Apr 26, 2026

Prevalence and determinants of exclusive breastfeeding in a context of extreme heat in Sub-Saharan Africa: A Scoping Review Protocol

DOI
https://dx.doi.org/10.17504/protocols.io.n92ld4d9nl5b/v1
  • Abdoulaye Sow1,
  • Jean Marc Goudet2,
  • Fatimata Sow2,
  • Makhan Danfakha3,
  • Veronique Filippi4,
  • Sarah Louart5,
  • Sari Kovats4,
  • Adama Faye3,
  • Valery Ridde2
  • 1Université Cheikh Anta Diop, Dakar, Sénégal;
  • 2Université Paris Cité, IRD, INSERM, Ceped, Paris, France;
  • 3Institut de Santé et Développement, Université Cheikh Anta Diop, Dakar, Sénégal;
  • 4London School of Hygiene and Tropical Medecine (LSHTM), London, United Kingdom;
  • 5Univ. Lille, CNRS, UMR 8019 - CLERSE - Centre Lillois d’Etudes Et de Recherches Sociologiques Et Economiques, 59000, Lille, France
Abdoulaye Sow
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DOI: https://dx.doi.org/10.17504/protocols.io.n92ld4d9nl5b/v1
Protocol Citation: Abdoulaye Sow, Jean Marc Goudet, Fatimata Sow, Makhan Danfakha, Veronique Filippi, Sarah Louart, Sari Kovats, Adama Faye, Valery Ridde 2026. Prevalence and determinants of exclusive breastfeeding in a context of extreme heat in Sub-Saharan Africa: A Scoping Review Protocol. protocols.io https://dx.doi.org/10.17504/protocols.io.n92ld4d9nl5b/v1
License: This is an open access  protocol  distributed under the terms of the  Creative Commons Attribution License,  which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Protocol status: Working
We use this protocol and it's working
Created: April 25, 2026
Last Modified: April 26, 2026
Protocol  Integer ID: 315735
Keywords: Exclusive breastfeeding, Extreme heat, Sub-Saharan Africa, Environmental factors, Household water insecurity, determinants of exclusive breastfeeding, breastfeeding practice, exclusive breastfeeding, ebf prevalence, context of extreme heat, environmental factor, saharan africa, extreme heat event, child health, unicef report, prevalence, national health survey, rising temperature, extreme heat, reviewed empirical research
Abstract
Introduction: Sub-Saharan Africa is increasingly impacted by rising temperatures and extreme heat events. Insufficient attention has been given to the environmental factors, particularly extreme heat and household water insecurity, that may affect exclusive breastfeeding practices in climatically vulnerable regions, despite growing evidence of their relevance to maternal and child health.

Objective: This review aims to explore the determinants of exclusive breastfeeding (EBF), specifically focusing on environmental factors, and to assess the methods used to measure EBF prevalence in Sub-Saharan Africa. Inclusion criteria: To be eligible, studies must be peer-reviewed empirical research or relevant grey literature (theses, WHO/UNICEF reports, national health surveys), published in English or French. Studies whose objectives, primary outcomes or main theme are related to exclusive breastfeeding in Sub-Saharan Africa will be included.

Methods: The review will follow the JBI methodology for scoping reviews. We will search four databases (PubMed, Web of Science, Embase, CINAHL) and grey literature for studies published from 2015 to present. Study selection and data extraction will be performed by two independent reviewers using Covidence.

Dissemination: The results will inform the SPRINT-Sen research project and will be submitted for publication. The protocol will be registered and the findings will be submitted for publication in a peer-reviewed journal. Additionally, a research brief will be produced to inform the stakeholders and decision-makers.
Introduction
Sub-Saharan Africa (SSA) region is highly impacted by frequent hazards associated with climate change,as increasing temperature, drought and flooding (Acosta et al., 2024). In scientific and academic literature, there is no single universally accepted definition of heat wave. However, standardized indices are often necessary to allow for consistent global comparisons or extreme weather events. To address this, Frich et al, (2002) defined the foundational Heat Wave Duration index (HWDI) to monitor climate change worldwide, formalizing the necessity of duration when defining a heat wave (Frich et al., 2002). Beyond the meteorological duration, public health literature defines extreme heat as an environmental exposure where thermal burden directly challenges the human body’s capacity for effective thermoregulation (McGregor et al., 2015).

