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

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Flynn" }, { "@type": "Person", "name": "Claire M. Timon" }, { "@type": "Person", "name": "Aisling Walsh" }, { "@type": "Person", "name": "Regien Biesma" }, { "@type": "Person", "name": "Mary Rose Sweeney" } ], "publisher": { "@type": "Organization", "name": "HRB Open Research", "logo": { "@type": "ImageObject", "url": "https://hrbopenresearch.org/img/AMP/HRB_image.png", "height": 566, "width": 60 } }, "image": { "@type": "ImageObject", "url": "https://hrbopenresearch.org/img/AMP/HRB_image.png", "height": 1200, "width": 127 }, "description": " Background Breastfeeding remains a critical public health strategy with the potential to lower childhood morbidity and mortality; however, breastfeeding rates remain below optimal levels. Extensive research suggests that the impact of individual and social determinants on breastfeeding is significant. Nevertheless, the influence of built, physical, or spatial environments remains largely underexplored or is included within other constructs. Given the generally low breastfeeding rates, understanding how the built environment affects maternal health is crucial for shaping policies, urban planning, and service provision. Objective This scoping review aims to systematically evaluate the global evidence on how built and physical environments influence breastfeeding practices. Methods and analysis This review will be conducted in accordance with the methodology established by the Joanna Briggs Institute for scoping reviews. The inclusion criteria will follow the Population, Concepts, and Contexts framework. A data charting tool will be developed and utilised for all articles meeting the inclusion criteria. Both qualitative and quantitative descriptive analyses will be performed. The PAGER (Patterns, Advances, Gaps, Evidence for practice, and Research recommendations) framework is proposed to analyse and present the review findings. Conclusion This review will summarise the evidence and identify gaps to inform interventions and guide future research. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://hrbopenresearch.org/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://hrbopenresearch.org/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://hrbopenresearch.org/articles/8-119", "name": "Influences of the Built, Physical,or Spatial Environment on Breastfeeding:A..." } } ] } Home Browse Influences of the Built, Physical,or Spatial Environment on Breastfeeding:A... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Akpanukoh A, Staines A, Flynn AC et al. Influences of the Built, Physical, or Spatial Environment on Breastfeeding: A Scoping Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :119 ( https://doi.org/10.12688/hrbopenres.14263.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Study Protocol Influences of the Built, Physical, or Spatial Environment on Breastfeeding: A Scoping Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] Andyno Akpanukoh https://orcid.org/0009-0008-4345-5060 1 , Anthony Staines https://orcid.org/0000-0001-9161-1357 2 , Angela C. Flynn 3 , [...] Claire M. Timon 3 , Aisling Walsh https://orcid.org/0000-0002-5312-5101 3 , Regien Biesma 4 , Mary Rose Sweeney 1 Andyno Akpanukoh https://orcid.org/0009-0008-4345-5060 1 , Anthony Staines https://orcid.org/0000-0001-9161-1357 2 , [...] Angela C. Flynn 3 , Claire M. Timon 3 , Aisling Walsh https://orcid.org/0000-0002-5312-5101 3 , Regien Biesma 4 , Mary Rose Sweeney 1 PUBLISHED 14 Nov 2025 Author details Author details 1 Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland, 121 St Stephen's Green, Dublin, Leinster, Ireland 2 School of Nursing, Psychotherapy and Community Health, Dublin City University, Dublin, Leinster, Ireland 3 School of Population Health, Royal College of Surgeons in Ireland, 121 St Stephen's Green, Dublin, Leinster, Ireland 4 UMC Utrecht, Utrecht, The Netherlands Andyno Akpanukoh Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Anthony Staines Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing Angela C. Flynn Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing Claire M. Timon Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing Aisling Walsh Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing Regien Biesma Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing Mary Rose Sweeney Roles: Conceptualization, Investigation, Methodology, Supervision, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Maternal and Child Health collection. Abstract Background Breastfeeding remains a critical public health strategy with the potential to lower childhood morbidity and mortality; however, breastfeeding rates remain below optimal levels. Extensive research suggests that the impact of individual and social determinants on breastfeeding is significant. Nevertheless, the influence of built, physical, or spatial environments remains largely underexplored or is included within other constructs. Given the generally low breastfeeding rates, understanding