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

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Introduction Breastfeeding is the human biological norm and is well established to be foundational for health throughout the life course. Population-level communication interventions, or mass communication interventions can support positive social and cultural norms and practices that enable breastfeeding. To inform the development of effective mass communication interventions there is a need to systematically identify, analyse and synthesise the existing evidence to inform such guidance. Inclusion criteria We will include evidence on the development, implementation and effectiveness of population-level communications interventions in high development index countries (including traditional mass media, social media or other mass communication interventions) aimed at influencing breastfeeding at scale. We will include empirical evidence from primary studies and evidence synthesis. Methods We will search databases for primary studies and reviews, written in English language, from 1990 onwards: PubMed, Embase, EBSCO, PsycInfo, MIDIRS and ProQuest. 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. Screening and data extraction will be conducted using EPPI reviewer web (ER6), making use of automation tools to support efficiency. Disagreements will be discussed until a consensus is reached or a third author makes a final decision. Data extraction will include information on study location, target and subject populations, message content, message framing, declared conflicts of interest and underlying theory used. 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HRB Open Res 2025, 8 :76 ( https://doi.org/10.12688/hrbopenres.14088.2 ) 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 Revised Population-level communication interventions for breastfeeding: Protocol for a scoping review [version 2; peer review: 3 approved, 1 approved with reservations] Jennifer Hanratty https://orcid.org/0000-0002-1076-240X 1 , Karl McGrath 1 , Karen Matvienko-Sikar https://orcid.org/0000-0003-2777-6581 2 , [...] Elaine Lehane 3 , Aoife Long https://orcid.org/0000-0001-5022-1969 3 , Caroline Rawdon 1 , Patricia Leahy-Warren https://orcid.org/0000-0002-4443-4471 3 Jennifer Hanratty https://orcid.org/0000-0002-1076-240X 1 , Karl McGrath 1 , [...] Karen Matvienko-Sikar https://orcid.org/0000-0003-2777-6581 2 , Elaine Lehane 3 , Aoife Long https://orcid.org/0000-0001-5022-1969 3 , Caroline Rawdon 1 , Patricia Leahy-Warren https://orcid.org/0000-0002-4443-4471 3 PUBLISHED 17 Nov 2025 Author details Author details 1 Centre for Effective Services, Dublin, Leinster, Ireland 2 School of Public Health, University College Cork, County Cork, Ireland 3 School of Nursing and Midwifery, University College Cork, County Cork, Ireland Jennifer Hanratty Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Karl McGrath Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Karen Matvienko-Sikar Roles: Funding Acquisition, Writing – Original Draft Preparation, Writing – Review & Editing Elaine Lehane Roles: Funding Acquisition, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Aoife Long Roles: Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Caroline Rawdon Roles: Writing – Review & Editing Patricia Leahy-Warren Roles: Funding Acquisition, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Maternal and Child Health collection. Abstract Objective The objective for this scoping review is to systematically identify and map the breadth, type, and characteristics of population-level communication interventions on breastfeeding. Introduction Breastfeeding is the human biological norm and is well established to be foundational for health throughout the life course. Population-level communication interventions, or mass communication interventions can support positive social and cultural norms and practices that enable breastfeeding. To inform the development of effective mass communication interventions there is a need to systematically identify, analyse and synthesise the existing evidence to inform such guidance. Inclusion criteria We will include evidence on the development, implementation and effectiveness of population-level communications interventions in high development index countries (including traditional mass media, social media or other mass communication interventions) aimed at influencing breastfeeding at scale. We will include empirical evidence from primary studies and evidence synthesis. Methods We will search databases for primary studies and reviews, written in English language, from 1990 onwards: PubMed, Embase, EBSCO, PsycInfo, MIDIRS and ProQuest. 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. Screening and data extraction will be conducted using EPPI reviewer web (ER6), making use of automation tools to support efficiency. Disagreements will be discussed until a consensus is reached or a third author makes a final decision. Data extraction will include information on study location, target and subject populations, message content, message framing, declared conflicts of interest and underlying theory used. READ ALL READ LESS Keywords breastfeeding, social change communication, behaviour change, mass media, scoping review Corresponding Author(s) Jennifer Hanratty ( [email protected] ) Close Corresponding author: Jennifer Hanratty Competing interests: No competing interests were disclosed. Grant information: Health Research Board [APRO-2023-015]. Health Research Board -APRO-2023-015 This review is being undertaken as part of the ‘Maximise support for breastfeeding for sustainable population health and wellbeing: Integrated knowledge translation approach, MaxSBF’ and is funded by the Health Research Board. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Hanratty J 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: Hanratty J, McGrath K, Matvienko-Sikar K et al. Population-level communication interventions for breastfeeding: Protocol for a scoping review [version 2; peer review: 3 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :76 ( https://doi.org/10.12688/hrbopenres.14088.2 ) First published: 07 Jul 2025, 8 :76 ( https://doi.org/10.12688/hrbopenres.14088.1 ) Latest published: 17 Nov 2025, 8 :76 ( https://doi.org/10.12688/hrbopenres.14088.2 ) Revised Amendments from Version 1 We have made minor changes in response to peer review, namely: Clarifying that we plan to assess declared conflicts of interest in included studies, editing the section on “Key concepts and terms” and adding illustrative examples for greater clarity, simplifying the planned approach to thematic analysis of campaign content and framing of breastfeeding, and added a statement on funding We have made minor changes in response to peer review, namely: Clarifying that we plan to assess declared conflicts of interest in included studies, editing the section on “Key concepts and terms” and adding illustrative examples for greater clarity, simplifying the planned approach to thematic analysis of campaign content and framing of breastfeeding, and added a statement on funding See the authors' detailed response to the review by Louisiana Montserrat Sanchez See the authors' detailed response to the review by Jessica L Schue See the authors' detailed response to the review by Monique M. Turner See the authors' detailed response to the review by Henriette Knold Rossau READ REVIEWER RESPONSES 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 ). Box 1. Key concepts, terms and approaches relevant to this scoping review We outline our definitions of the core terms used in this review below. Population-level communication interventions refer to interventions that seeks to communicate with the population at scale to influence health behaviours ( Stead et al ., 2019 ). Mass communication campaigns are a type of population-level communication interventions. Mass communication refers to the transmission of messages through one or more media to large audiences or populations. Media are the technologies that provide the means of transmitting such messages ( Deuze, 2020 ). Mass media refers to technologies that can transmit messages almost instantaneously to large audiences across great geographic distances. Common mass media technologies include television, newspapers, film and radio ( Storey et al ., 2011 ). Social media are a form of mass media. Social media does not have a definitive definition ( Morse & Brown, 2022 ; Orchard & Nicholls, 2022 ), though they typically have the ability to transmit messages across geographical distances to potential large audiences. Social media tend to have greater capacity for users to interact, generate, share their own content, and to target specific audiences more precisely that mass media ( Storey et al ., 2011 ). Mass media campaigns actively and systematically use mass media to communicate at scale with the intent of influencing the health behaviour of large target audience(s) or population(s). In this review, an eligible intervention would be, for example, a mixed media campaign with tv ads, radio spots and social media content with specific messaging targeted to specific audiences. Ineligible interventions would be those that require the target audience to seek out or opt in to receive campaign information. For example, a website that passively provides information, without an accompanying ‘push’ to advertise or otherwise engage people with the information or an mHealth intervention requiring the audience to opt-in to receive information, would be ineligible for this scoping review. 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. Existing evidence syntheses A preliminary search of PUBMED, OSF, the Cochrane Database of Systematic Reviews, The Campbell Library and JBI Evidence Synthesis and google scholar was conducted. We identified a number of existing evidence syntheses related to the topic of our scoping review. While there is overlap with our proposed scoping review, none of the reviews identified examine the evidence for the purpose of informing guidance on the design and development of mass media campaigns ( Barnett et al ., 2022 ; Darajat et al ., 2022 ; Eppes et al ., 2023 ; Galvão et al ., 2021 ; Gavine et al ., 2022 ; Graziose et al ., 2018 ; Henderson & Gow, 2023 ; Lamstein et al ., 2014 ; Mahumud et al ., 2022 ; Morse & Brown, 2022 ; Orchard & Nicholls, 2022 ; Schmidt, 2013 ; Susilawati & Wijhati, 2021 ; Tang et al ., 2019 ; Underwood, 2021 ; Wakefield et al ., 2010 ). For example, the Wakefield et al . (2010) systematic review examined the effectiveness of mass media campaigns in the context a wide range of health behaviours. This systematic review is a useful primer on the mechanisms of change and the factors that influence success in a broad sense, however, it does not focus specifically on breastfeeding behaviour. Orchard and Nicholls (2022) systematic review examined the impact of social media on breastfeeding but focused primarily on online communities and supports; it did not examine the use of social media as a channel for delivering a planned campaign. Darajat et al. ’s (2022) systematic review of social behaviour change communications to preventing stunting included breastfeeding communications campaigns but this was not the primary focus of their analysis. Similarly, Mahumud et al. ’s (2022) systematic review of behaviour change communications interventions for improving young child nutrition does include studies on mass media campaigns but breastfeeding is not the primary focus. One systematic review that does focus specifically on the development, implementation and effectiveness of mass media campaigns for infant feeding outcomes is by Graziose et al . (2018) . Their review was limited to research from low- and middle-income countries. Our proposed scoping review will complement this existing review with a focus on evidence produced in the context of countries ranked as ‘very high’ on the human development index. No other published current or underway systematic reviews or scoping reviews on the topic were identified. 