Week Four Proposal and Corrections

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Research Proposal: Breastfeeding Behavior of Active Duty Military Women

Student Name

Department of Community Health, National University

COH 611: Research Methods

Dr. Lori Bednarchik

Due Date

Abstract

The military is one of the largest employers in the United States, and its female population is rising (Mankowski, Tower, Brandt, & Mattocks, 2015). Studies that address the health and quality of life for women in the military lacks as compared to their male counterparts, especially regarding breastfeeding behaviors (Segal and Lane, 2016). Thus, the purpose of this study is to gain a profound understanding of the breastfeeding behaviors of women in the United States active duty military. This research proposal for a systematic review will focus on one central research question. What factors affect a woman’s breastfeeding behavior while she is serving? Research involving breastfeeding and active duty women from all branches of the military, Army, Air Force, Navy, and Coast Guard, will be gathered and analyzed. The results of this systematic review will reveal the determinants of thriving versus non-successful breastfeeding behaviors in the military and how the armed forces can improve their policies and support for these women.

Keywords: military, breastfeeding, systematic review, active duty

Breastfeeding Behavior of Active Duty Military Women

A young woman decides to join the military because she wants to serve her country. She feels the call to be a part of something bigger than herself, and she seeks to make a difference in the world. This young lady is not alone in her endeavors. More women are joining the armed forces because of recent policy changes that “provided increased opportunities for them to serve in active duty jobs previously closed to them. Moreover, the transition to an all volunteer U.S Armed Forces, coupled with recent regulations lifting the ban on women serving in combat positions, have resulted in a significant increase in young females serving in operational positions where health care was initially designed for male service members” (Braun, Kennedy, Sadler, Dixon, 2015, p. 1247). Since the military requires 100% medical readiness for deployment and operational duties of its members, the efficacy of the Department of Defense’s new healthcare policies and regulations for this rising female population within its ranks needs to be investigated (Braun et al., 2015).

Women may face many health challenges in the military, especially regarding breastfeeding. For instance, the U.S Department of Health and Human Services has recognized the importance of breastfeeding, and their goal is to raise the rate and duration of breastfeeding of U.S. women (Bell, 2003). With that, a few studies indicate that the lowest rates of breastfeeding are among minorities (Hispanics and African Americans), lower-income, and those with less than a college education, which is also common characteristics of women in active duty military. Active duty military policies also require women to return to work quickly after birth, and they must be deployable soon after (Bell, 2003; Martin, Drake, Yoder, Gibson, & Litke, 2015).

These regulations present many challenges for breastfeeding women. Many women who have breastfed on active duty or deployment have stated that they experienced obstacles with scheduling time to pump, uncomfortable interactions with coworkers and supervisors regarding pumping, and lack of resources to name a few (Bell, 2003; Sleutel, 2012; Stevens and Janke, 2003). On the other hand, studies have indicated that some women had positive experiences with breastfeeding while on active duty (Martin, et al., 2015; Stevens and Janke, 2003). Overall, the studies of these women indicated that their breastfeeding experiences are mixed, and more research needs to be done on how to improve policies and regulations for them.

Furthermore, there are gaps in the studies that explored the experiences or perceptions of breastfeeding active duty military women (Martin et al., 2015; Sleutel, 2012; Stevens and Janke, 2003). For example, Stevens and Janke (2003) only analyzed the experiences of active duty Air Force women at a Midwestern base. The experiences of these Air Force women were not accurate representations of women in other branches or jobs. Martin et al. (2015) mentioned that the Army had the lowest perceptions of breastfeeding support as compared to other branches, and the Air Force had the highest. Although, it is important to note in the Martin et al. (2015) study that the Army also had a larger minority, Hispanic, and less-educated population. The Army’s ethnic and education variances of its female population in comparison to other branches and how these differences relate to breastfeeding practices needs to be investigated further (Martin et al., 2015). Thus, more research remains to be done on the disparities in breastfeeding behaviors between the branches and various active duty occupations so that policies can be improved specifically for them.

