Journal of Health and Nutrition Research

• Evidence from this scoping review indicates that proactive, continuous, and structured nurse-led telecounseling interventions utilizing digital platforms can effectively enhance breastfeeding self-efficacy, offering a viable strategy to expand access to consistent maternal support

Nutrition during the first 1000 days of life plays a crucial role in supporting healthy growth and development in children (1). The most recommended source of nutrition for infants up to six months of age is exclusive breastfeeding (2). The World Health Organization (WHO) recommends initiating breastfeeding within the first hour after birth, continuing exclusively for six months, and maintaining breastfeeding up to two years of age alongside complementary feeding (3). The benefits of breastfeeding have been extensively documented, including optimal infant growth and development, enhanced immune protection, reduced maternal morbidity, and greater efficiency in healthcare costs, all contributing to improved public health outcomes (4, 5).

Despite these established benefits, global breastfeeding rates remain below the UNICEF target of 100%, with the current global rate estimated at only 40%. In Indonesia, the prevalence of exclusive breastfeeding is reported at 68.8%, and only five provinces have reached the national target of above 75% (6, 7). Several studies have identified factors influencing exclusive breastfeeding, including sociodemographic characteristics, physical and psychological conditions, previous breastfeeding experience, maternal knowledge, perceived milk insufficiency, social support, and access to skilled health personnel (8–11). Among these, breastfeeding self-efficacy (BSE) has been recognized as a pivotal determinant, as it enables mothers to overcome breastfeeding challenges and is closely related to other influencing factors (12).

In the context of breastfeeding, self-efficacy reflects a mother’s confidence in her ability to successfully feed her infant, influencing both the initiation and continuation of breastfeeding (13, 14). Mothers with high levels of breastfeeding self-efficacy tend to breastfeed for longer durations and manage breastfeeding problems more effectively, thereby achieving optimal exclusive breastfeeding rates (15, 16). A growing body of evidence has shown that interventions such as structured breastfeeding education, peer support, and counseling are effective in improving maternal self-efficacy (17, 18). Furthermore, technological developments have also contributed to enhancing breastfeeding self-efficacy and exclusive breastfeeding rates by providing easier access to support, particularly when interventions are interactive and scheduled (19).

However, evidence evaluating the effectiveness of nurse-led digital interventions, particularly those conducted through telecounseling, in improving breastfeeding self-efficacy remains scarce and fragmented. Previous reviews have not specifically mapped the types, mechanisms, and outcomes of digital breastfeeding interventions implemented by nurses. Therefore, this scoping review aims to systematically explore and describe the latest evidence on nurse-led digital and telecounseling interventions designed to enhance breastfeeding self-efficacy, thereby highlighting nurses’ contributions in digital maternal and child health care.

This scoping review was conducted using the method recommended by the Joanna Briggs Institute (JBI), which aims to systematically map the evidence. Reporting results in a clear and accurate way helps make sure everything is open and reliable. This is done by following the PRISMA-ScR guidelines, which include five main steps. First, research questions are created using the PCC framework, which stands for Population, Concept, and Context. Next, literature is searched across different sources like PubMed, Scopus, ScienceDirect, and Sage journals, as well as using Google Scholar for grey literature. Then, articles are picked based on set rules for what to include and exclude. After that, data is collected in a structured way that covers details about each study, what was done in them, and the results related to breastfeeding self-efficacy. Finally, the findings are analyzed and shared in both written descriptions and tables to spot patterns, key features, and areas that need more research. The research article search strategy used a combination of keywords and MeSH terms, including breastfeeding, breastfeeding self-efficacy, telecounseling, digital intervention, telehealth, mhealth, and nurse led. Adjustments were made to each database to ensure that the search results covered relevant and comprehensive literature.

Study Selection

The framework used in the study selection process was Population, Concept, and Context (PCC). The population was mothers breastfeeding infants aged 0-6 months, both primiparas and multiparas. The concept analyzed emphasized digital interventions or telecounseling conducted by nurses, with the aim of increasing breastfeeding self-efficacy (BSE). The research concept covered various health care facilities, such as primary health care, hospitals, and communities without geographical restrictions.

