title: Barriers and promoters of home-based pasteurization of breastmilk among HIV-infected mothers in greater Dar es Salaam, Tanzania.
abstract: BACKGROUND
  For the past decade, heat-treating breastmilk has been an infant feeding option recommended by the World Health Organization as a strategy to reduce vertical transmission. However, little is known about field experiences with it. Our primary objective was to explore the barriers and promoters of the implementation of breastmilk pasteurization, "flash-heating" (FH), in the real-world setting of Dar es Salaam, Tanzania.
  
  
  METHODS
  Nineteen in-depth interviews were conducted with participants in a home-based infant feeding counseling intervention in which FH was promoted after 6 months of exclusive breastfeeding. Additionally, three focus group discussions were conducted with peer counselors. Interviews were transcribed, translated, and coded independently using NVivo 8 software (QSR International). Data were analyzed using the socioecological framework.
  
  
  RESULTS
  Information and support provided by peer counselors were the most important promoters of initiation and continuation of FH; this impacted individual-, interpersonal-, and institutional-level promoters of success. Other promoters included perceived successful breastmilk expression, infant health after initiation of FH, and the inability to pay for replacement milks. Stigma was the most important barrier and cut across all levels of the framework. Other barriers included doubt about the safety or importance of pasteurized breastmilk, difficulties with expressing milk (often attributed to poor diet), and competing responsibilities. The most common suggestion for improving the uptake and duration of FH was community education.
  
  
  CONCLUSIONS
  Given the acknowledged role of breastmilk pasteurization in the prevention of vertical transmission, further implementation research is needed. A multilevel intervention addressing barriers to FH would likely improve uptake.
authors.affiliation: Division of Nutritional Sciences, Cornell University , Ithaca, NY 14853, USA.
authors.forename: Sera
authors.initials: S
authors.lastname: Young
authors.forename: Sebalda
authors.initials: S
authors.lastname: Leshabari
authors.forename: Chaele
authors.initials: C
authors.lastname: Arkfeld
authors.forename: Jennifer
authors.initials: J
authors.lastname: Singler
authors.forename: Emily
authors.initials: E
authors.lastname: Dantzer
authors.forename: Kiersten
authors.initials: K
authors.lastname: Israel-Ballard
authors.forename: Clara
authors.initials: C
authors.lastname: Mashio
authors.forename: Catherine
authors.initials: C
authors.lastname: Maternowska
authors.forename: Caroline
authors.initials: C
authors.lastname: Chantry
mesh_terms: D000328:Adult; D001942:Breast Feeding / Q000379:methods*; D003140:Communicable Disease Control / Q000379:methods*; D003376:Counseling; D003657:Decision Making; D005260:Female; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control* / Q000635:transmission; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008895:Milk, Human; D009035:Mothers / Q000193:education; D061352:Pasteurization; D011247:Pregnancy; D012944:Social Support; D011795:Surveys and Questionnaires; D013636:Tanzania / Q000453:epidemiology