national breastfeeding helpline evaluation...project approach vii overview of project findings vii...

National Breastfeeding Helpline Evaluation

Research Report

June 2012 Report to the Australian Government Department of Health and Ageing

Commercial in Confidence financial data has been removed from this document.

Evaluation of the appropriateness, effectiveness and efficiency of the National Breastfeeding Helpline Online ISBN: 978-1-74241-831-5 Publications approval number: D0977 Copyright Statements: Paper-based publications © Commonwealth of Australia 2012 This work is copyright. You may reproduce the whole or part of this work in unaltered form for your own personal use or, if you are part of an organisation, for internal use within your organisation, but only if you or your organisation do not use the reproduction for any commercial purpose and retain this copyright notice and all disclaimer notices as part of that reproduction. Apart from rights to use as permitted by the Copyright Act 1968 or allowed by this copyright notice, all other rights are reserved and you are not allowed to reproduce the whole or any part of this work in any way (electronic or otherwise) without first being given the specific written permission from the Commonwealth to do so. Requests and inquiries concerning reproduction and rights are to be sent to the Online, Services and External Relations Branch, Department of Health and Ageing, GPO Box 9848, Canberra ACT 2601, or via e-mail to [email protected]. Internet sites © Commonwealth of Australia 2012 This work is copyright. You may download, display, print and reproduce the whole or part of this work in unaltered form for your own personal use or, if you are part of an organisation, for internal use within your organisation, but only if you or your organisation do not use the reproduction for any commercial purpose and retain this copyright notice and all disclaimer notices as part of that reproduction. Apart from rights to use as permitted by the Copyright Act 1968 or allowed by this copyright notice, all other rights are reserved and you are not allowed to reproduce the whole or any part of this work in any way (electronic or otherwise) without first being given the specific written permission from the Commonwealth to do so. Requests and inquiries concerning reproduction and rights are to be sent to the Online, Services and External Relations Branch, Department of Health and Ageing, GPO Box 9848, Canberra ACT 2601, or via e-mail to [email protected].

The Allen Consulting Group iii

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Suggested citation: The Allen Consulting Group (2012). National Breastfeeding Helpline Evaluation: Final Research Report June 2012. Prepared for the Australian Government Department of Health and Ageing.

Disclaimer:

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© Allen Consulting Group 2012

The Allen Consulting Group iv

Contents

Executive summary vi

Background vi

Project approach vii

Overview of project findings vii

Conclusion viii

Chapter 1 1 Introduction 1

1.1 The National Breastfeeding Helpline 1

1.2 Context in which the Breastfeeding Helpline operates 1

1.3 Evaluation of the Breastfeeding Helpline 6

1.4 Structure of the research paper 8

Chapter 2 9 Framework for evaluation 9

2.1 Evaluation framework 9

2.2 Evaluation program logic 9

2.3 The research methods 11

2.4 The evaluation tools 13

Chapter 3 16 Evaluation results 16

3.1 Access to Helpline breastfeeding information and support 16

3.2 Quality of Breastfeeding Helpline information and support 39

3.3 Awareness among health professionals of breastfeeding benefits and support services 42

3.4 Marketing education and training 43

3.5 Summary of findings 44

Chapter 4 46 Discussion of results 46

Chapter 5 48 Conclusion 48

Appendix A 50

Evaluation framework 50

Evaluation framework, questions and indicators 50

Appendix B 55

Survey instruments 55

B.1 Caller survey 55

The Allen Consulting Group v

B.2 Counsellor survey 62

Appendix C 66

Consultation schedule 66

Focus groups 68

Appendix D 69

Discussion guides 69

D.2 Professional association discussion 70

D.3 Focus group discussion guide 72

References 73

N A T I O N A L B R E A S T F E E D I N G H E L P L I N E E V A L U A T I O N : R E S E A R C H R E P O R T

The Allen Consulting Group vi

Executive summary

Background

The National Breastfeeding Helpline (the Breastfeeding Helpline) provides information and support to

mothers and their families. Funding for the Breastfeeding Helpline was committed to in the 2007 federal

election. The service was consolidated as a national service and implemented in October 2008 through a toll

free number and trained volunteer counsellors taking calls from their homes on a 24 hour, 7 day a week basis.

The Australian Breastfeeding Association (ABA) manages and operates the National Breastfeeding Helpline

and a number of complementary services including the ABA website and breastfeeding training for volunteer

counsellors and health professionals. The ABA is a not for profit organisation.

The Commonwealth Government contributes to the infrastructure and operating costs of the National

Breastfeeding Helpline. Approximately $3.8 million has been provided by the Department of Health and

Ageing (the Department) over the four year period from 2008-09 to 2011-12. These funds are designed to

facilitate access to breastfeeding information and support, including referrals. Specifically, funds support:

training and education of Breastfeeding Counsellors working on the Helpline and health professionals;

establishment and maintenance of Breastfeeding Helpline infrastructure; and

promotion of the Breastfeeding Helpline.

The objectives of the Breastfeeding Helpline are outlined in Box ES 1.1.

Box ES 1.1

NATIONAL BREASTFEEDING HELPLINE OBJECTIVES

The objectives of the National Breastfeeding Helpline are to:

support breastfeeding initiation and duration for breastfeeding women through trained volunteer counsellors;

improve national access and equity of access to quality factual information and advice, regardless of geographic location and with particular reference to population subgroups, including culturally and linguistically diverse communities, women with a disability, Aboriginal and Torres Strait Islander mothers, and teenage mothers; and

provide a 24 hour, nationally accessible Breastfeeding Helpline for women, partners and families seeking information and advice to support decision making in relation to breastfeeding.

Source: Department of Health and Ageing

The Breastfeeding Helpline is required to provide a service that targets breastfeeding mothers including the

following groups:

teenage mothers;

mothers with a disability;

Aboriginal and Torres Strait Islander mothers; and

mothers with a culturally and linguistically diverse background.


The Allen Consulting Group vii

The ABA reports to the Department of Health and Ageing on the performance of the Breastfeeding Helpline

against six indicators that include measures of effectiveness and efficiency. Reports are provided on a

monthly and quarterly basis. A total of 273,463 calls have been received since implementation of the

Breastfeeding Helpline on 18 October 2008 to end March 2012.

Box ES 1.2

NATIONAL BREASTFEEDING HELPLINE ACTIVITY MARCH 2012

For the month of March 2012, the Breastfeeding Helpline:

received 7,422 calls; of which

67 per cent were answered within 5 minutes;

the average wait time before being connected to a counsellor was 129 seconds;

the number of calls lost (hang ups) totalled 1,933;

the number of volunteer counsellors staffing the Breastfeeding Helpline was 430.

Source: Based on ABA monthly Breastfeeding Helpline data.

Project approach

This project has been undertaken in line with review requirements for evaluation of lapsing Australian

Government funded programs.

A mixed methods approach has been implemented for the evaluation. Information has been collected from

existing and new sources of data identified in the construction of an evaluation framework. The framework is

populated by the outcomes for the Breastfeeding Helpline, evaluation questions designed to determine

progress towards the outcomes and a set of indicators to provide measures of performance.

Key information sources for the evaluation included:

ABA data that underpin reports to the Department of Health and Ageing;

surveys of Breastfeeding Counsellors working on the Helpline and callers;

stakeholder interviews with the Department, ABA, professional associations and state and territory

governments;

focus groups with mothers of infants; and

targeted literature review.

Analysis undertaken included a cost effectiveness analysis investigating aspects of program efficiency.

Overview of project findings

The Breastfeeding Helpline generally provides an appropriate and important source of breastfeeding

information and support to mothers and their families. Breastfeeding Helpline services are implemented by

volunteer counsellors who satisfy core competencies, commit to the Breastfeeding Helpline for two years and

offer peer support to mothers.

The Breastfeeding Helpline gains considerable leverage from its location within the ABA and is connected to

evidence based information and training. The Breastfeeding Helpline benefits from the high profile of the

ABA in the community, with stakeholder organisations and as an advisor to governments on policy.

Challenges to the effectiveness and efficiency of the Breastfeeding Helpline include:


The Allen Consulting Group viii

sustaining a sufficient supply of trained volunteer counsellors to meet a relatively constant demand for

breastfeeding information and support;

ensuring consistency of information and support provided by the Breastfeeding Helpline;

adapting to preferred communication methods for both mainstream users of the Breastfeeding Helpline

and priority population groups, which will be important to the continuing relevance and accessibility of

the service, such as call back in response to text message, video conferencing, integration with face to

face visits;

promoting Breastfeeding Helpline services to improve the level of awareness of communication options

to reinforce the inclusive nature of services for all mothers and their families, regardless for example of

disability or language proficiency; and

building on the distinctive features of the Breastfeeding Helpline to reinforce its role within the growing

number of related helpline services to benefit both consumers and service providers.

The Breastfeeding Helpline is more cost effective when its operating costs are compared to two other

modelled scenarios including an existing helpline. This compares favourably with the other models both of

which involve paid staff and a higher ratio of cost to output/outcome achieved. The analysis also indicates

additional costs might be involved if it was necessary to achieve a greater level of certainty for Breastfeeding

Helpline staffing through for example, a core of paid staff.

Other suggested areas for further development of the Breastfeeding Helpline include additional training

support for counsellors to ensure a sufficient level of confidence in supporting priority population groups and

continued vigilance in ensuring that caller experience of the service is consistent with an empathetic and

empowering response. In addition, there is scope for a more systematic approach to integration of the

Breastfeeding Helpline into workforce practices and local services with the aim to ensure appropriate

referrals to the Breastfeeding Helpline and minimise duplication of services.

Regular monitoring and review of the Breastfeeding Helpline should be undertaken with a view to a

comprehensive summary of trends, emerging issues and implications for operation drawing on current data

collection including quality surveys and emerging evidence of good practice.

Conclusion

The National Breastfeeding Helpline meets a clear need for non clinical breastfeeding information and

support, and makes an effective and efficient contribution to government policy to achieve better outcomes

for mothers and babies.

There is a high level of satisfaction among users with the service provided by the Breastfeeding Helpline,

which is testimony to the investment in service infrastructure including quality staff. Continued work is

required to ensure the consistency of information and support provided to callers.

The Breastfeeding Helpline has made good progress towards its objectives responding to a wide range of

information and support needs from breastfeeding mothers and making referrals to other services to more

widely meet the needs of callers. The service is utilised by callers from all jurisdictions with some making

better use of the resource than others. Similarly, while the service is well utilised by callers between the ages

of 26 and 39, there is poor reach to priority population groups including younger mothers, mothers with

disability, Aboriginal and Torres Strait Islander mothers and mothers with culturally and linguistically

diverse backgrounds.


The Allen Consulting Group ix

Suggestions for improved access to the Breastfeeding Helpline included better promotion of the service to

reinforce its relevance to all mothers, to assist in differentiating the service from other helplines with a view

to improving consumer choices and making best use of government resources, and to encourage better

utilisation of interpreter and teletypewriter capabilities.

The following recommendations are made based on the findings of the evaluation.

• A comprehensive strategy is developed to identify current and any further action required to staff the

Breastfeeding Helpline to meet existing demand and potential growth in demand, and to address call

waiting times and counsellor workload.

• A realistic assessment is undertaken of the extent to which the Breastfeeding Helpline in its current form

offers an appropriate medium to meet the information and support needs of priority population groups1

,

drawing from the evidence of good practice and emerging research in jurisdictions.

Promotion of the Breastfeeding Helpline be reviewed to ensure that messages and materials are appropriately

targeted to improve understanding of the Helpline as relevant and accessible to all women as a source of peer

support.

• A strategic set of performance indicators aligned to agreed Breastfeeding Helpline outcomes be

selected to enhance current reporting arrangements. This would form the basis an annual report on

Breastfeeding Helpline activity and insights about the needs of breastfeeding women, which would

include a breakdown of information to jurisdictional level.

• The role of the Breastfeeding Helpline within the service system is reinforced by differentiating the

Breastfeeding Helpline from other parenting and health helplines. This should be undertaken as a

shared responsibility of governments and other service providers for meeting consumer needs and

reducing service duplication. The Department could facilitate discussions with jurisdictions to consider

memorandum of understanding type arrangements between the Helpline and other helplines.

• The Breastfeeding Jurisdictional Officers Group investigate the opportunity for influencing greater

consistency in breastfeeding training of health professionals and the role for the ABA.

1

Priority population groups refers to subpopulations within the target group of breastfeeding mothers. These are identified as teenage mothers,

mothers with disability, Aboriginal and Torres Strait Islander mothers and mothers with culturally and linguistically diverse backgrounds.


The Allen Consulting Group 1

Chapter 1

Introduction

The National Breastfeeding Helpline sits within a policy context that recognises the value

of breastfeeding to improved health and wellbeing outcomes for infants and mothers.

The Breastfeeding Helpline contributes to the mix of services to improve breastfeeding

practice in Australia consistent with evidence for collaborative action provided by

professional, lay and peer support. Methods employed in this evaluation of the

Breastfeeding Helpline were designed to assess performance of the service against its

aims focusing on access, quality and awareness.

1.1 The National Breastfeeding Helpline

The National Breastfeeding Helpline (the Breastfeeding Helpline) is funded by the

Australian Government Department of Health and Ageing (the Department) and delivered

by the Australian Breastfeeding Association (ABA).

The Breastfeeding Helpline operates as a national, toll free 24 hour telephone information

and support service staffed by trained ABA volunteer counsellors. The ability to offer

peer support to callers is a distinguishing feature of the Breastfeeding Helpline service.

The Allen Consulting Group has been commissioned by the Department to evaluate the

effectiveness of the Breastfeeding Helpline, and report on its efficiency, transparency,

cost-effectiveness and appropriateness.

