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
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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
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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
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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.
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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:
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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.
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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.
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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.
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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
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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).
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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.
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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.
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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
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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.
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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.
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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.
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NATIONAL BREASTFEEDING HELPLINE EVALUATION PROGRAM LOGIC
Source: The Allen Consulting Group
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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
24 hours a day, 7 days a week.
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
24 hours a day, 7 days a week.
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
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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).
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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.
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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.
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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.
Source: The Allen Consulting Group
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.
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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.
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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.
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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.
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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.
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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.
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CALLER PERCEPTIONS OF THE IMPORTANCE OF INFORMATION AND ADVICE SOURCES
(N = 96 RESPONDENTS)
Source: The Allen Consulting Group National Breastfeeding Helpline Caller Survey, 2012.
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)
Source: The Allen Consulting Group National Breastfeeding Helpline Caller Survey, 2012.
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.
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TOP REASONS FOR CONTACTING THE HELPLINE AS REPORTED BY CALLERS (N = 96
RESPONDENTS)
Source: The Allen Consulting Group National Breastfeeding Helpline Caller Survey, 2012.
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.
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TOP REASONS FOR CONTACTING THE BREASTFEEDING HELPLINE AS REPORTED BY
COUNSELLORS (N = 174 RESPONDENTS)
Source: The Allen Consulting Group National Breastfeeding Helpline Counsellor Survey, 2012.
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.
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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.
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Over three quarters of the callers considered that the wait time before connecting to a
counsellor was appropriate.
CALLERS EXPERIENCE OF THE BREASTFEEDING HELPLINE
Source: The Allen Consulting Group National Breastfeeding Helpline Caller Survey, 2012.
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
Breastfeeding Helpline service.
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!
Caller survey respondent
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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!
Caller survey respondent
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.
Caller survey respondent
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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.
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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
Source: The Allen Consulting Group National Breastfeeding Helpline Caller Survey, 2012.
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).
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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;
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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.
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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:
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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.
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RATES OF ACCESS TO ABA TRAINING, INFORMATION AND SUPPORT IN THE LAST SIX
MONTHS BY LOCATION OF COUNSELLOR (N = 174)
Source: The Allen Consulting Group National Breastfeeding Helpline Counsellor Survey, 2012.
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)
Source: The Allen Consulting Group National Breastfeeding Helpline Counsellor Survey, 2012.
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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.
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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.
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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.
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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.
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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
Breastfeeding Helpline service.
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:
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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.
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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.
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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.
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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
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Intermediate Outcomes
Evaluation Questions Indicators Data Sources
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
Interview feedback from DoHA stakeholders, professional associations & jurisdictions
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
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Intermediate Outcomes
Evaluation Questions Indicators Data Sources
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
Interview feedback from DoHA stakeholders, professional associations & jurisdictions
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
Survey of counsellors
Interview feedback from DoHA stakeholders, professional
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Intermediate Outcomes
Evaluation Questions Indicators Data Sources
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
Survey of counsellors
Interview
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Intermediate Outcomes
Evaluation Questions Indicators Data Sources
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
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Appendix B
Survey instruments
B.1 Caller survey
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B.2 Counsellor survey
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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
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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
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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.
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Appendix D
Discussion guides
D.1 Government representatives discussion guide
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D.2 Professional association discussion
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D.3 Focus group discussion guide
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