how the built environment affects maternal health is crucial for shaping policies, urban planning, and service provision. Objective This scoping review aims to systematically evaluate the global evidence on how built and physical environments influence breastfeeding practices. Methods and analysis This review will be conducted in accordance with the methodology established by the Joanna Briggs Institute for scoping reviews. The inclusion criteria will follow the Population, Concepts, and Contexts framework. A data charting tool will be developed and utilised for all articles meeting the inclusion criteria. Both qualitative and quantitative descriptive analyses will be performed. The PAGER (Patterns, Advances, Gaps, Evidence for practice, and Research recommendations) framework is proposed to analyse and present the review findings. Conclusion This review will summarise the evidence and identify gaps to inform interventions and guide future research. READ ALL READ LESS Keywords Breastfeeding, Built Environment, Spatial Design, Public Spaces Corresponding Author(s) Andyno Akpanukoh ( [email protected] ) Close Corresponding author: Andyno Akpanukoh Competing interests: No competing interests were disclosed. Grant information: This study is funded by the Board of the Faculty of Nursing and Midwifery, RCSI. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Akpanukoh A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Akpanukoh A, Staines A, Flynn AC et al. Influences of the Built, Physical, or Spatial Environment on Breastfeeding: A Scoping Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :119 ( https://doi.org/10.12688/hrbopenres.14263.1 ) First published: 14 Nov 2025, 8 :119 ( https://doi.org/10.12688/hrbopenres.14263.1 ) Latest published: 14 Nov 2025, 8 :119 ( https://doi.org/10.12688/hrbopenres.14263.1 ) Introduction Evidence continues to suggest that breastfeeding remains a cost-effective public health strategy with the potential to improve the survival, health, and development of infants and mothers across high-, middle-, and low-income countries 1 . Approximately $302 billion (equivalent to 0.49%) of the world's gross national income is attributed to the lower cognitive development associated with inadequate breastfeeding practices 2 . Despite the evidence highlighting the health, economic, and psychosocial advantages of breastfeeding, global rates remain suboptimal due to inconsistent adherence to recommendations. The World Health Organisation (WHO) recommends initiating breastfeeding initiation within the first hour after birth, exclusive breastfeeding for up to six months, followed by continued breastfeeding for up to two years 3 . Nevertheless, only 48% of infants under six months are being exclusively breastfed worldwide 4 . While this percentage falls short of the 60% target set by the World Health Assembly by 2030, there is also a notable decline in breastfeeding continuation rates, dropping from around 71% at one year to 45% by age two 4 . Except in cases of severe medical complications, nearly all women are biologically capable of adhering to the breastfeeding guidelines 5 . However, according to the conceptual framework of the Components of an Enabling Environment for Breastfeeding, breastfeeding is primarily influenced by factors at the structural, individual, and setting levels 2 . While individual-level and social determinants have received significant attention 6 – 8 , there is increasing focus on how broader environmental and structural conditions influence breastfeeding behaviours 2 . At the setting level, the role of the built environment, encompassing the physical and infrastructural components of areas where people reside, work, and engage with one another 9 , has received comparatively less focus. According to Collinge 10 , places and environments are often defined as location (physical coordinates), locale (a socially constructed setting), and sense of place (subjective experiences). Regarding breastfeeding, elements of the built environment, such as the availability of breastfeeding rooms in public areas and workplace facilities, can significantly influence breastfeeding behaviours 11 . Since many environments are perceived as unsupportive of breastfeeding 12 , 13 , structural inequalities have been identified as one of the five primary factors influencing breastfeeding, according to an international review of qualitative literature 13 . Specifically, inadequate access to comfortable and clean breastfeeding spaces, along with issues related to poor-quality or inaccessible dedicated facilities, can impact breastfeeding. Furthermore, insights from qualitative research with parents in both low- and high-income neighbourhoods in Bristol show that even within a single city, variations in the built environment and social norms can either promote or hinder breastfeeding, with higher socioeconomic status groups receiving better support than those in economically disadvantaged situations 14 . Therefore, it is crucial for policies to address and improve the availability of "pro-breastfeeding" spaces in socially underprivileged areas to ensure equitable access 14 . Despite increasing evidence emphasising the significance of the built or spatial environment, most studies on breastfeeding continue to focus on social factors (such as family support, cultural norms, and professional attitudes), with the built environment often overlooked or subsumed under social constructs 15 . This review aims to address this imbalance by systematically compiling global evidence on the influence of built and physical environments on breastfeeding support and hindrance. 