This report describes the findings of the evaluation and implications for further

development of the Breastfeeding Helpline service.

1.2 Context in which the Breastfeeding Helpline operates

Significant attention has been given in policy, legislation and services, to support and

promote breastfeeding practice in Australia. These efforts are premised on the agreed

evidence and research on recommended breastfeeding practice and duration, and its

importance and benefit to the community (WHO 2001; Innocenti 2005 and NHMRC

2003).

Australian National Breastfeeding Strategy 2010–15

In response to the tabling of the 2007 Parliamentary Report into the benefits of

breastfeeding, Best Start, the Australian Government developed the Australian National

Breastfeeding Strategy 2010–15 to protect, promote, support and monitor breastfeeding in

Australia.

The Strategy defines an agreed breastfeeding continuum. This continuum, and factors

associated with each of the different stages is represented in Table 1.1.



Table 1.1

BREASTFEEDING CONTINUUM

Stage Factors influencing breastfeeding decisions

Pre-natal Preparatory stage for breastfeeding. Education, knowledge, commitment to breastfeeding, and development of support networks shown to impact on duration of breastfeeding.

Immediate post-natal (0–4 days)

Breastfeeding commences. Experience in the birthing environment has a direct impact on the establishment of breastfeeding practice.

Medium post-natal (4 days–8 weeks)

Mothers transition from health environment to home environment. Social networks, lay advice and peer support inform breastfeeding practice.

Long-term post-natal (8 weeks–6 months)

Breastfeeding practice during this stage is reliant on the continuation of health professional and peer support, and the extent of breastfeeding environments across different settings, including workplaces, public spaces and across the broader community.

Beyond 6 months

Source: Australian National Breastfeeding Strategy 2010–15

The Strategy was formally endorsed by all levels of government in 2010, with the

Department assuming a leadership role in its implementation. The implementation plan

for the Strategy identifies ten key action areas that facilitate breastfeeding and emphasise

the quality, accessibility and continuity of support within a continuous improvement

process (see Box 1.1).

Box 1.1

KEY ACTION AREAS FOR IMPLEMENTATION OF THE AUSTRALIAN NATIONAL

BREASTFEEDING STRATEGY 2010-15

The following action areas have been identified as key to progressing the aims of the Australian National Breastfeeding Strategy 2010-15.

Monitoring and surveillance

Health professionals’ education and training

Dietary guidelines and growth charts

Breastfeeding friendly environments

Support for breastfeeding in health care settings

Revisiting Australia’s response to the World Health Organization’s International Code of Marketing of Breast-milk Substitutes and related World Health Assembly resolutions

Exploring the evidence, quality assurance, cost-effectiveness and regulatory issues associated with the establishment and operation of milk banks

Breastfeeding support for priority groups

Continuity of care, referral pathways and support networks

Education and awareness, including antenatal education.

Source: AHMC, Communiqué 22 April 2010



Breastfeeding in Australia

The 2010 Australian National Infant Feeding Survey provides baseline data on the

practice and duration of breastfeeding and other feeding practices across the country. Key

findings from the survey demonstrate near universal breastfeeding initiation for

newborns, with over 90 per cent of infants being first fed with breastmilk. However rates

of exclusive, predominant or complementary breastfeeding drop off significantly in the

first six months of an infant’s life. The survey results indicate that by 6 months of age:

around 60 per cent of infants were receiving some breastmilk; but

only 15 per cent of infants were being exclusively breastfed.

0 presents data collected by the survey on breastfeeding rates in Australia tracked over

the first six months of an infant’s life.

BREASTFEEDING RATES IN AUSTRALIA

Exclusive breastfeeding — infant fed only breastmilk Predominant breastfeeding — breastmilk the predominant source of nourishment, with other certain liquids,

drops and syrups permitted Any breastmilk — a combination of breastmilk, formula and other type of food or liquid Source: 2010 Australian National Infant Feeding Survey

These rates indicate a significant gap between breastfeeding practice in Australia and the

recommendations of the National Health and Medical Research Council (NHMRC)

guidelines that all infants be fed exclusively on breastmilk from birth until at least six

months of age and that breastfeeding should continue in some form until the infant is at

least 12 months of age.

Breastfeeding interventions

The framework of factors influencing commitment to breastfeeding adopted by the

Australian National Breastfeeding Strategy identifies environmental and societal

conditions that operate at individual, group and society level.

Individual level factors — associated with the health and capacity of the mother and

infant.

Group level factors — associated with environment of the mother and infant,

including health and hospital settings, home and work settings, and level of support

available in the community.

Society level factors — associated with social and cultural attitudes to breastfeeding,

and broader public policy approaches to health and nutrition (Hector 2005).



When considered against the breastfeeding continuum outlined in Table 1.1, this

framework of factors provides a useful reference point with which to understand

strategies and specific interventions designed to support breastfeeding practice.

Key findings from systematic reviews of different types and forms of interventions that

cross the framework of factors described above, identify that education and support for

mothers is important.

Education — education, particularly during the pre natal stage, maximises

breastfeeding initiation. However its effectiveness in supporting breastfeeding

duration is less clear, especially when delivered in isolation, particularly at four and

six months of age.

Support — support, provided at antenatal and postnatal stages, that encompasses both

services and environments. It can include support from health professionals, support

staff, health service settings, social networks, and peer support.

Importantly, the literature emphasises integrated interventions, whereby a combination of

professional, lay, and peer support, delivered in different settings, has shown to be most

effective in improving breastfeeding duration (Amir et al 2010; Chung et al 2008; and

Hector 2005).

The role of peer support

Initiation of breastfeeding in Australia is high. However, as 0 demonstrates, duration of

breastfeeding practice by mothers is short of NHMRC recommendations. Recent research

has found there are a range of issues that impact upon sustaining breastfeeding beyond

initiation, including: a disjunct between the expectation and reality of a mother’s

experience of breastfeeding, difficulties encountered in breastfeeding, concerns about the

adequacy of breastmilk to meet the health and wellbeing needs of the baby, the physical

demands of breastfeeding, and myths and misconceptions about breastfeeding provided to

mothers (HoR 2007; and Osborne et al 2009).

Peer support is cited in the literature as a particular form of intervention that can address

many of these issues (HoR 2007: CCCH 2006). The National Breastfeeding Strategy

identifies peer support as, ‘being provided by people who have had some experience in

breastfeeding and have received a level of specific training to assist in their support role’

(AHMC 2010). This definition clearly distinguishes peer provided support from the

support that is provided by health professionals and lay support provided by social and

family networks.

The Australian Breastfeeding Association

The Australian Breastfeeding Association (ABA) is a voluntary, not for profit

organisation that encourages and supports mothers to breastfeed, and at the same time

drives greater community awareness of the importance of breastfeeding. The ABA has

branches across all jurisdictions and at 30 June 2011 had over 14,000 members, over 250

ABA groups, and nearly 1,200 trained volunteer counsellors (ABA 2011).

The ABA's vision, mission and values are outlined in Box 1.2.



Box 1.2

ABA VISION, MISSION AND VALUES

Vision

Breastfeeding is the normal way to feed and nurture infants, with babies being breastfed exclusively for 6 months and continuing to breastfeed for 2 years and beyond.

Mission

As Australia’s leading authority on breastfeeding, we:

educate society and support mothers, using up-to-date research findings and the practical experiences of many women; and

influence society to acknowledge breastfeeding as normal and important to parenting and the physical and mental health of babies, children and mothers.

Values

Mother-to-mother support

Skilled and loving parenting (in society)

Excellence and innovation in breastfeeding support

The wellbeing and diversity of our people

Cooperation and teamwork

Honest, open and respectful communication

Clear and transparent processes.

Source: Australian Breastfeeding Association website <https://www.breastfeeding.asn.au/aboutaba/purpose>

Activities conducted by the ABA include the following.

Local ABA groups — run by volunteer counsellors and community educators who

work within local networks to educate the community about breastfeeding.

Breastfeeding Education classes — delivered by ABA qualified counsellors and

community educators providing information and support to new and expectant

mothers and their families.

Delivery of breastfeeding training — as a Registered Training Organisation, the ABA

delivers Certificate IV in Breastfeeding Education for all new counsellors.

Seminars — seeks to drive greater awareness of breastfeeding amongst health

professionals through the delivery of a program of seminars, webinars and

workshops.

Workplace accreditation — delivers the Breastfeeding Friendly Workplace

Accreditation program, assisting workplaces to provide a breastfeeding supportive

environment.

Breastfeeding Friendly Communities — encompasses a number of programs that

support breastfeeding practice in the community and drive awareness and acceptance

of breastfeeding in public.

National Breastfeeding Helpline — provides national access to breastfeeding

counselling and support 24 hours a day, 7 days a week, through a toll free

Breastfeeding Helpline number.

The National Breastfeeding Helpline

Commonwealth Government funding for a national breastfeeding helpline was committed

to in the 2007 election. The funding was to allow the ABA to build the capacity and

consistency of existing ABA telephone support for mothers and their families.



The establishment of the Breastfeeding Helpline constitutes a significant response to

issues identified in the Best Start report, and directly relates to identified actions

contained in the National Breastfeeding Strategy, specifically action on ‘continuity of

care, referral pathways and support networks’ in promoting and supporting breastfeeding

in Australia. The objectives of the Breastfeeding Helpline are outlined in Box 1.3.

Box 1.3

NATIONAL BREASTFEEDING HELPLINE OBJECTIVES

Objectives of the National Breastfeeding Helpline are:

to support breastfeeding initiation and duration for breastfeeding women through trained volunteer counsellors;

to improve national access and equity of access to quality factual information and advice, regardless of geographic location and with particular reference to population subgroups, including culturally and linguistically diverse communities, women with a disability, Aboriginal and Torres Strait Islander mothers, and teenage mothers; and

to provide a 24 hour, nationally accessible Helpline for women, partners and families seeking information and advice to support decision making in relation to breastfeeding.

Source: Department of Health and Ageing

To deliver the Breastfeeding Helpline, the ABA has entered into agreements with the

Department for funding of $3,859,161 over the four-year period from 1 July 2008 to 30

June 2012. These funds include support for training and education of the volunteer

Breastfeeding Counsellors working on the Helpline, establishment and maintenance of

the infrastructure for an effective national telephone helpline and promotion of the

Breastfeeding Helpline.

The Breastfeeding Helpline operates as a national telephone information and support

service. Volunteer counsellors who staff the Breastfeeding Helpline, meet the minimum

qualifications of a Certificate IV in Breastfeeding Education. Volunteers are bound by the

ABA Code of Ethics and are also required to have experience of breastfeeding

themselves. The ability to offer peer support to callers is a distinguishing feature of the

Breastfeeding Helpline service.

The funding for the Breastfeeding Helpline is designed to facilitate access to advice and

support for breastfeeding for mothers and their families including information and referral

services. The ABA website is integral to the continuing education of volunteer

counsellors, to communication with and between counsellors, as a source of ongoing

information for mothers and their families and to the promotion of the Breastfeeding

Helpline.

1.3 Evaluation of the Breastfeeding Helpline

Evaluation objectives

Evaluation of the Breastfeeding Helpline has the following objectives:

assess the effectiveness of the Helpline.

report on the efficiency, transparency, cost-effectiveness and appropriateness of the

Breastfeeding Helpline; and



recommend options for addressing any significant issues that are identified that might

warrant changes to the content, coverage or operation of the Breastfeeding Helpline.

Project tasks included:

development of the evaluation framework; and

implementation of preliminary evaluation.

This research paper describes the evaluation approach and the findings of the preliminary

evaluation.

The quality and content of training provided to Breastfeeding Counsellors working on the

Helpline was out of scope for this project other than the extent to which, for example,

counsellor feedback on training needs and access has potential implications for the

training provided. Breastfeeding education provided to health professionals is enmeshed

in the funding for Breastfeeding Helpline counsellor education and was similarly out of

scope other than the extent to which stakeholder feedback reflects on the level of

awareness of the Breastfeeding Helpline resource and active referrals.

High level questions

The evaluation posed a series of high level evaluation questions to enable assessment of

the Helpline in achieving its outcomes. These questions, listed in Box 1.4 guided the

establishment of indicators of performance and determination of the underlying data

sources.

Existing data sources available to the evaluation included ABA information and data,

including reports provided to the Department as part of its funding commitment.

New data sources identified for the evaluation included:

counsellor and caller perspectives through online surveys;

ABA and Department input on the expectations and operation of the Breastfeeding

Helpline through interviews;

cost effective analysis using comparator helpline scenarios;

professional associations and jurisdictional feedback through interviews; and

priority populations groups’ perspectives through focus groups.

The methodology for evaluating the Breastfeeding Helpline is summarised in the

evaluation framework discussed more fully in the following chapter.



Box 1.4

KEY EVALUATION QUESTIONS

The following key evaluation questions were developed to frame evaluation of the extent to which the National Breastfeeding Helpline is achieving the desired outcomes of the service.

Access to breastfeeding advice support for mothers, partners and their families:

Has the Breastfeeding Helpline service been implemented as intended?

To what extent have mothers and their families utilised the service of the Breastfeeding Helpline?

Are callers satisfied with the support provided by the Breastfeeding Helpline?

How well is the Breastfeeding Helpline utilised by priority population groups?

Standards for counselling / quality of information and support:

Do the minimum qualifications for a Breastfeeding Helpline counsellor comply with requirements of the national regulator AQSA?

Are there appropriate bridging courses available to counsellors that meet the increased compliance requirements?

