Influences of the Built, Physical, or Spatial Environment on Breastfeeding: A Scoping Review Protocol

Study rationale, aims and objectives

According to Peters et al.¹⁶, scoping reviews are used to map the literature and identify evidence that has not been thoroughly investigated. Since the concept of the built or spatial environment has not been thoroughly examined in relation to breastfeeding or is often included under other constructs, this review is relevant as it would outline the extent of existing evidence, identify gaps in current knowledge, clarify key concepts, and highlight research that supports and addresses practical applications. This is significant, as a preliminary literature review indicates a lack of recognised efforts to synthesise the overall body of evidence on the factors in the built environment that influence breastfeeding, and there has been no recent synthesis of empirical research on this topic.

Stage 1: Identifying the research question

Guided by an initial literature review, the objectives of this scoping review were developed through ongoing discussions among the research team. This review is part of a larger research initiative examining the factors in the built environment that affect breastfeeding continuation in Ireland. Notably, Ireland has one of the lowest breastfeeding rates among high-income countries with similar socio-economic characteristics^22,23. This situation persists despite various policies designed to promote breastfeeding, including workplace initiatives to support ongoing breastfeeding nationwide.

To our knowledge, various efforts have been undertaken to systematically compile evidence regarding the influences on breastfeeding. However, these reviews often emphasise biopsychosocial factors or focus primarily on the individual level^6,8. Given that the decision to continue breastfeeding is influenced not only by individual choices but also by the surrounding environment, and considering that much of the existing research predominantly addresses the social environment, this review aims to synthesise evidence on the influences of the built environment across health systems, families and communities, workplaces, and employment settings.

This scoping review poses the question: How does the built environment influence breastfeeding globally? This review aims to map and examine the global evidence related to the built environment and breastfeeding. The specific objectives are therefore to:

Stage 2: Identifying relevant articles

Search strategy. This review will follow the three-step search strategy by JBI²⁴. The initial step consists of a limited search for peer-reviewed, published articles on the PubMed and CINAHL databases, which has already been completed (see Extended Data²⁵). An academic research librarian at the Royal College of Surgeons in Ireland (RCSI) was consulted. The search terms will be tested to evaluate the suitability of the databases and keywords. The second step involves collaboration with the librarian to refine the search terms. The final step will be to review the references of key articles identified for full-text evaluation and verify that they meet the inclusion criteria. The following databases were chosen in collaboration with an academic librarian: PubMed, CINAHL, Scopus, Web of Science, PsycINFO, and Cochrane Library.

Inclusion and exclusion criteria. The inclusion criteria are guided by the Population, Concepts, Context (PCC) approach (Peters et al., 2024), as presented in Table 1 below.

All research designs will be accepted, including qualitative, quantitative, and mixed-methods designs. Quantitative studies will encompass both experimental (such as randomised trials and non-randomised trials) and observational (including cohort and cross-sectional) study designs. Qualitative studies will feature designs like grounded theory, ethnography, phenomenology, action research, and qualitative descriptive approaches. Grey literature, like government reports and academic studies, will be included in the review. A draft set of inclusion and exclusion criteria will be applied to a sample of 15 articles to evaluate the effectiveness of the requirements, which will be modified as needed.

Inclusion criteria

Studies that:

Exclusion criteria

Studies that:

Stage 3: study selection

The screening procedure will involve two stages: i) an evaluation of titles and abstracts; ii) an examination of full texts. In the first stage, two reviewers will assess all titles and abstracts: one reviewer will check 100% of the articles, while two additional reviewers will each review 50%. The screening will be conducted using Covidence software, and duplicates will be eliminated. When reviewers disagree about whether to include or exclude an article, a third reviewer will serve as a mediator. Similarly, full text will be retrieved and screened by two independent reviewers, and disagreements will be resolved through discussion or with a third review.

Stage 4: charting the data

Data extraction will be conducted in accordance with the JBI framework²⁴. A data charting form will be created and used for all included articles (See Extended Data²⁵). Two reviewers will independently test the form on a random selection of approximately five included articles. The data will be coded and recorded in Microsoft Excel by one reviewer and checked by another reviewer. In line with the methodology for scoping reviews, the quality of the individual articles will not be evaluated. Consequently, since the quality of the evidence will not be assessed, there are limitations on the conclusions that can be drawn regarding the evidence gap.

Stage 5: collating, summarising and reporting results

A ‘descriptive-analytical’ approach will be used. Since this is a scoping review, it is not expected that individual research results will be combined or synthesised. The PAGER (Patterns, Advances, Gaps, Evidence for practice and Research recommendations) methodological framework will be used to analyse and present the findings of the review²⁶. This will initially involve a descriptive overview of the conclusions included. A patterning chart will be created to facilitate the identification of advancements in the research area on the breastfeeding-built environment. Gaps will subsequently be determined through this analytical procedure. A framework for presenting evidence for practice will consider stakeholders like policymakers, urban planners, HR managers, research funders, and practitioners/service providers. The research recommendations will be based on the identified gaps. The final two stages of the framework will be carried out in collaboration with stakeholders in Stage 6 of the review. Key reflective questions at each stage of the framework will direct the analysis²⁶.

Stage 6: consulting with stakeholders

The results of the review will be compiled for stakeholders with knowledge of the physical/built environment of breastfeeding. This group will consist of researchers, practitioners, and policymakers at both the global and WHO regional levels. It is proposed at this stage that breastfeeding mothers be consulted on whether the review captures evidence aligned with their perspectives/expectations, and whether any essential topics have been missed. The proposed aim is to present the findings and incorporate feedback into the review recommendations.