time yet their babies remained with them throughout the rehearsals. In addition they felt that they were doing something that might make a difference and this was rewarding. 56 ‘so through this project we weren’t just stuck at home with the baby we were actually doing something that might make a difference and I felt from the feedback from the groups, it was so good from the whole concept of forum theatre or theatre of the oppressed, that the audience participation was so brilliant, to get that feedback, you could see it already, I didn’t have that many scenes so it was my pleasure to watch the audience and just see the heads nodding and the recognition in peoples’ faces so much yes been there done that so much’ (Actor 3) ‘when you are on maternity leave you’re doing your bit and all this stuff but to do something really different that you wouldn’t normally get to do, I loved it and it gave me a real boost as well to be part of it all’ (Actor 1) Some of the actors also felt a real sense of involvement in the play and this added to their enjoyment of the whole process. They appreciated being involved in the different aspects of the production. ‘I was very happy to be part of it and I felt really involved with all of it and even when Margaret and Sarah came down to talk about it, they’d be asking us what we thought, you know that kind of way, you weren’t just the actors in a play, you were involved in how it was developing and Marie was talking about where we were going to take it and who would be seeing it, you know that kind of way’ (Actor 1) The actors also felt supported by those that commissioned the play and appreciated how positive they remained throughout the whole process of the plays development. ‘They were so happy about the whole thing. I mean if they had turned around at any stage and said oh I don’t know if this is going to go down very well I probably would have gotten even more scared and just you know, it was a scary thing because you never knew how it was going to turn out. They definitely helped to keep the enthusiasm going’ (Actor 2) Involvement in the play One of the actors explained her reason for getting involved in the project originally and this stemmed from her own experience when breastfeeding her daughter of peoples attitudes and her wanting to try and change the negative attitude that some people had. ‘I think the reason I did it in the first place was because of the prejudices that I 57 witnessed myself in my own experience with feeding my baby that I knew I wasn’t going to be able to change certain people but if I could change another thousand people around them around the people I couldn’t change then it might start having an impact so I suppose out of a negative experience came a very positive experience’ (Actor 5) Some of the scenes that were played out in the play has also been experienced by the actors in their own lives and so in acting out these scenes one of the actors described how she could let out her own frustration with something that had happened to her. ‘We definitely played characters that we would be used to, I mean the Granny for instance, that happened to me, that was so, I could just let out all my frustration. That was great you know and that’s what like I could really express myself through drama’ (Actor 3) Involvement in the play was voluntary and one of the actors explained how it was her interest in the subject that initially grabbed her interest in the play. She did not care about the voluntary aspect of being involved in the play but did find that near the end where rehearsal times were a longer there was more difficulty with organising her kids etc. ‘Well for me personally it was a topic I am really interested in, something I’m very supportive of and that’s obviously what got my interest sparked and I mean I was happy to do it voluntary and I quite enjoyed it and personally for me I learned lots and lots of new stuff about drama and facilitating groups and stuff and you know it personally brought me out a lot. I didn’t think I’d be doing any acting in a play or anything. I wouldn’t have had that confidence. Whereas suddenly you’re in that and you’re doing it and it was great fun’ (Actor 1) One of the actors felt that ideally he would have gotten paid for the work but could recognise too that he had had got other benefits out of being a part of the play. These benefits included learning about forum theatre and the different uses for drama such as in health promotion and also he had the opportunity to learn about breastfeeding and have exposure to it. While another of the actors felt that more people would have been interested in taking part in the play if they had been paid, she also commented on how she liked the aspect of involvement in the play not being about money at all. ‘I’d say she would have had more people if we were paid. But I liked the way this wasn’t about money at all’ (Actor 3) 58 The process of developing the play Many of the actors described the importance of having trust in the whole process of the play’s development and also in the drama facilitator. They praised the drama facilitator for the ease with which she got them to develop the play without them really realizing that was what they were doing. All of what the actors did in the workshops built up to the final play being written and performed but it was a process whereby the play slowly evolved into what would become ‘Milk It! Much ado about Nothing?’ ‘One thing was you know it was having trust in the whole evolving, the whole process and what we come up with and then bringing it to an outside audience was really scary cause I didn’t know how they were going to react and then it was keeping that trust and then as well’ (Actor 2) ‘when I think back to some of the drama games that she (the drama facilitator) did even like the power plays and the tables thrown up on top of chairs and all the different things over the weeks it was amazing to actually draw back on them when we were actually doing the play and she was talking about your character and stuff like that and you know because some weeks we were doing all sorts of mad stuff that didn’t seem to relate to what we were doing but it was amazing that she knew, she had her way that she was working with us and bringing us through different things you know and some weeks we were doing different drama exercises and like we did a lot of power play, power struggles and stuff like that and it was amazing then thinking back on all those weeks as it was building’ (Actor 1) The different performances The actors commented on how different each of the performances were because the audiences were so diverse. One of the actors mentioned how she had wondered if the audience would be able to relate to things in the play and was happy that they could all relate to things on different levels. ‘Different people saw different things in this play which was good but we are only a certain group and to kind of have reached people on many different levels was good you know’ (Actor 3) Some of the actors were surprised how receptive and interested each audience was and commented on how there is a lot of work that could be done with people on the topic of breastfeeding. 59 ‘I was surprised that the people were so receptive, especially the younger people. They were so interested and so receptive. I would see that there’s a huge amount of work that could be done’ (Actor 6) One of the actors commented on how they had made every effort while writing the script during the rehearsals to ensure that they were balanced in the message of the play and did not want women in the audience to feel guilty if they had not breastfed their child. Some of the actors felt that this balance was reached better in some of the performances than in others and that it seemed to depend on the audience. ‘we talked about it an awful lot when we were doing the rehearsals and stuff to hit the right notes with everybody, I mean obviously breastfeeding was the aim of the play and information and stuff like that but to hit the right notes, we battled a lot with hitting the right notes with women who found it difficult or women who didn’t like it ……………….I felt we really got it across really well with Youthreach and the travellers and stuff. I just felt the balance was really good. I just felt the Thursday we got kind of caught up in breastfeeding’ (Actor 1) The actors commented on the use of forum theatre and the potential use for the play in the future. They felt that forum theatre is a brilliant way of stimulating debate and getting a message across in a way that people will remember it. Some of the actors felt that the play should be performed with young people and also women in the antenatal period. One of the actors said how much she would like to see it performed in hospitals on wards. ‘I think it’s a brilliant way to stimulate debate and actually get everything across in a way that you know that people will retain a certain amount of information’ (Actor 5) ‘I think to do a few hospitals around the country, I’d like that. I think that’s really worth and then if they have a question sure all the midwives are there to ask, you know’ (Actor 3) ‘Young people I suppose, could you show it at antenatal classes, I don’t know. At an antenatal class and if you had a tool to show how things could be changed. If they’re prepared properly it works much better. They are more armoured themselves when it happens’ (Actor 6) 60 Views from the project managers and the drama facilitator An interview was conducted with the two project managers and the drama facilitator. The interview focused on all aspects of the project and issues that had arisen throughout the project. These are discussed below. The two project managers were very happy with the project and with the content and delivery of the play. They congratulated the drama facilitator for her work in developing and producing the play. They also praised the commitment and work of the actors, especially the three women who were breastfeeding their children and had a real interest in the play. ‘it covered a lot of ground and a lot of journey