Enhancement of breastfeeding counsellor skills:

Is the training provided for Breastfeeding Helpline sufficient to ensure the supply of a skilled workforce and the sustainability of a quality, responsive Breastfeeding Helpline service?

Greater awareness among health professionals:

Is there improved knowledge and understanding of breastfeeding and the role of the Breastfeeding Helpline?

Expanded network of volunteers and health professionals aware of breastfeeding education opportunities:

To what extent are ABA education and training opportunities taken up on the provision of advice and support for breastfeeding?

Source: The Allen Consulting Group

1.4 Structure of the research paper

This research paper is a central component of the evaluation project and builds on the key

stakeholder workshop of preliminary evaluation findings held on 13 June 2012.

The following chapters of the research paper provide:

Chapter 2 — description of the evaluation framework, including the program logic,

and research methods and mechanisms of the project;

Chapter 3 — analysis of evaluation results examining issues of access, quality,

awareness of health professionals and marketing of ABA education and training

services;

Chapter 4 — discussion of project results; and

Chapter 5 — concluding remarks on the overall performance of the Breastfeeding

Helpline.



Chapter 2

Framework for evaluation

A mixed methods approach was developed for implementation of the evaluation of the

National Breastfeeding Helpline. This approach is mapped in the evaluation framework

that establishes intermediate and ultimate outcomes for the Breastfeeding Helpline

service and support activities of the ABA within scope. The approach draws from

primary and secondary data capturing aspects of program operation and perspectives of

key stakeholders including Breastfeeding Helpline callers and counsellors. The

methodology included a cost effectiveness analysis and a targeted literature review

focusing on good practice in the delivery of telephone support services.

2.1 Evaluation framework

Development of the project evaluation framework was informed by the desktop review of

program documentation and administrative data, and the further direction provided by the

Department.

The program logic provided the context for the initiative including the community need

being addressed, the wider policy context and tracks the program inputs, activities and

outputs to show how the Breastfeeding Helpline will deliver on desired outcomes.

The evaluation questions were developed to measure achievements of the Breastfeeding

Helpline towards the intermediate outcomes identified in the program logic.

A set of realistic and practical indicative indicators were developed for measuring

performance that have regard for minimising the burden on stakeholders and the

volunteer nature of the workforce. Potential data sources to populate the indicators were

identified from existing data sources and an assessment of suitable methods for the

generation of new data to meet information gaps within the timeframe of the evaluation.

The new data sources were refined in the process of completing the consultation plan

incorporated into the project plan.

The evaluation framework is provided at 0.

2.2 Evaluation program logic

The development of a program logic map was the initial component of the evaluation

framework process. It was informed by discussion and workshop between the evaluation

project team and the Department’s project reference group, and was subject to final

approval by the Department.

The agreed program logic map for the Breastfeeding Helpline is described in 0.



NATIONAL BREASTFEEDING HELPLINE EVALUATION PROGRAM LOGIC




The program logic map provides the broader context for the Breastfeeding Helpline,

identifying community need, and responding to agreed national priorities that focus on

the protection, promotion, support and valuing of breastfeeding by the whole community.

The program logic includes the different roles played by the Commonwealth Government

and the ABA in the development, funding and delivery of the Breastfeeding Helpline

service.

The program logic map identifies the desired outcomes (high level), outputs and

outcomes that were used in determining the effectiveness of the intervention. Similarly,

articulation of the inputs and outputs guided assessment of the efficiency of the

Breastfeeding Helpline.

2.3 The research methods

The following research methods were undertaken for this project.

Data analysis — of policy and program documentation, and various administrative

datasets to inform performance measurement including the cost effective analysis

component of the project.

Survey analysis — exploring caller and counsellor perspectives.

Consultation — of key stakeholders and parents from priority population groups.

Desktop review — of relevant websites and literature.

Data analysis

The evaluation included a review of related policy and program documentation. This

information provided the background and context for the project, and informed the

development of the evaluation framework.

Data was also sourced from different agreements and administrative datasets providing

information about activity and outputs associated with the delivery of telephone helplines.

Data analysis in this report included data from the sources in Table 2.2.

Table 2.2

DATA SETS

Data set Detail

National Breastfeeding Helpline funding agreements

Provided by the Department, the funding agreements outline the aim, scope and reporting requirements associated with the delivery of the Breastfeeding Helpline and the training and education component for volunteer counsellors and health professionals.

National Breastfeeding Helpline progress reports

Accessed from ABA and the Department for the period of December 2010 to March 2012, providing summary detail on numbers and characteristics of calls.

ABA administrative data sets

ABA monthly administrative data for the six Breastfeeding Helpline performance measures.

Comparator helpline administrative data

Accessed about an existing helpline to inform the development of the cost effectiveness analysis component of the project.

StrategyCo research Augmented primary research data collected through the evaluation's survey instruments.



Survey analysis

With the approval of the Department and cooperation of the ABA, two surveys were

implemented during the project. The caller and counsellor surveys ran over the period 28

May to 17 June 2012. Breastfeeding Counsellors working on the Helpline were briefed on

the surveys and where appropriate, directed callers at the end of the discussion, to the

ABA website to participate in the survey.

Individual emails were sent to each counsellor rostered on during the survey

implementation period inviting their involvement in the counsellor survey. For

counsellors, access to the survey was through a link included in the email invitation to

participate.

Email reminders were sent to counsellors rostered on in that current week on two

occasions over the survey period, which prompted their participation in both referring

callers to the survey and completing their own survey.

The survey analysis for this report was based on survey results obtained over a period of

18 days (approximately two and a half weeks). The size of the survey samples included a

total of 99 callers to the Breastfeeding Helpline who had participated in the caller survey,

and 174 ABA Breastfeeding Helpline volunteer counsellors who had participated in the

counsellor survey.

A limitation of the caller survey was that it provided perceptions about information

sources and the Breastfeeding Helpline from a sample of mothers currently using the

service. This was overcome to some extent by other components of information

collection, which provided wider access to public perceptions, both directly and indirectly

as described below.

Caller and counsellor survey instruments are included at Appendix B..

Consultation

The evaluation included consultation with key stakeholders from the Department, ABA,

jurisdictional representatives and professional associations. Small focus group discussions

were also held with mothers from a number of different population groups. Discussion

guides were developed for consultation with stakeholders other than the Department and

ABA.

Consultations were conducted with the following stakeholders:

Department of Health and Ageing;

Australian Breastfeeding Association;

Breastfeeding Jurisdictional Officers Group (BJOG) (not including NSW and the

NT); and

professional associations (Lactation Consultants of Australia and New Zealand and

Australian College of Midwives/Baby Friendly Health Initiative) .

Input from maternal and child health workers was available through feedback provided

by a number of BJOG members.



Focus groups were held with a total of 14 new mothers from the following population

groups:

mothers with disabilities (conducted as semi structured telephone interviews);

young mothers;

mothers from culturally and linguistically diverse backgrounds; and

mothers from a growth corridor in the outer suburbs of Melbourne.

The final focus group with Aboriginal and Torres Strait Islander mothers was not able to

meet in the required project timeframes. As an alternative, consultation was undertaken

with the breastfeeding support group coordinator at the Aboriginal Health Service.

The full list of stakeholders consulted and details about each of the focus groups is

provided at Appendix C.

Desktop review

A targeted desktop review was conducted to explore service enablers and barriers in the

provision of telephone breastfeeding support, and to explore forms of support currently

available to breastfeeding mothers.

The targeted review of literature was sourced from the MEDLINE database for academic

articles published between 2000 and 2012. A search for grey literature from non-

government organisations, academic institutes and government agencies was also

undertaken. Search terms included non-government organisation and service delivery,

breastfeeding, interventions, practice, support, telephone and helplines.

A snapshot of different telephone helplines and online support was also developed to

populate the landscape of current support available and to identify differentiation amongst

them.

2.4 The evaluation tools

Evaluation tools utilised in this project comprised:

Breastfeeding Helpline caller survey tool;

Breastfeeding Helpline counsellor survey tool;

stakeholder discussion guides; and

focus group questions.

Development and use of each of the tools is described below.

Caller survey tool

The caller survey tool was designed to be a principal source of new data for the

evaluation, capturing the characterisitics and needs of callers to the Breastfeeding

Helpline and their experience of using the service.

This new data contributed to information about utilisation of the Breastfeeding Helpline,

levels of satisfaction with the service received, and the impact of the Breastfeeding

Helpline in driving greater knowledge and understanding of the benefits of breastfeeding.



The design of the caller survey tool was informed by existing survey tools currently

deployed by the ABA as part of their own quality assurance methods, and recent research

conducted on behalf of the ABA by StrategyCo. This ensured a level of consistency

between the data sets, but also minimised confusion amongst callers who may have

responded to quality surveys undertaken periodically by the ABA.

Development of the caller survey tool was undertaken in close consultation with the

Department and ABA. The final tool was approved by the Department.

Implementation involved extensive communication through the ABA to volunteer

counsellors who were rostered on between 28 May and 17 June 2012, informing

counsellors of the purpose and intent of the survey, and providing direction on how to

alert callers to the existence of the survey.

The caller survey tool was hosted on the homepage of the ABA website. A short

preamble outlined the intent and purpose of the evaluation and survey, and a link to the

online survey was provided.

The caller survey tool is included at Appendix B.

Counsellor survey tool

The counsellor survey tool was designed to be a principal source of new data for the

evaluation capturing the operation of the Breastfeeding Helpline from the counsellor’s

perspective, the utilisation of the Breastfeeding Helpline by callers from different

backgrounds, and providing an insight into skills, education and qualifications of the

ABA counsellor workforce.

This new data assisted in determining how appropriate and effective the implementation

of the Breastfeeding Helpline has been, utilisation of the Breastfeeding Helpline, levels of

satisfaction with the service provided, adequacy of training and education for counsellors,

and the impact of the Breastfeeding Helpline in driving greater knowledge and

understanding of the benefits of breastfeeding.

The design of the counsellor survey tool was informed by existing survey tools currently

deployed by the ABA as part of their own quality assurance methods. This minimised

potential for confusion amongst counsellors who may have responded to previous surveys

and built on quality measures determined by the ABA.

Development of the counsellor survey tool was undertaken in close consultation with the

Department and ABA. Feedback and suggestions were incorporated where appropriate,

before final endorsement of the counsellor survey by the Department.

Implementation of the survey involved extensive communication through the ABA to

volunteer counsellors rostered on between 28 May and 17 June 2012. Emails were sent

from the evaluation team to all the volunteer counsellors who had at least one shift

rostered on during the survey period. Reminder emails were sent at weeks two and three

of the survey period.

A link to the survey tool was emailed directly to each of the rostered on volunteer

counsellors.

The counsellor survey tool is included at Appendix B.



Stakeholder discussion guide

The iterative and ongoing dialogue with members of the Department and stakeholders

from the ABA during the life of the project was guided by the requirements of the

evaluation project.

Discussion guides supported consultations with BJOG members and representatives from

relevant professional associations. The guides provided a brief background to the project

and outlined suggested areas of discussion.

These consultations sought to explore the level of coordination between the Breastfeeding

Helpline and the broader service system operating in each jurisdiction, and whether the

Breastfeeding Helpline had contributed to improved breastfeeding outcomes in the

community.

The Department endorsed the discussion guides prior to their distribution. The discussion

guides are included at 0.

Focus group questions

The purpose of the focus group discussions with different population groups was to

examine utilisation of the Breastfeeding Helpline by mothers, and, where appropriate, to

determine their levels of satisfaction with the Breastfeeding Helpline.

Accordingly, the discussion guide questions were designed to elicit information from the

participants about their awareness and experience of the Breastfeeding Helpline. A

further consideration for the focus groups was the expectation that mothers had not used

the Breastfeeding Helpline. To address this issue, questions were also designed to explore

other sources of information and support that mothers may have used to assist them in

making decisions about how to feed their baby.

The focus group questions were designed to be exploratory in nature, and to suit the

format of an informal group discussion. They were drafted by the evaluation team and

endorsed by the Department prior to their distribution in facilitating focus group

organisation and discussion.

A copy of the focus group discussion guide is included at 0.



Chapter 3

Evaluation results

The findings of the evaluation provide insights into issues of access, quality and

awareness in relation to the Breastfeeding Helpline. These broad issues are further

investigated as follows.

Access — service implementation, cost effectiveness, utilisation, caller satisfaction

and access by priority population groups.

Quality — counsellor standards, supply, and supporting and maintaining the

workforce.

Awareness — support for health professionals and health professionals’

understanding of the Breastfeeding Helpline role.

Marketing — communication about ABA education and training activities and

strategies to encourage participation.

3.1 Access to Helpline breastfeeding information and support

Service implementation

Has the Helpline service been implemented as intended?

Trained volunteer counsellors are rostered on to shifts over the 24 hour period of the

Breastfeeding Helpline service, on seven days of the week. The roster takes account of

patterns of demand for the service, which fluctuates within the 24 hour period, between

week days, weekends and on public holidays. There is a core of approximately 100

counsellors rostered in a week with additional capacity through unscheduled log in of

counsellors during shifts.

Information about counsellors on roster and the number of calls to the Breastfeeding

Helpline shows that the proportion of calls to counsellors has gradually increased over the

period from July 2009 to March 2012 from approximately 15 to 17 calls per counsellor

respectively. Over the same period, the proportion of counsellors to calls answered has

remained relatively constant at around 13 calls per counsellor (see 0). Counsellor survey

feedback, however, suggests that some shifts at least can be very busy with little time for

pause. As volunteers are home based, a heavy caseload would reduce the flexibility for

counsellors to attend to other matters over the period of the shift and potentially reduce

their capacity to volunteer.