In regions such as northern Senegal, populations experience extreme heat frequently, with temperatures exceeding 41°C (ANACIM, 2025). Recent primary studies conducted in Sahelian and East African contexts suggest that heat stress and household water insecurity can affect lactation physiology and infant feeding practices, potentially leading to the early introduction of water or other liquids (Lusambili et al., 2024; Part et al., 2022; Roba et al., 2026). Currently, the national prevalence of exclusive breastfeeding (EBF) in Senegal is around 34.4% (ANSD, 2024), which remains suboptimal compared to the WHO Global Nutrition Targets of 50% by 2025 and 60% by 2030 (WHO, 2024).

Three previous reviews have addressed related questions and inform the rationale for the present scoping review. Edney et al. (2022), within the CHAMNHA (Climate, Heat and Maternal and Neonatal Health in Africa) consortium, conducted a systematic review of hot weather impacts on infant feeding practices in low- and middle-income countries, identifying 16 studies and documenting heterogeneous associations between heat exposure and exclusive breastfeeding duration across a 50-year window (Edney et al., 2022). Howells et al. (2025) published a narrative review from an evolutionary medicine perspective on water insecurity and heat stress effects on pregnancy and lactation, highlighting the mediating role of household water insecurity in shaping infant feeding behaviours (Howells et al., 2025). Kalhor et al. (2025) reported a systematic review and meta-analysis of 38 studies on demographic, socio- economic and clinical predictors of exclusive breastfeeding, without addressing environmental or climatic exposures.

Despite these contributions, three gaps persist. First, no review has specifically focused on Sub-Saharan Africa, where the intersection of extreme heat, household water insecurity and suboptimal EBF prevalence presents a distinct public health challenge, with particularly scarce primary evidence from the Sahelian Francophone region. Second, the methodological heterogeneity in measuring both heat exposure (thresholds, composite indices, data sources) and EBF prevalence (operational definitions, recall periods) has not been systematically mapped. Third, the primary evidence published after 2020, including recent studies from the CHAMNHA consortium in Kenya and Burkina Faso, has not been integrated into a synthesis focused on the African context.

