Applying the theory of planned behavior to examine breastfeeding determinants in countries of the Gulf Cooperation Council: a systematic review

Abstract

Background: Appropriate and timely nutrition during infancy constitutes a critical window of opportunity to ensure proper growth and development. Despite the established benefits of breastfeeding (BF), the proportions of breastfed infants remain disappointingly low in countries of the Gulf Cooperation Council (GCC). Using the Theory of Planned Behavior (TPB), this systematic review aims at examining infant feeding intentions, attitudes, subjective norms, perceived behavioral control and beliefs towards BF amongst women in various countries of the GCC.

Methods: Pertinent data were obtained through a search of peer-reviewed studies published between 2012 and 2024. A total of 12 electronic databases have been searched.

Results: A total of 101 studies were retained. The largest number of studies was from the Kingdom of Saudi-Arabia (80 studies). The results were mapped across the five TPB constructs: intention, subjective norms, attitude, perceived behavioural control and beliefs. Findings showed that, although the intention to BF was high, the intention to exclusively BF was considerably lower. BF was found to align well with the religious norms and social expectations in countries of the GCC. However, factors such as shyness, embarrassment and reticence over BF in public and pumping at work were reported by various studies. There was a negative attitude towards the suitability of BF for working mothers and it was common for women to consider that formula feeding and BF provide equal benefits. Perceived behavior control towards exclusive BF and the sufficiency of breast milk supply was identified as low in several studies, particularly amongst primigravida women and mothers of twins. Women believed that BF in public may expose them to the "evil eye" and that BF may lead to breast sagging.

Conclusions: By identifying opportunities and gaps under each of the TPB constructs, the results of this review may assist in the development of future culture-specific interventions aimed at BF promotion in countries of the region. These include multi-level interventions encompassing the educational system, the media and social media, in addition to community and hospital-based interventions. The results also call for the development of policies tailored to the identified factors in each of the TPB constructs.

Keywords: Attitudes; Beliefs; Breastfeeding; Gulf Cooperation Council; Intentions; Perceived behavioral control; Subjective norms; Systematic review; Theory of planned behavior.

Fig. 1

Conceptual framework of the adopted theory of planned behavior (TPB). (adapted from Ajzen 2015 [30])

Fig. 2

Search and identification process of potential references from the literature. *The records identified from the various databases were as follows: Academic Search Ultimate (n = 35); Al Manhal (n = 9); APA PsyclNFO (n = 5); Arab World Research Source (AWRS) (n = 10); CAB Direct (n = 69); CINAHL Ultimate (n = 68); Directory of Open Access Journals (n = 64); E-Marefa (n = 4); Embase (n = 126); MEDLINE (n = 103); Scopus (n = 172); Web of Science Core Collection (n = 145)

Fig. 3

Total number of publications from GCC countries for the period between 2012 and 2023 Abbreviations: GCC: Gulf Cooperation Council

Fig. 4

Proportions (%) of women reporting the intention to breastfeed based on available data in countries of the GCC Abbreviations: GCC: Gulf Cooperation Council; KSA: Kingdom of Saudi Arabia

Fig. 5

Intentions to exclusively breastfeed based on available data in countries of the GCC Abbreviations: GCC: Gulf Cooperation Council; KSA: Kingdom of Saudi Arabia; UAE: United Arab Emirates

Fig. 6

Intentions to provide mixed feeding based on available data in countries of the GCC Abbreviations: GCC: Gulf Cooperation Council; KSA: Kingdom of Saudi Arabia

Fig. 7

Proportions of women with positive, neutral or negative attitude based on the validated Iowa Infant Feeding Attitude Scale (IIFAS) questionnaire and scale*. *: Qatar– Chaabna et al. 2022: Positive attitude is defined with a score of 70–85, neutral attitude with a score of 49–69 and negative attitude with a score of 17–48. KSA– Al-Thubaity et al. 2023: Positive attitude is defined with a score of 52–85 and negative attitude with a score of 17–51. KSA– Abulreesh et al. 2018: Positive attitude is defined with a score of 76–85, neutral attitude with a score of 61–75 and negative attitude with a score of 17–60. KSA– Elbur et al. 2014: Positive attitude is defined with a score above the median score and negative attitude with a score below the median score. KSA– Saied et al. 2013: Positive attitude is defined with a score of 70–85, neutral attitude with a score of 49–69 and negative attitude with a score of 17–48

Fig. 8

Summary of gaps in relation to the BF constructs in countries of the GCC Abbreviations: BF: breastfeeding; GCC: Gulf Cooperation Council