Population-level communication interventions for breastfeeding: Protocol for a scoping review

Introduction

The importance of breastfeeding for children, women and society is well established, bringing with it a myriad of health, developmental (Victora et al., 2016), environmental (Bai & Alsaidi, 2024) and economic benefits (Hansen, 2016). The World Health Organisation (WHO) recommends that children are exclusively breastfed for the first 6 months of life, and continue to be breastfed after complementary foods are introduced to at least 2 years of age or beyond (WHO, 2025). Yet, breastfeeding rates fall well below both biologically feasible rates and the WHO global infant feeding recommendations in most countries. Past estimates suggested only 37% of infants younger than 6 months were exclusively breastfed in low- and middle-income countries (LMIC), with even lower rates in high income countries (HIC) (Hansen, 2016; Victora et al., 2016). Global trends in breastfeeding rates over time indicate some progress in HIC in the past 20 years, but rates still fall far below in LMIC (Neves et al., 2021). In Ireland, the situation is especially concerning. A recent report by the World Breastfeeding Trends Initiative (WTBi) described Ireland’s breastfeeding rates as one of the lowest in the world. So much so that in 2021, exclusive breastfeeding rates were as low as 37% by hospital discharge, roughly 3 days after the mother had given birth with no current national data available on breastfeeding rates beyond this point (WBTi, 2023).

Social and cultural norms, beliefs and practices strongly influence breastfeeding rates (The Lancet, 2016). Pérez-Escamilla et al.’s (2023) conceptual model of the components of an enabling environment illustrate that breastfeeding decisions and practices are influenced over time by many interacting factors at multiple levels (Pérez-Escamilla et al., 2023; Rollins et al., 2016). At a structural level, the context for breastfeeding is shaped by cultural attitudes, social norms and market forces, amongst other factors (Pérez-Escamilla et al., 2023; Rollins et al., 2016). For example, in Ireland, the WTBi reported that formula feeding is the norm for infants rather than breastfeeding. Moreover, Ireland is a major producer of infant commercial milk formula and the economic benefits of mass producing infant commercial milk formula potentially creates a conflict of interest at a political level (WBTi, 2023). Given the many and multi-level factors that influence breastfeeding decisions and practices, breastfeeding should be seen as a collective societal responsibility rather than the sole responsibility of mothers, thus requiring multi-level, multi-component interventions (Pérez-Escamilla et al., 2023; Rollins et al., 2016; WBTi, 2023) to sustain and accelerate improvements in breastfeeding rates in high income countries.

Population-level communication interventions can form part of a multi-level, multi-component approach to improving breastfeeding rates. Such interventions can support positive social and cultural norms and practices that enable breastfeeding. Communication through provision of information about importance of health behaviours, their antecedents and their outcomes, and how to perform health behaviours are typically the most commonly used behaviour change techniques used in complex behaviour change interventions, including in those aiming to support optimal infant feeding Eidhin et al. (2025); (Matvienko-Sikar et al., 2019). Providing information by itself is rarely sufficient to change behaviour. Efforts to ‘promote’ breastfeeding by providing information about its importance, without addressing the barriers to breastfeeding has resulted in something of a backlash against a perceived pressure to breastfeed (Entwistle, 2018; UNICEF, 2017). Given the challenges of communication about breastfeeding, evidence-based guidance on how to communicate effectively would be welcome. Preliminary searches conducted in preparation for this scoping review protocol suggest there is currently little available guidance on population-level communication interventions for breastfeeding specifically.

Mass media campaigns are an example of a population-level communication intervention. Mass media campaigns may be a component of a larger package of interventions that could improve breastfeeding outcomes and population health (Pérez-Escamilla et al., 2023; Rollins et al., 2016; WBTi, 2023). For the purpose of this review, we define mass media campaigns as population-level communication interventions that actively and systematically use mass media for mass communications with the intent of influencing the health behaviour of large target audience(s) or population(s) (for a full explanation of this definition and its key terms, see Box 1). Mass media campaigns have long been recognised as important tools in public health promotion (Flay et al., 1980; Kreps & Maibach, 2008; Tones et al., 1990), that can target single or multiple levels of health determinants, that can be used alone or in combination with other interventions, and which can influence the health behaviours of populations (Abroms & Maibach, 2008; Maibach et al., 2007; Wakefield et al., 2010).