Again, the limited amount of research on the breastfeeding behaviors of active duty military women is apparent. This population continues to rise, and the healthcare policies created by the Department of the Defense for this minority group may not be up to par, especially regarding breastfeeding practices. Clearly, with a stronger and healthier female active duty force, the military will be a powerful military force overall. Additionally, the United States recognizes breastfeeding as a necessary and valuable practice for mothers and children, which is why there are recent initiatives to increase the rate and duration of breastfeeding behaviors among women in the U.S. (Bell, 2003). Thus, exploring how the military can help its female population will not only benefit the military, but it will benefit the health and well-being of mothers and children nationwide.

With that, the purpose of this study is to gain a profound understanding of the breastfeeding behaviors of women in the United States active duty military, across all branches. This research proposal for a systematic review attempts to explore the factors that affect a woman’s breastfeeding behavior while serving. The results will reveal the determinants of successful and non-successful breastfeeding behaviors in the military and how the U.S. Department of Defense can improve their policies and support for these women.

Literature Review

The sections of this literature review include active duty military, life of women in the military, breastfeeding, breastfeeding and active duty military, and implications for more research. The organization of this literature review is meant to introduce the independent (active duty military status of women) and dependent (breastfeeding behavior) variables of this systematic review, and it describes studies that address both variables.

Active Duty Military

The military is now a volunteer force and there are full-time and part-time positions. The reserve and national guard are part-time jobs and active-duty military is full-time. Defense organizations screen whoever volunteers to serve for mental and physical health issues. Security checks also are conducted to ensure that only qualified individuals serve in the ranks. Previously, only men were permitted to serve. However, now women can join and their numbers are increasing. “In 1973, women represented approximately 1.6% of the U.S. Active Duty military forces. Department of Defense data indicates that women currently represent 199,584, 15.16% of the active military force” (Braun, Kennedy, Sadler, & Dixon, 2015, para. 1). That is a dramatic jump in numbers, 1.6% to 15.16%, over a span of thirty plus years. Additionally, active duty women back in the day were mostly performing administrative or medical duties. Now, women can participate in combat roles. The active duty military is a diverse force, but the primary objective of the entity is to defend, protect, and fight for freedom.

Why women join the military. Indeed, the military has been a part of history since the beginning of civilization. Although women were recently permitted to enter, males continue to dominate the ranks. Many people still question why women choose to join a highly masculine profession. The reasons why women join the military may be different for every individual. A study indicated similar reasons why most women join; they considered it “a means to an end: financial stability or a vocational calling” (Mankowski, Tower, Brandt & Mattocks, 2015, Discussion). In other words, women join not so much to go to war and fight on the front lines, but to receive educational, financial, and healthcare benefits that sometimes lacked on the civilian side. Moreover, most women see the military as a vocation or a calling. The military does not force people into membership; its members volunteer to serve. Volunteerism was not the case back in the day when military drafts during world wars occurred. Times have changed drastically and women join the ranks for educational, financial, and job opportunities.

Military life for women. Since more women are choosing to serve, what is life like for women who volunteer to be in the armed forces? Indeed, the number of women entering the armed forces continues to rise but most people do not understand what women experience in the military. Currently, researchers are beginning to study this minority population, but the research is still lacking. However, one study revealed that military women face unique challenges compared to their men co-workers. They tend to be more affected by issues with childcare, and mental health before, after, and during deployments (Segal and Lane, 2016). They also tend to have higher divorce rates compared to military males and female civilians (Segal and Lane, 2016). Therefore, the life of military women deserves more exploration because the well-being of this growing group is at risk.

Breastfeeding

The saying “breast is best” is the most popular piece of advice when it comes to nourishing a newborn. There have been numerous studies that support the practice of breastfeeding over formula-feeding. The list of benefits for mother and baby is practically endless. Thus, new mothers are highly encouraged to breastfeed their children. “The AAP recommends breastfeeding exclusively for 6 months with the addition of complementary foods and continuing to breastfeed for an additional 6 months or longer. Also, Healthy People 2020 objectives now include exclusivity of breastfeeding as the standard recommendation, as differences in outcomes have been found for many illnesses in infants fed mixed feedings (CDC)” (Hughes, Rodriguez‐Carter, Hill, Miller, & Gomez, 2015, Evidence Review). With that said, women in the military may face unique challenges when it comes to breastfeeding. The nursing behaviors of these women need to be investigated because they may or may not be meeting recommended guidelines.