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? Sub-question 1: What strategies, processes or approaches were used to develop mass media campaigns aimed at influencing breastfeeding? Sub-question 2: What, if any, theories, models or frameworks were reported to underpin the development of mass media campaigns aimed at influencing breastfeeding? Sub-question 3: What were the components of mass media campaigns in terms of their source, message, channel, receiver and destination? Sub-question 4: What theories, models or frameworks were reported to underpin the implementation of mass media campaigns aimed at influencing breastfeeding? Sub-question 5: What strategies, processes or approaches were used to implement mass media campaigns aimed at influencing breastfeeding? Sub-question 6: What research designs, methods and outcomes were used to evaluate the design, implementation and effectiveness of mass media campaigns aimed at influencing breastfeeding? Eligibility criteria Participants The populations of interest are the general public and/or the people and places (i.e. the social and physical environment) through which mass media campaigns seek to directly or indirectly influence breastfeeding outcomes. These include, for example, campaigns aimed at grandparents, workplaces, young people who are not yet parents, public spaces, services, places of work, and broader social systems and institutions, at local and distal levels. Concept Eligible articles should contain the following core concepts of interest: 1) A description of, or guidance on, 2) the design, implementation and/or evaluation of a mass media campaign/other mass communication campaign (whether delivered as a standalone intervention or as part of a package of interventions) that actively and systematically use mass media or other means of communication, such as social media, with the intent of influencing the health behaviour of a large target audience 3) with the aim of influencing breastfeeding at scale. Articles missing any of the core concepts above will be excluded. Note: We do not intend to include mHealth technologies as an eligible form of mass media for this review. We define mHealth as the use of mobile devices to support medical practice. We exclude mHealth technologies because scoping searches indicated that they tend to be used to improve access to and uptake of medical supports and require active consent of the message recipient to receive messages, whereas mass media campaigns require no such consent. Context Eligible studies must be conducted in one or more of the 68 countries classified as ‘very high’ on the Human Development Index (HDI) in 2022, which is the most recent year with data available at the time of publication ( United Nations Development Programme, 2025 ; World Population Review, 2024 ). Types of sources Peer-reviewed and grey literature (including research theses) are both eligible for inclusion as long as they also contain at least one of the following features: Empirical research, which we take to refer to research whose data comes from real-world observations and experiments. This includes both primary research and secondary research such as evidence syntheses and narrative literature reviews. Non-empirical reports or documents that are intended as discussion papers, position papers, opinion pieces or which provide relevant models, frameworks or guidance. We will exclude blogs, conference extracts, and news articles because they typically lack rigorous methodological frameworks and empirical data. Similarly, books and book chapters will be excluded unless they present original empirical research not published elsewhere. Language and publication date Only studies published in English will be included. Studies published since 1990 will be included as this was when the Innocenti Declaration On the Protection, Promotion and Support of Breastfeeding ( WHO/Unicef, 1990 ) was first produced, which was foundational for the Global Strategy on Breastfeeding ( WHO/Unicef, 2003 ). Knowledge user consultation Knowledge users were engaged throughout this work and as part of the larger MaxSBF programme, including in the development of the research grant application. For this scoping review specifically knowledge users contributed through: structured conversations with two community-based knowledge users with expertise in breastfeeding support and the social and cultural influences on infant feeding decisions two expert methodologists in evidence synthesis pen and paper-based consultation with 30 lactation consultants who identified priority target groups for communications interventions and local factors that influence breastfeeding one local lead for child health development. Knowledge user insights informed key decisions about the review, including the choice of methodology, shaping the inclusion and exclusion criteria, and key concepts included in data extraction. These consultations were essential in building a data extraction tool that could identify relevant information and gaps in the research evidence from the perspective of expert practitioners and knowledge users. In terms of JBIs guidance this involvement would meet the levels of controlling, influencing and contributing to the work. Information sources The information sources for this scoping review include: Databases and platforms of peer-reviewed literature Databases and websites of grey literature Citation chaining of included studies Directly contacting via email expert authors and organisations. 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. Peer-reviewed literature There are two core concepts of interest to this review: (1) breastfeeding, and (2) mass communications and mass media. The search strategy for peer-reviewed literature will be conducted around these two core concepts over four stages. In stage 1, two members of the review team (JH and KMG) conduct limited scoping searches on MEDLINE (PubMed) and Google Scholar to identify an initial bank of relevant articles on the topic (complete) In stage 2, search terms are identified for the core concept of ‘breastfeeding’. We will use a verified search string developed using the ‘pearl harvesting’ methodology ( Sandieson, 2006 ) 2 . Pearl harvesting is an exhaustive process that builds and tests a search string designed to maximise both sensitivity and specificity and remove redundant search terms ( Sandieson, 2006 ). In stage 3, search terms for mass communications and mass media are gathered through identifying related terms used in the titles, abstracts and keywords and index terms of articles identified in stage 1. In stage 4, the search terms identified in stages 2 and 3 are tested by an experienced evidence synthesis specialist (JH) in PubMed for sensitivity and specificity. The search strategy for PubMed is provided below, the concept is in bold, the search terms to capture that concept follow. This core strategy will be tailored to the notation and indexing practices of each database and the full list of searches will be provided in the scoping review. Breastfeeding: ((infant N3 feeding) OR (neonatal N3 feeding) OR (breast N3 feeding) OR (breast N3 milk) OR (mother* N3 milk) OR (maternal N3 milk) OR (human N3 milk) OR (infant N3 lactation) OR (infant N3 nutrition*) OR (infant N3 food) OR (breastfeeding OR breastfed OR breastmilk)) AND Communication campaign : digital media OR electronic media OR social media OR social network OR broadcast media or mass media or print media or radio or television or TV or newspaper OR news media OR online news OR digital technology or news media or online media OR health promotion campaign OR behaviour change communication OR communication campaign OR Social norm OR social marketing OR health marketing OR commercial milk formula marketing OR advert* AND Evaluation, development or implementation: efficacy OR effective* OR sample OR cross-section* OR design* OR develop* OR implement* OR intervention* OR "evaluation studies" OR "evaluation studies as topic" OR "program evaluation" OR "validation studies as topic" OR (pre- AND post-) OR (pretest AND posttest) OR (program* AND (evaluat* OR effectiveness)) OR intervention OR random* OR (controlled N3 trial*) Grey literature The interfaces and search capabilities of grey literature databases are usually less sophisticated than those of peer-reviewed literature, requiring a simplified list of search terms to be used when searching. This simplified list will be based on the two core concepts of the review, breastfeeding and communication campaigns. However, this also risks increasing the sensitivity of the search to an impractical level for screening. To maintain feasibility, stopping criteria will be implemented to limit the screening of grey literature. Searches will be ordered by relevance, and at least 50 initial results will be screened before applying stepwise evaluation (every 25 results) to determine if screening should continue. The stopping criteria will be applied to searches on Google, Google Scholar, OSF. Websites of WHO, UNICEF and will be searched by screening relevant webpages (e.g. ‘resources’ or ‘publications’) and using keyword searches if a search bar exists for the website. 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. If automated screening performs poorly as the ‘second reviewer’ automated screening will be abandoned, and a second human reviewer will review each record.8u 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. Table 1. Data charting items. Article Characteristics • Author(s) • Year published • Title • Type of Source • Purpose/aim of article • Funder/commissioner • Conflicts of interest declared Breastfeeding Mass Media Campaign (MMC) Characteristics • MMC name, country, target audience setting, and type of MMC • Processes, approaches and strategies of MMC development and implementation • Theories, models or frameworks informing MMC development and implementation • Components of MMC (Target issue, outcomes and audience; Messaging core idea, message content, source, framing and channels of communication). • MMC evaluation design, methods and outcomes measured • Recommendations on the design, implementation or evaluation of MMCs 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. Table 2. Data analysis and presentation methods for the scoping review. Extracted Data Related to Basic Descriptive Statistics Tabular Presentation Narrative Summary Basic Thematic Analysis Article Characteristics ✓ ✓ ✓ Sub-Question 1 ✓ ● ✓ Sub-Question 2 ✓ ● ✓ Sub-Question 3 ✓ ● ✓ Sub-Question 4 ✓ ● ✓ Sub-Question 5 ✓ ● ✓ ✓ Sub-Question 6 ✓ ● ✓ ✓ The data will be analysed and presented with this method in the main scoping review article. ● The data will be analysed with this method but the results will be presented in supplementary material rather than in the main scoping review article. 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 data exported from EPPI reviewer, 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 content, 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. One reviewer, with expertise in breastfeeding communication (JH) will assess how breastfeeding is presented in each campaign using both descriptions extracted from study reports and any available imagery from the campaign using the following steps: 1. Familiarisation with the relevant extracted data. 2. Inductively code extracted data and available campaign imagery, by recording initial thoughts on each extracted piece of data and assigning a short label that represents the reviewers interpretation of the content, message strategy and its framing. 