While socio-demographic determinants of exclusive breastfeeding are well documented in Sub-Saharan Africa (Kalhor et al., 2025), the impact of environmental factors, particularly extreme heat and household water insecurity, remains insufficiently explored in the regional literature. Furthermore, there is a need to examine the methodological rigor of existing studies, including how EBF prevalence and heat exposure are measured (indicators used, recall periods, heat thresholds, composite indices), to ensure data reliability for future interventions(WHO & UNICEF, 2021). The 2015 temporal boundary of this review corresponds to the adoption of the Sustainable Development Goals and the revised WHO Global Nutrition Targets (WHO, 2024), marking a shift in international commitment to maternal and child nutrition. Consequently, the purpose of this scoping review is to address the three gaps identified above by systematically mapping the heterogeneous evidence base on extreme heat and exclusive breastfeeding in Sub-Saharan Africa, and to highlight future research priorities needed to mitigate this growing public health burden.
Review question
What is known about the influence of extreme heat on the prevalence and determinants of exclusive breastfeeding in Sub-Saharan Africa?
Sub-questions (specific objectives):
  • What are the reported prevalences of exclusive breastfeeding in Sub-Saharan African countries?
  • What are the determinants (including extreme heat and household water insecurity) of exclusive breastfeeding in Sub-Saharan Africa?
  • What socio-cultural beliefs, norms, and contextual factors (urban vs. rural settings) influence EBF practices in heat- exposed SSA contexts?
  • What are the methodological approaches used to measure both EBF prevalence and heat exposure (temperature metrics, thresholds, composite indices, data sources) in the existing literature?
Eligibility criteria
Participants
This review will include studies focusing on lactating women and infants aged 0 to 6 months (mother-infant dyads), consistent with the WHO definition of the exclusive breastfeeding window. Studies focusing exclusively on populations with specific medical contraindications to breastfeeding (e.g., HIV-positive mothers without access to antiretroviral therapy, maternal chemotherapy) will be excluded.
Concept
This scoping review addresses three interrelated concepts:
(i) Exclusive breastfeeding (EBF): prevalence, determinants, duration, and operational measurement approaches (WHO indicator: exclusive maternal milk feeding 0–6 months; recall periods; definition variations).
(ii) Exposure to extreme heat: operationalised as ambient temperature, humidity, heatwaves (meteorological or percentile-based definitions), hot season, or composite heat indices such as the Universal Thermal Climate Index (UTCI) or heat index. Multiple definitional approaches will be captured, reflecting the methodological heterogeneity identified as one of the mapping objectives of this review.
(iii) Household water insecurity, as a recognised mediator between heat exposure and infant feeding practices. Studies using validated instruments (Household Water Insecurity Experiences [HWISE] scale) or equivalent contextual measures will be included. Determinants of EBF will include socio-demographic factors (maternal education, income, parity, employment), socio-cultural factors (traditional beliefs and social norms regarding breastfeeding and maternal milk, recognised co-determinants of EBF practices in West and Central Africa; (Alive & Thrive & UNICEF, 2022)), and behavioural factors, categorised according to Godin's integrated model (Godin, 2015).
Context
This review focuses on Sub-Saharan Africa, as defined by the WHO African Region (48 countries). No restriction on setting (urban, peri-urban, or rural) will be applied.
Types of Sources
This review will include observational studies (cross-sectional, cohort, case-control), qualitative studies, mixed-methods studies, and relevant grey literature (theses, WHO and UNICEF reports, national demographic and health surveys such as DHS, MICS, and ANSD reports). Documents published in English and French from 2015 to the present will be included, to ensure coverage of both Anglophone and Francophone SSA. Drought and maternal undernutrition, while acknowledged as correlated exposures particularly in Sahelian contexts, fall outside the primary scope of this review, which focuses on direct thermal exposure and its immediate mediators.
Methods
A scoping review was deemed most appropriate given the heterogeneous and nascent nature of the evidence base linking extreme heat to exclusive breastfeeding, where the primary aim is to map existing literature, identify methodological gaps, and inform future analytical research rather than synthesize effect estimates. The proposed scoping review will be conducted in accordance with the JBI methodology for scoping reviews and reported using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist (Peters et al., 2024; Tricco et al., 2018).
Search Strategy
The search strategy will be implemented in three steps:
An initial limited search on PubMed was conducted to identify relevant keywords and MeSH terms, and to estimate the volume of available literature. A preliminary search on PubMed restricted to Sub-Saharan Africa (2015–present) yielded 25 records, supporting the feasibility and regional focus of the review.
A comprehensive search across four biomedical databases: PubMed, Embase, Web of Science, and CINAHL. These four databases were selected to ensure broad coverage across biomedical, multidisciplinary, and nursing literature. CINAHL was specifically included to capture midwifery and lactation-focused publications often underrepresented in purely biomedical databases. African Journals Online (AJOL) will be searched in addition as a regional database to capture African-published research, particularly in the Francophone West African literature. A full draft search strategy for PubMed is provided in Appendix. A search for grey literature via Google Scholar and relevant organizational websites (WHO, UNICEF, ANACIM, ANSD), and a review of the reference lists of included sources. Studies published in French and English will be included.
Study Selection
All identified citations will be uploaded to Covidence and duplicates will be removed. Two independent reviewers will screen titles and abstracts against the inclusion criteria. The full text of selected citations will be assessed in detail by two independent reviewers. Any disagreements between the reviewers will be resolved through discussion or by a third reviewer.
Data Extraction
Data will be extracted by two independent reviewers using a charting form developed for this review and piloted on three studies before full extraction. The data extracted will include: Study characteristics: author, year, country, setting (urban, peri-urban, rural), study design, sample size, funding. EBF measurement: operational definition of the indicator, recall method (24h vs. since birth), sample size calculation, representativeness of the sample. Heat exposure measurement: definition of heat exposure (ambient temperature, heat wave, composite index such as UTCI or heat index), thresholds used, data sources (ground station, reanalysis, satellite), spatial and temporal resolution. Household water insecurity (when reported): measurement instrument used (HWISE scale, WASH indicators, or contextual measures), level of measurement (household vs. community). Prevalence: reported EBF rates and confidence intervals. Determinants: socio-demographic, socio-cultural (including traditional beliefs and social norms regarding breastfeeding; Alive & Thrive, 2022), behavioural, and environmental factors associated with EBF, categorised according to Godin's integrated model (Godin, 2015). The results will be presented using a PRISMA flow diagram. A narrative summary will accompany the tabulated results, describing the relationship between determinants and EBF, with a focus on environmental gaps and methodological diversity. This scoping review will produce a comprehensive map of the existing evidence on the prevalence and determinants of exclusive breastfeeding in Sub-Saharan Africa, with a specific focus on the underexplored role of extreme heat and environmental factors. By systematically documenting how EBF and heat exposure are measured across studies, it will also provide a critical methodological inventory to guide future primary research in the region. The findings will directly inform the SPRINT -Sen research agenda on the health impacts of extreme temperatures in the Sahel, and contribute to evidence-based policy recommendations for maternal and child nutrition programs operating in climate-vulnerable, resource-limited settings.
Conflicts of interest
The authors declare no conflict of interest.
Appendix
Search Strategy
Timeframe: 2015 – 2026
Search query (PubMed)