The studies included in this review met the predefined eligibility criteria. They explored nurse-led digital interventions such as telecounseling, mobile health applications, or telehealth programs designed for breastfeeding mothers with infants aged between 0 and 6 months. Eligible studies assessed how these digital strategies influenced breastfeeding self-efficacy, either as a main outcome or a supporting measure. Research using quantitative, qualitative, or mixed methods was included. Only studies published in English between 2015 and 2025 were considered for inclusion. Meanwhile, articles were excluded if they met the exclusion criteria, namely not involving nurses as intervention implementers, only discussing general breastfeeding education without digital interventions or telecounseling, including nonempirical publications, and not available in full for free.

Article Screening Process

The article selection process was carried out by three researchers (NA, HSM, and SH) who obtained articles from several databases and then entered them into Mendeley for reference management and duplication detection. The selection process began with the removal of duplicates, review of titles and abstracts, and examination of the full text based on predetermined inclusion and exclusion criteria, until finally the articles to be included in the analysis were obtained. This process was visualized using the PRISMA ScR flowchart to illustrate the number of articles at each stage of the selection process. Subsequently, three authors assessed the methodological quality of the selected studies using the Joanna Briggs Institute (JBI) Critical Appraisal Tools, which were adapted according to each study’s research design, including randomized controlled trials, quasi-experimental studies, and qualitative research. This appraisal aimed to identify the methodological strengths and weaknesses of each study to ensure that the evidence mapping could be interpreted in a comprehensive and transparent manner. The summary of the quality appraisal results based on the JBI Critical Appraisal Tools is presented in Table 1.

Table 1. Article Analysis Using JBI Assessment

The methodological quality of the included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Tools according to the respective study designs. The numerical scores presented in Table 1 represent the proportion of appraisal criteria fulfilled by each study based on the applicable JBI checklist items. Higher scores indicate greater methodological rigor and a lower risk of bias. These scores were used to describe the overall quality of the evidence and were not applied as exclusion criteria.

Data Extraction and Analysis

In this review, a table was used to summarize all data from the selected studies, highlighting key information related to the research findings. The data extraction process was carried out by the first author (NA) and double-checked by the other two authors (HSM and SH) to ensure the accuracy and consistency of the collected data. The extraction table included details of the study design, such as country of origin, study type, sample size, and the breastfeeding self-efficacy measurement tool used. In addition, participant characteristics (age, parity, and breastfeeding status) were also included, as well as a description of the form of digital intervention applied and the main results obtained.

The analysis stage was conducted using descriptive and thematic approaches to identify patterns, trends, and factors that influencing telecounseling and nurse-led digital interventions. Findings from the included studies were subsequently organized into broader themes through discussion and consensus among the research team to ensure that the results remained consistent, clear, and aligned with the objectives of this review.

Study Selection Result

The database search initially proceeded 515 records sourced from five electronic databases: PubMed (n = 10), Scopus (n = 2), ScienceDirect (n = 101), SAGE Journals (n = 112), and Google Scholar (n = 290). After removing 16 duplicate entries, a total of 499 studies proceeded to the screening phase. Of these, 316 were excluded because their titles and abstracts were not relevant to the review objectives. The remaining 183 full-text articles were assessed according to the predetermined inclusion and exclusion criteria. Following this assessment, 171 studies were excluded for reasons such as the absence of nurse-led interventions, lack of digital or telecounseling components, omission of breastfeeding self-efficacy as an outcome, or failure to meet methodological standards. Ultimately, twelve studies satisfied all inclusion criteria and were incorporated into the final scoping review (Figure 1. PRISMA flow diagram).

Study Characteristics

This scoping review analysis included twelve studies that met the inclusion criteria. Six studies used a randomized controlled trial (RCT) design, five used a quasi-experimental design, and one was a qualitative study . The studies were conducted in several countries, including Iran, Brazil, Turkey, Thailand, China, and Australia. The included studies described a range of nurse-led digital interventions aimed at strengthening breastfeeding self-efficacy, such as telephone-based counseling, social messaging platforms, mobile health applications, and online nursing consultations. Across all included studies, breastfeeding self-efficacy was consistently assessed as the primary outcome.

These interventions were implemented in various healthcare settings, including maternity hospitals, primary health care services, and community-based breastfeeding support programs. The participants were predominantly mothers of infants aged 0–6 months, although several studies also involved pregnant women or mothers in the early postpartum period. The diversity of study designs, intervention formats, and settings reflects the broad application of nurse-led digital approaches to support breastfeeding self-efficacy.