Figure 3.1

COUNSELLOR CASELOAD BY CALLS RECEIVED AND BY CALLS ANSWERED

Source: ACG analysis of Helpline administrative data.

Promotion of the Breastfeeding Helpline as a toll free call is diminished by the increase in

mobile phone users. Calls from mobiles to 1800 numbers are charged at standard rates.

Mobile phone calls made up 27 per cent of calls received by the Breastfeeding Helpline

since October 2008 to February 2012 and 32 per cent of unanswered calls for the same

period. Stakeholder feedback including comments from focus group participants

suggested that cost may have an impact on young mothers using the Breastfeeding

Helpline. This potentially restricts their choice of support services rather than necessarily

their access to alternative sources of information and support. However, professional

associations and jurisdictions consulted expressed concerns about equity of access for

mobile phone users.

In relation to service coordination and facilitating pathways to services, information about

the Breastfeeding Helpline is provided by a wide range of service providers and in

different settings. 02 shows that the hospital setting is the most likely place for callers

responding to the evaluation survey to have first heard about the Breastfeeding Helpline.

Friend or family member was the highest single source of information about the

Breastfeeding Helpline followed by health professionals dispersed across the workforce

and including midwife, maternal and child health nurse and to a lesser extent, doctor and

lactation consultant. Information provided by the ABA featured in access to the website,

brochure and most likely in information provided in hospital.



Figure 3.2

FIRST SOURCE OF INFORMATION ABOUT THE BREASTFEEDING HELPLINE REPORTED

BY CALLERS (N = 97 CALLERS)

Source: ACG National Breastfeeding Helpline Caller Survey, 2012.

The Breastfeeding Helpline support has also included active referrals to other services.

Counsellor feedback through the evaluation survey showed that 85 per cent of

respondents made a referral on their last shift (see 03). Fifteen per cent of respondents

also indicated that a referral would have been made if they had been able to access

information on the appropriate agency.

Counsellors also noted that where callers on their last shift indicated that they had been

referred to the Breastfeeding Helpline, this referral was made by friends or family (77

callers) or health professionals (72 callers). Eight callers indicated a referral by another

helpline.

COUNSELLOR REFERRALS DURING LAST SHIFT (N = 174 RESPONDENTS)

Source: ACG National Breastfeeding Helpline Counsellor Survey, 2012.

Stakeholder feedback, however, suggests that there is not a systematic or integrated

process for referrals to the Breastfeeding Helpline at jurisdictional level and through the

related workforce.

It was also evident from consultations that other national and jurisdictional helplines

attract breastfeeding calls (over 40,000 calls in a 12 month period to two helplines in one

jurisdiction) reinforcing the view that callers may go to several sources for support. There

was some concern about the need for clear differentiation between helplines to assist in

minimising duplication of services, appropriate referrals and improving consumer

choices.

To this extent, stakeholders articulated the key features of the Breastfeeding Helpline as

including non - clinical, peer support, available at all times and anonymous.



Effectiveness of telephone helplines to support breastfeeding

Telephone helplines

Telephone based interventions are an increasingly common and legitimate method for the

delivery of health services. They can provide a flexible and in home support for callers

that bypasses barriers to healthcare such as accessibility, geography, transportation and

cost. They are not without limitations however, relying on caller initiative and preclude

face-to-face contact.

Table 3.11 provides a snapshot of selected helplines available to parents and other callers

to provide information, advice and support about infant feeding and breastfeeding.

Table 3.1

HELPLINES AVAILABLE TO MOTHERS, PARENTS AND CAREGIVERS

Helpline Coverage Staffing Aim

National Breastfeeding Helpline

1800 686 268

National coverage

24 hours a day, 7 days a week

Volunteer counsellors

Reassurance, support and counselling for breastfeeding mothers and other callers.

Pregnancy Birth and Baby Helpline

1800 882 436

National coverage.

24 hours a day, 7 days a week. Registered nurses General advice and counselling about

pregnancy, childbirth and parenting issues during the first 12 months of a baby’s life.

Health Direct Australia (incorporating the after hours GP Helpline)

1800 022 222

Available in the Australian Capital Territory, New South Wales, Northern Territory, Western Australia, South Australia, Tasmania.

24 hours a day, 7 days a week

Registered nurses and General Practitioners

Health information and assistance about any health issue, with capacity for referral to a GP for diagnosis and medical advice.

Victorian Maternal and Child Health Helpline

13 22 29

Available in Victoria.

24 hours a day, 7 days a week.

Qualified maternal and child health nurses

Information, support and guidance regarding child health, nutrition, breast feeding, maternal and family health and parenting for Victorian families with children from birth to school age.

NURSE-ON-CALL

1300 60 60 24

Available in Victoria


Registered nurses Expert health advice from a registered nurse, 24 hours a day, 7 days a week.

13HEALTH

13 43 25 84

Available in Queensland


Registered nurses Health related information and advice including provision of a child health advice service that provides parenting support, education and advice to parents/carers and service providers of children aged 0-5 years.

Parenting lines

Various numbers across each jurisdiction

Operates in each jurisdiction – operating hours vary across each jurisdiction

Professional counsellors from a range of backgrounds including social work and psychology

Support, counselling and parent/carer education for children aged between 0–18 years of age.

Source: Helpline websites



The rise of Web 2.0 technology and the proliferation of smart phones is driving change

amongst service delivery models and the manner in which individuals source information.

Video conferencing and other interactive internet based interventions are an emerging

(though at times problematic) field of healthcare, that have been shown to provide an

important role in facilitating peer support and gathering information (Cowie et al 2008;

and Hardyman et al 2005).

Table 3.2 provides an overview of selected websites, types of information available, and

the level of user interaction available to users seeking breastfeeding information and

support.

Table 3.2

WEBSITES AVAILABLE TO MOTHERS, PARENTS AND CAREGIVERS

Website Information and education User interaction

The Australian Breastfeeding Association

https://www.breastfeeding.asn.au/

Comprehensive information about breastfeeding; information also available about weaning and other forms of infant feeding. Activities and promotion of membership to Australian Breastfeeding Association also provided.

E-counselling provided.

Online forum hosted by the Australian Breastfeeding Association.

The Pregnancy, Birth and Baby web portal

http://www.healthdirect.org.au/pbb

Fact sheets covering the first 12 months of a baby’s life, including breastfeeding, and other forms of infant feeding.

Not applicable.

Raising Children Network

http://raisingchildren.net.au/

Resources to assist parents raise children from birth to teens. A range of formats and methods used, including streaming video demonstrations.

Online forums hosted by Raising Children Network.

The Bub Hub

http://www.bubhub.com.au

Independent pregnancy and parenting website, providing information from conception to the early years.

Online forums hosted.

Babycenter

http://www.babycenter.com.au/

Pregnancy and parenting website, providing information from conception to the early years.

Online forums hosted.

Web Child

http://www.webchild.com.au/

Parenting resource, from pregnancy to schooling. Online forums hosted.

Good practice in the delivery of telephone information and support

Noting these features, a systematic review of different telephone support services for

women during pregnancy and early post partum, provided inconclusive findings on

services such as smoking cessation advice, but did find that telephone support can

positively impact on breastfeeding duration and exclusivity (Dennis & Kingston 2008).

Significant features of these studies on the effectiveness of telephone helplines, includes:

the capacity for mothers to call when they need to, rather than relying on set times;

and

the greater relevance of peer support and counselling support, rather than professional

or clinical advice, in contributing to improved breastfeeding outcomes, noting that

peer support and counselling is highly dependent on the quality of training provided

and accordingly more susceptible to service variability (Dennis & Kingston 2008).

https://www.breastfeeding.asn.au/

http://www.healthdirect.org.au/pbb

http://raisingchildren.net.au/

http://www.bubhub.com.au/





The importance of providing a service that ensures continuity of care is borne out by an

evaluation of a service operating from a local government authority in Melbourne that

incorporated both a telephone support line and in home visits. The evaluation found that

mothers were breastfeeding longer and were better educated about the benefits of

breastfeeding (Coffield 2008). In this instance, the staffing of the telephone helpline is

undertaken by a Maternal and Child Health Nurse Lactation Consultant and is integrated

into a broader service system response.

Key features of approaches to telephone helplines in other countries includes:

findings that quality rather than the quantity of peer support contact appeared to be

the most important factor in a peer telephone support and assistance service

established in Canada for first time mothers (Dennis et al 2002);

establishment of a language-specific newborn feeding telephone helpline serviced a

hard to reach culturally and linguistically diverse population and appeared to

contribute to improved breastfeeding exclusivity and duration (Janssen et al 2009);

and

Breastfeeding helplines in Taiwan and Lebanon found that use of the service was

highest by mothers calling during the first month after birth (Wang & Chen 2008; and

Osman et al 2010).

Drawing on the review of services currently available, the selected literature, and

consultations undertaken during the project, identified good practices associated with the

delivery of a breastfeeding support helpline have been summarised in Box 3.1.



Box 3.1

GOOD PRACTICE RELEVANT TO A BREASTFEEDING SUPPORT HELPLINE

Availability and responsiveness

The provision of 24 hour, 7 day a week access is required of a breastfeeding support line if it is to service the demands and potential stresses associated with breastfeeding.

The flexibility and responsiveness to accommodate different types of calls, ranging from simple information requests through to the counselling of distraught mothers, is another indicator of an effective service. Significant wait times are an inhibitor to ongoing engagement of mothers.

Quality and consistency of information and support

A staffing profile of well trained and supported counsellors or practitioners is required to ensure a quality service, retention of the workforce and to sustain confidence within the service population.

Variability in breastfeeding information and support can confuse mothers and impact decisions they make about breastfeeding their child. Accordingly, the presence of a: trained and competent telephone staffing workforce; consistent and up to date organisational resources and guidelines; linkages with other services and research organisations; and ongoing quality assurance measures, are essential to ensuring a consistency of information and advice provided to callers.

Integration of services, and continuity between professional and peer support

Mothers trust and rely on quality health and clinical advice to assist them in promoting their child's health and wellbeing. They also value their own informal social networks, and peer support provided by other mothers who have real life experience of the issues they are facing. An effective breastfeeding support helpline needs to sit within a broader service system with appropriate linkages and referral pathways that assist mothers access the particular form of advice, information or support they require and when they most need it.

Capacity to meet diverse needs of callers

The strength of a peer support model of service provision is in having the trust and recognition of the different population groups that need to access it. This requires a staffing profile with an appropriate mix of training, skills and lived experience that aligns with potential callers. An associated promotional requirement involves appropriate marketing of the service amongst particular populations, and partnering with existing services or platforms.

Source: The Allen Consulting Group based on a targeted literature review.

Service cost effectiveness

As part of considering the efficiency of the National Breastfeeding Helpline, a cost

effectiveness analysis (CEA) was undertaken, which compared the Breastfeeding

Helpline with two alternative models. The methodology of the CEA is outlined, with the

results and limitations of the analysis discussed. The results suggest that for all modelled

scenarios, the National Breastfeeding Helpline was more cost effective than the

alternatives.

Cost Effectiveness Analysis of the National Breastfeeding Helpline

A CEA compares the relative costs and outcomes of two or more interventions. In many

instances, outcomes are difficult to measure, so outputs are used instead as a measure of

effectiveness. When comparing the relative costs and effects of two or more

interventions, an incremental analysis is performed. An incremental analysis seeks to

determine how much more should be invested in a new intervention to derive an

additional benefit or outcome, relative to the status quo.



From a breastfeeding helpline perspective, this will assist in identifying whether the

Commonwealth Government should invest additional funds, and if so what quantity of

funds, to secure additional benefits in improving current helpline arrangements.

The methodology adopted for the analysis is described in Box 3.2.

Box 3.2

COST EFFECTIVENESS ANALYSIS METHODOLOGY

For this review, we have undertaken a CEA, which compares the current arrangements — the National Breastfeeding Helpline — with two alternative models. The models that have been considered in this review are:

Model 1: the National Breastfeeding Helpline (NBH) (status quo arrangements), with

the volunteer workforce working approximately 172 hours per week which equates to 4.6 Full-Time Equivalent (FTE) workers (May 2012);

Model 2: a Breastfeeding Helpline with Paid Staff, which is based on the experience of the NBH with a paid workforce. Similar to the NBH, this paid workforce is estimated at 4.6 FTE workers, with wage estimates derived for a low and high salary band, for relevant classifications in the Social and Community Services (SACs) Modern Award; and

Model 3: an Existing Comparator Helpline, which provides advice on a range of

issues, including breastfeeding. This model is fully funded and employs nurses to operate the helpline.

The cost effectiveness of Model 1 was compared to Model 2 and Model 3 for the 2010-11, and 2011-12 financial years. Analysis was completed for total and variable (operational costs) for each of the helplines, with the measures assessed including:

the cost per call received, which provide a measure of demand and access for the service;

the cost per call answered, which measures the actual use of the service;

the cost per call from callers who believed support was relevant. This provides a measure of overall effectiveness and performance of the telephone helpline.

Analysis was also completed on the cost per call for priority groups, focusing on calls from Aboriginal and Torres Strait Islanders. However the sample size was too small for this cohort to provide meaningful results.


Results

A CEA was completed assessing the relative merits of the models for 2010-11 and 2011-

12 financial years. This evaluation focused on calculating the CEA using the operational

costs. This provided a more realistic representation of the variable labour costs associated

with running a helpline, and removed some of the fixed costs, which were not measured

consistently across the models.

Note : The individual model details inclusive of Table 3.3 have been removed from this

document as they contain Commercial in Confidence data.



Findings

The results of the analysis suggest that Model 1 (the National Breastfeeding Helpline) is

more cost effective than the alternatives.