through that decision making process so I think anybody at any stage could have related to something within that’ (Project manager 1) ‘Well done Marie because I felt it did hit home and I thought it was real and there were some excellent scenes in it’ (Project manager 1) The project was quite novel and the project managers highlighted the fact that a risk had been taken in developing and performing the play as the promotion of breastfeeding had never been done in such a way before. ‘I think it was a very novel way of trying to engage well the younger people which is what we really wanted to engage’ (Project manager 2) ‘people took a risk, and I think that’s important …………because we are so traditional, we are so black and white in so many ways that to be able to give something a shot in this climate and to reflect and evaluate it is a very big thing’ (Project manager 1) The drama facilitator also commented on her satisfaction with the play and with how it had gotten diverse responses from the different audiences. ‘I think we got a good cross section in the way of responses to the play. I think the play was great, dare I say it myself, I think with the material that we had, with the people that we had, with the time that we had, I think it turned out to be a very good product, given those elements’ (Drama facilitator) 61 The drama facilitator also acknowledged how supportive the two project managers were throughout the whole process and appreciated the ease of communication between them. ‘I found it really very easy to communicate with you and that made my work much easier because I knew that you were there, I knew that you were saying yes, carry on and you just believed in it and it helped a lot’ (Drama facilitator) The drama facilitator discussed how exciting it was when the play was being developed from the initial stories that were collected into the final end product, ‘Milk it! Much ado about nothing?’. ‘The development into a play was exciting, I mean it really was a very exciting process to have these stories from groups of people from the health centres to develop that through the process and the people and the workshops and the rehearsals into an actual play was very exciting and it was very energising and motivating ultimately’ (Drama facilitator) During the interviews with the actors some of them had mentioned how they had had to trust the process of the plays development and the drama facilitator to actually produce the play as a real piece of theatre. The importance of trusting the process was also discussed by the drama facilitator. ‘I knew it was going to be a play it’s just getting then that trust you know to say yes, look this is going to be a play, it looks all over the place right now but it is going to be a play because we know where we are going’ (Drama facilitator) Issues that arose throughout the project The forum theatre production was a pilot project and so provided a huge learning experience for all involved. A few difficulties arose throughout the process and these concerned personnel issues, budgeting issues, communication and role definitions. Ownership of the play was also an issue that arose and clarity around the fact that the play was a HSE project needed to be defined on a few occasions. These issues were all part of the learning gleaned during the process and were valuable lessons for any future projects. It was felt that in the future, communication could be improved upon by having regular face-to-face meetings with all stakeholders which would allow for open communication and the ironing out of any difficulties. ‘I think what would have been good is to have had what I would call production meetings, this is completely in hindsight where we would all get together and have a 62 production meeting, you know to talk about stuff that we need to as they come up so that they don’t escalate’ (Drama facilitator) Liberties were also taken in some performances with people recording the performance with out having been given permission. In the future this should be taken into consideration and an announcement could be made prior to the performance asking people not to record the play. Project managers along with some of the actors commented on how one of the performances had gotten ‘stuck’ when the audience were invited to change the play as they had concentrated on one scene three different times. This is not in itself an issue in forum theatre, and from the evaluation it would seem that it did not affect the message that the audience took from it. It was thought, however, that in any future performances the drama facilitator should know the audience so that she could understand better the point of view of where they are coming from. Views of Blue Drum Blue Drum is a specialist support agency working with the community development sector in Ireland, particularly Family Resource Centres and other community groups. The Agency works in the area of Arts Based Community Development (ABCD), addressing issues of access to arts and cultural provision. Blue Drum was commissioned by the HSE to