Evaluation Toolkit for Breastfeeding Programs and Projects

June 2012

Appendix G – Questionnaire template

Page last updated: 04 November 2013

(These instructions can be deleted once you have finalised your document.)

The questions you decide to ask in a questionnaire will depend on what you are trying to learn. Generally, a self-complete survey is useful when you want to learn a lot of things about a respondent which can be easily counted, and also when you want to preserve women’s confidentiality. A paper survey can be made available in a reception area for people to complete if they want, or an online survey link can be provided, without any pressure to participate. The introduction and questions below are purely for example purposes and will need to be adapted to suit your own setting, target population, key evaluation questions and capacity to analyse the data you collect.

These types of questions could equally be adapted for hospitals, maternal/child or community health settings, support groups/organisations, etc. You will need to change the wording accordingly: for example, a survey for a lactation clinic may refer mainly to breastfeeding (and expressing), while a survey for a general postnatal service might ask about infant feeding. If the service is only for very young babies, you might not need to ask about introduction of solids. You will also need to think about who you want to include in the survey (e.g. mothers only, or mothers, partners and other carers).

If your evaluation seeks to obtain the views of people with low literacy levels or from linguistically diverse backgrounds, you will need to check that your survey can be completed by people in these groups. You may need to arrange for the survey to be translated or consider alternatives such as one on one interviews or focus groups with translator support if necessary.

Examples of additional question types, and previously used questions that could be used in your survey for comparison purposes, are available from the questionnaire used for the 2010 Australian National Infant Feeding Survey available at: AIHW website . This will be particularly important if you want to compare breastfeeding rates in your survey population to national or state/territory rates.

Alternative sources of questions include state/territory surveys, postnatal hospital discharge forms, and the breastfeeding research literature.

Finally, please remember to amend the text of this survey to make sure that it suits your own service and the questions you are trying to answer.

Introduction
This survey will ask you about your experiences of [name of service]. We are interested to hear your views so that we can improve the way we do things. You do not have to fill in the survey if you don’t want to, and you are free to add any comments that you wish. We will not ask for your name or any details which might identify you, and your decision to fill in the survey will not make any difference to your ability to access any services in the future.
1. Did you receive information or advice about breastfeeding while attending [name of service]?
No (please go to question 3) Check Box
Yes Check Box

2. If you answered Yes, was that information or advice about…? (Tick as many boxes as you need)
Check Box Benefits of breastfeeding
Check Box How to breastfeed
Check Box Dealing with difficulties in breastfeeding
Check Box Services available to help me with breastfeeding
Check Box Formula feeding
Check Box Other (please specify)

3. How was the information or advice provided to you? (Tick as many boxes as you need)
Check Box Printed form/brochure only
Check Box Video
Check Box Group class/information session
Check Box Individual appointment
Check Box Midwife
Check Box Lactation consultant
Check Box General Practitioner (GP)
Check Box Maternal and Child Health Nurse
Check Box Other health professional
Check Box Community worker
Check Box Australian Breastfeeding Association volunteer counsellor or educator
Check Box Other (please specify)

4. Using the following scale, how helpful was the information provided to you?
Check Box Very helpful
Check Box Somewhat helpful
Check Box Neither helpful nor unhelpful
Check Box Not very helpful
Check Box Not at all helpful

5. If you received infant feeding information or advice from different sources within [name of service], how did that advice seem, each time you received it? Was it:
Check Box Similar (go to question 7)
Check Box Somewhat the same (go to question 7)
Check Box Somewhat different
Check Box Different

6. If it was different, in what ways was the advice different?
Type your answer here

7. How important was the advice you received in assisting your decisions about breastfeeding?
Check Box Very important
Check Box Somewhat important
Check Box Neither important nor unimportant
Check Box Not very important (go to question 9)
Check Box Not at all important (go to question 9)