Table 2. Study Characteristics

This scoping review examined previous research on the use of digital tools and nurse-led telecounseling to support breastfeeding self-efficacy. The findings from the twelve included studies suggest that digital approaches, including text messaging, telephone consultations, and nurse-led digital services, can facilitate ongoing communication and access to breastfeeding support. Although the interventions varied in design and duration, many studies reported improvement in mothers’ confidence in breastfeeding. These findings indicate that the potential benefits of digital interventions may be influenced not only by the type of technology used but also by the quality of therapeutic relationships and the continuity of communication established between nurses and mothers (26, 27, 30).

Telecounseling Models and Intervention Patterns

Telecounseling interventions were delivered through proactive or reactive approaches. In proactive models, nurses initiated scheduled follow-up contact, whereas in reactive models, mothers sought support when needed. Studies applying proactive models reported more favorable patterns related to breastfeeding self-efficacy. These interventions commonly involved regular telephone calls or text-based communication during the postpartum period, which supported ongoing engagement and confidence building among mothers (23–25,27). Similarly, the use of mobile applications or video consultations facilitated continuous support and communication, allowing mothers to access guidance and reassurance when facing breastfeeding challenges (29, 30).

In contrast, studies using reactive telecounseling approaches reported more variable outcomes. Improvements in breastfeeding self-efficacy were observed primarily when nurse-mother interactions were characterized by supportive and empathetic communication. Conversely, limited or less supportive interactions were associated with weaker confidence outcomes. Overall, the available evidence suggests that proactive nurse-led telecounseling may offer more consistent support for breastfeeding self-efficacy than reactive or single-contact approaches, although the effectiveness appears closely linked to the quality of communication rather than the delivery mode alone (31).

Mechanisms of Breastfeeding Self-Efficacy Improvement

According to Bandura’s Social Cognitive Theory, there are four main sources that enhance breastfeeding self-efficacy namely mastery experience, vicarious experience, verbal persuasion, and emotional arousal. Several included studies reflected these mechanisms within nurse-led digital interventions. Mastery experiences were facilitated through practical guidance, demonstrations, and educational videos that enabled mothers to practice and refine breastfeeding techniques (27, 28). Vicarious experiences were supported through digital group interactions, where mothers could observe and learn from the experiences of peers, fostering shared learning and encouragement (23). Verbal persuasion was commonly delivered through motivational messages and telephone-based support from nurses, reinforcing maternal confidence and commitment to breastfeeding (24, 31). Emotional arousal was addressed by providing timely professional support, which helped reduce maternal anxiety and stress and promoted a more confident approach to breastfeeding (26, 30). Collectively, these mechanisms suggest that digital interventions may support breastfeeding self-efficacy by addressing both practical skills and psychological readiness.

Intervention Duration and Sustainability of Support

The included studies reported intervention durations ranging from one week to six months. Short-term interventions were commonly associated with immediate improvements in breastfeeding self-efficacy (27, 28). In contrast, interventions implemented over longer periods were more frequently associated with sustained breastfeeding practices, including continued exclusive breastfeeding (25, 30). These findings indicate that continuity of nurse-led support may play an important role in maintaining maternal confidence over time. However, evidence regarding the sustainability of breastfeeding self-efficacy beyond six months remains limited. This highlights the need for future studies with extended follow-up periods to better understand the long-term impact of digital and telecounseling interventions.

Cultural Adaptation and Technology Access

Cultural context and familiarity with commonly used digital platforms appear to influence the implementation of nurse-led digital breastfeeding interventions. Several studies reported that the use of locally familiar applications, such as WeChat in China, LINE in Thailand, and WhatsApp in Egypt, supported more active engagement and facilitated communication between mothers and nurses. The use of these platforms allowed breastfeeding support to be integrated into mothers’ daily routines more naturally. These findings underline the importance of aligning digital interventions with local communication practices and sociocultural contexts to enhance acceptability and engagement at the community level (20, 23).