support the drama facilitator in her work and also to liaise with community organisations that may be potential audiences for the play. An interview was held with a member of staff in Blue Drum and she described her opinion of the production, her experience in engaging groups in watching the play and in supporting the drama facilitator and also how she feels the play could be used in the future. She was very positive in her response to the play and in how it was real to what happens with women before and after having a baby. ‘I thought it was great. I thought it was really great. It was humorous, it captured three or four key scenarios or key situations that you would find or that you would experience as a breastfeeding mum and then in the whole choice leading up to it. I think they captured the different types of scenarios well or the different types of places that women may be in and then the different experiences that they had when they’re trying or when they’re not trying. I thought it was very good’ (Blue Drum) 63 ‘I thought it struck all the right cords and I thought it was light enough and yet it got the message across very powerfully and I thought the humour you know it was a good mix of humour and getting the message across. You know what I mean, it wasn’t self righteous and it didn’t move the points in the humour, I thought it got the balance really well’ (Blue Drum) There was no difficulty in engaging community groups in participating in the project and for the most part people were very open and interested in hearing about the project and in watching the play. ‘When I called the youth officer in the VEC she was like oh we could do it here we could do it there. Send me the information, I’ll send it out everywhere’ (Blue Drum) It was felt that Blue Drum played an important role in supporting the drama facilitator because she could bounce off ideas and share any worries and apprehensions regarding the production of the play. In addition it was felt that it was important to maintain regular communication between the drama facilitator and Blue Drum to ensure that they were kept up-to-date with what was happening. Blue Drum could see huge potential for the drama amongst community groups and felt that they could play an important role in engaging community groups for any further productions. The importance of the interventions that members of the audience put in place during the play being documented was also highlighted in the interview as it was felt some interventions could be taken on board by the breastfeeding steering committee or other organisations that could make a difference. Views of the members of the Breastfeeding Steering Committee Three members of the breastfeeding steering committee attended one or more of the performances. Individual interviews were conducted with them and their views were divided into themes. Opinion of the play All three members of the group commented very positively about the play. ‘I was very impressed. I was pleasantly surprised’ (Committee member 3) ‘I just thought it was very well dramatised, very imaginative and yet the message was very accurate from a breastfeeding perspective and it got across in a unique way, you 64 know, I’ve seen so much education on breastfeeding that it was just a unique way and it was done very much in a good learning way’ (Committee member 2) They discussed how the play differed from normal health promotion in that it differed from the usual booklets and leaflets that are given out and also it involved the audience having to reflect on their own opinion and attitude to breastfeeding as well as having to consider what could be done to change the situation. ‘I think that probably does make people think about their own attitude, society’s attitude and what we can change, you know the power we have, which is what Marie was saying, you know it’s the underdog and what can you do to change your situation or to make it work for you. This is where you’re at and this is what you’re up against. How can you make it work for you, which is a powerful message’ (Committee member 3) ‘I think all the money in the health board seems to be spent on producing booklets about every single aspect of everything, who’s reading them. So this is totally different. It is much more labour intensive and not cost effective but it’s very empowering and it’s very inclusive and it’s and it allows people to participate. It’s a wonderful exercise actually’ (Committee member 1) One of the interviewees commented on how the play was different yet it had a very strong message. ‘That drama was a little bit different from the staffs’ normal day or from my normal day and fun but yet it had a very strong message, very effective message so, but sometimes I think it’s the little things that can achieve more’ (Committee member 2) Organisation and uses for the play The two project managers were praised for their work with the project and for getting funding, involving a range of people in the project and for availing of an opportunity to have the project evaluated. It was felt