3. Review the coded data to identify recurring patterns and themes across the codes. 4. Review, define and name the themes. 5. A second reviewer will then review the coded data and imagery. 6. Any disagreements or expansions on the coding will be discussed until consensus is reached or a third reviewer will provide the final decision. 7. Write basic analysis to summarise the prevalence of identified themes in included campaigns. Ethics and consent Ethical approval and consent were not required. Data availability statement Underlying data No data are associated with this article Extended data Extended data is available via OSF and includes the data extraction template, PRISMA-ScR Checklist and sample search strategy DOI 10.17605/OSF.IO/DXNSB { Hanratty, 2025 #7061}. Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Acknowledgements The authors wish to acknowledge and thank: Dr Nuala Livingstone for her advice and support as expert evidence synthesis methodologist. The association of lactation consultants Ireland (ALCI) who facilitated engagement between their members and the research team at their conference in 2024. Mairead O’Sullivan IBCLC and president of ALCI for her insights into cultural influences on breastfeeding. La Leche League of Ireland and Siobhan Ward in particular for contributing expertise gained from decades of volunteering in communities supporting women. Health Service Executive (HSE) child health programme development officer Emma Reilly for her valuable insights from expert experience in running campaigns to improve child health in South Dublin. The wider “Maximising Support for Breastfeeding” research programme team who provided feedback on the review plans and supported integration of this scoping review with the wider programme of work. 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Reference Source World Population Review: Human Development Index (HDI) by Country 2024. 2024. Reference Source Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 07 Jul 2025 ADD YOUR COMMENT Comment Author details Author details 1 Centre for Effective Services, Dublin, Leinster, Ireland 2 School of Public Health, University College Cork, County Cork, Ireland 3 School of Nursing and Midwifery, University College Cork, County Cork, Ireland Jennifer Hanratty Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Karl McGrath Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Karen Matvienko-Sikar Roles: Funding Acquisition, Writing – Original Draft Preparation, Writing – Review & Editing Elaine Lehane Roles: Funding Acquisition, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Aoife Long Roles: Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Caroline Rawdon Roles: Writing – Review & Editing Patricia Leahy-Warren Roles: Funding Acquisition, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information Health Research Board [APRO-2023-015]. Health Research Board -APRO-2023-015 This review is being undertaken as part of the ‘Maximise support for breastfeeding for sustainable population health and wellbeing: Integrated knowledge translation approach, MaxSBF’ and is funded by the Health Research Board. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (2) version 2 Revised Published: 17 Nov 2025, 8:76 https://doi.org/10.12688/hrbopenres.14088.2 version 1 Published: 07 Jul 2025, 8:76 https://doi.org/10.12688/hrbopenres.14088.1 Copyright © 2025 Hanratty J 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 Hanratty J, McGrath K, Matvienko-Sikar K et al. Population-level communication interventions for breastfeeding: Protocol for a scoping review [version 2; peer review: 3 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :76 ( https://doi.org/10.12688/hrbopenres.14088.2 ) 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 2 VERSION 2 PUBLISHED 17 Nov 2025 Revised Views 0 Cite How to cite this report: Rossau HK. Reviewer Report For: Population-level communication interventions for breastfeeding: Protocol for a scoping review [version 2; peer review: 3 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :76 ( https://doi.org/10.21956/hrbopenres.15725.r51527 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-76/v2#referee-response-51527 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 22 Nov 2025 Henriette Knold Rossau , University of Copenhagen, Copenhagen, Denmark Approved VIEWS 0 https://doi.org/10.21956/hrbopenres.15725.r51527 I am satisfied with the responses provided by the authors and ... Continue reading READ ALL I am satisfied with the responses provided by the authors and look forward to reading the finalized scoping review. All the best Competing Interests: No competing interests were disclosed. Reviewer Expertise: Complex interventions, public health, breastfeeding intervention, social inequalities in health 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 Rossau HK. Reviewer Report For: Population-level communication interventions for breastfeeding: Protocol for a scoping review [version 2; peer review: 3 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :76 ( https://doi.org/10.21956/hrbopenres.15725.r51527 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-76/v2#referee-response-51527 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 Version 1 VERSION 1 PUBLISHED 07 Jul 2025 Views 0 Cite How to cite this report: Turner MM. Reviewer Report For: Population-level communication interventions for breastfeeding: Protocol for a scoping review [version 2; peer review: 3 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :76 ( https://doi.org/10.21956/hrbopenres.15475.r48341 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-76/v1#referee-response-48341 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 09 Oct 2025 Monique M. Turner , Michigan State University, East Lansing, Michigan, USA Approved VIEWS 0 https://doi.org/10.21956/hrbopenres.15475.r48341 I think this scoping review is important and I am pleased to see this work being conducted. But I do recommend that the authors extract additional data, when available, from the literature. In communication, the essential ingredients ... Continue reading READ ALL I think this scoping review is important and I am pleased to see this work being conducted. But I do recommend that the authors extract additional data, when available, from the literature. In communication, the essential ingredients to a successful campaign/intervention are: source, message, channel, receiver, objectives. This scoping review will pull some of these ingredients--but for this review to be really good it needs to extract all of it. WHO is the source of the message? WHAT is the message strategy (narrative, emotion (what emotion), facts, framing etc), who is the intended audience and what channel(s) are used. I think these details will make this review much better. 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? Yes Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: communication, campaign design, message strategy, public health 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 Turner MM. Reviewer Report For: Population-level communication interventions for breastfeeding: Protocol for a scoping review [version 2; peer review: 3 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :76 ( https://doi.org/10.21956/hrbopenres.15475.r48341 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-76/v1#referee-response-48341 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 Author Response 17 Nov 2025 Jennifer Hanratty , Centre for Effective Services, Dublin, Ireland 17 Nov 2025 Author Response Thank you for your review and expert constructive suggestions. We have included source, message, channel, receiver, and objectives in our data extraction tool. We have also included consideration of the ... Continue reading Thank you for your review and expert constructive suggestions. We have included source, message, channel, receiver, and objectives in our data extraction tool. We have also included consideration of the intended audience and the subject(s) featured in the campaign. We welcome your suggestion of attempting to capture more detail on who the source is, the message strategy, emotion and framing. We will attempt to achieve this in the thematic analysis of campaign content. For reference, this section of the protocol now reads: "Finally, for mass media campaign content, 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. One reviewer, with expertise in breastfeeding communication (JH) will assess how breastfeeding is presented in each campaign using both descriptions extracted from study reports and any available imagery from the campaign using the following steps: Familiarisation with the relevant extracted data. Inductively code extracted data and available campaign imagery, by recording initial thoughts on each extracted piece of data and assigning a short label that represents the reviewer's interpretation of the content, message strategy and framing. Review the coded data to identify recurring patterns and themes across the codes. Review, define and name the themes. A second reviewer will then review the coded data and imagery. Any disagreements or expansions on the coding will be discussed until consensus is reached or a third reviewer will provide the final decision. Write a basic analysis to summarise the prevalence of identified themes in included campaigns." Thank you again for sharing your expert advice. Thank you for your review and expert constructive suggestions. We have included source, message, channel, receiver, and objectives in our data extraction tool. We have also included consideration of the intended audience and the subject(s) featured in the campaign. We welcome your suggestion of attempting to capture more detail on who the source is, the message strategy, emotion and framing. We will attempt to achieve this in the thematic analysis of campaign content. For reference, this section of the protocol now reads: "Finally, for mass media campaign content, 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. One reviewer, with expertise in breastfeeding communication (JH) will assess how breastfeeding is presented in each campaign using both descriptions extracted from study reports and any available imagery from the campaign using the following steps: Familiarisation with the relevant extracted data. Inductively code extracted data and available campaign imagery, by recording initial thoughts on each extracted piece of data and assigning a short label that represents the reviewer's interpretation of the content, message strategy and framing. Review the coded data to identify recurring patterns and themes across the codes. Review, define and name the themes. A second reviewer will then review the coded data and imagery. Any disagreements or expansions on the coding will be discussed until consensus is reached or a third reviewer will provide the final decision. Write a basic analysis to summarise the prevalence of identified themes in included campaigns." Thank you again for sharing your expert advice. Competing Interests: None Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 17 Nov 2025 Jennifer Hanratty , Centre for Effective Services, Dublin, Ireland 17 Nov 2025 Author Response Thank you for your review and expert constructive suggestions. We have included source, message, channel, receiver, and objectives in our data extraction tool. We have also included consideration of the ... Continue reading Thank you for your review and expert constructive suggestions. We have included source, message, channel, receiver, and objectives in our data extraction tool. We have also included consideration of the intended audience and the subject(s) featured