#1 Concept: Breastfeeding & Infant Feeding
"Breast Feeding"[Mesh] OR "breast feed*"[tw] OR "breastfeed*"[tw] OR "breastfed*"[tw] OR "wet nursing"[tw] OR"breast milk"[tw]

#2 Concept: Climate Change, Heat & Environment "Climate Change"[Mesh] OR "Extreme Heat"[Mesh] OR "Hot Temperature"[Mesh] OR "Global Warming"[Mesh] OR "Droughts"[Mesh] OR "Water Insecurity"[Mesh] OR "heat wave*"[tw] OR "high temperature*"[tw] OR "heat stress"[tw] OR "climate change"[tw] OR "global warming"[tw] OR "drought*"[tw] OR "water insecurity"[tw]

#3 Concept: Context (Sub-Saharan Africa) "Africa South of the Sahara"[Mesh] OR "Africa"[tw] OR "Sub-Saharan Africa"[tw] OR "West Africa"[tw] OR "Sahel"[tw] OR "Angola"[tw] OR "Benin"[tw] OR "Botswana [tw] OR "Burkina Faso"[tw] OR "Burundi"[tw] OR "Cameroon"[tw] OR "Cape Verde"[tw] OR "Central African Republic"[tw] OR "Chad"[tw] OR "Comoros"[tw] OR "Congo"[tw] OR "Cote d'Ivoire"[tw] OR "Democratic Republic of the Congo"[tw] OR "Djibouti"[tw] OR "Equatorial Guinea"[tw] OR "Eritrea"[tw] OR "Eswatini"[tw] OR "Ethiopia"[tw] OR "Gabon"[tw] OR "Gambia"[tw] OR "Ghana"[tw] OR "Guinea"[tw] OR "Guinea Bissau"[tw] OR "Kenya"[tw] OR "Lesotho"[tw] OR "Liberia"[tw] OR "Madagascar"[tw] OR "Malawi"[tw] OR "Mali"[tw] OR "Mauritania"[tw] OR "Mauritius"[tw] OR "Mozambique"[tw] OR "Namibia"[tw] OR "Niger"[tw] OR "Nigeria"[tw] OR "Rwanda"[tw] OR "Sao Tome and Principe"[tw] OR "Senegal"[tw] OR "Seychelles"[tw] OR "Sierra Leone"[tw] OR "Somalia"[tw] OR "South Africa"[tw] OR "South Sudan"[tw] OR "Sudan"[tw] OR "Tanzania"[tw] OR "Togo"[tw] OR "Uganda"[tw] OR "Zambia"[tw] OR "Zimbabwe"[tw]

#4 Final Combination: #1 AND #2 AND #3
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