that the play could be used with many different groups such as youth groups, secondary schools, hospital staff and in antenatal clinics. ‘like get into things like Youthreach and schools, secondary schools maybe just where you’d have a little bit of, they’re young enough not to have formed too strong an 65 opinion, or maybe they have an opinion but they’re willing to change, they’re open to it’ (Committee member 3) ‘It might have a place in schools of midwifery and in medical schools where junior doctors and young midwives could explore some of their unconscious or preconceived ideas’ (Committee member 1) ‘I’d love it in secondary schools, I’d love it in any outreach groups that are open to it, there could be many groups that could actually benefit from it, but certainly people before they’ve made up their minds, that they have, so teenagers when they’re open to the discussion and yet haven’t made up their minds into fixed ideas. However people with fixed ideas could also explore where they’re getting them from’ (Committee member 1) ‘I’d love to see it going into all transition year and secondary schools, third level colleges, even maybe national schools, it would probably be lost in some of the national schools but I think ummm and of course then any antenatals, you know the doctors could use it if they were doing antenatal clinics and that. Anywhere and everywhere’ (Committee member 2) 66 DISCUSSION ________________________________________________________________________________ The aim of this project was to engage young people in discussion and debate about breastfeeding, to promote breastfeeding as the norm rather than the exception and to allow participants develop solutions to identified barriers to breastfeeding, through forum theatre. The aim of the evaluation was to assess these outcomes and also to determine the experience and attitude of the project team in developing the forum theatre production. This project was quite novel in so far as it aimed to get people discussing and debating breastfeeding through the use of drama. It also presented breastfeeding in many different guises and so did not only present the benefits of breastfeeding, as is sometimes typical of health promotion, but also presented the stories of real women who had experienced both breastfeeding and bottle feeding, hence drawing a more realistic picture that the audience could connect with and believe in. Because the play was presented in the form of forum theatre the audience had the opportunity to change scenes in the play and to discuss and debate the different issues that arose. This resulted in what has been described as the transformation of the audience from passive spectators to engaged spectactors (Sullivan et al., 2008). This transformation is empowering because the audience takes control of what happens in the play and this in turn creates an awareness of issues and can also provide the opportunity for a ‘rehearsal for reality’ as described by Boal (Boal, 2004). This play was performed in front of four diverse groups, those in a youth training centre, a traveller training centre, a college of further education and a maternity hospital. Although each group was different from the other, each audience engaged well with the play and the concept of forum theatre, all getting involved in the intervention part of the play. The response to the play was very positive with nearly all of those that responded to the postcard survey saying that they enjoyed the play and agreeing that the play was a good way of discussing breastfeeding. In addition almost eighty percent of the audience felt that the play was relevant to them. The comments regarding what respondents felt was the main message of the play were all related to social aspects of breastfeeding, such as challenging attitudes to breastfeeding and cultural norms and highlighting the obstacles that exist around breastfeeding. It is important that such social aspects of breastfeeding are recognised because the social environment has been acknowledged as a crucial target of a comprehensive policy for breastfeeding promotion (Department of Health and Children, 2005). Societal embarrassment and perceived social isolation have been identified as barriers to breastfeeding (Stewart-Knox et al., 67 2003). Greene et al., (2003) acknowledge how ‘breastfeeding is a social decision and not just a nutritional one’. A play such as ‘Milk it! Much ado about nothing?’ can bring these social aspects to the fore and this allows for people to appreciate this aspect of breastfeeding and in turn become more accepting of it. The play achieved its aim of getting people discussing and debating breastfeeding and this was the case for all groups. Due to the play being ‘literacy friendly’ and the story being easy to relate to there was certain universality about it with people from all ages and professions being able to relate to something in the play. Many interviewees felt that there were different ways in which the play could be used in the future. These included it being used in schools with teenagers, in antenatal classes and in hospitals after a woman has had a baby. This evaluation also shows that the play got health professionals in the maternity hospital discussing and reflecting on their practice around breastfeeding. There is therefore a potential for using the play amongst this group to create a greater awareness of breastfeeding and the culture within which they are promoting it. Using forum theatre to promote breastfeeding is quite novel and as already mentioned different to usual health promotion. People in this study discussed how they are tired of being given leaflets on different topics and so appreciated the originality of the play. It would seem then that there is great potential for its use in various settings. In addition to the play being received positively by the audiences, those involved in the management and production of the play also had a positive experience. Some of the actors discussed how they had gained in their own personal development as a result of participating in the play. On the production side of this play there was collaboration between the HSE, the drama facilitator and Blue Drum. As the play was a pilot project it provided a learning experience for all involved. A lack of communication between the different parties involved in the production of the play was an issue that arose and it was felt that regular face-to-face meetings would have helped to reconcile any difficulties or differences. Such issues in communication are not unusual in projects such as this (Orme et al., 2006). Overall, however, the collaboration was successful in that the end product, the play, was commended by all. 68 Conclusion This play was a pilot project and as such the evaluation provided a preliminary analysis of the use of forum theatre in the promotion of breastfeeding. The play proved to be a useful tool to create awareness around breastfeeding in a ‘literacy friendly’ way. Although the play was performed in front of four diverse groups, each audience engaged well with the play. Feedback was very positive and the play can only be built upon for future use in the promotion of breastfeeding to a diversity of subgroups in the population. 69 REFERENCES ________________________________________________________________________________ Arenz S, Ruckerl R, Koletzko B & von Kries R (2004) Breast-feeding and childhood obesity--a systematic review. Int J Obes Relat Metab Disord 28, 1247-1256. Boal A (2004) Games for Actors and Non-Actors. pp xxiv. Trans. by A Jackson. London: Routledge. Camillin J (2006) An Evaluation of a Forum Theatre Performance tackling Community Cohesion issues in schools. Transparent Theatre. http://www.bristol-cyps.org.uk/services/pdf/eit-48-StreetsEvaluation.pdf (accessed August 18th 2008) Danforth KN, Tworoger SS, Hecht JL, Rosner BA, Colditz GA & Hankinson SE (2007) Breastfeeding and risk of ovarian cancer in two prospective cohorts. Cancer Causes Contol 18, 517523. Department of Health and Children (2005) Breastfeeding in Ireland - A Five Year Strategic Action Plan. Department of Health and Children: Dublin. Department of Health and Children (2008) Perinatal Statistics Report. Health Research and Information Division. Economic and Social Research Institute. Dewey KG, Heinig MJ & Nommsen-Rivers LA (1995) Differences in morbidity between breast-fed and formula-fed infants. J Pediatr 126, 696-702. Fewtrell M (2004) The long-term benefits of having been breast-fed. Current Paediatrics 14, 97103. Greene J, Stewart-Knox B, Wright M (2003) Feeding Preferences and Attitudes to Breastfeeding and Its Promotion Among Teenagers in Northern Ireland. J Hum Lact 19, 57-65. 70 Howie PW, Forsyth JS, Ogston SA, Clark A & Florey CD (1990) Protective effect of breast feeding against infection. BMJ 300, 11-16. Kac G, Benicio MH, Valesquez-Melendez G, Valente JG & Struchiner CJ (2004) Breastfeeding and postpartum weight retention in a cohort of Brazilian women. Am J Clin Nutr 9, 487-493. Marcus PM, Baird DD, Millikan RC, Moorman PG, Qaqish B & Newman B (1999) Adolescent reproductive events and subsequent breast cancer risk. Am J Public Health 89, 1244-1247. Mayer-Davis EJ, Rifas-Shiman SL, Zhou L, Hu FB, Colditz GA & Gillman MW (2006) Breastfeeding and risk for childhood obesity: does maternal diabetes or obesity status matter? Diabetes Care 29, 2231-2238. McClimens A & Scott R (2007) Lights, camera, education! The potentials of forum theatre in a learning disability nursing program. Nurse Educ Today 27, 203-209. McKinney PA, Parslow R, Gurney KA, Law GR, Bodansky HJ & Williams R (1999) Perinatal and neonatal determinants of childhood type 1 diabetes. A case-control study in Yorkshire, U.K. Diabetes Care 22, 928-932. Newcomb PA, Storer BE, Longnecker MP, Mittendorf R, Greenberg ER, Clapp RW, Burke KP, Willett WC & MacMahon B (1994) Lactation and a reduced risk of premenopausal breast cancer. N Engl J Med 330, 81-87. Oddy WH, Kendall GE, Blair E, De Klerk NH, Stanley FJ, Landau LI, Silburn S & Zubrick S (2003) Breastfeeding and cognitive development in childhood: a prospective birth cohort study. Paediatr Perinat Epidemiol 17, 81-90. Orme J, Salmon D, Mages L (2006) An evaluation of Project Jump 2006: a sexual health drama for ‘hard to reach’ young people. University of the West of England, Bristol. Rosenblatt KA & Thomas DB (1993) Lactation and the risk of epithelial ovarian cancer. The WHO Collaborative Study of Neoplasia and Steroid Contraceptives. Int J Epidemiol 22, 192-197. 