Interventions for breastfeeding success. Indeed, breastfeeding is highly encouraged but it is also a challenging experience for most mothers, regardless of status. Some women choose not to breastfeed due to various circumstances, such as lack of support or education. However, there are a few interventions that may help. One study showed that educating nurses and hospital staff on how to help a new mother in the labor and delivery unit breastfeed her child after birth may help these women successfully breastfeed after hospital discharge (Hughes, et al., 2015). Additionally, immediate skin-to-skin contact after birth, and educating a mother about how to be successful at breastfeeding can help her continue to nurse without hindrance (Hughes, et al., 2015). Likewise, another study examined the efficacy of Lactation Consultants on supporting breastfeeding women. A significant increase in successful breastfeeding with Lactation Consultants was not found, but examining how personal coaching and support can affect nursing mothers should continue to be explored (Rishel & Sweeney, 2005).

Breastfeeding in the Military

Again, breastfeeding is not an easy endeavor for any mother. Many women, regardless of socioeconomic status or vocation, have challenges when it comes to nursing. Similarly, the combination of active duty military service and breastfeeding can be a stressful experience. Undoubtedly, more studies need to investigate these mothers because the percentage of women in the active duty military continues to rise. The healthcare concerns of this growing population lack support and quality research. A few studies have ventured into the realm to get a deeper understanding of the relationship between active duty military and breastfeeding.

Positive and negative experiences. For example, Martin, Drake, Yoder, Gibson, & Litke (2015) revealed that “current perceptions of breast-feeding support among active duty women are divided between positive and negative perceptions” (p. 1158). Similarly, Stevens and Janke (2003) elaborated on particular positive and negative perceptions communicated by active duty women at a Midwestern Air Force base. They mentioned that similar obstacles reported were “finding time to express milk, inflexible work schedules, nonempathetic supervisors, and absence of a suitable place to express” (p. 382). Moreover, common breastfeeding issues were commitment and bonding. One participant in Stevens and Janke’s (2003) study said this about commitment, “I know a lot of people that only do it for a couple of months and they quit because of the fact that it’s such a hassle” (p. 382). Likewise, in the Martin, et al. (2015) study many women mentioned that finding a place to pump and opposition from coworkers negatively affected their motivation to continue breastfeeding. One participant said that “while nursing, some coworkers would complain that I had to pump. They felt that I was nursing to get out of work” (Qualitative Analysis).

However, despite these obstacles, Stevens and Janke (2003) concluded that for their participants, “combining breastfeeding and employment in the military was a good experience. They were successful in breastfeeding for an average of 6 months and had the work support and commitment that was needed to overcome any obstacles” (p. 383).

Implications for More Research

Although the results of Stevens and Janke’s (2003) study seems favorable, their study was very narrow and focused only on active duty Air Force women at a Midwestern base. The active duty military includes all branches, Army, Air Force, Navy, Marines, and Coast Guard. Sometimes there are dramatic differences between the cultures of these military branches. The experiences of active duty Air Force breastfeeding women may be drastically different from active duty women in the Army or Marines. Therefore, more research needs to be conducted on active duty women across all branches. Military healthcare organizations should not generalize care for breastfeeding active duty women based on research of a small group of Air Force women.

In summary, because of a rising active duty military women population, the breastfeeding behaviors of these women needs to be examined. There are obvious benefits to breastfeeding but most women in the active duty military have communicated obstacles to being able to successfully nurse according to recommended guidelines. Many obstacles stem from their active military status. A deeper understanding of their experiences and proposed interventions will help alleviate negative behaviors. Furthermore, with more positive breastfeeding support for women in active duty military, the military will be a stronger force overall.