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. Methods and analysis The review is registered with the Open Science Framework and can be accessed via https://doi.org/10.17605/OSF.IO/EV8CN Consistent with similar studies 17 , 18 , this scoping review will be conducted by the Joanna Briggs Institute (JBI) methodology for scoping reviews 19 . The approach will be based on the updated framework for scoping reviews established by Arksey & O’Malley 20 . This framework comprises six distinct stages, outlined in the subsequent sections of this protocol. Furthermore, this review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) to ensure thorough reporting 21 . 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: Provide an overview of the factors within the built or spatial environment in relation to breastfeeding. Identify barriers and facilitators to breastfeeding present within the built or spatial environment. Determine whether and which conceptual frameworks have been used in creating a breastfeeding-built environment. Highlight knowledge gaps related to research on the breastfeeding-built environment. Stage 2: Identifying relevant articles Search strategy. This review will follow the three-step search strategy by JBI 24 . 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 Data 25 ). 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. Table 1. Population, Concepts, and Context. Criteria Determinants Population Breastfeeding mothers Concepts Built environment, physical environment, environmental support, infrastructure (e.g., breastfeeding rooms, seating, signage, spatial design) Context Clinical and non-clinical settings, like postnatal environments, public spaces, and workplaces 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: examine breastfeeding (defined as any breastfeeding report on built or spatial environmental influences Peer-reviewed articles and relevant grey literature (e.g., policy reports, NGO publications) All study designs (qualitative, quantitative, mixed methods) English language publications from 2000 onwards Exclusion criteria Studies that: are focused solely on initiation or early hospital-based feeding are published in a language other than English Interventions with no reference to the built or spatial environmental factors 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 framework 24 . A data charting form will be created and used for all included articles (See Extended Data 25 ). 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 review 26 . 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 analysis 26 . 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. Research checklist This scoping review protocol was drafted using the PRISMA-SCR extension checklist (See Extended Data 25 ). Study status The review is currently at Stage 3: Study Selection, specifically the pilot screening phase. The database and grey literature searches have been completed using a predefined strategy. Conclusion The purpose of this scoping review is to identify and analyse the evidence on elements of the built environment that may affect breastfeeding. Findings will be shared in a peer-reviewed publication and presented at conferences and/or seminars. This review will identify areas where evidence is lacking, which will guide future research related to this global initiative. Data availability statement Underlying data No data are associated with this article. Extended data Open Science Framework: Influences of the Built, Physical, or Spatial Environment on Breastfeeding: A Scoping Review Protocol. https://doi.org/10.17605/OSF.IO/SXBJD 25 . The project contains the following data: 1. Sample Search Strategy 2. Sample Data Charting Form 3. Reporting guidelines OSF: PRISMA-ScR checklist for “Influences of the Built, Physical, or Spatial Environment on Breastfeeding: A Scoping Review Protocol” https://doi.org/10.17605/OSF.IO/SXBJD 25 . Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Faculty Opinions recommended References 1. Victora CG, Bahl R, Barros AJD, et al. : Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016; 387 (10017): 475–90. PubMed Abstract | Publisher Full Text 2. Rollins NC, Bhandari N, Hajeebhoy N, et al. : Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016; 387 (10017): 491–504. PubMed Abstract | Publisher Full Text 3. World Health Organization (WHO): Global strategy for infant and young child feeding. Geneva, Switzerland, 2003. Reference Source 4. UNICEF and World Health Organization: Global breastfeeding scorecard 2023. New York, USA, 2023. Reference Source 5. World Health Organization: Acceptable medical reasons for use of breast-milk substitutes. Geneva, Switzerland, 2009. Reference Source 6. Asimaki E, Dagla M, Sarantaki A, et al. : Main biopsychosocial factors influencing breastfeeding: a systematic review. Maedica (Bucur). 