Elsevier

Health Policy

Volume 90, Issue 1, April 2009, Pages 89-93
Health Policy

The effect of an area-based intervention on breastfeeding rates in Victoria, Australia

https://doi.org/10.1016/j.healthpol.2008.08.004Get rights and content

Abstract

Objectives

Best Start is an area-based early childhood intervention where projects are developed and implemented through a community partnership. A core tenet of the initiative is that implementing projects through a partnership generates greater value than would be expected if projects were undertaken independently by partner members. In this study we examine whether: (1) Best Start is effective in increasing the proportion of infants being fully breastfed at 3 months and 6 months. (2) The quality of community partnerships is a potential mechanism for change.

Methods

Best Start was implemented in Victoria, Australia. The study examined breastfeeding rates before and after Best Start in sites with Best Start breastfeeding projects compared to the rest of state. The relationship between partnership quality scores and breastfeeding percentages was also examined. Both analyses controlled for socioeconomic and demographic differences and clustering by area.

Results

Best Start targeted some of the most socially disadvantaged communities in Victoria. In the 3 years of its operation, the rates of fully breastfeeding at 3 months (OR 1.30, 95% CI 1.14–1.47) and 6 months (OR 1.33, 95% CI 1.1–1.61) increased in Best Start sites compared to the rest of the state. Quality of partnership scores was positively associated with increased percentages of fully breastfeeding (3 months = OR 1.03, 95% CI 1.01–1.06; 6 months = OR 1.03, 95% CI 0.98–1.08).

Conclusions

These results suggest that area-based interventions are effective in increasing percentages of fully breastfeeding. The study also supported the idea that developing quality community partnerships had a positive influence on their success.

Introduction

It is unequivocal that human breast milk is the best source of nutrition for infants [1]. Breastfeeding is associated with improved health and developmental outcomes [1], [2], [3], [4], [5], [6], [7] as well as reducing the cost of healthcare for individuals and communities [8], [9]. Despite breast milk’s long list of benefits most countries do not meet targets for exclusive breastfeeding (where infants receive only breast milk with no other liquids or solids except vitamins, mineral supplements or medicines) [10]. Breastfeeding rates in Australia have remained relatively stable since the mid 90s with a slight decline in rates of fully breastfed (includes infants exclusively breastfed and predominantly breastfed where infants receive breast milk and water, water-based drinks, fruit juice or oral rehydration salts but no breast milk substitutes or solids) [11] infants under 3 months [12], [13]. Accordingly breastfeeding is an important area for public health intervention.

Cochrane reviews of breastfeeding initiatives suggest that education is effective in increasing the initiation of breastfeeding [14] and that support, both peer and professional, is effective in increasing the duration of breastfeeding [15]. Such interventions have therefore been included as a priority in community initiatives to improve developmental outcomes among socioeconomically disadvantaged children through area-based partnerships [16]. These include Sure Start in UK and Best Start [17], among others, in Australia. These initiatives reflect a wider shift towards area-based interventions as part of the Health for All (HFA) principles promoted by the World Health Organisation [18].

The synthesis of local evaluation data from Sure Start suggested that there had been increases in breastfeeding rates associated with the delivery of support for breastfeeding through multidisciplinary teams [19]. The synthesis was limited because it was based on local evaluations which used different measures, making it difficult to identify intervention processes and impact [20]. In addition there has been concern that area-based partnership approaches may not deliver appropriate benefits because they are not effectively implemented [21], [22], [23], [24], [25].

Best Start is an initiative of the Department of Human Services (DHS) in partnership with the Department of Education and Training (DE&T) and other departments of the Victorian State Government. Best Start aimed to improve the health, development, learning and well-being of all young children across Victoria from pregnancy through transition to school.

Five Best Start demonstration sites were identified for funding in 2002 and an additional six sites were identified in 2003. The selected sites included metropolitan, regional and rural areas. Each site had a facilitator, funded through the program, and a partnership with representatives from state and local government, non-government agencies as well as local community groups and local parents. This marked a change from past practice when agencies in the early childhood sector worked in isolation or even in competition for government funding [26]. Projects, developed and delivered on behalf of the partnerships were largely designed to add value by increasing co-ordination, co-operation and linkages between existing services rather than introduce new services or expand existing services [26].

DHS identified seven health outcome areas as well as other educational outcome areas that Best Start programs could choose to target. For this reason the portfolio of projects offered by Best Start sites varied considerably. The program documentation fully describes the government policy direction [17] and project implementation [26].

The major health outcome areas targeted by the projects were breastfeeding and attendance at maternal and child health assessments [26]. In this paper we focus on breastfeeding. There were 30 breastfeeding projects at seven sites. Six of these seven sites were in areas with lower rates of breastfeeding than the rest of the state. The breastfeeding projects all aimed to promote breastfeeding among mothers, their communities and their health care practitioners. In some sites this was achieved through the appointment of lactation consultants. Another strategy involved introducing protocols to improve the consistency of breastfeeding information provided through different service organisations. Other strategies included improving community and professional support for breastfeeding through new linkages as well as support for breastfeeding friendly environments. Program logics were developed for each of the projects. Progress was assessed through site visits and reported on at six monthly intervals.

A core tenet of initiatives like Best Start is that implementing specific projects through a partnership generates greater value than would be expected if projects were undertaken independently by partner members. In this paper we aim to answer two questions:

  • (1)

    Is Best Start effective in increasing the proportion of fully breastfed infants at 3 months and 6 months?

  • (2)

    Is the quality of community partnerships a potential mechanism for change in the proportion of fully breastfed infants at 3 months and 6 months?

Section snippets

Best Start and breastfeeding

The study assessed changes in the proportion of fully breastfed infants at 3 months and 6 months before and after the introduction of Best Start projects in Best Start sites compared to local government areas (LGAs) in the rest of the state. Best Start sites were only included in the intervention group when a breastfeeding project had been implemented. The sites were selected by DHS before the start of the study through a competitive process. The sites were selected on the basis of social and

Discussion

Best Start targeted some of the most socially disadvantaged communities in Victoria. In the 3 years of its operation, the percentage of infants fully breastfed at 3 months and 6 months increased. This occurred though projects aimed at enhancing the consistency of the information provided by different service organisations, improving community and professional support for breastfeeding and supporting breastfeeding-friendly environments. This is consistent with previous research demonstrating the

Conclusion

There has been a great deal of criticism of the constraints imposed on area-based partnership approaches to improving health in many contexts [21], [22]. While these certainly apply in the Australian context, the results suggest that improvements in the proportion of fully breastfed infants can be achieved through establishing local partnerships with minimal additional resources. The effectiveness of partnership approaches may be further improved by providing a more supportive policy

Acknowledgements

The evaluation was commissioned by the Victorian Government’s Department of Human Services and the Department of Education and Training with support from the Community Support Fund. Margaret Kelaher was supported in part by an Australian National Health and Medical Research Council Career Development award and VicHealth. The Statewide evaluation team would like to thank the Steering committee and Best Start projects, particularly the community facilitators, for their assistance and advice in

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