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

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.