The Role of Nurse in Digital Interventions

Nurses play a central role in supporting mothers through digital breastfeeding interventions. Their involvement commonly includes providing practical guidance, offering emotional support, and responding to mothers’ concerns in a timely and attentive manner. Several studies emphasized that the quality of communication between nurses and mothers is an important factor influencing breastfeeding self-efficacy. Supportive, empathetic, and encouraging communication was associated with greater maternal confidence in breastfeeding, whereas interactions perceived as rigid or judgmental were linked to lower confidence and reduced engagement with breastfeeding support (27, 31).

Implications for Nursing Practice

The findings of this scoping review suggest that nurse-led digital interventions may expand the scope of nursing practices in breastfeeding support. The integration of telecounseling into primary and community health care services has the potential to improve access to breastfeeding support, enhance time efficiency, and strengthen continuity of care, particularly in settings with limited health resources. Digital approaches may enable nurses to maintain regular contact with mothers and provide timely guidance beyond traditional face-to-face encounters. This direction aligns with global health priorities that emphasize the use of digital health technologies to improve the availability and accessibility of health services. The World Health Organization highlights digital health as a means to support universal health coverage and promote more equitable service delivery, particularly for mothers and children (32).

Research Limitations

This scoping review has several limitations that should be considered when interpreting the findings. Many of the included studies employed quasi-experimental designs with relatively small sample sizes, which limits the generalizability of their findings to wider populations. In addition, most studies focused on short-term outcomes, with limited examination of the long-term sustainability and cost-effectiveness of nurse-led digital interventions. Variations in intervention design, duration, and outcome measures also make direct comparisons across studies challenging. Future research should examine the long-term impact of digital breastfeeding support, explore implementation-related considerations, and assess how family involvement and health system integration may influence the effectiveness and sustainability of telecounseling interventions.

This scoping review highlights the use of digital tools and nurse-led telecounseling as emerging approaches to support breastfeeding self-efficacy. The included studies indicate that digital interventions can facilitate access to breastfeeding education, emotional support, and ongoing communication between nurses and mothers. Proactive nurse-led approaches, characterized by scheduled follow-up and continuous engagement, were more frequently associated with supportive patterns of breastfeeding self-efficacy compared with reactive models. The findings further indicate that the effectiveness of digital breastfeeding support is shaped by the continuity of care, the suitability of the platforms used within specific contexts, and nurses’ capacity to build supportive relationships through digital communication.

The authors declare that no artificial intelligence (AI), AI-assisted technologies, or large language models (LLMs) were used in the conception of the study, data analysis, or the drafting, writing, and editing of this manuscript. The only exception is the graphical abstract, which was created using the design platform Illustrae (https://illustrae.co/). The authors take full responsibility for the content and accuracy of the graphical abstract and the entire manuscript

This research received no external funding.

The authors would like to express their sincere gratitude to Padjadjaran University for providing access to international databases, which greatly supported the literature search and analysis process in this review. The authors also thank colleagues and collaborators who offered valuable feedback and technical assistance during manuscript preparation. Minor language assistance was received to improve the clarity and readability of the manuscript without altering its content or interpretation.

The authors declare no conflict of interest

1. Uwaezuoke SN, Eneh CI, Ndu IK. Relationship Between Exclusive Breastfeeding and Lower Risk of Childhood Obesity: A Narrative Review of Published Evidence. Clinical Medicine Insights: Pediatrics. 2017;11. doi:10.1177/1179556517690196

2. Zhou Y, Xu Y. Nutrition and Metabolism in the First 1000 Days of Life. Nutrients. 2023;15(11):3–6. doi:10.3390/nu15112554 PubMed PMID: 37299517.

3. Rahimparvar FV, Nayebian S, Kalan ME, Haghani S, Sighaldeh SS. Mother’s milk-mother’s gift: Mobile-based training to increase self-efficacy of nursing women during postpartum and puerperium: A quasi-experimental study. Journal of Pediatric Nursing. 2024;75:e10–5. doi:10.1016/j.pedn.2023.12.008 PubMed PMID: 38302399.

4. Chowdhury R, Sinha B, Sankar MJ, Taneja S, Bhandari N, Rollins N, et al. Breastfeeding and maternal health outcomes: A systematic review and meta-analysis. Acta Paediatrica, International Journal of Paediatrics. 2015;104:96–113. doi:10.1111/apa.13102 PubMed PMID: 26172878.

5. Gökşen D, Özkan S. The effect of online breastfeeding education on breastfeeding motivation: A randomized controlled study. Journal of Pediatric Nursing. 2024;75:e42–8. doi:10.1016/j.pedn.2023.12.026 PubMed PMID: 38182483.