However these results may be impacted by the fact that the costs of Model 3 may be

significantly higher than Model 1, given that services other than feeding advice are

provided. In addition, it may be the case, that Model 3 is still in an early establishment

phase, and this may account for its lower volume of calls when compared to Model 1.

It may also be suggested that the performance of the National Breastfeeding Helpline may

improve if staff are paid and this results in an increased number of call takers being

available, given that the number of calls answered have declined over time, whereas the

number of calls received have remained roughly constant over time (ABA Helpline Data

2012). These trends are in line with an increase in average call waiting time and an

increase in calls lost (due to hang-ups), which correspond to a decline in the number of

available volunteers. This analysis suggests that the supply of active volunteers to staff

the National Breastfeeding Helpline is at a critical point with any reduction in volunteers

having a direct impact on capacity to respond to demand.

In addition, 95 per cent of the callers believe that the support provided by the National

Breastfeeding Helpline is relevant (StrategyCo 2011). This high rating of customer

satisfaction may suggest that the room for further quality of service improvements are

limited if volunteers are paid. There is also evidence to suggest there is no significant

difference in service delivery performance (including productivity improvements)

between paid and volunteer workers staffing the helplines (Campos 2008).

Both the high consumer satisfaction rate of the National Breastfeeding Helpline,

combined with the conclusion that paid and volunteer workers perform equally (Campos

2008) also weakens the possibility that the gap between calls received and calls answered

is due to a productivity issue rather than a labour shortage.

Sensitivity analysis was undertaken which adjusted the existing comparator model

(Model 3) to better align with the focus of the Breastfeeding Helpline model (Model 1)

and to allow for growth in calls in out years. Model 1 remained dominant for both

options.

CEA discussion

The results of the CEA analysis suggest that Model 1 (the National Breastfeeding

Helpline) is more cost effective than Model 2 (the Breastfeeding Helpline with paid staff)

and is dominant compared to Model 3 (the Existing Comparator Helpline). These results

did not change for Model 3, when sensitivity analysis was completed.

Given that volunteers staff the National Breastfeeding Helpline, these results are not

unexpected. The other comparator helplines face an additional cost impost through

payments for staff. In addition, the National Breastfeeding Helpline could be viewed as a

more ‘mature’ helpline as it has been in operation for a number of years, compared to

Model 3, which is only in its second year of operation. This may account for the

differential between these helplines in terms of calls received.



These results should be interpreted with these factors in mind. In addition, there are a

number of assumptions used in the modelling, which may not hold up in practice:

all the outputs used in the CEA are based on ‘annualised’ estimates for the 2011-12

financial year, as data were only available for three-quarters of this year. While past

trends can be used to indicate future trends, there is no reason to pre-suppose that the

existing trends may apply to the last quarter of the 2011-12 financial year;

for the National Breastfeeding Helpline (Model 1), we have not been able to provide

representative results for calls for Aboriginal and Torres Strait Islanders, given that

their assumed participation rate in calling the helpline is very low at 0.58 per cent of

the total (ABS 2006);2

for the Breastfeeding Paid Staff Model (Model 2), the costs and output data have

been assumed from Model 1, with the addition of the total annual wage costs. These

costs are conservative estimates and may be higher if labour on-costs are included

(representing an additional 10 per cent of estimated costs). However, the

incorporation of these extra costs would not impact on any conclusions from the

analysis; and

the Existing Comparator Helpline Model (Model 3) can be considered not as ‘mature’

as Model 1, given that it only started taking calls in the financial year 2010-11. Even

though the calls have increased in the current financial year, the data suggests that

this helpline has not reached a ‘stable state’ where calls are consistent over the years.

Furthermore, the cost data are almost five times higher than those for Model 2, given

that this helpline provides advice on more topics than breastfeeding alone. In

addition, the costing breakdown for this model compared to the breakdown in Model

1 and Model 2, may not be strictly comparable as insufficient information was

available to allow this analysis.

In terms of the sensitivity analyses, the two modelled options did not impact the results

significantly, as Model 1 (the National Breastfeeding Helpline) remained dominant

throughout. The first sensitivity analysis proved to be even less cost effective than the

original Model 3 (Existing Comparator Helpline) since all costs ratios were roughly 20

per cent higher when compared to Model 3. However, the results of the second sensitivity

analysis were improved compared to the original Model 3. This was largely due to the

high assumed growth of 88 per cent and 85 per cent in calls received and calls answered

respectively. However these results could be questioned, as it is not likely that the same

level of growth can be sustained over time.

This analysis confirms that the National Breastfeeding Helpline is the most cost-effective

option, which has been considered in this review.

Service utilisation

To what extent have mothers and their families utilised the services of the Helpline?

2

This estimate is based on the number of females aged 15 to 44 years in the Aboriginal and Torres Strait Islander population.



The number of calls to the Breastfeeding Helpline totalled 86,214 in 2010-2011. This

represented a small increase of approximately 6 per cent over the previous year. 0 draws

from the evaluation survey sample to provide a snapshot of the profile of callers. While

the majority of calls were from metropolitan areas, almost one quarter were from regional

Australia. A very small proportion of calls were from remote areas of some states. Over

the survey period, calls were received from all states and the ACT with the majority

coming from NSW and Victoria. This accords with ABA data that show the highest

number of calls to the Breastfeeding Helpline since its inception originated in NSW and

Victoria.

CALLER LOCATION (N = 94 RESPONDENTS)

Source: The Allen Consulting Group National Breastfeeding Helpline Caller Survey, 2012.

Based on ABA data, the NT is the lowest user of the Breastfeeding Helpline accounting

for 0.8 per cent of all calls received since implementation of the service in October 2008

up to May 2012, followed by Tasmania (0.95 per cent) and the ACT (1.7 per cent). The

demand for the Breastfeeding Helpline continues to be lowest for the NT when

adjustment is made for the relevant jurisdiction populations as shown in 0. The figure

provides an overview of the number of calls received by the number of births for each

jurisdiction and Australia as a whole mapped for the period July 2009 to October 2010.

The figure shows that the demand for Breastfeeding Helpline services varies across

jurisdictions, with the highest demand in the ACT and the lowest in the NT. This could be

explained in part by lower breastfeeding rates amongst disadvantaged population groups,

including Aboriginal and Torres Strait Islander mothers, less educated women and

younger mothers (ABS 2011b, 2007). For comparison purposes, calls to the Pregnancy,

Birth and Baby Helpline indicate that in the first quarter of 2012, calls from the NT

accounted for 0.6 per cent of all calls to the helpline (National Health Direct 2012)

suggesting that low usage may be more widely applicable to telephone helplines.



NUMBER OF CALLS RECEIVED PER BIRTH JULY 2009 TO OCTOBER 2010

Source: ABA Helpline data; ABS 2011a.

Counsellors surveyed reported that the calls taken in their last shift were largely from

callers about their infants who were under the age of 12 months (see 0). Of these infants,

45 per cent were four weeks old or younger and 40 per cent were between one and six

months old. The single highest age category was two to four weeks old making up18 per

cent of infants under the age of 12 months.

AGE OF BABY & NUMBER OF CALLERS REPORTED BY COUNSELLORS DURING LAST

SHIFT (N = 172 RESPONDENTS)

Source: The Allen Consulting Group National Breastfeeding Helpline Counsellor Survey, 2012.



As shown in 0, a large proportion (almost 48 per cent) of caller survey respondents were

aged between 30 and 34 years. The age of the majority of callers ranged from 26 to 39

years (around 95 per cent). A small proportion of callers were born overseas.

The significance of this population group amongst callers to the Breastfeeding Helpline is

broadly consistent with two other sources of data, specifically:

ABS data on the age of mothers giving birth, with 74 per cent of all births in 2010

occurring to mothers aged between 26 and 39 and those aged between 30 and 34

being the dominant group (32 per cent) (ABS 2011a); and

Quarterly data from the Pregnancy, Birth and Baby Helpline with 70 per cent of

female callers aged 25 to 39 and those aged between 30 and 34 being the dominant

group (30 per cent) (National Health Direct 2012).

AGE AND PLACE OF BIRTH OF CALLERS (N = 94 RESPONDENTS)

Source: The Allen Consulting group National Breastfeeding Helpline Caller Survey, 2012.

Callers to the Breastfeeding Helpline indicated that they considered a telephone helpline

to be a very important source of information and advice in supporting decisions they

made about breastfeeding (see 0). This was followed by maternal and child health nurse

and family. A majority of respondents considered social media sources were not

important.



CALLER PERCEPTIONS OF THE IMPORTANCE OF INFORMATION AND ADVICE SOURCES

(N = 96 RESPONDENTS)


Consistent with previous research on callers to the Breastfeeding Helpline, 0 shows that

the majority (60 per cent) of survey respondents were feeding their child exclusively on

breastmilk with a further one quarter (26 per cent) partly breastfeeding and providing

solids.

BREASTFEEDING PRACTICE OF CALLERS (N = 96 RESPONDENTS)


Also relevant to consideration of service utilisation, is the reason for contacting the

Breastfeeding Helpline. 0 shows that the top reasons for contacting the Breastfeeding

Helpline recorded by caller survey respondents were to obtain information on feeding

patterns, sore breast or nipples, reassurance, and milk supply and storage issues.



TOP REASONS FOR CONTACTING THE HELPLINE AS REPORTED BY CALLERS (N = 96

RESPONDENTS)


The counsellors understanding of the callers main reasons for contacting the

Breastfeeding Helpline varies slightly as shown in 0. The single most often recorded

reason is sore breast or nipples, followed by concern with milk supply, wanting

reassurance and seeking information on feeding patterns.



TOP REASONS FOR CONTACTING THE BREASTFEEDING HELPLINE AS REPORTED BY

COUNSELLORS (N = 174 RESPONDENTS)


Stakeholder feedback suggests that caller wait times are an issue based on comments by

mothers to other helplines and to health professionals. As shown in 0, the number of

counsellors fell over the period July 2009 to March 2012, the numbers of calls answered

fell and the numbers of calls lost rose. This suggests a correlation between Helpline

resourcing and service delivery that poses a potential barrier to caller utilisation of

services.



CALL WAIT TIMES

Source: The Allen Consulting Group analysis based on ABA data 2012.

The conclusion of a correspondence between Breastfeeding Helpline resourcing and

effectiveness is supported by the increase in average waiting time for a caller to be

connected to a counsellor from approximately 80 seconds to 120 seconds over the same

time period. As the total number of calls received has remained roughly constant, the

increase in waiting time appears to correspond to the decreasing number of counsellors

over the time period.

Utilisation of the Breastfeeding Helpline should be in part linked to consumer awareness

of the service. Stakeholder feedback suggests that awareness is facilitated by a wide base

of support for the Helpline among health professionals and services, and the multiple

sources of information about the service. In addition, the Breastfeeding Helpline was

strongly associated with the ABA and benefited from the organisation’s high profile.

Additional impetus was provided by the interest of some jurisdictions in health facility

accreditation under the Baby Friendly Health Initiative (BFHI). This had involved

provision of training on breastfeeding to health professionals in some public hospitals as

part of meeting facility accreditation standards.

Despite this, a small number of caller survey respondents suggested that advertising of

the Breastfeeding Helpline could be improved (see below).

Caller satisfaction

Are callers satisfied with the support provided by the Helpline?

Insight into caller satisfaction with the Breastfeeding Helpline service is provided by

responses to the caller survey seeking their rating of the experience. The responses are

summarised in 0. A high level of satisfaction with the service can be inferred from strong

agreement indicated for recommending the service to others, the professionalism of the

counsellor and the relevance of the information and support provided. In addition, almost

half of the respondents strongly agreed that the information received changed their

breastfeeding practice and a further one quarter agreed.



Over three quarters of the callers considered that the wait time before connecting to a

counsellor was appropriate.

CALLERS EXPERIENCE OF THE BREASTFEEDING HELPLINE


Callers were also asked explicitly whether the service they had received from the

Breastfeeding Helpline had met their needs. Of the 96 respondents to this question, only

one caller indicated they had not had their needs met. Asked to elaborate further, the

caller outlined that:

The counsellor offered to email me further information but did not follow through. Also this was my

third attempt at contacting the ABA. The first time I hung up after waiting on hold for nearly 15

minutes. The second time I used the online form but it took 4 or 5 days to get a response (during which

time I had called again).

Caller survey respondent

All callers were invited to provide suggestions to improve the


Amongst the responses collected, waiting times were a consistent theme. A number of

callers surveyed reported that lengthy wait times had been experienced. Callers generally

were prepared to hold on, ‘but I don’t really mind given that I can talk for as long as I

need’, and appreciated the advice of where they were in the queue. Some callers found it

stressful to wait, and others saw the counsellor caseload as a function of inadequate

funding from government and out of the control of the ABA.

The only aspect of the helpline that has not been fantastic in my experience is

that a couple of times there have been

long delays and I've been told by the recorded message to call at another

time... which is hard when you're in a

crisis and have a baby!




Other suggested improvements from callers included a need for:

greater advertising and promotion of the Breastfeeding Helpline to

new mothers, as well as the importance of challenging perceptions of

the ABA within the community, and broadening their appeal to all

mothers;

consistency of advice and support received;

exploring opportunities for greater continuity of service and care when accessing the

Breastfeeding Helpline, including the option of speaking to the same counsellor; and

options to better tailor the service, specifically by matching the needs of callers to the

specific strengths or experiences of counsellors, including transfer of calls or call

backs at agreed times.