2022; 17 (4): 955–962. PubMed Abstract | Publisher Full Text | Free Full Text 7. Norman A, Mortimer S, Baptie G, et al. : Breastfeeding experiences and support: identifying factors influencing breastfeeding behaviour. Br J Midwifery. 2022; 30 (4): 190–201. Publisher Full Text 8. Meedya S, Fahy K, Kable A: Factors that positively influence breastfeeding duration to 6 months: a literature review. Women Birth. 2010; 23 (4): 135–45. PubMed Abstract | Publisher Full Text 9. Giles-Corti B, Vernez-Moudon A, Reis R, et al. : City planning and population health: a global challenge. Lancet. 2016; 388 (10062): 2912–2924. PubMed Abstract | Publisher Full Text 10. Collinge C, Gibney J, Mabey C: Leadership and place. Policy Stud. 2010; 31 (4): 367–378. Publisher Full Text 11. Chen TL, Chen LL, Gau ML: Association between breastfeeding-friendly environmental factors and breastfeeding practices at 6 months in mothers in Taiwan. Int Breastfeed J. 2024; 19 (1): 78. PubMed Abstract | Publisher Full Text | Free Full Text 12. Grant A: Breasts and the city: an urban ethnography of infant feeding in public spaces within Cardiff, United Kingdom. Int Breastfeed J. 2021; 16 (1): 37. PubMed Abstract | Publisher Full Text | Free Full Text 13. Grant A, Pell B, Copeland L, et al. : Views and experience of breastfeeding in public: a qualitative systematic review. Matern Child Nutr. 2022; 18 (4): e13407. PubMed Abstract | Publisher Full Text | Free Full Text 14. Isherwood J, Boyer K, Dowling S: Local Landscapes of Breastfeeding: a comparison of breastfeeding amongst mothers in low- and high-income neighborhoods in Bristol, UK. Health Place. 2019; 59 : 102125. PubMed Abstract | Publisher Full Text 15. Wu Q, Tang N, Wacharasin C: Factors influencing exclusive breastfeeding for 6 months postpartum: a systematic review. Int J Nurs Knowl. 2022; 33 (4): 290–303. PubMed Abstract | Publisher Full Text 16. Peters MD, Godfrey CM, Khalil H, et al. : Guidance for conducting systematic scoping reviews. Int J Evid Based Healthc. 2015; 13 (3): 141–6. PubMed Abstract | Publisher Full Text 17. Walsh A, Pieterse P, McCormack Z, et al. : Improving breastfeeding support through the implementation of the Baby Friendly Hospital and community Initiatives: a scoping review protocol [version 2; peer review: 2 approved]. HRB Open Res. 2021; 4 : 1. PubMed Abstract | Publisher Full Text | Free Full Text 18. Durocher K, Jackson KT, Booth R, et al. : Scoping review of women's experiences of breastfeeding associated with maternity care in hospitals that implement baby-friendly policies. J Obstet Gynecol Neonatal Nurs. 2025; 54 (2): 176–88.e29. PubMed Abstract | Publisher Full Text 19. Peters MDJ, Godfrey C, McInerney P, et al. : Scoping reviews. In: Aromataris E; Lockwood C; Porritt, K.; Pilla, B.; Jordan, Z., editor. JBI Manual for Evidence Synthesis . Adelaide, Australia: JBI, 2024. Publisher Full Text 20. Arksey H, O'malley L: Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005; 8 (1): 19–32. Publisher Full Text 21. Tricco AC, Lillie E, Zarin W, et al. : PRISMA extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018; 169 (7): 467–473. PubMed Abstract | Publisher Full Text 22. O’Sullivan EJ, O’Grady A, Pawlak K, et al. : A qualitative exploration of the attitudes and experiences of polish breastfeeding mothers in Ireland. J Hum Lact. 2021; 37 (2): 370–379. PubMed Abstract | Publisher Full Text 23. Lawlor N, Prihodova L, Byrne D, et al. : A qualitative analysis of women’s postnatal experiences of breastfeeding supports during the perinatal period in Ireland. PLoS One. 2023; 18 (7): e0288230. PubMed Abstract | Publisher Full Text | Free Full Text 24. Peters MD, Godfrey C, McInerney P, et al. : Scoping reviews. JBI Manual for Evidence Synthesis. 2020; 10 : 10-46658. Publisher Full Text 25. Akpanukoh AU, Staines A, Flynn A, et al. : Influences of the built, physical, or spatial environment on breastfeeding: a scoping review protocol. OSF. 2025. http://www.doi.org/10.17605/OSF.IO/SXBJD 26. Bradbury-Jones C, Aveyard H, Herber OR, et al. : Scoping reviews: the PAGER framework for improving the quality of reporting. Int J Soc Res Methodol. 2022; 25 (4): 457–470. Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 14 Nov 2025 ADD YOUR COMMENT Comment Author details Author details 1 Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland, 121 St Stephen's Green, Dublin, Leinster, Ireland 2 School of Nursing, Psychotherapy and Community Health, Dublin City University, Dublin, Leinster, Ireland 3 School of Population Health, Royal College of Surgeons in Ireland, 121 St Stephen's Green, Dublin, Leinster, Ireland 4 UMC Utrecht, Utrecht, The Netherlands Andyno Akpanukoh Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Anthony Staines Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing Angela C. Flynn Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing Claire M. Timon Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing Aisling Walsh Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing Regien Biesma Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing Mary Rose Sweeney Roles: Conceptualization, Investigation, Methodology, Supervision, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information This study is funded by the Board of the Faculty of Nursing and Midwifery, RCSI. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (1) version 1 Published: 14 Nov 2025, 8:119 https://doi.org/10.12688/hrbopenres.14263.1 Copyright © 2025 Akpanukoh A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics VIEWS $counts.viewCount downloads Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Akpanukoh A, Staines A, Flynn AC et al. Influences of the Built, Physical, or Spatial Environment on Breastfeeding: A Scoping Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :119 ( https://doi.org/10.12688/hrbopenres.14263.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 14 Nov 2025 Views 0 Cite How to cite this report: Couto C. Reviewer Report For: Influences of the Built, Physical, or Spatial Environment on Breastfeeding: A Scoping Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :119 ( https://doi.org/10.21956/hrbopenres.15687.r51792 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-119/v1#referee-response-51792 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 07 Jan 2026 Cristina Couto , Universidade Católica Portuguesa, Porto, Portugal Approved VIEWS 0 https://doi.org/10.21956/hrbopenres.15687.r51792 Reviewer Comments Considering the principles of publication quality, this manuscript addresses a topic of clear relevance to women’s health, particularly in relation to the quality and satisfaction associated with breastfeeding healthcare. For greater clarity, it is suggested that ... Continue reading READ ALL Reviewer Comments Considering the principles of publication quality, this manuscript addresses a topic of clear relevance to women’s health, particularly in relation to the quality and satisfaction associated with breastfeeding healthcare. For greater clarity, it is suggested that the components of the data extraction instrument be presented. Overall, this manuscript represents a valuable and timely contribution to the field of research on quality of care during the breastfeeding process. It has the potential to make a meaningful impact on the evidence base surrounding maternal healthcare quality. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Breastfeeding; Nursing; Midwifery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Couto C. Reviewer Report For: Influences of the Built, Physical, or Spatial Environment on Breastfeeding: A Scoping Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :119 ( https://doi.org/10.21956/hrbopenres.15687.r51792 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-119/v1#referee-response-51792 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Al Jawaldeh A. Reviewer Report For: Influences of the Built, Physical, or Spatial Environment on Breastfeeding: A Scoping Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :119 ( https://doi.org/10.21956/hrbopenres.15687.r52140 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-119/v1#referee-response-52140 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 05 Jan 2026 Ayoub Al Jawaldeh , World Health Organization, Cairo, Egypt Approved with Reservations VIEWS 0 https://doi.org/10.21956/hrbopenres.15687.r52140 Thank you for the opportunity to review the draft protocol for the scoping review, "Influences of the Built, Physical, or Spatial Environment on Breastfeeding." This is a well-structured and methodologically sound protocol that addresses a significant and ... Continue reading READ ALL Thank you for the opportunity to review the draft protocol for the scoping review, "Influences of the Built, Physical, or Spatial Environment on Breastfeeding." This is a well-structured and methodologically sound protocol that addresses a significant and timely gap in the breastfeeding literature. The focus of authors on the built environment as a structural determinant of health is highly recommended and aligns with global public health priorities. Overall, the protocol is excellent. To further strengthen its global public health impact, policy relevance, and alignment with World Health Organization (WHO) frameworks, I suggest the following strategic suggestions for your consideration: 1. Enhance Explicit Alignment with WHO Frameworks & Targets Suggestion: In the Introduction or Rationale , add a statement explicitly linking the review's purpose to supporting WHO's global targets (e.g., the Global Nutrition Target 2025, the 2030 World Health Assembly target) and foundational documents like the WHO/UNICEF Global Strategy for Infant and Young Child Feeding . This will immediately frame the work within the key policy context it aims to inform. Reasoning: This strengthens the narrative for why the review matters on the global stage and clarifies its utility for WHO member states and partners. 