in the campaign. We welcome your suggestion of attempting to capture more detail on who the source is, the message strategy, emotion and framing. We will attempt to achieve this in the thematic analysis of campaign content. For reference, this section of the protocol now reads: "Finally, for mass media campaign content, 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. One reviewer, with expertise in breastfeeding communication (JH) will assess how breastfeeding is presented in each campaign using both descriptions extracted from study reports and any available imagery from the campaign using the following steps: Familiarisation with the relevant extracted data. Inductively code extracted data and available campaign imagery, by recording initial thoughts on each extracted piece of data and assigning a short label that represents the reviewer's interpretation of the content, message strategy and framing. Review the coded data to identify recurring patterns and themes across the codes. Review, define and name the themes. A second reviewer will then review the coded data and imagery. Any disagreements or expansions on the coding will be discussed until consensus is reached or a third reviewer will provide the final decision. Write a basic analysis to summarise the prevalence of identified themes in included campaigns." Thank you again for sharing your expert advice. Thank you for your review and expert constructive suggestions. We have included source, message, channel, receiver, and objectives in our data extraction tool. We have also included consideration of the intended audience and the subject(s) featured in the campaign. We welcome your suggestion of attempting to capture more detail on who the source is, the message strategy, emotion and framing. We will attempt to achieve this in the thematic analysis of campaign content. For reference, this section of the protocol now reads: "Finally, for mass media campaign content, 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. One reviewer, with expertise in breastfeeding communication (JH) will assess how breastfeeding is presented in each campaign using both descriptions extracted from study reports and any available imagery from the campaign using the following steps: Familiarisation with the relevant extracted data. Inductively code extracted data and available campaign imagery, by recording initial thoughts on each extracted piece of data and assigning a short label that represents the reviewer's interpretation of the content, message strategy and framing. Review the coded data to identify recurring patterns and themes across the codes. Review, define and name the themes. A second reviewer will then review the coded data and imagery. Any disagreements or expansions on the coding will be discussed until consensus is reached or a third reviewer will provide the final decision. Write a basic analysis to summarise the prevalence of identified themes in included campaigns." Thank you again for sharing your expert advice. Competing Interests: None Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Schue JL. Reviewer Report For: Population-level communication interventions for breastfeeding: Protocol for a scoping review [version 2; peer review: 3 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :76 ( https://doi.org/10.21956/hrbopenres.15475.r50078 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-76/v1#referee-response-50078 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 Oct 2025 Jessica L Schue , Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Approved VIEWS 0 https://doi.org/10.21956/hrbopenres.15475.r50078 The article presents the protocol for a scoping review of mass media interventions used to promote breastfeeding in high income countries. The authors demonstrate a clear rational and need for the project, explaining that this project is a critical step ... Continue reading READ ALL The article presents the protocol for a scoping review of mass media interventions used to promote breastfeeding in high income countries. The authors demonstrate a clear rational and need for the project, explaining that this project is a critical step in a multi-step process to develop normative guidance for high income countries. The research questions are broad and cover several aspects of a mass media campaign, from the development, methods, implementation, and research methods to evaluate campaigns. The article is well written and clear, there are no major concerns to be addressed. Minor comments include the following. Only articles and literature in English will be included, which may bias the findings towards cultures with predominantly english speakers. While historically the exclusion of articles based on language was reasonable given limited accessibility, recent computing advances have made this less necessary. If including non-english articles is not feasible during this scoping review, it should be considered for any subsequent systematic review. The second comment is related to quality control of the screening tool used. Do the authors have a specific threshold that must be met to accept the automated screening results? Overall, the article is clear and the methods are sufficiently described for reproducibility. 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? Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: Maternal and child health, research design, demand generation. 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 Schue JL. Reviewer Report For: Population-level communication interventions for breastfeeding: Protocol for a scoping review [version 2; peer review: 3 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :76 ( https://doi.org/10.21956/hrbopenres.15475.r50078 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-76/v1#referee-response-50078 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 Author Response 17 Nov 2025 Jennifer Hanratty , Centre for Effective Services, Dublin, Ireland 17 Nov 2025 Author Response Thank you for your through review and constructive suggestions. Point 1: We agree that including only English language publications has the potential to bias the review and will note that ... Continue reading Thank you for your through review and constructive suggestions. Point 1: We agree that including only English language publications has the potential to bias the review and will note that as a limitation in the scoping review and, as you suggest, consider expanding our inclusion criteria if a systematic review follows. Point 2: We did not set a specific threshold for automated screening, we will include this point in the discussion in the scoping review. Thank you for your through review and constructive suggestions. Point 1: We agree that including only English language publications has the potential to bias the review and will note that as a limitation in the scoping review and, as you suggest, consider expanding our inclusion criteria if a systematic review follows. Point 2: We did not set a specific threshold for automated screening, we will include this point in the discussion in the scoping review. Competing Interests: None. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 17 Nov 2025 Jennifer Hanratty , Centre for Effective Services, Dublin, Ireland 17 Nov 2025 Author Response Thank you for your through review and constructive suggestions. Point 1: We agree that including only English language publications has the potential to bias the review and will note that ... Continue reading Thank you for your through review and constructive suggestions. Point 1: We agree that including only English language publications has the potential to bias the review and will note that as a limitation in the scoping review and, as you suggest, consider expanding our inclusion criteria if a systematic review follows. Point 2: We did not set a specific threshold for automated screening, we will include this point in the discussion in the scoping review. Thank you for your through review and constructive suggestions. Point 1: We agree that including only English language publications has the potential to bias the review and will note that as a limitation in the scoping review and, as you suggest, consider expanding our inclusion criteria if a systematic review follows. Point 2: We did not set a specific threshold for automated screening, we will include this point in the discussion in the scoping review. Competing Interests: None. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Sanchez LM. Reviewer Report For: Population-level communication interventions for breastfeeding: Protocol for a scoping review [version 2; peer review: 3 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :76 ( https://doi.org/10.21956/hrbopenres.15475.r50077 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-76/v1#referee-response-50077 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 Oct 2025 Louisiana Montserrat Sanchez , University of Southern California, Los Angeles, CA, USA Approved with Reservations VIEWS 0 https://doi.org/10.21956/hrbopenres.15475.r50077 Summary of the article: Thank you so much for the opportunity of reviewing this manuscript. The manuscript describes a protocol for a scoping review that will map and synthesize the evidence on population-level communication interventions for breastfeeding ... Continue reading READ ALL Summary of the article: Thank you so much for the opportunity of reviewing this manuscript. The manuscript describes a protocol for a scoping review that will map and synthesize the evidence on population-level communication interventions for breastfeeding in very high Human Development Index (HDI) countries. The rationale is grounded in persistently low breastfeeding rates in high-income settings, the influence of social and cultural norms, and the absence of clear evidence-based guidance on designing effective mass communication interventions. The authors plan to search multiple databases (PubMed, Embase, PsycInfo, Proquest, etc.) and grey literature sources (Google, OSF, UNICEF, WHO), conduct citation chaining, and engage with knowledge users. Screening and extraction will be managed using EPPI Reviewer with automation features, and the PRISMA-ScR checklist will be followed. Extracted data will include interventions characteristics, theoretical underpinnings, message framing, conflicts of interest, and evaluation outcomes. Data will be summarized descriptively, tabulated, and analyzed thematically to identify recurring patterns in intervention design and messaging. The protocol is robust and methodologically aligned with best practices, but a few refinements could improve reproducibility and clarity. Responses to key questions: 1. Is the rationale for, and objectives of, the study clearly described? Yes, the introduction provides strong justification, citing epidemiological evidence, socio-ecological frameworks, and gaps in existing reviews. The objectives and six sub-questions are clearly presented, offering a roadmap for the scoping review. 2. Is the study design appropriate for the research question? Yes, a scoping review is the correct approach for mapping breadth and characteristics of the literature. The design is consistent with JBI and PRISMA-ScR guidance, and the authors appropriately note that a systematic review may follow if sufficient evidence is identified. 