6. Kemenkes. Survei Kesehatan Indonesia (SKI). Kemenkes. 2023.

7. Syahri IM, Laksono AD, Fitria M, Rohmah N, Masruroh M, Ipa M. Exclusive breastfeeding among Indonesian working mothers: does early initiation of breastfeeding matter? BMC Public Health. 2024;24(1):1–10. doi:10.1186/s12889-024-18619-2 PubMed PMID: 38702668.

8. Henshaw E, Cooper M, Wood T, Krishna S, Lockhart M, Doan S. A randomized controlled trial of the Happy, Healthy, Loved personalized text-message program for new parent couples: impact on breastfeeding self-efficacy and mood. BMC Pregnancy and Childbirth. 2024;24(1):1–9. doi:10.1186/s12884-024-06684-9 PubMed PMID: 39060974.

9. Mirghafourvand M, Malakouti J, Mohammad-Alizadeh-Charandabi S, Faridvand F. Predictors of breastfeeding self-efficacy in Iranian women: A cross-sectional study. International Journal of Women’s Health and Reproduction Sciences. 2018;6(3):338–85. doi:10.15296/ijwhr.2018.62

10. Ngo LTH, Chou HF, Gau ML, Liu CY. Breastfeeding self-efficacy and related factors in postpartum Vietnamese women. Midwifery. 2019;70(2019):84–91. doi:10.1016/j.midw.2018.12.014 PubMed PMID: 30594613.

11. Putri SA, Sudaryanto A. Penggunaan Telehealth atau Telenursing di Indonesia selama Pandemi COVID-19. Journal of Telenursing (JOTING). 2023;5(1):1093–102. doi:10.31539/joting.v5i1.6144

12. Al-Thubaity DAD, Alshahrani MA, Elgzar WT, Ibrahim HA. Determinants of High Breastfeeding Self-Efficacy among Nursing Mothers in Najran, Saudi Arabia. Nutrients. 2023;15(8):1–13. doi:10.3390/nu15081919 PubMed PMID: 37111138.

13. Ghasemi V, Simbar M, Banaei M, Saei M, Naz G. The Effect of Interventions on Breastfeeding Self-efficacy by Using Bandura’s Theory in Iranian Mothers: A Systematic Review Adolescent girls’ sexual and reproductive self-care View project sexual health View project. Int J Pediatr. 2019;7(68):9939–54. doi:10.22038/ijp.2019.40842.3446

14. Titaley RC, Dibley M, Ariawan I, Mu’asyaroh A, Alam A. Determinants of low breastfeeding self-efficacy amongst mothers of children aged less than six months: results from the BADUTA study in East Java, Indonesia. International Breastfeeding Journal [revista en Internet] 2021 [acceso 20 de noviembre de 2023]; Vol. 5. 2021;5:1–15. PubMed PMID: 33468196.

15. Poorshaban F, Pakseresht S, Bostani Khalesi Z, KazemNejad Leili E. Factors Associated with Breastfeeding Self-Efficacy of Mothers Within 6 Weeks of Delivery . Journal of Holistic Nursing and Midwifery. 2017;27(1):27–34. doi:10.18869/acadpub.hnmj.27.1.27

16. Topuz Ş, DUMAN NB, Uysal GK, Öcalan D. Breastfeeding self-efficacy and related factors during early postpartum period. Universa Medicina. 2021;40(3):216–25. doi:10.18051/univmed.2021.v40.216-225

17. Brockway M, Benzies K, Hayden KA. Interventions to Improve Breastfeeding Self-Efficacy and Resultant Breastfeeding Rates: A Systematic Review and Meta-Analysis. Journal of Human Lactation. 2017;33(3):486–99. doi:10.1177/0890334417707957 PubMed PMID: 28644764.

18. Wong MS, Mou H, Chien WT. Effectiveness of educational and supportive intervention for primiparous women on breastfeeding related outcomes and breastfeeding self-efficacy: A systematic review and meta-analysis. International Journal of Nursing Studies. 2021;117:103874. doi:10.1016/j.ijnurstu.2021.103874 PubMed PMID: 33548592.