This was consistent with suggestions that were made from callers that were collected as

part of the StrategyCo research in 2011, specifically, that:

the wait times for the Breastfeeding Helpline were too long;

there was a need for more counsellors, and a call back service;

there needed to be back up options if a counsellor could not answer a

query; and

that counsellors should be regularly updated on new breastfeeding

information, research and alternative feeding methods, and that callers

should not be judged or pressured about breastfeeding decisions.

Other stakeholder feedback collected through this project (survey respondents and focus

group members) suggests that on occasions the experience can be variable depending on

the counsellor for those calling on more than one occasion, however, this did not appear

to dissuade return calls. There has also been consistent reference to information being

provided that is at odds with advice provided from other sources. However, the clear

majority of the survey respondents strongly agreed (56 per cent) or agreed (35 per cent)

that the information they received was consistent with other information sources.

In assessing the satisfaction with the Breastfeeding Helpline service, consideration has

also been given to the systems in place to provide appropriate oversight and development

of the service. Governance arrangements for the Breastfeeding Helpline embed the

service within the wider capability of the ABA leveraging from the organisation’s

infrastructure including:

the Lactation Resource Centre and the generation of accurate and appropriate

information material;

training activities including continuous improvement strategies at all levels (national,

branch, local) of the organisation;

marketing and promotion of ABA services; and

dedicated national Breastfeeding Helpline manager positions to facilitate monitoring

including against service agreement indicators and on a day to day basis, such as

maintenance of the web portal and staffing of the Breastfeeding Helpline roster.

I wish it was advertised more as I

only just found the ad after three months and it has helped me

enormously!


I hear often from women that the

ABA are breastfeeding nazi's and don't support formula feeding if

it's needed and they are scared to

call. A boost to their image would be great.




Priority population groups

How well is the Breastfeeding Helpline utilised by priority population groups?

The Breastfeeding Helpline provides a universal service, accessible to all mothers. Within

that scope, there are also a number of subpopulations identified. It is evident from the

data collected through this project that reach into these population groups is low. Project

findings for each of these population groups, is explored below.

Young mothers

Younger mothers are increasingly disengaged from the broader health and support service

system, and are less likely to initiate and sustain breastfeeding than older mothers (Amir

et al 2010). This view from the literature was confirmed in consultation with

jurisdictional representatives and in discussion with several Maternal and Child Health

Service across Victoria during the coordination of the different focus groups. It was also

borne out in the proportion of young mothers who participated in the caller survey.

From the caller sample size of 94 mothers, only one was aged under 21 years of age.

Nevertheless discussion in the focus group indicated a level of awareness of the

Breastfeeding Helpline and its role and purpose amongst younger mothers, principally

through the promotion of the Breastfeeding Helpline in hospital and through contact with

local Maternal and Child Health nurses.

Other findings from the discussion with young mothers included:

no personal use of the Breastfeeding Helpline, though aware of other young mothers

who had used and valued the service;

valuing of social networks and peer support from others who had experienced similar

issues, with a strong preference for face to face contact; and

wariness of services they felt would judge them for particular decisions they had

made about whether to breastfeed their children.

The increasingly prevalent use of smart phones by young people presents both as a

challenge and opportunity for telephone based service delivery. Higher costs for mobile

phone calls to toll free numbers was recognised as a major inhibitor to usage amongst

young mothers (and Aboriginal and Torres Strait Islander mothers) by most jurisdictions.

However this also presents as an opportunity to explore new methods of communication

through messaging and social media to interact with hard to reach priority population

groups. For example, the StrategyCo research found that 42 per cent of survey

respondents would use SMS reminders and support mails for new mothers if they were

available.

This is an issue that the ABA recognises and has sought to address. As demonstrated by

the caller profile at 0, the majority of mothers who used the service and participated in the

survey were 26 years of age or older and born in Australia.

Mothers from a culturally and linguistically diverse (CALD) background

Of the caller survey sample, 18 callers, or nearly 20 per cent of respondents, were born in

a country outside of Australia. Table 3.4 identifies each of the countries of origin, and the

numbers of callers.



Table 3.4

COUNTRY OF ORIGIN

Country No. Country No. Country No. Country No.

Canada 1 Ireland 1 Philippines 1 Swaziland 1

England 2 Lithuania 1 Serbia 1 Sweden 1

Finland 1 Netherlands 1 South Africa 1 Taiwan 1

Hong Kong 1 New Zealand 1 Sri Lanka 1 USA 2


Only two of the 98 callers had English as a second language at home. For those two

callers, the dominant language at home was Greek and Sinhalese. From the counsellor

survey, four counsellors indicated that they had used the Translating and Interpreting

Service on their last shift.

By definition, the attitudes, expectations and experiences of breastfeeding amongst

mothers from CALD backgrounds are not uniform. Best practice peer support and

counselling programs makes the case for matching of age, socioeconomic status and

cultural background (CCCH 2006). This presents a particular challenge for a telephone

based peer support service model, as the service is dependent on a volunteer workforce

that responds to calls as they are received.

This dilemma was borne out in some of the discussion within the focus group where

overall, mothers who had used the Breastfeeding Helpline, had appreciated the service

and support but who had also experienced less satisfactory responses, primarily because

of the views, attitude and approach of the counsellor.

Other findings from the discussion with mothers included:

a mixed level of awareness and use of the Breastfeeding Helpline amongst the group;

although

mothers valued having the option of being able to access the service at any time,

particularly when they felt isolated and needing comfort.

Anecdotal feedback from jurisdictions and professional associations suggested a lack of

proficiency in English amongst CALD communities was the biggest barrier to CALD

mothers accessing the Breastfeeding Helpline. This was compounded by perceptions

amongst some jurisdictions about the volunteer staff profile as predominantly white and

English speaking. There was also a lack of awareness amongst stakeholders of the

availability of translator services for the Breastfeeding Helpline.

Mothers with a disability

Mothers with disabilities experience a number of issues and attitudes regarding their

capacity to breastfeed. This includes a lack of awareness and engagement throughout the

child and family support service system of the issues faced by parents with a disability,

and is compounded by an absence of coordinated and accessible services that accurately

reflect their needs and aspirations (WWDA 2009).



From the counsellor survey, none of the counsellors indicated that they had used the

Teletypewriter service to assist callers with a disability. However a significant proportion

of the counsellor survey sample size (over 30 per cent) felt their training did not equip

them with the skills needed to meet the needs of callers with a disability.

Forms of disability experienced by mothers engaged through consultation included,

Multiple Sclerosis, borderline developmental disorders, cerebral palsy, learning disorders,

and rheumatoid arthritis. Despite the challenges associated with these disabilities, all of

the mothers had initiated breastfeeding and most of them had sustained breastfeeding

beyond six months.

One older mother had used ABA services extensively when she breastfed, but amongst

the others there was limited awareness of the ABA and the Breastfeeding Helpline. Key

themes from the focus group included:

24 hour telephone support is important;

local health service networks such as Maternal and Child Health Nurses are key

sources of information and advice, and in home one-on-one support is especially

valued, however most mothers had also experienced episodes of inconsistent or

contradictory advice from health professionals;

peer support from other mothers with disabilities is particularly important —there is a

view amongst mothers that health professionals remain unconvinced about the

parenting or breastfeeding capacity of mothers with disabilities;

there is a reluctance to engage with the formal service network for fear of risking

statutory intervention from child protection services; and that

general support services for people for disabilities are fragmented and disconnected,

and that is compounded by a lack of support and expertise to meet the particular

needs of mothers with disabilities who are breastfeeding.

Adequacy of training and awareness of disability amongst volunteers was raised as a

concern by some stakeholders.

Aboriginal and Torres Strait Islander mothers

Rates of breastfeeding amongst Aboriginal and Torres Strait Islander mothers are lower

than amongst the broader community (NHMRC 2003). This issue is inextricably linked to

wider Aboriginal and Torres Strait Islander disadvantage that includes poorer access to

health services including antenatal sessions, high rates of smoking during pregnancy and

lower birthweight babies, all of which compound poorer life outcomes for Aboriginal and

Torres Strait Islander mothers and babies (PC 2011).

From the caller survey sample, only one mother identified as being of Aboriginal or

Torres Strait Islander origin, who indicated that overall the service was valuable and met

her needs.

There are a number of factors that impact on breastfeeding rates amongst Aboriginal and

Torres Strait Islander mothers. An overview compiled by the Best Start report includes:

proximity to urban centres — with lower rates of breastfeeding associated with

Aboriginal and Torres Strait Islander mothers who are closer to major urban centres;



access to services — a lack of available support services, or services that are

culturally appropriate is a significant barrier to accessing quality health information;

strength of social and kinship networks — social and kinship networks are

particularly important for Aboriginal and Torres Strait Islander mothers, with

supportive breastfeeding environments, and relationships playing a significant role in

decisions that mothers make about breastfeeding;

housing and accommodation — the quality of housing stock and the level of

overcrowding occurring can inhibit decisions to continue breastfeeding; and

cultural factors — younger Aboriginal and Torres Strait Islander mothers are less

inclined to breastfeed, and view bottle feeding as a more convenient form of infant

feeding.

Other considerations that were highlighted in consultation with jurisdictions included:

discussion around the prohibitive cost of mobile phone calls to toll free number. This

is seen as a major barrier to access for Aboriginal and Torres Strait Islander mothers.

However it should also be seen as an opportunity to explore innovative approaches to

connect with mothers and provide information and support (such as text message

reminders and call backs);

the importance that Aboriginal and Torres Strait Islander mothers place on seeking

information and support about breastfeeding from trusted friends, family members,

and health professionals they know and can relate to. Face to face contact is preferred

over phone contact as well; and

the need for the services to leverage off existing Aboriginal and Torres Strait Islander

services and networks to promote the benefits of breastfeeding and the Breastfeeding

Helpline.

Consultation with an Aboriginal Health Service group facilitator of an Aboriginal and

Torres Strait Islander breastfeeding support group emphasised the strengths of peer

support approaches, highlighting the value of linking young mothers with older mentors

in the community who had breastfed, and to whom the younger mothers could relate. The

appropriateness of marketing and promotional material that overloaded mothers with

textual information was also raised. The facilitator felt that visual approaches were likely

to be more effective.

It was also of interest that in light of decreasing interest and attendance of their

breastfeeding support group, the Service was looking at restructuring the program to

focus more broadly on parenting issues, including provision of breastfeeding support.

This was seen as an important move to encourage greater participation from fathers and

other family members.

Summary

The Breastfeeding Helpline has been established with the infrastructure that provides an

accessible service to mothers and their families across the country seeking breastfeeding

information and support. The service is cost effective when compared to another existing

helpline.

A consistent demand for services has been experienced and there is a high level of

satisfaction with the service provided.



Through the ABA, the Breastfeeding Helpline is networked with health professional

organisations, governments and health services. In addition, the Breastfeeding Helpline is

able to benefit from the wider activities of the ABA including training and resource

development.

Potential barriers to access include workforce supply, cost of calls from mobiles, lack of

awareness of communication supports for those with a hearing impairment and non

English speaking callers, and failure to differentiate from available helplines providing

parenting and health advice.

3.2 Quality of Breastfeeding Helpline information and support

Is the training provided for Breastfeeding Counsellors working on the Helpline is sufficient to

ensure the supply of a skilled workforce and the sustainability of a quality, responsive Helpline

service?

A series of formal and informal education and training programs are available to ensure

the quality of support provided by the Breastfeeding Helpline. An annual quality survey

is also conducted to contribute to monitoring of counsellor performance and identify

knowledge and practice gaps.

Standards for volunteer Breastfeeding Counsellors working on the Helpline

ABA has completed replacement of the Certificate IV in Breastfeeding Education

(Counselling), complying with the requirements of the national regulator.

All volunteer Breastfeeding Counsellors who work on the Breastfeeding Helpline are

required to meet these standards. While training is provided free of charge, Breastfeeding

Counsellors are required to commit to the Helpline for two years and to undertake

continuous improvement activities.

The quality of the information and support provided by Breastfeeding Counsellors is

monitored through annual quality surveys of counsellors and callers. Additional

independent research was commissioned in 2011 to undertake a telephone survey of

callers to broaden the sample size and capture users of the Breastfeeding Helpline who do

not visit the ABA website (StrategyCo 2011).

Supply of trained counsellors

Volunteers

As demonstrated in Table 3.11, a key point of differentiation for the Breastfeeding

Helpline is the volunteer profile of the workforce. Volunteers can be defined as

individuals who willingly give unpaid help, in the form of time, services or skills, through

an organisation or group, and which otherwise would have to be paid for, or be left

undone (ABS 2011b).

Recruitment and retention of volunteers is an issue for many not for profit organisations.

Motivation and recruitment is commonly underpinned by values and a belief in the

importance of helping others. Recognition of the contribution of volunteers and an

association with the purpose or mission of the organisation they are volunteering with, are

key drivers to volunteer retention (PC 2009).

Across Australia, the key social and demographic characteristics of the volunteer

workforce, finds that most are adults who:



have a family and live with a co-resident dependent child;

have a higher level of educational attainment; and

possess a high proficiency in English (ABS 2012).

Key challenges associated with the attraction and retention of volunteers include:

a changing profile of volunteers — there is a gradual decline in the numbers of

volunteers associated with health and community services that has been linked to

greater workforce participation and increased mobility; and

increasing costs associated with engaging and training of volunteers — associated

with a lack of organisational capacity and resources to engage, support and train

volunteers (PC 2010).

ABA volunteer Breastfeeding Counsellors working on the Helpline

There are approximately 700 enrolments in the Certificate courses (counselling and

community) compared to the usual number of trainees of about 450. There are multiple

entry and exit points in the online education course and most complete the Certificate in

14 months.

A recent development has been to offer a practicum period at the end of the counsellor

course. This innovation is supported by a new position of Breastfeeding Helpline mentor.