3. Are sufficient details of the methods provided to allow replication by others? Partly, the manuscript provides substantial methodological detail (1) search and selection, databases and grey literature sources and listed; a sample PubMed strategy is included; PRISMA-ScR compliance is noted. (2) screening and extraction, independent and duplicate review is planned; EPPI Reviewer will be used; piloting and consensus procedures are described. (3) data analysis, descriptive statistics, narrative summaries, and thematic analysis are planned, guided by JBI recommendations. Gaps that limit full reproducibility, include: definitions of interventions. Box 1 offers useful definitions, but operational boundaries between “mass communication,” “mass media,” and “social media” are blurred. The authors should add explicit examples of eligible versus ineligible interventions (e.g., a systematic social media campaign vs. a static informational website; a broad Facebook push vs. mHealth opt-in texts). Standardized procedures. Thematic analysis steps are described, but details on coder reliability, consensus procedures, and sharing of coding frameworks are lacking. Clarifying these would ensure reproducibility. Data management. While EPPI Reviewer is identified, the manuscript does not specify whether descriptive statistics will be generated within EPPI or exported, nor whether all variables will be tabulated. Greater detail would strengthen transparency. Conflict of interests coding. The authors note conflict of interest will be captured, but not detail is provided on how funders/sponsors will be categorized (governments, NGO, commercial, academic). Given the political economy of formula marketing, this is an important addition. I recommend that authors: (1) specify whether they will extract declared and undeclared conflicts of interests, (2) clearly categorize the type of sponsor/funder (e.g., government, NGO, academic, commercial/industry), consider noting whether industry-affiliated authorship or partnerships are reported, as these can influence the framing of communication campaigns. Adding this structure will improve transparency and allow the review to capture critical contextual differences between government/NGO-led breastfeeding promotion campaigns versus commercially influenced campaigns. 4. Are the datasets clearly presented in a usable and accessible format? Not application, this is a protocol, no results are yet available. However, the authors provided extended data on OSF, including the data extraction template, PRISMA-ScR checklist, and sample search strategy, which is appropriate and accessible. Major points to be addressed : (1) clarify definitions in Box 1, provide concrete examples of what counts as an eligible intervention versus excluded forms (e.g., broad social media campaigns vs. passive informational websites); (2) detail thematic analysis procedures, specify how coding will be conducted, inter-rater reliability assessed, and disagreements resolved. Consider committing to share the coding framework as supplementary data; (3) expand on data management plans, clarify whether descriptive analysis will be performed in EPPI reviewer or another platform, and which variables will be reported in the main article versus supplementary material; (4) enhance conflict of interest/funding coding, explicitly state how conflicts of interests and funding sources will be categorized, for example, government, NGO, academic, commercial. Minor points : (1) readability, some section of the introduction could be streamlined for clarity; (2) Box 1 presentation, presenting the definitions in a tabular form with columns for term/definition/example could make them more easy to read; (3) knowledge user engagement, the manuscript described knowledge user consultation, but linking this directly to data extraction items (e.g., why particular variables were prioritized) would strengthen justification. This is a timely and well-prepared protocol that addresses a significant public health gap. With minor but important clarification, particularly in definitions, coding, and data management, the protocol will be fully reproducible and scientifically sound. 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? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: Maternal and child health; breastfeeding promotion; population-level and social media communication interventions; evidence synthesis (scoping and systematic reviews); health behavior change 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 Sanchez LM. Reviewer Report For: Population-level communication interventions for breastfeeding: Protocol for a scoping review [version 2; peer review: 3 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :76 ( https://doi.org/10.21956/hrbopenres.15475.r50077 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-76/v1#referee-response-50077 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 Author Response 17 Nov 2025 Jennifer Hanratty , Centre for Effective Services, Dublin, Ireland 17 Nov 2025 Author Response Thank you for your expert review and the obvious attention to detail. In response to your comments and suggestions: Point 1: We have revised box 1 to add specific examples. ... Continue reading Thank you for your expert review and the obvious attention to detail. In response to your comments and suggestions: Point 1: We have revised box 1 to add specific examples. Thank you for the suggestions. Point 2: Thank you, we have revised our approach and simplified our thematic analysis, removing reference to Braun and Clarke and adding detail on consensus procedures. The section now reads: "Finally, for mass media campaign content, 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. One reviewer, with expertise in breastfeeding communication (JH) will assess how breastfeeding is presented in each campaign using both descriptions extracted from study reports and any available imagery from the campaign using the following steps: Familiarisation with the relevant extracted data. Inductively code extracted data and available campaign imagery, by recording initial thoughts on each extracted piece of data and assigning a short label that represents the reviewer's interpretation of the content, message strategy and framing. Review the coded data to identify recurring patterns and themes across the codes. Review, define and name the themes. A second reviewer will then review the coded data and imagery. Any disagreements or expansions on the coding will be discussed until consensus is reached or a third reviewer will provide the final decision. Write basic analysis to summarise the prevalence of identified themes in included campaigns." Point 3: We have added “calculated with data exported from EPPI reviewer”. The variables that will be reported in the main article vs supplementary material are specified in table 2. Point 4: Thank you, we agree on the importance of highlighting the source of funding in this context; however, we did not use pre-specified categories of funder. We planned to extract information verbatim from papers. In practice, we categorised funder types post-hoc so it would be disingenuous to add categories to the protocol. We added “declared conflicts of interest” to specify that we focused on those rather than undeclared. In practice we examine declared conflicts of interest in the context of the funding source to gain a more full picture of potential conflicts but we didn’t go into the level of detail of analysing the affiliation of individual authors due to resource limitations. Minor points: Thank you, we have reviewed and edited to improve readability throughout. Thank you for your expert review and the obvious attention to detail. In response to your comments and suggestions: Point 1: We have revised box 1 to add specific examples. Thank you for the suggestions. Point 2: Thank you, we have revised our approach and simplified our thematic analysis, removing reference to Braun and Clarke and adding detail on consensus procedures. The section now reads: "Finally, for mass media campaign content, 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. One reviewer, with expertise in breastfeeding communication (JH) will assess how breastfeeding is presented in each campaign using both descriptions extracted from study reports and any available imagery from the campaign using the following steps: Familiarisation with the relevant extracted data. Inductively code extracted data and available campaign imagery, by recording initial thoughts on each extracted piece of data and assigning a short label that represents the reviewer's interpretation of the content, message strategy and framing. Review the coded data to identify recurring patterns and themes across the codes. Review, define and name the themes. A second reviewer will then review the coded data and imagery. Any disagreements or expansions on the coding will be discussed until consensus is reached or a third reviewer will provide the final decision. Write basic analysis to summarise the prevalence of identified themes in included campaigns." Point 3: We have added “calculated with data exported from EPPI reviewer”. The variables that will be reported in the main article vs supplementary material are specified in table 2. Point 4: Thank you, we agree on the importance of highlighting the source of funding in this context; however, we did not use pre-specified categories of funder. We planned to extract information verbatim from papers. In practice, we categorised funder types post-hoc so it would be disingenuous to add categories to the protocol. We added “declared conflicts of interest” to specify that we focused on those rather than undeclared. In practice we examine declared conflicts of interest in the context of the funding source to gain a more full picture of potential conflicts but we didn’t go into the level of detail of analysing the affiliation of individual authors due to resource limitations. Minor points: Thank you, we have reviewed and edited to improve readability throughout. Competing Interests: None Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 17 Nov 2025 Jennifer Hanratty , Centre for Effective Services, Dublin, Ireland 17 Nov 2025 Author Response Thank you for your expert review and the obvious attention to detail. In response to your comments and suggestions: Point 1: We have revised box 1 to add specific examples. ... Continue reading Thank you for your expert review and the obvious attention to detail. In response to your comments and suggestions: Point 1: We have revised box 1 to add specific examples. Thank you for the suggestions. Point 2: Thank you, we have revised our approach and simplified our thematic analysis, removing reference to Braun and Clarke and adding detail on consensus procedures. The section now reads: "Finally, for mass media campaign content, 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. One reviewer, with expertise in breastfeeding communication (JH) will assess how breastfeeding is presented in each campaign using both descriptions extracted from study reports and any available imagery from the campaign using the following steps: Familiarisation with the relevant extracted data. Inductively code extracted data and available campaign imagery, by recording initial thoughts on each extracted piece of data and assigning a short label that represents the reviewer's interpretation of the content, message strategy and framing. Review the coded data to identify recurring patterns and themes across the codes. Review, define and name the themes. A second reviewer will then review the coded data and imagery. Any disagreements or expansions on the coding will be discussed until consensus is reached or a third reviewer will provide the final decision. Write basic analysis to summarise the prevalence of identified themes in included campaigns." Point 3: We have added “calculated with data exported from EPPI reviewer”. The variables that will be reported in the main article vs supplementary material are specified in table 2. Point 4: Thank you, we agree on the importance of highlighting the source of funding in this context; however, we did not use pre-specified categories of funder. We planned to extract