19. Dağlı E, Topkara FN. The effect of tele-education delivered to mothers during the COVID-19 pandemic on breastfeeding success and perceived breastfeeding self-efficacy: Randomized controlled longitudinal trial. Health Care for Women International. 2023;44(3):345–60. doi:10.1080/07399332.2022.2132251 PubMed PMID: 36227641.

20. Ylkar SK, Nazik E. Effects of home care and e-mobile training/consultancy on women’s postpartum symptoms and breastfeeding self-efficacy: A randomized clinical trial. European Journal of Public Health. 2024;34(5):936–42. doi:10.1093/eurpub/ckae119 PubMed PMID: 39251406.

21. Seddighi A, Khalesi ZB, Majidi S. The effect of mobile-based training on maternal breastfeeding self-efficacy: a randomized clinical trial. African Health Sciences. 2022;22(3):648–55. doi:10.4314/ahs.v22i3.69 PubMed PMID: 36910415.

22. Chaves AFL, Ximenes LB, Rodrigues DP, Vasconcelos CTM, Monteiro JC dos S, Oriá MOB. Telephone intervention in the promotion of self-efficacy, duration and exclusivity of breastfeeding: Randomized controlled trial. Revista Latino-Americana de Enfermagem. 2019;27. doi:10.1590/1518-8345.2777-3140 PubMed PMID: 31038634.

23. Chegeni MF, Valizadeh F, Ghasemi SF, Changaee F, Anbari K. Comparison of Different Virtual Follow-ups on Mother’s Lactation. The Journal for Nurse Practitioners. 2022;18(9):988–94. doi:https://doi.org/10.1016/j.nurpra.2022.08.005

24. Dodou HD, Bezerra RA, Chaves AFL, Vasconcelos CTM, Barbosa LP, Oriá MOB. Telephone intervention to promote maternal breastfeeding self-efficacy: randomized clinical trial*. Revista da Escola de Enfermagem. 2021;55:1–8. doi:10.1590/1980-220X-REEUSP-2020-0520 PubMed PMID: 34528994.

25. Dodou HD, Chaves AFL, Pinho MAT, Lopes BB, Silva BGS, Rodrigues DP, et al. Effects of a telephone educational intervention on breastfeeding: a clinical trial. ACTA Paulista de Enfermagem. 2023;36:1–10. doi:10.37689/ACTA-APE/2023AO01101

26. García JA, Pedraz A, Rosa M, Alba M, Ana D, Santos P, et al. Efficacy of an Online Nursing Consultation to Encourage Breastfeeding. 2025.

27. Chuektong C, Nirattharadorn M, Buaboon N. The Breastfeeding Self-Efficacy Enhancement Program with LINE Application among Mothers with Cesarean Section: A Quasi-Experimental Study. Pacific Rim International Journal of Nursing Research. 2023;27(4):711–21. doi:10.60099/prijnr.2023.262349

28. N. Sadek B, Attia Abdalla Z, Abdo Abdel Haleem S, A. Ali E. Effect of Electronic-Based Instructions Guide on Supporting Mothers of Preterm Infants Regarding Safe Breastfeeding during Covid-19 Pandemic. Egyptian Journal of Health Care. 2021;12(2):1979–97. doi:10.21608/ejhc.2021.316043

29. Shamsi A, Ehteshami A, Zandi Esfahani H, Namnabati M. Effects of Telenursing on Breastfeeding Self-efficacy, Infant Weight and Readmission to Neonatal Intensive Care Units in Mothers of Premature Infants. Iran Journal of Nursing. 2025;38(01):0–0. doi:10.32598/ijn.38.3447.2

30. Wang P, Chen Y, Li J, Xu X. Evaluation of the Effectiveness of WeChat-Based Continuing Care Services on Maternal Parenting Competence. Journal of Community Health Nursing. 2025;42(2):135–46. doi:10.1080/07370016.2025.2449871 PubMed PMID: 39927564.

31. Gallegos D, Cromack C, Thorpe KJ. Can a phone call make a difference? Breastfeeding self-efficacy and nurse responses to mother’s calls for help. Journal of Child Health Care. 2018;22(3):433–46. doi:10.1177/1367493518757066 PubMed PMID: 29514511.

32. WHO. World Health Organization, Global Strategy on Digital Health. Indian Pediatrics. 2021. 356–358 p. PubMed PMID: 32284477.