2. Deepen the Equity Lens in Methodology Suggestion A (Concepts): In your PCC table, consider adding "Equity," "Socioeconomic Factors," or "Health Inequalities" as a sub-concept under "Concepts." This will ensure your data extraction form prompts reviewers to systematically capture findings related to differential access or outcomes across population groups. Suggestion B (Analysis): In Stage 5, mandate that the "Gaps" analysis within the PAGER framework specifically identifies equity-related evidence gaps (e.g., research lacking from low-resource settings, informal settlements, or among displaced populations). Reasoning: Your introduction powerfully highlights structural inequalities. Baking this equity focus into the methods ensures the review's outputs will directly inform strategies to reduce disparities, a core WHO principle. 3. Broaden Search for Global Grey Literature Suggestion: Complement your excellent database search by including targeted searches of key WHO/UN repositories , such as the WHO IRIS and PAHO/WHO library . These sources contain crucial grey literature—regional reports, country case studies, and program evaluations—that are vital for capturing evidence from low- and middle-income countries (LMICs) and the work of UN agencies. Reasoning: This mitigates the potential high-income country bias inherent in bibliographic databases and ensures the "global" scope of the review is more fully realized. 4. Address the Language Limitation Strategically Suggestion: In the Exclusion Criteria section, actively acknowledge that the "English language only" criterion is a significant limitation that may bias the findings towards high-income, English-speaking contexts. You might note this as an area for future synthesis efforts. Reasoning: Transparency about this constraint is important for interpreting the review's global applicability. It aligns with scientific rigor and demonstrates awareness of the challenge of achieving truly comprehensive global evidence synthesis. 5. Frame Stakeholder Engagement for Maximum Policy Impact Suggestion: In Stage 6 , specify plans to engage technical officers from WHO regional offices or representatives from WHO-collaborating centres . Furthermore, frame the consultation's goal as not only validating findings but co-creating actionable policy and practice recommendations . These could feed into tools like the expanded Baby-Friendly Hospital Initiative (BFHI) for communities and workplaces . Reasoning: This elevates the review from an academic exercise to a direct input for WHO and national policy development, maximizing its real-world impact. Minor Editorial Point: For consistency, consider standardizing the term "built environment" as the primary keyword throughout the manuscript, using "physical/spatial environment" as secondary synonyms. I hope the above comments are helpful Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Partly Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Nutrition I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Al Jawaldeh A. Reviewer Report For: Influences of the Built, Physical, or Spatial Environment on Breastfeeding: A Scoping Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :119 ( https://doi.org/10.21956/hrbopenres.15687.r52140 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-119/v1#referee-response-52140 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 14 Nov 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 1 14 Nov 25 read read Ayoub Al Jawaldeh , World Health Organization, Cairo, Egypt Cristina Couto , Universidade Católica Portuguesa, Porto, Portugal Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Couto C. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 07 Jan 2026 | for Version 1 Cristina Couto , Universidade Católica Portuguesa, Porto, Portugal 0 Views copyright © 2026 Couto C. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Comments Considering the principles of publication quality, this manuscript addresses a topic of clear relevance to women’s health, particularly in relation to the quality and satisfaction associated with breastfeeding healthcare. For greater clarity, it is suggested that the components of the data extraction instrument be presented. Overall, this manuscript represents a valuable and timely contribution to the field of research on quality of care during the breastfeeding process. It has the potential to make a meaningful impact on the evidence base surrounding maternal healthcare quality. