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Using social media is one important strategy to communicate research and public health guidelines to the scientific community and general public. Empirical evidence about which communication strategies are effective around breastfeeding messaging is scarce. To fill this gap, we aimed to identify influencers in the largest available Twitter database using social network analysis ( n = 10,694 users), inductively analyze tweets, and explore communication strategies, motivations, and challenges via semi-structured interviews. Influencers had diverse backgrounds within and beyond the scientific health community (SHC; 42.7%): 54.7% were from the general public and 3% were companies. SHC contributed to most of the tweets ( n = 798 tweets), disseminating guidelines and research findings more frequently than others ( p < 0.001). Influencers from the general community mostly tweeted opinions regarding the current state of breastfeeding research and advocacy. Interviewees provided practical strategies (e.g., preferred visuals, tone, and writing style) to achieve personal and societal goals including career opportunities, community support, and improved breastfeeding practices. Complex challenges that need to be addressed were identified. Ideological differences regarding infant feeding may be hampering constructive communication, including differences in influencers' interpretation of the WHO International Code of Marketing of Breast-milk Substitutes and in perspectives regarding which social media interactions encompass conflict of interest.

Using Twitter to implement public health awareness campaigns is on the rise, but campaign monitoring and evaluation are largely dependent on basic Twitter Analytics. To establish the potential of social network theory-based metrics in better understanding public health campaigns, we analyzed real-time user interactions on Twitter during the 2020 World Breastfeeding Week (WBW) as an exemplar case. Social network analysis (SNA), including community and influencer identification, as well as topic modeling were used to compare the activity of n = 29,958 campaign participants and n = 10,694 reference users from the six-months pre-campaign period. Users formed more inter-connected relationships during the campaign, retweeting and mentioning each other 46,161 times compared to 10,662 times in the prior six months. Campaign participants formed identifiable communities that were not only based on their geolocation, but also based on interests and professional background. While influencers who dominated the WBW conversations were disproportionally members of the scientific community, the campaign did mobilize influencers from the general public who seemed to play a "bridging" role between the public and the scientific community. Users communicated about the campaign beyond its original themes to also discuss breastfeeding within the context of social and racial inequities. Applying SNA allowed understanding of the breastfeeding campaign's messaging and engagement dynamics across communities and influencers. Moving forward, WBW could benefit from improving targeting to enhance geographic coverage and user interactions. As this exemplar case indicates, social network theory and analysis can be used to inform other public health campaigns with data on user interactions that go beyond traditional metrics., Competing Interests: The authors have declared that no competing interests exist.