information verbatim from papers. In practice, we categorised funder types post-hoc so it would be disingenuous to add categories to the protocol. We added “declared conflicts of interest” to specify that we focused on those rather than undeclared. In practice we examine declared conflicts of interest in the context of the funding source to gain a more full picture of potential conflicts but we didn’t go into the level of detail of analysing the affiliation of individual authors due to resource limitations. Minor points: Thank you, we have reviewed and edited to improve readability throughout. Thank you for your expert review and the obvious attention to detail. In response to your comments and suggestions: Point 1: We have revised box 1 to add specific examples. Thank you for the suggestions. Point 2: Thank you, we have revised our approach and simplified our thematic analysis, removing reference to Braun and Clarke and adding detail on consensus procedures. The section now reads: "Finally, for mass media campaign content, 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. One reviewer, with expertise in breastfeeding communication (JH) will assess how breastfeeding is presented in each campaign using both descriptions extracted from study reports and any available imagery from the campaign using the following steps: Familiarisation with the relevant extracted data. Inductively code extracted data and available campaign imagery, by recording initial thoughts on each extracted piece of data and assigning a short label that represents the reviewer's interpretation of the content, message strategy and framing. Review the coded data to identify recurring patterns and themes across the codes. Review, define and name the themes. A second reviewer will then review the coded data and imagery. Any disagreements or expansions on the coding will be discussed until consensus is reached or a third reviewer will provide the final decision. Write basic analysis to summarise the prevalence of identified themes in included campaigns." Point 3: We have added “calculated with data exported from EPPI reviewer”. The variables that will be reported in the main article vs supplementary material are specified in table 2. Point 4: Thank you, we agree on the importance of highlighting the source of funding in this context; however, we did not use pre-specified categories of funder. We planned to extract information verbatim from papers. In practice, we categorised funder types post-hoc so it would be disingenuous to add categories to the protocol. We added “declared conflicts of interest” to specify that we focused on those rather than undeclared. In practice we examine declared conflicts of interest in the context of the funding source to gain a more full picture of potential conflicts but we didn’t go into the level of detail of analysing the affiliation of individual authors due to resource limitations. Minor points: Thank you, we have reviewed and edited to improve readability throughout. Competing Interests: None Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Rossau HK. Reviewer Report For: Population-level communication interventions for breastfeeding: Protocol for a scoping review [version 2; peer review: 3 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :76 ( https://doi.org/10.21956/hrbopenres.15475.r48637 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-76/v1#referee-response-48637 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 Sep 2025 Henriette Knold Rossau , University of Copenhagen, Copenhagen, Denmark Approved VIEWS 0 https://doi.org/10.21956/hrbopenres.15475.r48637 Thank you for inviting me to review the article: Population-level communication interventions for breastfeeding: Protocol for a scoping review The article describes the protocol for conducting a scoping review as a first step towards developing a guidance ... Continue reading READ ALL Thank you for inviting me to review the article: Population-level communication interventions for breastfeeding: Protocol for a scoping review The article describes the protocol for conducting a scoping review as a first step towards developing a guidance to inform development of population-level communications interventions for breastfeeding in high-income countries. The article is well written and meticulously describes the methodology for conducting the scoping review. As such, I have very few comments. The first comment pertains to the perspective of population-level communication interventions in whole. While such interventions may be beneficial for information dissemination, they risk strengthening health behaviours (such as breastfeeding) among socially advantaged groups and leave the more disadvantaged behind, thereby augmenting the social gap in health behaviours and -outcomes. The authors refer to the socioecological model in their article, which ensures me that this perspective will be included in subsequent research. I suggest supplementing the model with the so-called Rainbow Model (Dahlgren and Whitehead, Public Health 2021). The second comment pertains to the search strategy section. When describing the stages in the review process, present and past tenses are mixed. I would make for a better reading experience if tenses were aligned. Moreover, the three search strings for Breastfeeding, Communication campaign and Evaluation, development or implementation all stem from PubMed searches according to the description. However, all of them are different in their layout with the third appearing to be the most descriptive due to the subscripts (tiab, mesh etc). Could they be aligned, perhaps by providing the reader with the most ‘readable’ like the first string, and supplementing with the extensive strings online or elsewhere? And could a similar ‘string’ be included for the Grey literature section? Just to exemplify. The third comment is for the Source of evidence selection section. This is thoroughly described but could be supplemented by informing the reader what the proceeding will be if the quality control of the automated screening appears to be poor (“A further random sample of 10% of all excluded records will be screened by a second human reviewer for quality control.”). For nitty gritty details, there appears to be a full stop misplaced in this sentence: “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/ .” But overall, I wish the authors best of luck in their endeavours. The manuscript is of high quality and nearly ready for publication. I do not have to see it again before finalisation but will look forward to reading the scoping review when it is completed and published. 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? Not applicable References 1. Dahlgren G, Whitehead M: The Dahlgren-Whitehead model of health determinants: 30 years on and still chasing rainbows. Public Health . 2021; 199 : 20-24 Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Complex interventions, public health, breastfeeding intervention, social inequalities in health 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 Rossau HK. Reviewer Report For: Population-level communication interventions for breastfeeding: Protocol for a scoping review [version 2; peer review: 3 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :76 ( https://doi.org/10.21956/hrbopenres.15475.r48637 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-76/v1#referee-response-48637 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 Author Response 17 Nov 2025 Jennifer Hanratty , Centre for Effective Services, Dublin, Ireland 17 Nov 2025 Author Response Thank you for your detailed comments and constructive suggestions. Your point on the potential for population-level communication interventions to widen inequalities in health is pertinent and thank you ... Continue reading Thank you for your detailed comments and constructive suggestions. Your point on the potential for population-level communication interventions to widen inequalities in health is pertinent and thank you for suggesting Dahlgren G, Whitehead M. The Dahlgren-Whitehead model of health determinants: 30 years on and still chasing rainbows. Public Health. 2021 Oct;199:20-24. doi: 10.1016/j.puhe.2021.08.009. Epub 2021 Sep 14. PMID: 34534885. We will incorporate this model into the scoping review itself rather than tokenistic inclusion in the protocol at this point. We have reviewed tenses and kept to present and future tense throughout the description of the search strategy and streamlined the presentation of the search strings in the main article text to make them more readable, thank you for this suggestion. We have added that “if automated screening performs poorly as the ‘second reviewer’ automated screening will be abandoned, and a second human reviewer will review each record” Thank you for spotting this, the errant full stop has been corrected. Thank you for your detailed comments and constructive suggestions. Your point on the potential for population-level communication interventions to widen inequalities in health is pertinent and thank you for suggesting Dahlgren G, Whitehead M. The Dahlgren-Whitehead model of health determinants: 30 years on and still chasing rainbows. Public Health. 2021 Oct;199:20-24. doi: 10.1016/j.puhe.2021.08.009. Epub 2021 Sep 14. PMID: 34534885. We will incorporate this model into the scoping review itself rather than tokenistic inclusion in the protocol at this point. We have reviewed tenses and kept to present and future tense throughout the description of the search strategy and streamlined the presentation of the search strings in the main article text to make them more readable, thank you for this suggestion. We have added that “if automated screening performs poorly as the ‘second reviewer’ automated screening will be abandoned, and a second human reviewer will review each record” Thank you for spotting this, the errant full stop has been corrected. Competing Interests: None Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 17 Nov 2025 Jennifer Hanratty , Centre for Effective Services, Dublin, Ireland 17 Nov 2025 Author Response Thank you for your detailed comments and constructive suggestions. Your point on the potential for population-level communication interventions to widen inequalities in health is pertinent and thank you ... Continue reading Thank you for your detailed comments and constructive suggestions. Your point on the potential for population-level communication interventions to widen inequalities in health is pertinent and thank you for suggesting Dahlgren G, Whitehead M. The Dahlgren-Whitehead model of health determinants: 30 years on and still chasing rainbows. Public Health. 2021 Oct;199:20-24. doi: 10.1016/j.puhe.2021.08.009. Epub 2021 Sep 14. PMID: 34534885. We will incorporate this model into the scoping review itself rather than tokenistic inclusion in the protocol at this point. We have reviewed tenses and kept to present and future tense throughout the description of the search strategy and streamlined the presentation of the search strings in the main article text to make them more readable, thank you for this suggestion. We have added that “if automated screening performs poorly as the ‘second reviewer’ automated screening will be abandoned, and a second human reviewer will review each record” Thank you for spotting this, the errant full stop has been corrected. Thank you for your detailed comments and constructive suggestions. Your point on the potential for population-level communication interventions to widen inequalities in health is pertinent and thank you for suggesting Dahlgren G, Whitehead M. The Dahlgren-Whitehead model of health determinants: 30 years on and still chasing rainbows. Public Health. 