From a socioecological perspective, mass media campaigns can influence health behaviours through three main fields of influence: (1) influencing people, (2) influencing places, and (3) influencing the interaction between people and places (Abroms & Maibach, 2008). By targeting people, mass media campaigns can directly or indirectly influence health behaviours by changing individual-level attributes (like knowledge, skills, beliefs), social network level outcomes (like social support from family and peers), or population or community-level outcomes (like social norms or cultural attitudes and practices) (Abroms & Maibach, 2008; Maibach et al., 2007). By targeting places, mass media campaigns attempt to indirectly influence health behaviours by advocating for changes in physical and social structures (like workplace spaces and policies), the availability of products and services to support a health behaviour, or the cultural and media messages in an environment (like those transmitted in advertisements). These place-based factors can be targeted at local or distal levels (Abroms & Maibach, 2008; Maibach et al., 2007). From this socio-ecological perspective, communications campaigns have typically sought to directly influence individual-level factors, rather than influencing indirectly by targeting change in the wider environments in which individuals live and work (Abroms & Maibach, 2008; Maibach et al., 2007).

This review represents the first step towards developing guidance to inform the development of population-level communications interventions for breastfeeding in HICs by scoping the relevant evidence from very highly developed countries. The review will place a particular focus on the development of campaigns, their content, target audiences and theoretical underpinnings.

Rationale and objectives

The design and implementation of health communications can significantly affect their influence (Abroms & Maibach, 2008; Keller & Lehmann, 2008; Maibach et al., 2023; Wakefield et al., 2010). While the findings across existing systematic reviews highlight that mass media interventions for breastfeeding exist, and can produce positive outcomes, including improved exclusive breastfeeding rates and improved child nutritional outcomes (Mahumud et al., 2022; Orchard & Nicholls, 2022; Wakefield et al., 2010), there remains a need to scope the evidence on communications interventions; development of campaigns, their content, target audiences, theoretical underpinning, message framing with a precise focus on population-level breastfeeding communications campaigns delivered via mass media/social media specifically, and not individually mediated communications (such as group antenatal classes, peer support, individual lactation support).

Graziose et al.’s (2018) systematic review of mass media interventions for infant and young child feeding (IYCF) in LMICs called for more consistent reporting of the detail of the design of interventions to better understand how, why, for whom and under what conditions mass media interventions for IYCF may be effective. From our preliminary searches of the databases, we have not identified any published guidance for intervention development on the common elements, components, specific content or message framing for mass media communications interventions on breastfeeding. This scoping review will inform the development of such guidance.

The goal of this scoping review is to describe the state of the evidence on mass media campaigns related to breastfeeding. This represents the first step towards generating theory-based and evidence-informed guidance on how to develop, implement and evaluate mass media campaigns on breastfeeding. Our first objective is to systematically identify and map the breadth, type and characteristics of the research on developing, implementing and evaluating mass media campaigns designed to influence breastfeeding behaviour.

Scoping reviews can serve several purposes. They can be conducted to identify the types of available evidence in a given field in a systematic and transparent way, as per our first objective. They can also be used as a precursor to a systematic review (Munn et al., 2018; Munn et al., 2022; Pollock et al., 2024). If we identify sufficient evidence in our scoping review, we will then conduct a systematic review to critically appraise and synthesise the research on the effectiveness and implementation of campaigns.

The proposed scoping review will be conducted in accordance with the JBI methodology for scoping reviews (Peters et al., 2020) and this protocol will be made publicly available on OSF.io and via HRB open.¹

Review question

Overarching question: What research has been conducted that can inform the development, implementation and evaluation of mass media campaigns, in highly developed countries, aimed at influencing breastfeeding rates?

Eligibility criteria

Information sources

The information sources for this scoping review include:

We will search for peer-reviewed literature and relevant evidence synthesis via PubMed, Embase, CINAHL, PsycInfo, Proquest, Academic Search Complete (EBSCO) and Cochrane Library.

We will conduct forward and reverse citation searching of included studies and reviews and grey literature searches via web searches, OSF, and contact with known authors/ organisations in the field. The search will be undertaken in January/February 2025.

We will search for grey literature on Google, Google Scholar, Open Science Framework (OSF) and the websites of relevant organisations including the WHO, UNICEF, World Alliance for Breastfeeding Action, and the World Breastfeeding Trends Initiative.

We will conduct backward citation chaining by screening the reference lists of included studies and reviews and forward citation chaining by using ‘Citation Chaser’ (Haddaway et al., 2022) to screen other studies that reference the included articles.