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Breastfeeding; Nursing; Midwifery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Couto C. Peer Review Report For: Influences of the Built, Physical, or Spatial Environment on Breastfeeding: A Scoping Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :119 ( https://doi.org/10.21956/hrbopenres.15687.r51792) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/8-119/v1#referee-response-51792 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Al Jawaldeh A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 05 Jan 2026 | for Version 1 Ayoub Al Jawaldeh , World Health Organization, Cairo, Egypt 0 Views copyright © 2026 Al Jawaldeh A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for the opportunity to review the draft protocol for the scoping review, "Influences of the Built, Physical, or Spatial Environment on Breastfeeding." This is a well-structured and methodologically sound protocol that addresses a significant and timely gap in the breastfeeding literature. The focus of authors on the built environment as a structural determinant of health is highly recommended and aligns with global public health priorities. Overall, the protocol is excellent. To further strengthen its global public health impact, policy relevance, and alignment with World Health Organization (WHO) frameworks, I suggest the following strategic suggestions for your consideration: 1. Enhance Explicit Alignment with WHO Frameworks & Targets Suggestion: In the Introduction or Rationale , add a statement explicitly linking the review's purpose to supporting WHO's global targets (e.g., the Global Nutrition Target 2025, the 2030 World Health Assembly target) and foundational documents like the WHO/UNICEF Global Strategy for Infant and Young Child Feeding . This will immediately frame the work within the key policy context it aims to inform. Reasoning: This strengthens the narrative for why the review matters on the global stage and clarifies its utility for WHO member states and partners. 2. Deepen the Equity Lens in Methodology Suggestion A (Concepts): In your PCC table, consider adding "Equity," "Socioeconomic Factors," or "Health Inequalities" as a sub-concept under "Concepts." This will ensure your data extraction form prompts reviewers to systematically capture findings related to differential access or outcomes across population groups. Suggestion B (Analysis): In Stage 5, mandate that the "Gaps" analysis within the PAGER framework specifically identifies equity-related evidence gaps (e.g., research lacking from low-resource settings, informal settlements, or among displaced populations). Reasoning: Your introduction powerfully highlights structural inequalities. Baking this equity focus into the methods ensures the review's outputs will directly inform strategies to reduce disparities, a core WHO principle. 3. Broaden Search for Global Grey Literature Suggestion: Complement your excellent database search by including targeted searches of key WHO/UN repositories , such as the WHO IRIS and PAHO/WHO library . These sources contain crucial grey literature—regional reports, country case studies, and program evaluations—that are vital for capturing evidence from low- and middle-income countries (LMICs) and the work of UN agencies. Reasoning: This mitigates the potential high-income country bias inherent in bibliographic databases and ensures the "global" scope of the review is more fully realized. 4. Address the Language Limitation Strategically Suggestion: In the Exclusion Criteria section, actively acknowledge that the "English language only" criterion is a significant limitation that may bias the findings towards high-income, English-speaking contexts. You might note this as an area for future synthesis efforts. Reasoning: Transparency about this constraint is important for interpreting the review's global applicability. It aligns with scientific rigor and demonstrates awareness of the challenge of achieving truly comprehensive global evidence synthesis. 5. Frame Stakeholder Engagement for Maximum Policy Impact Suggestion: In Stage 6 , specify plans to engage technical officers from WHO regional offices or representatives from WHO-collaborating centres . Furthermore, frame the consultation's goal as not only validating findings but co-creating actionable policy and practice recommendations . These could feed into tools like the expanded Baby-Friendly Hospital Initiative (BFHI) for communities and workplaces . Reasoning: This elevates the review from an academic exercise to a direct input for WHO and national policy development, maximizing its real-world impact. Minor Editorial Point: For consistency, consider standardizing the term "built environment" as the primary keyword throughout the manuscript, using "physical/spatial environment" as secondary synonyms. I hope the above comments are helpful Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Partly Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Nutrition I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Al Jawaldeh A. Peer Review Report For: Influences of the Built, Physical, or Spatial Environment on Breastfeeding: A Scoping Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :119 ( https://doi.org/10.21956/hrbopenres.15687.r52140) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/8-119/v1#referee-response-52140 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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