2021 Oct;199:20-24. doi: 10.1016/j.puhe.2021.08.009. Epub 2021 Sep 14. PMID: 34534885. We will incorporate this model into the scoping review itself rather than tokenistic inclusion in the protocol at this point. We have reviewed tenses and kept to present and future tense throughout the description of the search strategy and streamlined the presentation of the search strings in the main article text to make them more readable, thank you for this suggestion. We have added that “if automated screening performs poorly as the ‘second reviewer’ automated screening will be abandoned, and a second human reviewer will review each record” Thank you for spotting this, the errant full stop has been corrected. Competing Interests: None Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 07 Jul 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 3 4 Version 2 (revision) 17 Nov 25 read Version 1 07 Jul 25 read read read read Henriette Knold Rossau , University of Copenhagen, Copenhagen, Denmark Louisiana Montserrat Sanchez , University of Southern California, Los Angeles, USA Jessica L Schue , Johns Hopkins Bloomberg School of Public Health, Baltimore, USA Monique M. Turner , Michigan State University, East Lansing, USA 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 © 2025 Rossau H. 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. 22 Nov 2025 | for Version 2 Henriette Knold Rossau , University of Copenhagen, Copenhagen, Denmark 0 Views copyright © 2025 Rossau H. 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 I am satisfied with the responses provided by the authors and look forward to reading the finalized scoping review. All the best Competing Interests No competing interests were disclosed. Reviewer Expertise Complex interventions, public health, breastfeeding intervention, social inequalities in health 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) Rossau HK. Peer Review Report For: Population-level communication interventions for breastfeeding: Protocol for a scoping review [version 2; peer review: 3 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :76 ( https://doi.org/10.21956/hrbopenres.15725.r51527) 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/8-76/v2#referee-response-51527 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Turner M. 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. 09 Oct 2025 | for Version 1 Monique M. Turner , Michigan State University, East Lansing, Michigan, USA 0 Views copyright © 2025 Turner M. 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 (1) 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 I think this scoping review is important and I am pleased to see this work being conducted. But I do recommend that the authors extract additional data, when available, from the literature. In communication, the essential ingredients to a successful campaign/intervention are: source, message, channel, receiver, objectives. This scoping review will pull some of these ingredients--but for this review to be really good it needs to extract all of it. WHO is the source of the message? WHAT is the message strategy (narrative, emotion (what emotion), facts, framing etc), who is the intended audience and what channel(s) are used. I think these details will make this review much better. 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? Yes Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests No competing interests were disclosed. Reviewer Expertise communication, campaign design, message strategy, public health 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 (1) Author Response 17 Nov 2025 Jennifer Hanratty, Centre for Effective Services, Dublin, Ireland Thank you for your review and expert constructive suggestions. We have included source, message, channel, receiver, and objectives in our data extraction tool. We have also included consideration of the intended audience and the subject(s) featured in the campaign. We welcome your suggestion of attempting to capture more detail on who the source is, the message strategy, emotion and framing. We will attempt to achieve this in the thematic analysis of campaign content. For reference, this section of the protocol now reads: "Finally, for mass media campaign content, 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. One reviewer, with expertise in breastfeeding communication (JH) will assess how breastfeeding is presented in each campaign using both descriptions extracted from study reports and any available imagery from the campaign using the following steps: Familiarisation with the relevant extracted data. Inductively code extracted data and available campaign imagery, by recording initial thoughts on each extracted piece of data and assigning a short label that represents the reviewer's interpretation of the content, message strategy and framing. Review the coded data to identify recurring patterns and themes across the codes. Review, define and name the themes. A second reviewer will then review the coded data and imagery. Any disagreements or expansions on the coding will be discussed until consensus is reached or a third reviewer will provide the final decision. Write a basic analysis to summarise the prevalence of identified themes in included campaigns." Thank you again for sharing your expert advice. View more View less Competing Interests None reply Respond Report a concern Turner MM. Peer Review Report For: Population-level communication interventions for breastfeeding: Protocol for a scoping review [version 2; peer review: 3 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :76 ( https://doi.org/10.21956/hrbopenres.15475.r48341) 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/8-76/v1#referee-response-48341 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Schue J. 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 Oct 2025 | for Version 1 Jessica L Schue , Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 0 Views copyright © 2025 Schue J. 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 (1) 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 The article presents the protocol for a scoping review of mass media interventions used to promote breastfeeding in high income countries. The authors demonstrate a clear rational and need for the project, explaining that this project is a critical step in a multi-step process to develop normative guidance for high income countries. The research questions are broad and cover several aspects of a mass media campaign, from the development, methods, implementation, and research methods to evaluate campaigns. The article is well written and clear, there are no major concerns to be addressed. Minor comments include the following. Only articles and literature in English will be included, which may bias the findings towards cultures with predominantly english speakers. While historically the exclusion of articles based on language was reasonable given limited accessibility, recent computing advances have made this less necessary. If including non-english articles is not feasible during this scoping review, it should be considered for any subsequent systematic review. The second comment is related to quality control of the screening tool used. Do the authors have a specific threshold that must be met to accept the automated screening results? Overall, the article is clear and the methods are sufficiently described for reproducibility. 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? Not applicable Competing Interests No competing interests were disclosed. Reviewer Expertise Maternal and child health, research design, demand generation. 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 (1) Author Response 17 Nov 2025 Jennifer Hanratty, Centre for Effective Services, Dublin, Ireland Thank you for your through review and constructive suggestions. Point 1: We agree that including only English language publications has the potential to bias the review and will note that as a limitation in the scoping review and, as you suggest, consider expanding our inclusion criteria if a systematic review follows. Point 2: We did not set a specific threshold for automated screening, we will include this point in the discussion in the scoping review. View more View less Competing Interests None. reply Respond Report a concern Schue JL. Peer Review Report For: Population-level communication interventions for breastfeeding: Protocol for a scoping review [version 2; peer review: 3 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :76 ( https://doi.org/10.21956/hrbopenres.15475.r50078) 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/8-76/v1#referee-response-50078 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Sanchez L. 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 Oct 2025 | for Version 1 Louisiana Montserrat Sanchez , University of Southern California, Los Angeles, CA, USA 0 Views copyright © 2025 Sanchez L. 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 (1) 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 Summary of the article: Thank you so much for the opportunity of reviewing this manuscript. The manuscript describes a protocol for a scoping review that will map and synthesize the evidence on population-level communication interventions for breastfeeding in very high Human Development Index (HDI) countries. The rationale is grounded in persistently low breastfeeding rates in high-income settings, the influence of social and cultural norms, and the absence of clear evidence-based guidance on designing effective mass communication interventions. The authors plan to search multiple databases (PubMed, Embase, PsycInfo, Proquest, etc.) and grey literature sources (Google, OSF, UNICEF, WHO), conduct citation chaining, and engage with knowledge users. Screening and extraction will be managed using EPPI Reviewer with automation features, and the PRISMA-ScR checklist will be followed. Extracted data will include interventions characteristics, theoretical underpinnings, message framing, conflicts of interest, and evaluation outcomes. Data will be summarized descriptively, tabulated, and analyzed thematically to identify recurring patterns in intervention design and messaging. The protocol is robust and methodologically aligned with best practices, but a few refinements could improve reproducibility and clarity. Responses to key questions: 1. Is the rationale for, and objectives of, the study clearly described? Yes, the introduction provides strong justification, citing epidemiological evidence, socio-ecological frameworks, and gaps in existing reviews. The objectives and six sub-questions are clearly presented, offering a roadmap for the scoping review. 2. Is the study design appropriate for the research question? Yes, a scoping review is the correct approach for mapping breadth and characteristics of the literature. The design is consistent with JBI and PRISMA-ScR guidance, and the authors appropriately note that a systematic review may follow if sufficient evidence is identified. 