A list of expert authors and organisations to be contacted will be developed as the review progresses, in consultation with knowledge users of the broader MaxSBF programme.

These information sources have been selected because of their relevance to the scoping review questions and their accessibility to the review team.

Search strategy

Searches will be conducted of each information source by one review team member. Information sources with peer-reviewed literature will be searched first, followed by searching sources with grey literature, citation chaining and contacting expert authors.

Source of evidence selection

Following the search, all identified citations will be collated and uploaded into EndNote x20 (Clarivate Analytics, PA, USA) and duplicates removed. Screening and data extraction will be supported by EPPI Reviewer Web Evidence Synthesis Software (Version: 6)., similar review management software, with more limited capabilities, is available free of charge via https://www.rayyan.ai/.

At title and abstract screening two reviewers will first independently screen at least 10% of the retained records to provide data to train EPPI reviewers’ priority screening tool. This tool uses text mining to list references in order of similarity to studies identified by human reviewers as ‘include’ on title and abstract. Once the tool is trained, we will switch to single screening. A further random sample of 10% of all excluded records will be screened by a second human reviewer for quality control.

Potentially relevant sources will be retrieved in full text, supported by EPPI reviewers Zotero link tool that can automatically identify and bulk import pdfs of full texts. The full text of selected citations will be screened against the inclusion criteria by two reviewers working independently. Reasons for exclusion of sources of evidence at full text that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion, or with an additional reviewer/s. The results of the search and the study inclusion process will be reported in full in the final scoping review and presented in a flow diagram, in line with guidance provided by the “Priority Items for Systematic Reviews and Meta-analysis Scoping review extension (PRISMA-ScR) checklist (Tricco et al., 2018). Our completed PRISMA-ScR checklist is made available as extended data.

Data charting process

Data will be charted (extracted) from papers included in the scoping review by two or more reviewers working independently using a data extraction tool developed by the reviewers. As shown in Table 1, extracted data will include background information about the article itself (e.g. author(s), funder(s), type of evidence, etc.), as well as information about mass media campaigns for breastfeeding (e.g. the components of communications; development and implementation processes; underlying theories, models and frameworks, etc.). The items have been selected based on their relevance to the review questions.

The data extraction tool we have developed will be piloted using five randomly selected included records and modifications agreed within the team. Any proposed modifications to the data extraction tool after this pilot period will be discussed and agreed within the review team. Any necessary modifications will be retrospectively applied to sources where data extraction was already completed. Modifications will be detailed in the scoping review. Data extraction will be conducted independently and in duplicate by two reviewers. Any disagreements that arise between the reviewers will be resolved through discussion, or with an additional reviewer/s. If appropriate and required, authors of papers will be contacted to request missing or additional data.

Data analysis and presentation

Recent guidance published by the Joanna Briggs Institute (Pollock et al., 2023) recommends several different methods for analysing and presenting the extracted data. These include the use of basic descriptive statistics, tabular presentation, graphical presentation and narrative summaries (Pollock et al., 2023). To this, we also add a basic form of thematic analysis.

The evidence will be mapped and summarised in line with the objectives for the review and research question and sub questions. The precise format of presentation will be finalised after piloting and in consultation with knowledge users to maximise its usability. However, Table 2 shows the planned analysis and presentation methods at the time of developing this protocol. Any deviations from the protocol in the final scoping review will be reported with rationale.

Data extracted on the characteristics of included articles and on all seven sub-questions of the review will be analysed and presented using basic descriptive statistics. Namely, the number of times specific strategies, processes, approaches, theories, models, frameworks, mass media campaign components, research designs, methods, and outcomes are reported in included articles will be presented as counts and percentages to demonstrate how frequently these items appeared in the included literature. We will describe the results of the basic descriptive statistical analysis with narrative summaries to help readers interpret the findings and their potential meanings.

Tables presenting information for all data extraction items will be developed to assist the review team to compare data across the included articles. However, we anticipate only a table on article characteristics will be provided in the main scoping review article, with the remainder provided as supplementary material.

Finally, for mass media campaign components, if there is sufficient data available, we will conduct a basic thematic analysis of the content and framing of the messages of the mass media campaigns to understand the basic themes of messages that have been used to promote or undermine breastfeeding. Thematic analysis is a method identifying themes and patterns of meaning across a dataset (Braun & Clarke, 2013). Two review team members will conduct a basic thematic analysis of the content and framing of messages using the following steps:

Ethics and consent

Ethical approval and consent were not required.