The newly qualified counsellor is provisionally appointed as a breastfeeding counsellor

and required to complete five shifts of two hours in less than three months with graduated

support. This support can also be offered to counsellors who have been away from the

Breastfeeding Helpline for a period of time. The practicum has resulted in improved take

up by new counsellors.

The development of the Diploma of Breastfeeding Management meets a demand from

health professionals who volunteer and from volunteers who are keen to convert their

Certificate qualification to a Diploma. The Diploma may assist in attracting more

volunteers from among health professionals.

Supporting and maintaining counsellor workforce

Breastfeeding Counsellors working on the Helpline were able to access a diverse range of

ABA training initiatives. As shown in 0, the most common forms of training, information

and support accessed in the last six months were newsletters, website updates and

meetings. These activities were common to all counsellors regardless of location. Of the

other activities available, counsellors residing in metropolitan areas favoured conferences,

those in regional areas conferences and counsellor forums, and those in rural areas

Breastfeeding Helpline mentoring and debriefing.



RATES OF ACCESS TO ABA TRAINING, INFORMATION AND SUPPORT IN THE LAST SIX

MONTHS BY LOCATION OF COUNSELLOR (N = 174)


Areas of training for continuing attention included the provision of support to priority

population groups. Although approximately 60 per cent or more of counsellors were

satisfied that the ABA training gave them the skills necessary to support callers from

different priority groups, this varied across groups as shown in 0. A greater lack of

confidence was reported in relation to Aboriginal and Torres Strait Islander mothers and

mothers with a disability.

COUNSELLOR PERCEPTIONS OF ABA TRAINING TO SUPPORT MOTHERS FROM

PRIORITY POPULATION GROUPS (N = 171)




Summary

The quality of Breastfeeding Counsellors working on the Helpline is ensured through the

establishment of minimum core competencies, a counsellor practicum period of graduated

support and a diverse program of continuing education.

The level of support provided for counsellors is designed to sustain the volunteer

workforce and there is evidence of increased interest in recruitment to counselling

courses.

Current gaps in skills, and possibly experience, are suggested by the lack of certainty

about competence in supporting priority population groups, especially mothers with a

disability and Aboriginal and Torres Strait Islander mothers.

3.3 Awareness among health professionals of breastfeeding benefits

and support services

Is there improved knowledge and understanding of breastfeeding and the role of the Breastfeeding

Helpline?

The ABA has a role in increasing the awareness of health professionals about the benefits

and practice of breastfeeding and about the supports available for mothers including the

National Breastfeeding Helpline.

ABA support for health professionals

As indicated in 0, the ABA offers a wide range of information and training including

activities that are accessible to and promoted among health professionals. Stakeholder

feedback shows a familiarity with ABA activities especially conferences that are well

regarded. Professional associations promote ABA training events and in some instances

there is support for members to attend.

ABA is represented on several statewide committees involved in developing strategic

responses to improved rates and duration of breastfeeding. In this capacity, ABA is well

placed to influence the understanding of breastfeeding practice and engage with key

sector stakeholders.

There is increasing jurisdictional interest in securing breastfeeding training for health

professionals, in part driven by interest in BFHI accreditation of health services and

hospitals. In some instances, jurisdictions are considering development of in-house

training capacity. The training available from the ABA was considered by some

jurisdictions to be too costly and not in a suitable format.

Health professionals understanding of the Breastfeeding Helpline role

Stakeholder feedback suggests that there is clarity about the role of the Breastfeeding

Helpline in the continuum of support services for mothers and their families. The

Breastfeeding Helpline was commonly described as offering non clinical, peer support

rather than professional advice. However, details of the operation of the Breastfeeding

Helpline are less well known including the use of interpreter services and teletypewriter.

There was also a view that the ABA could have a narrower appeal because of its image as

committed advocates of breastfeeding and appealing to white, middle class women.



Summary

ABA’s education and training activities appear to be well known among health

professionals. It is likely that jurisdictions will have an increasing role in providing

breastfeeding education to its workforce especially where there is interest in hospital

accreditation under the BFHI.

Jurisdictions and health professional associations understand that the Breastfeeding

Helpline offers non clinical, peer support but there is a paucity of familiarity with the

detail of the Breastfeeding Helpline’s operation.

3.4 Marketing education and training

The ABA is supported to market its education and training for volunteers and health

professionals.

Communication

The ABA structure includes a Marketing Coordinator and a Health Professional Seminar

Coordinator. The ABA website provides a vehicle for advertising training opportunities

and events which are also disseminated through the ABA’s newsletters and network.

Strategies to encourage participation

Attracting volunteers to the counsellor course is being facilitated by the benefit that can

accrue to the volunteer through a career pathway and the future possibility of progression

to the Diploma course. A survey of 80 per cent of ABA volunteers found that 80 per cent

were using their training in their paid work and 27 per cent gained work as a result of

their ABA training.

Development of the Diploma course responded to an interest expressed by health

professionals who make up approximately 40 per cent of ABA volunteers. This is likely

to attract other health professionals with potential benefit to the sector and the ABA.

Training is delivered in a mix of methods to facilitate participation and promote self

guided learning. This includes virtual study groups facilitated by trainers, face to face

workshops and weekend activities.

Summary

ABA education and training is marketed through formal and informal mechanisms and

networks. A range of strategies is used to encourage participation having regard for

access, commitments and the needs of volunteers and health professionals.



3.5 Summary of findings

Appropriateness

The Breastfeeding Helpline has a high volume of callers that has been sustained since

inception of the consolidated national service in October 2008. The service model has all

the features of an appropriately constructed helpline seeking to provide an accessible

support to the community. The model is especially appropriate to meeting the needs of

breastfeeding mothers and their families, a potentially vulnerable target population,

wanting information and support at any time of the day or night. The model has been

adapted to a volunteer workforce and has sought to meet quality outcomes through

competency standards, continuing education, quality surveys, counsellor mentoring and

debriefing.

Sustaining an adequate workforce supply to meet demand poses a threat to the viability of

the service. However, the caller waiting times are generally acceptable to callers who

value the support, the counsellors are supported to manage their workload and there is

innovation in counsellor training to attract new volunteers and widen the workforce base.

As for other helplines in the health and parenting sector, the service model struggles to

meet the needs of priority population groups. Those strategies that have been introduced

to facilitate communication would appear to be underutilised and there is little

opportunity for counsellor practical experience of the circumstances and needs of priority

population groups.

The Breastfeeding Helpline is receiving calls from all jurisdictions with some making

better use of the service than others. The trend towards increasing reliance on mobile

telephones poses an equity issue because of the cost of using a telephone support system.

Consistent with good practice in service arrangements, the Breastfeeding Helpline

provides an option within the suite of professional, lay and peer support services that are

available for mothers and their families. The high rate of caller referrals to other services

and the wide range of sources of information about the Breastfeeding Helpline indicate an

active emphasis on coordinated service delivery and the ability to meet the wider advice

and support needs of callers to the Breastfeeding Helpline. However, there is opportunity

for a more systematic approach to service integration especially at state level and through

professional associations.

The Breastfeeding Helpline service is cost effective when compared to other modelled

scenarios. The costs per call received and per call answered from callers who found the

service relevant, compares favourably with the other models both of which involved paid

staff and a higher ratio of cost to output/outcome achieved.

Effectiveness

There was a high level of caller satisfaction with the availability of the Breastfeeding

Helpline resource and the relevance of information and support provided by the

Breastfeeding Helpline. Calls to the Breastfeeding Helpline were predominantly

appropriate to the service and the majority of callers would recommend the service to a

friend or relative. The information provided by the Breastfeeding Helpline was

considered to be relevant and in many instances led to a change in breastfeeding practice.



The issues managed by the Breastfeeding Helpline and the ability to support the caller

with strategies for overcoming difficulties or providing reassurance are highly relevant to

contributing to duration of breastfeeding and meeting the policy objectives in this area.

Transparency

Providing a national service supported by governments (financially and in kind) requires

an appropriate level of transparency to ensure accountability, to facilitate service

integration and optimise resources.

The ABA has a high profile and is known for its specialist breastfeeding expertise. This

has been built on its long history of advocacy, volunteerism, and peer support and

counselling activity, in and amongst the community.

However, there is little understanding outside of the ABA, about the operations,

capability and processes of the Breastfeeding Helpline itself. Given the public investment

in the Breastfeeding Helpline, a better knowledge of Breastfeeding Helpline operations

would assist in appreciating the role of the Breastfeeding Helpline and the way in which it

can complement local service arrangements.

Consideration needs to be given to the impact that a growing reliance on government

funding for the Breastfeeding Helpline, with accompanying regulatory and reporting

requirements, could have on the organisational structure of the ABA, its mission, and its

capacity to remain an innovative and responsive, volunteer based organisation.



Chapter 4

Discussion of results

The National Breastfeeding Helpline is an appropriate, efficient and effective service that

forms a core activity of the ABA. However, as with all services there is both an

opportunity and imperative for continuous improvement to remain a dynamic and

relevant program.

An immediate priority for the Breastfeeding Helpline is to secure a sufficient workforce

to ensure the efficient operation of its service. There are a number of initiatives in place to

support workforce retention and improve workforce recruitment. A clearly articulated

strategic approach is required assessing the options for staffing the Breastfeeding

Helpline in the context of the role it plays in the service landscape and the philosophy of

the ABA. This approach would take into account the changing nature of volunteering and

its practical implications for staffing of the Breastfeeding Helpline.

Similarly, there is a requirement especially with the use of public monies for the service,

to better address the needs of priority population groups. The extent to which this can be

achieved through the Helpline, the learnings of jurisdictions and organisations in tackling

similar challenges and making better use of current Breastfeeding Helpline facility to

provide access to priority groups, should be assessed and the earlier work of the ABA in

this area refreshed with wider input. A further consideration is the need to enable a focus

on priority groups without neglecting the current and appropriate demand for the


There are a growing number of support services for the health and wellbeing of mothers

and infants. It is timely for the role of the Breastfeeding Helpline to be more

systematically promoted amongst consumers, governments and service providers. There

would appear to be scope for increased clarity about the service provided by the

Breastfeeding Helpline to avoid confusion, improve consumer choices and better

integrate the Breastfeeding Helpline into mainstream services.

The increased interest and commitment of governments in Australia to improved

breastfeeding practices has implications for the training of health professionals. This

current development presents an opportunity to promote consistent practice across

Australia and to draw on the expertise of the ABA in that endeavour.

Across the public sector there is a growing expectation and trend for higher levels of

governance, accountability and service responsiveness (Commonwealth of Australia 2010

& Holmes 2011). Services delivered by the not for profit sector but funded by public

monies are not exempt from this trend.

Reform of the not for profit sector is a key focus of the Council of Australian

Governments, with a range of initiatives underway, encompassing improvements in

transparency and governance, whilst at the same time reducing the administrative burden

on not for profit agencies.

These reforms are driven by the growth in government funded services delivered by not-

for-profit organisations, particularly in the health and community services sectors. This

growing reliance on government funding does present significant challenges for not for

profit organisations. These challenges have been identified as:



an undermining and confusing of the not for profit’s advocacy role or mission and

purpose;

an increased regulatory and administrative burden; and

a stifling of innovation through the adoption of prescriptive reporting regimes (PC

2010)

Governments have a clear responsibility to ensure that public expenditure on service

delivery provided by not-for-profit organisations is of a high quality, is monitored and is

accountable. The dilemma is to ensure that such performance management measures do

not undermine the very features of the not for profit organisation in delivering the service.

The role of the Breastfeeding Helpline in supporting breastfeeding practices and its place

in the service system requires processes in place to share information about the operation

and performance of the Breastfeeding Helpline and to ensure that any changes to the

operation of the service are communicated to key stakeholders to ensure currency of

information and promotional material.

A strategic set of performance indicators that are aligned to agreed Breastfeeding

Helpline outcomes would enhance current reporting arrangements. These arrangements

could include a brief annual report on activity and experiences of the Breastfeeding

Helpline made relevant to jurisdictional level.



Chapter 5

Conclusion

Evaluation of the Breastfeeding Helpline has been guided by a comprehensive framework

developed to track the progress of the Breastfeeding Helpline and training initiatives of

the ABA against intended outcomes. These outcomes align to the objectives of the

Breastfeeding Helpline, which focus on accessible, quality advice and support for

breastfeeding practice.

The preliminary evaluation has sought the views of the Department, the ABA and other

key stakeholders in assessing the appropriateness, effectiveness and efficiency of the

Breastfeeding Helpline. Through the collection and analysis of quantitative and

qualitative information, the operation of the Breastfeeding Helpline since October 2008

has been assessed including its administrative arrangements, utilisation, user satisfaction,

quality of service and integration into service supports for breastfeeding mothers.

The Breastfeeding Helpline has made solid progress towards its objectives responding to

a wide range of information and support needs from breastfeeding mothers and making

referrals to other services to more widely meet the needs of callers.

The Breastfeeding Helpline service has benefitted from location within the ABA and the

lead role the organisation plays within the community promoting and protecting

breastfeeding practice. An evidence informed information and resource centre, a national

network of volunteer counsellors and an extensive program of education and training

underpin the role of the ABA and provide a dynamic environment for the Breastfeeding

Helpline service.

There are a number of challenges for the Breastfeeding Helpline including the

consistency of Breastfeeding Helpline support, sustaining and growing its volunteer

workforce to meet demand, effective reach of the service into priority population groups,

ensuring that its support role continues to be recognised alongside helpline advice

services, remaining relevant to all mothers and contributing more widely to the

consistency of breastfeeding information and support.