Methods

The research approach for this systematic review included various inclusion and exclusion criteria, and all articles were assessed for quality. Studies were selected with careful and ethical concerns in mind. No human subjects are involved in this research proposal, and an IRB application will be filed to approve data analysis of selected studies for the topic. The research for this systematic review of breastfeeding behaviors and active duty military women was obtained lawfully and mostly using National University resources.

Research Strategy

First, a majority of the research for this systematic review was conducted through the National University online library and databases. The National University Smart Search engine was the most helpful agent in this process, which also provided links to the ProQuest, and EBSCO Host database for further online literature exploration. The second most utilized search engine for this systematic review was the Google Scholar online database, which had user-friendly features that located additional studies apart from the National University Smart Search platform. General, comprehensive, and cited reference searches were conducted on these databases.

Next, identifying critical keywords for this systematic review started with a general search of topics related to women in the military. The initial stages of research for this systematic review included the keywords: ‘military women’, ‘challenges of military women’, ‘military women health’, ‘active duty military women’, ‘military women issues’, ‘health behaviors military women’, ‘military gender’, ‘health effects military women’, ‘health readiness military women’, and ‘motherhood in the military’.

After performing a general search, critical keywords were identified and used for a comprehensive search. The important keywords included: ‘breastfeeding’ AND ‘military women’, ‘breastfeeding experiences’ AND ‘military women’, ‘breastfeeding practices military families’, ‘military population breastfeeding rates’, and ‘breastfeeding in the military service women’. Thus, articles retrieved from the comprehensive search included these common keywords: ‘breastfeeding’, ‘military’, ‘women’.

Furthermore, a narrower search was conducted in Google Scholar after a quality article was found during the comprehensive search. Google Scholar’s “Related articles” feature provided many other articles related to Stevens and Janke’s (2003), Breastfeeding Experiences of Active Duty Military Women.

Inclusion Criteria

Again, the research topic for this systematic review is about breastfeeding behaviors of active duty military women. Thus, the inclusion criteria for all searches adhered to the main themes of breastfeeding behaviors, military women, military woman, breastfeeding practices, breastfeeding experiences, breastfeeding perceptions, women in the military, and active duty military women. Also, the Cochrane acronym PICO (population, intervention, comparison, and outcomes) was considered for inclusion criteria (Uman, 2011). For instance, the population relevant to this systematic review is active duty military women in the United States, so articles that studied this particular population were included. Moreover, the outcomes or behaviors/ experiences of these women were desired, so articles that pertained to these themes were selected for analysis.

Exclusion Criteria

On the other hand, there were various reasons for excluding articles from this systematic review. Exclusion criteria items included geography, career status, gender, and other health issues. For instance, articles that did not focus on military women in the United States were excluded. Articles that focused mainly on working women in the civilian sector were excluded. Articles that focused on men in the military and health issues or behaviors other than breastfeeding (i.e., mental health, PTSD, sexual assault) were excluded. Comparisons can be made to these articles, but the main theme of this systematic review is analyzing the breastfeeding behaviors of active duty women in the United States military.

Quality Assessment

Lastly, all articles were assessed for quality. To ensure only quality, peer-reviewed, current articles appeared during the searches, all search engine filters were set with the following features: date range, 2012-2017, ‘peer-reviewed’, and ‘full-text available’. ‘Full-text available’ ensured that cited articles could be accessed quickly. The procedure for identifying quality, peer-reviewed studies included focusing on articles that were relevant to the topic (met inclusion criteria) and ignoring those that had exclusion criteria. Qualitative, quantitative, and mixed methods approaches were considered. However, most cited literature was qualitative and there were a few quantitative studies.

Conclusion

After reading this research proposal for a systematic review, the requirement for investigating the breastfeeding behaviors of active duty military women is evident. The introduction, literature review, and methods section all contributed to justifying the significance of this unique topic. Breastfeeding and the military is a new phenomenon for the U.S. armed forces and the Department of Defense health care system. The military’s female population is rising, and the Department of Defense is one of the largest employers in the nation (Mankowski, Tower, Brandt, & Mattocks, 2015). Therefore, this research proposal for a systematic review of literature that addresses breastfeeding and military women will benefit not only the health of the United States military, but the general population as well.

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