71 Seguin A & Rancourt C (1996) The theatre: an effective tool for health promotion. World Health Forum 17, 64-69. Stewart-Knox B, Gardiner K, Wright M (2003) What is the problem with breastfeeding? A qualitative analysis of infant feeding perceptions. J Hum Nutr Diet 16, 265-73. Sullivan J, Petronella S, Brooks E, Murillo M, Primeau L & Ward J (2008) Theatre of the Oppressed and Environmental Justice Communities: a Transformational Therapy for the Body Politic. J Health Psychol 13, 166-179. von Kries R, Koletzko B, Sauerwald T, von Mutius E, Barnert D, Grunert V & von Voss H (1999) Breast feeding and obesity: cross sectional study. BMJ 319, 147-150. Wright AL, Holberg CJ, Taussig LM & Martinez FD (1995) Relationship of infant feeding to recurrent wheezing at age 6 years. Arch Pediatr Adolesc Med 149, 758-763. 72 APPENDIX 1 ________________________________________________________________________________ Consent form for viewers of the drama Evaluation of the drama Milk it! Much a do about nothing? Researcher: Barbara Whelan, School of Biological Sciences, Dublin Institute of Technology. I am doing a research study to find out whether a theatre production, which you will have the opportunity to see, will have any effect on your thoughts and ideas of infant feeding. If you would like to be in this study you will be asked to take part in a group discussion which will last about 1 hour, before and after you see the drama. The discussion will be recorded. You do not have to be in the study and if you decide not to be that is fine. If you do decide to take part, you are free to stop at any stage you want. When this study is finished a report will be written however your name will never be used in the report. A paper may also be published with the results but again you will never be personally identifiable. If you have any questions please ask me. Please tick the following boxes if you agree I understand that my name will not be used in any reports or publications arising from this research __________________ Name _____________________ Signature ______________ Date __________________ Researcher’s name _____________________ Signature ______________ Date 73 Consent form for the project team Evaluation of the drama Milk it! Much a do about nothing? Researcher: Barbara Whelan, School of Biological Sciences, Dublin Institute of Technology. I would like to invite you to take part in a group/individual discussion to get your views on the forum theatre production Milk it? Much a do about nothing?. The aim of this discussion is to discuss the process involved in the preparation and delivery of the play and also your views on the organisation of the play. The discussion will last about 1 hour and it will be recorded. You do not have to be in the study and if you decide not to be that is fine. If you do decide to take part, you are free to stop at any stage you want. When this study is finished a report will be written however your name will never be used in the report. A paper may also be published with the results but again you will never be personally identifiable. If you have any questions please ask me. Please tick the following boxes if you agree I understand that my name will not be used in any reports or publications arising from this research __________________ Name _____________________ Signature ______________ Date __________________ Researcher’s name _____________________ Signature ______________ Date 74 APPENDIX 2 ________________________________________________________________________________ Ple W ase hat hel do p yo by u fillithi ng nk thi wa s ins an the d ma pla in cin me g it ssa in ge the of boxthe as pla youy? lea ___ ve ___ ___ Ag ___ e ___ ___ Ar ___ e ___ yo ___ u ___ ma le ___ or ___ fe ___ ma ___ le ___ ___ W ___ hat ___ is ___ yo ___ ur ___ job ___ ? M F 75 ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Di ___ d ___ yo ___ u ___ enj ___ oy ___ the ___ pla ___ y? yes ___ no ___ ___ ___ Do ___ yo ___ u ___ thi ___ nk ___ the ___ pla ___ y ___ wa ___ s: ___ Int ___ ere ___ sti ___ ng ___ ___ ___ Inf ___ or ___ ma ___ tiv e yes yes no no 76 Pr ofe ssi on al yes no Do yo u thi nk the thi ngs dis cus sed in the pla y are rel eva nt to yo u? yes no ________________________________________________ ________________________________________________ ________________________________________________ Do you thin k the play is a goo d way of disc 77 ussi ng bre astf eedi ng? yes no Wh y? ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ 78 ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ________________________________________________ ________________________________________________ Thank you. 79