The following recommendations are made for further development of the Breastfeeding

Helpline in line with the objectives of the service and based on the findings of the

evaluation.

A comprehensive strategy is developed to identify current and any further action required to

staff the Breastfeeding Helpline to meet existing demand and potential growth in demand,

and to address call waiting times and counsellor workload.

A realistic assessment is undertaken of the extent to which the Breastfeeding Helpline in its

current form offers an appropriate medium to meet the information and support needs of

priority population groups3

, drawing from the evidence of good practice and emerging

research in jurisdictions.

Promotion of the Breastfeeding Helpline be reviewed to ensure that messages and materials

are appropriately targeted to improve understanding of the Breastfeeding Helpline as

relevant and accessible to all women as a source of peer support.

A strategic set of performance indicators aligned to agreed Breastfeeding Helpline outcomes

be selected to enhance current reporting arrangements. This would form the basis an annual

report on Breastfeeding Helpline activity and insights about the needs of breastfeeding

women, which would include a breakdown of information to jurisdictional level.

The role of the Breastfeeding Helpline within the service system is reinforced by

differentiating the Breastfeeding Helpline from other parenting and health helplines. This

should be undertaken as a shared responsibility of governments and other service providers

for meeting consumer needs and reducing service duplication. The Department could

facilitate discussions with jurisdictions to consider memorandum of understanding type

arrangements between the Breastfeeding Helpline and other helplines.

The Breastfeeding Jurisdictional Officers Group investigate the opportunity for influencing

greater consistency in breastfeeding training of health professionals and the role for the

ABA.

The Breastfeeding Helpline has an important role in contributing to the outcomes of the

Australian National Breastfeeding Strategy. The Breastfeeding Helpline’s community

based service model emphasises the peer support and provision of a quality service that

responds to the needs of every caller.

It is timely for the Breastfeeding Helpline’s role to be strengthened in the mix of

professional, lay and peer support for breastfeeding practice and in the achievement of

integrated services for better mother and child outcomes.

3

Priority population groups refers to subpopulations within the target group of breastfeeding mothers. These are

identified as teenage mothers, mothers with disability, Aboriginal and Torres Strait Islander mothers and mothers with culturally and linguistically diverse backgrounds.



Appendix A

Evaluation framework

Evaluation framework, questions and indicators

Intermediate Outcomes

Evaluation Questions Indicators Data Sources

Secondary Primary

1. Increased access to breastfeeding advice and support for mothers, partners and their families

1.1 Has the Breastfeeding Helpline service been implemented as intended?

Administrative arrangements:

Does the Breastfeeding Helpline operate as a national, 24-hour service

Is the Breastfeeding Helpline adequately and appropriately staffed

Is the data collection robust

How well is the service coordinated

Is the service efficient

What is the overall cost of providing the service

Time distribution of calls taken over the 24-hour period

Proportion of accredited Breastfeeding Counsellors working on the Helpline available to be rostered on duty

Average caller counsellor ratio over a 24-hour period

Occasions of referrals from the Breastfeeding Helpline to health professionals

Referrals to the Helpline by health professionals

Average cost per call

Production of an annual Breastfeeding Helpline data collection report

NBH data on Helpline operation

NBH protocols and counsellor support documentation

ABA Breastfeeding Helpline training data

ABA Breastfeeding Helpline expenditure data

Survey feedback from Breastfeeding Counsellors working on the Helpline and callers

Interview feedback from DoHA stakeholders, professional associations & jurisdictions

Cost effectiveness analysis

Literature review of effectiveness of telephone helplines to support breastfeeding

1.2 To what extent have mothers and their families utilised the services of the Breastfeeding Helpline?

Callers:

What are the characteristics and needs of the callers

What type of assistance are

Number and profile of callers to the national Breastfeeding Helpline

Calls to the Breastfeeding Helpline are appropriate

NBH data on Helpline usage

Survey feedback from Breastfeeding Helpline callers and counsellors

Interview feedback from DoHA





Secondary Primary

the callers receiving

What strategies are in place to optimise caller access to counsellors

Consumers:

What is the level of consumer awareness of the Breastfeeding Helpline

Proportion of callers who are connected to a counsellor

Caller wait times

stakeholders, professional associations & jurisdictions

Focus groups with young mothers, Aboriginal and Torres Strait Islander mothers, mothers with a disability and mothers from culturally and linguistically diverse backgrounds

1.3 Are callers satisfied with the support provided by the Breastfeeding Helpline?

Callers:

What is the level of demand for services? How is the service dealing with unmet demand

Has the service met the needs of the callers

Provider:

What factors have impacted on service delivery and capacity to meet objectives (staffing, availability of local support services, available training and tools)

Are there program performance/service targets

What quality assurance system is in place including formal reporting requirements

What governance arrangements are in place for the Breastfeeding Helpline and how are they supported

Reasonable waiting time for access to a counsellor

Ratio of counsellors to callers

Percentage of callers for whom the Breastfeeding Helpline support was relevant

Number, type and outcome of complaints to ABA about the Helpline

Development and monitoring of service targets

Development and implementation of a continuous improvement strategy

NBH data on Breastfeeding Helpline operation, usage and satisfaction survey

ABA Breastfeeding Helpline complaints information

ABA documented processes underpinning effective operation of the Breastfeeding Helpline

Survey feedback from Breastfeeding Helpline callers

Focus groups with young mothers, Aboriginal and Torres Strait Islander mothers, mothers with a disability and mothers from culturally and linguistically diverse backgrounds


1.4 How well is the Helpline utilised by priority population groups?

Callers & service providers:

Proportion of callers to the Breastfeeding Helpline from priority population groups

NBH caller survey data

ABA administrative data regarding use

Online caller & counsellor surveys

Focus groups





Secondary Primary

How does the service target consumers from rural and remote communities and areas of socio-economic disadvantage

Breastfeeding Counsellors working on the Helpline & provider:

What are the critical success factors in engaging and supporting consumers with special needs such as those from culturally and linguistically diverse backgrounds, those with disability and young mothers

Is the service model appropriate in meeting the needs of all targeted population groups

Service providers & jurisdictions:

Is the service model appropriate to the wider service system

Occasions of use of interpreters for callers contacting the Breastfeeding Helpline

Occasions of use of a telecommunications device for the deaf for callers contacting the Breastfeeding Helpline

Perception of the Breastfeeding Helpline as a relevant and accessible source of support for priority population groups

Implementation of strategies to improve Breastfeeding Helpline accessibility for priority population groups

of interpreters by Breastfeeding Counsellors working on the Helpline

ABA interviews for information about strategies to reach priority population groups

with young mothers, Aboriginal and Torres Strait Islander mothers, mothers with a disability and mothers from culturally and linguistically diverse backgrounds


Literature review on models of good practice

2. Agreed minimum standards for counselling on breastfeeding

2.1 Do the minimum qualifications for a Breastfeeding Helpline volunteer counsellor comply with requirements of the national regulator AQSA?

Are there appropriate bridging courses available to counsellors that meet the increased compliance requirements?

Counselling courses meet industry standards

Regular feedback and review processes in place to ensure currency and comprehensiveness of counsellor support documentation

ABA course and accreditation documentation

ABA interview feedback

Survey of counsellors

3. Enhancement of breastfeeding counsellor skills

3.1 Is the training provided for Breastfeeding Counsellors working on the Helpline sufficient to ensure the supply of a skilled workforce and the sustainability of a quality, responsive Helpline service?

Numbers of accredited volunteer Breastfeeding Counsellors working on the Helpline

Number of active accredited Breastfeeding Counsellors working

ABA documentation/reports on training for counsellors

ABA data on pool of accredited volunteer counsellors

ABA data on counsellor

ABA interview feedback


Interview feedback from DoHA stakeholders, professional





Secondary Primary

on the Helpline

Number of mentoring programs for new counsellors

Proportion of counsellors who have upgraded their skills to meet increased compliance requirements

Number, type and location of continuing education opportunities for counsellors

Provision of continuing education resources to volunteer counsellor workforce

Quality assurance processes

mentoring program

ABA information on counsellor resources

ABA quality surveys

associations & jurisdiction

4. Greater awareness among health professionals of the benefits of breastfeeding and available support services

4.1 Is there improved knowledge and understanding of breastfeeding and the role of the Breastfeeding Helpline?

Callers:

Is there more consistent information across services provided about breastfeeding

Are there appropriate sources of information about available support services

Service providers:

Is there clarity about the benefits of breastfeeding

What is the perception of the role the Breastfeeding Helpline fulfils

Number and type of breastfeeding skills development opportunities conducted by ABA for health professionals

Number and category of health professionals participating in breastfeeding skills development opportunities

ABA administrative data on skills development programs offered for health professionals and their participation

ABA Breastfeeding Helpline caller surveys

Survey of callers and counsellors

Interview feedback from DoHA maternity services stakeholders, professional associations and jurisdictions

5. Expanded network of volunteers and health professional

5.1 To what extent are ABA education and training opportunities taken up on the provision of advice and support for breastfeeding?

Communication plan for promoting and publicising breastfeeding education

ABA administrative data and other documentation on rationale, frequency, nature, target and


Interview





Secondary Primary

s aware of breastfeeding education opportunities

Provider:

How are education opportunities promoted and disseminated to the ABA volunteer workforce and relevant service providers

What strategies are used to encourage participation

Service providers (professional and volunteer workforce):

How relevant are the ABA education opportunities

How accessible are the ABA educational opportunities

opportunities

Strategies for encouraging participation in breastfeeding education

type of promotional activity undertaken to publicise breastfeeding education opportunities

feedback from professional associations and jurisdictions



Appendix B

Survey instruments

B.1 Caller survey



B.2 Counsellor survey



Appendix C

Consultation schedule

C.1 Stakeholders

Table C.1

DEPARTMENT OF HEALTH AND AGEING PROJECT REFERENCE GROUP

Input Position

Project design; evaluation framework; evaluation tools; and workshopping of preliminary findings

Director, Healthy Children, Healthy Workers Section, Healthy Living Branch, Department of Health and Ageing

Healthy Children, Healthy Workers Section, Healthy Living Branch, Department of Health and Ageing

Healthy Children Healthy Workers Section, Healthy Living Branch, Department of Health and Ageing

Assistant Director, Gender and Reproductive Health Section, Health in Social Policy Branch, Population Health Division, Department of Health and Ageing

Table C.2

STAKEHOLDER CONSULTATIONS

Agency Input Participant

Department of Health and Ageing

Implementation of the Breastfeeding Helpline, performance reporting and data collection

Assistant Director, National Health Call Centre Network

Australian Breastfeeding Association

Project design; evaluation framework; evaluation tools; and workshopping of preliminary findings.

Training and education of ABA counsellors.

Breastfeeding Helpline engagement of callers from priority population groups

Executive Officer, ABA

Manager Lactation Resource Centre

National Breastfeeding Helpline Manager

National Breastfeeding Helpline Manager

Training Manager

Breastfeeding Jurisdictional Officials Group (BJOG)

Coordination between the Breastfeeding Helpline and broader service system.

Victoria —Department of Education and Early Childhodhood Development

Queensland —Queensland Health



The following consultations did not occur.

Northern Territory BJOG member — was uncontactable for the duration

of the project;

New South Wales BJOG member — had recently resigned from her position. Discussion occurred with the

relevant program area within the NSW Ministry of Health to arrange for a delegate. An appropriate

representative for NSW was not provided by the Ministry;

Royal College of Nursing Australia — declined the offer to participate; and

Australian Association of Maternal Child and Family Health Nurses — the offer to participate was canvassed by

AAMCFHN committee, but was not taken up.

Tasmania — Department of Health and Human Services

Australian Capital Territory — Health Directorate

Western Australia — , Department of Health (written submission)

South Australia — , SA Health

Australian College of Midwives

Contribution of Breastfeeding Helpline to improved breastfeeding outcomes in the community

Manager Baby Friendly Health Initiative

Lactation Consultants of Australia and New Zealand

Contribution of Breastfeeding Helpline to improved breastfeeding outcomes in the community

Director for Education, Research and Media



Focus groups

Table C.3

FOCUS GROUPS

Population group Input Partner organisation and location

New mothers Utilisation and satisfaction of the Breastfeeding Helpline amongst new mothers

City of Wyndham Maternal and Child Health Service, Point Cook.

Young mothers Utilisation and satisfaction of the Breastfeeding Helpline amongst young mothers

City of Wyndham Youth Services, Youth Resources Centre, Hoppers Crossing

CALD mothers Utilisation and satisfaction of the Breastfeeding Helpline amongst mothers from a CALD background

City of Hume Maternal and Child Health Service, Broadmeadows

Aboriginal and Torres Strait Islander mothers

Utilisation and satisfaction of the Breastfeeding Helpline amongst mothers from an Aboriginal and Torres Strait Islander background

Victorian Aboriginal Health Services, Thornbury

Mothers with a disability

Utilisation and satisfaction of the Breastfeeding Helpline amongst mothers with disabilities

Yooralla. Telephone discussions held with members of the Parents with Disability Support Network.

Challenges associated with coordinating the focus groups included the following.

VAHS breastfeeding support group — the day prior to the scheduled focus group, the facilitator informed the

evaluation team that all proposed attendees had indicated they would not be attending. As an alternative,

consultation with the group coordinator occurred to explore her views of the group's awareness of breastfeeding

support; and

Infrequency of meetings of the Parents with Disability Support Network — the schedule of meetings of this

group were outside of the timelines for this project. As an alternative, phone interviews were conducted with

participants who had indicated a willingness to participate.



Appendix D

Discussion guides

D.1 Government representatives discussion guide



D.2 Professional association discussion



D.3 Focus group discussion guide



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