8. Did the advice influence your decision to…? (Tick as many boxes as you need)
(These instructions can be deleted once you have finalised your document.)
You can add or remove options depending on the focus of your evaluation.
Check Box Initiate (or start) breastfeeding at birth
Check Box Continue breastfeeding until leaving hospital
Check Box Continue breastfeeding up to ____ weeks/months after giving birth (please provide number of weeks/months)
Check Box Not to breastfeed
Check Box Other (please state) (If you ticked any of the above, please go to question 10)
Check Box No, I was not influenced at all by the advice (please go to question 9)

9. If the information or advice provided by [name of service] did not help you to make decisions about infant feeding, why was that? (Tick as many boxes as you need)
Check Box Already decided to breastfeed
Check Box Already decided to provide infant formula
Check Box Already decided to combine breastfeeding and formula feeding
Check Box Printed information not clear
Check Box Advice not clear
Check Box Conflicting advice
Check Box Other (please specify)

10. What was the best thing you recall about the infant feeding advice you received from [name of service]?
Type your answer here

11. Did you receive information or advice from other sources about breastfeeding?
Check Box Yes
Check Box No (please go to question 14)

12. What other sources provided information or advice to you? (Tick as many boxes as you need)
Check Box Partner
Check Box Other family member (please specify)
Check Box Friend
Check Box Australian Breastfeeding Association
Check Box Other health staff (please specify)
Check Box Other source (internet, magazine, etc. – please specify)

13. How important was this advice in assisting your decisions about breastfeeding?
Check Box Very important
Check Box Somewhat important
Check Box Neither important nor unimportant
Check Box Not very important
Check Box Not at all important

14. This next set of statements is about your experiences with [name of service] staff. (Please tick the box that best describes your experience)

Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
Staff arranged for my attendance at education sessionCheck BoxCheck BoxCheck BoxCheck BoxCheck Box
Staff were too busy to help me muchCheck BoxCheck BoxCheck BoxCheck BoxCheck Box
Staff did not know answer to my question but offered to find information or advisorCheck BoxCheck BoxCheck BoxCheck BoxCheck Box
Staff were generally friendly and helpful Check BoxCheck BoxCheck BoxCheck BoxCheck Box
Staff helped me to find specialist serviceCheck BoxCheck BoxCheck BoxCheck BoxCheck Box
Staff helped me to manage the problem and find a good solutionCheck BoxCheck BoxCheck BoxCheck BoxCheck Box

15. From your experience, if you could suggest one change to improve the way information and advice is provided to mothers using this service, what would it be?
Type your answer here

16. How is your infant currently fed? (please tick all that apply)
Check Box Breast milk from the breast
Check Box Expressed breast milk
Check Box Infant formula
Check Box Follow-on formula
Check Box Water
Check Box Other drinks (please specify)
Check Box Soft/semi-solid foods
Check Box Solid foods
Check Box Other (please specify)

17. What is your date of birth?

18. What is your baby’s date of birth?

19. Are you of Aboriginal or Torres Strait Islander origin?

For persons of both Aboriginal and Torres Strait Islander origin, mark both ‘Yes’ boxes
Check Box No
Check Box Yes, Aboriginal
Check Box Yes, Torres Strait Islander

20. Do you identify with a culture other than Australian?
Check Box NO- Go to question 25
Check Box YES (please specify)

21. Do you speak a language other than English at home?
Check Box No
Check Box Yes (please specify)

22. Do you feel that [name of service] staff understood, respected and were responsive to your cultural needs in relation to breastfeeding? (Use the following scale to tick your response)
Check Box Very responsive
Check Box Somewhat responsive
Check Box Neither responsive nor unresponsive
Check Box Somewhat unresponsive
Check Box Unresponsive

23. If possible, please provide an example of what helpful things staff did to respect your cultural needs in the box below.
Type your answer here

24. If possible, please provide an example of what things staff might have done better to respect your cultural needs in the box below.
Type your answer here

25. Is there anything else you would like to tell us about the service?
Type your answer here

Thank you for taking the time to complete this survey.(These instructions can be deleted once you have finalised your document.)

Add here directions on what to do with the completed survey (e.g. please put your completed survey in the box at the reception desk.)

For more information please visit Department of Health website.

All the information in this publication is correct as of June 2012.