3. Are sufficient details of the methods provided to allow replication by others? Partly, the manuscript provides substantial methodological detail (1) search and selection, databases and grey literature sources and listed; a sample PubMed strategy is included; PRISMA-ScR compliance is noted. (2) screening and extraction, independent and duplicate review is planned; EPPI Reviewer will be used; piloting and consensus procedures are described. (3) data analysis, descriptive statistics, narrative summaries, and thematic analysis are planned, guided by JBI recommendations. Gaps that limit full reproducibility, include: definitions of interventions. Box 1 offers useful definitions, but operational boundaries between “mass communication,” “mass media,” and “social media” are blurred. The authors should add explicit examples of eligible versus ineligible interventions (e.g., a systematic social media campaign vs. a static informational website; a broad Facebook push vs. mHealth opt-in texts). Standardized procedures. Thematic analysis steps are described, but details on coder reliability, consensus procedures, and sharing of coding frameworks are lacking. Clarifying these would ensure reproducibility. Data management. While EPPI Reviewer is identified, the manuscript does not specify whether descriptive statistics will be generated within EPPI or exported, nor whether all variables will be tabulated. Greater detail would strengthen transparency. Conflict of interests coding. The authors note conflict of interest will be captured, but not detail is provided on how funders/sponsors will be categorized (governments, NGO, commercial, academic). Given the political economy of formula marketing, this is an important addition. I recommend that authors: (1) specify whether they will extract declared and undeclared conflicts of interests, (2) clearly categorize the type of sponsor/funder (e.g., government, NGO, academic, commercial/industry), consider noting whether industry-affiliated authorship or partnerships are reported, as these can influence the framing of communication campaigns. Adding this structure will improve transparency and allow the review to capture critical contextual differences between government/NGO-led breastfeeding promotion campaigns versus commercially influenced campaigns. 4. Are the datasets clearly presented in a usable and accessible format? Not application, this is a protocol, no results are yet available. However, the authors provided extended data on OSF, including the data extraction template, PRISMA-ScR checklist, and sample search strategy, which is appropriate and accessible. Major points to be addressed : (1) clarify definitions in Box 1, provide concrete examples of what counts as an eligible intervention versus excluded forms (e.g., broad social media campaigns vs. passive informational websites); (2) detail thematic analysis procedures, specify how coding will be conducted, inter-rater reliability assessed, and disagreements resolved. Consider committing to share the coding framework as supplementary data; (3) expand on data management plans, clarify whether descriptive analysis will be performed in EPPI reviewer or another platform, and which variables will be reported in the main article versus supplementary material; (4) enhance conflict of interest/funding coding, explicitly state how conflicts of interests and funding sources will be categorized, for example, government, NGO, academic, commercial. Minor points : (1) readability, some section of the introduction could be streamlined for clarity; (2) Box 1 presentation, presenting the definitions in a tabular form with columns for term/definition/example could make them more easy to read; (3) knowledge user engagement, the manuscript described knowledge user consultation, but linking this directly to data extraction items (e.g., why particular variables were prioritized) would strengthen justification. This is a timely and well-prepared protocol that addresses a significant public health gap. With minor but important clarification, particularly in definitions, coding, and data management, the protocol will be fully reproducible and scientifically sound. 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? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests No competing interests were disclosed. Reviewer Expertise Maternal and child health; breastfeeding promotion; population-level and social media communication interventions; evidence synthesis (scoping and systematic reviews); health behavior change 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 (1) Author Response 17 Nov 2025 Jennifer Hanratty, Centre for Effective Services, Dublin, Ireland Thank you for your expert review and the obvious attention to detail. In response to your comments and suggestions: Point 1: We have revised box 1 to add specific examples. Thank you for the suggestions. Point 2: Thank you, we have revised our approach and simplified our thematic analysis, removing reference to Braun and Clarke and adding detail on consensus procedures. The section now reads: "Finally, for mass media campaign content, 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. One reviewer, with expertise in breastfeeding communication (JH) will assess how breastfeeding is presented in each campaign using both descriptions extracted from study reports and any available imagery from the campaign using the following steps: Familiarisation with the relevant extracted data. Inductively code extracted data and available campaign imagery, by recording initial thoughts on each extracted piece of data and assigning a short label that represents the reviewer's interpretation of the content, message strategy and framing. Review the coded data to identify recurring patterns and themes across the codes. Review, define and name the themes. A second reviewer will then review the coded data and imagery. Any disagreements or expansions on the coding will be discussed until consensus is reached or a third reviewer will provide the final decision. Write basic analysis to summarise the prevalence of identified themes in included campaigns." Point 3: We have added “calculated with data exported from EPPI reviewer”. The variables that will be reported in the main article vs supplementary material are specified in table 2. Point 4: Thank you, we agree on the importance of highlighting the source of funding in this context; however, we did not use pre-specified categories of funder. We planned to extract information verbatim from papers. In practice, we categorised funder types post-hoc so it would be disingenuous to add categories to the protocol. We added “declared conflicts of interest” to specify that we focused on those rather than undeclared. In practice we examine declared conflicts of interest in the context of the funding source to gain a more full picture of potential conflicts but we didn’t go into the level of detail of analysing the affiliation of individual authors due to resource limitations. Minor points: Thank you, we have reviewed and edited to improve readability throughout. View more View less Competing Interests None reply Respond Report a concern Sanchez LM. Peer Review Report For: Population-level communication interventions for breastfeeding: Protocol for a scoping review [version 2; peer review: 3 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :76 ( https://doi.org/10.21956/hrbopenres.15475.r50077) 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/8-76/v1#referee-response-50077 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Rossau H. 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 Sep 2025 | for Version 1 Henriette Knold Rossau , University of Copenhagen, Copenhagen, Denmark 0 Views copyright © 2025 Rossau H. 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 (1) 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 Thank you for inviting me to review the article: Population-level communication interventions for breastfeeding: Protocol for a scoping review The article describes the protocol for conducting a scoping review as a first step towards developing a guidance to inform development of population-level communications interventions for breastfeeding in high-income countries. The article is well written and meticulously describes the methodology for conducting the scoping review. As such, I have very few comments. The first comment pertains to the perspective of population-level communication interventions in whole. While such interventions may be beneficial for information dissemination, they risk strengthening health behaviours (such as breastfeeding) among socially advantaged groups and leave the more disadvantaged behind, thereby augmenting the social gap in health behaviours and -outcomes. The authors refer to the socioecological model in their article, which ensures me that this perspective will be included in subsequent research. I suggest supplementing the model with the so-called Rainbow Model (Dahlgren and Whitehead, Public Health 2021). The second comment pertains to the search strategy section. When describing the stages in the review process, present and past tenses are mixed. I would make for a better reading experience if tenses were aligned. Moreover, the three search strings for Breastfeeding, Communication campaign and Evaluation, development or implementation all stem from PubMed searches according to the description. However, all of them are different in their layout with the third appearing to be the most descriptive due to the subscripts (tiab, mesh etc). Could they be aligned, perhaps by providing the reader with the most ‘readable’ like the first string, and supplementing with the extensive strings online or elsewhere? And could a similar ‘string’ be included for the Grey literature section? Just to exemplify. The third comment is for the Source of evidence selection section. This is thoroughly described but could be supplemented by informing the reader what the proceeding will be if the quality control of the automated screening appears to be poor (“A further random sample of 10% of all excluded records will be screened by a second human reviewer for quality control.”). For nitty gritty details, there appears to be a full stop misplaced in this sentence: “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/ .” But overall, I wish the authors best of luck in their endeavours. The manuscript is of high quality and nearly ready for publication. I do not have to see it again before finalisation but will look forward to reading the scoping review when it is completed and published. 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? Not applicable References 1. Dahlgren G, Whitehead M: The Dahlgren-Whitehead model of health determinants: 30 years on and still chasing rainbows. Public Health . 2021; 199 : 20-24 Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Complex interventions, public health, breastfeeding intervention, social inequalities in health 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 (1) Author Response 17 Nov 2025 Jennifer Hanratty, Centre for Effective Services, Dublin, Ireland Thank you for your detailed comments and constructive suggestions. Your point on the potential for population-level communication interventions to widen inequalities in health is pertinent and thank you for suggesting Dahlgren G, Whitehead M. The Dahlgren-Whitehead model of health determinants: 30 years on and still chasing rainbows. Public Health. 2021 Oct;199:20-24. doi: 10.1016/j.puhe.2021.08.009. Epub 2021 Sep 14. PMID: 34534885. We will incorporate this model into the scoping review itself rather than tokenistic inclusion in the protocol at this point. We have reviewed tenses and kept to present and future tense throughout the description of the search strategy and streamlined the presentation of the search strings in the main article text to make them more readable, thank you for this suggestion. We have added that “if automated screening performs poorly as the ‘second reviewer’ automated screening will be abandoned, and a second human reviewer will review each record” Thank you for spotting this, the errant full stop has been corrected. View more View less Competing Interests None reply Respond Report a concern Rossau HK. Peer Review Report For: Population-level communication interventions for breastfeeding: Protocol for a scoping review [version 2; peer review: 3 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :76 ( https://doi.org/10.21956/hrbopenres.15475.r48637) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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