An Adaptable Communication Strategy for Chlorhexidine

This roadmap for communication design focuses on advocacy for use of chlorhexidine, one of "13 Life-Saving Commodities." The commodity is used for newborn umbilical cord care to prevent infection. The document forms part of a comprehensive Demand Generation Implementation Kit for Underutilized Commodities in RMNCH (Reproductive, Mother, Newborn, and Child Health from the Implementation Kit (I-Kit), offering resources for advocacy and demand generation communication. It is offered by the Health Communication Collaborative (HC3) in cooperation with the United Nations Children's Fund (UNICEF) and the United States Agency for International Development (USAID). The first part of the document outlines foundational guidance for communication on the 13 Lifesaving Commodities (see description below of the foundational guidance section); then, the section on the specific commodity, chlorhexidine, is presented.

The illustrative strategy for chlorhexidine advocacy communication (beginning on page 29) details each step for this specific commodity used for infant cord care. The health and commodity contexts are detailed with information on standard treatment for newborn cord care guidelines, cost, and availability. Barriers to uptake include: traditional practices and local or cultural norms on treating infection, drying, lubricating, softening, protecting, or healing the cord stump or accelerating cord detachment. Because the treatment often delays detachment and most women, families, and communities value speedy detachment of the stump, communication strategies, messages, and materials "should anticipate and address the issue of potential delay."

The audience and communication analysis section details key determinants from an evidence review:

• Individual-level evidence showed widespread use of local cord care substances by mothers, influenced by grandmothers. Nurses were influential in facility-based births. Traditional beliefs and practices, especially concern for detachment timing, were widespread.
• Family/community-level evidence showed strong influences of grandmothers, family networks, and community beliefs and practices.
• Society-level evidence showed that the degree of autonomy of mothers influenced their birth procedure choices. Also, access to trained birth attendants (TBAs) and to clinical facilities, as well as stocked medicines, affected choices.
• Health system-level evidence showed that prices for chlorhexidine mattered to choices made by couples, though there was a willingness to pay something for the commodity. In Bangladesh, there was a willingness to borrow money to purchase, and a willingness on the part of pharmacists to stock the commodity as long as it was recommended by physicians. The quality of antenatal care (ANC) was an impediment. Where TBAs and others in the communities had insufficient knowledge of cord care, "[a] disconnect found between health providers and communities indicates the need for providers and communities to work together to develop strategies to improve care and outcomes."
• Production and distribution evidence showed that the commodity can be distributed in channels available for antenatal and postnatal care systems, and it is recommended that "countries conduct a user preference study prior to selecting the formulation [gel, liquid, or lotion] for distribution."

The illustrative vision is: "Through the use of chlorhexidine for umbilical cord care, a dramatic and sustained decrease in newborn sepsis, cord infection, and death will be achieved."

The primary audiences are: 1) pregnant women, 2) grandmothers and family members who provide newborn care, 3) community health workers (CHWs) and TBAs, and 4) skilled birth attendants. Influencing audiences are: 1) ANC providers, 2) fathers and community members, and 3) pharmacists and social marketers. The document gives case study examples of potential audience members. "It will be necessary to conduct additional research around local population health seeking behaviors and providers of newborn care, such as identifying who is likely to provide cord care immediately after birth and in the following days, and use this research to define the primary and influencing audiences and to inform the audience profiles and strategic design."

Message design strategy is elaborated through charts beginning on page 46, by designated audience. For example, an objective for pregnant women is to "increase the number who would recommend chlorhexidine to a relative or friend to protect the newborn's health." Message positioning: "7.1% chlorhexidine digluconate is a best buy for newborn health. It does everything a mother wants cord care to do - including fighting infection - and gets the baby off to a great start in life." Key promise: "Using 7.1% chlorhexidine digluconate for cord care helps protect your baby, keeping him or her safe from infection and possibly even death." A key message: "Mothers have tried many different things to protect the cord and protect the newborn. Chlorhexidine for cord care is the only thing you need."

Many approaches, activities, and interventions are charted beginning on page 63 and include the following categories, with an example for each:

• Mass Media, for example: for long-form mass media, produce radio call-in shows that include chlorhexidine for cord care as a newborn care topic.
• Clinic‐Based Services, for example: Hold essential newborn care (ENC) practice sessions for people waiting for ANC services.
• Community‐Based Services, Outreach, and Community Approach, for example: for TBAs, develop/adapt materials and job aides (practice dolls, flipbooks, pictorial checklists, etc.) to provide guidance on counseling on clean delivery and ENC including chlorhexidine.
• Structural, for example: for pre-service trainings, integrate chlorhexidine for cord care into pre-service training for all providers, including pharmacists, doctors, nurses, midwives, and CHWs.

The monitoring and evaluation step suggests illustrative indicators for measuring inputs, outputs, outcomes, and impact, with examples of potential data sources, for instance, proportion of public and private facilities with chlorhexidine in stock or proportion of facility-based providers who have or have seen (updated) guidelines on cord care.

The foundational guidance section: Materials associated with the I-Kit, like this commodity-specific strategy document for chlorhexidine, were created to support the efforts of: communication professionals working directly on social and behaviour change communication (SBCC) programmes, as well as, other professionals working in RMNCH. It was created as a "quick-start foundation based on available evidence to provide guidance" for communication designed to: create new users; convince members of the intended audience to adopt new behaviours, products, or services; increase demand among existing users; convince current users to increase or sustain the practice of the promoted behaviour and/or to increase or sustain the use of promoted products and services; take market share from competing behaviours (e.g., convincing caregivers to seek health care immediately) and products or services (e.g., convincing caregivers to use chlorhexidine). Thus, the goal is to create informed and voluntary demand, help providers and clients interact effectively, shift social and cultural norms to support sustained commodity uptake, and encourage appropriate use of the commodity.

The strategy document offers key concept discussions on SBCC, social marketing, and channels and approaches, including advocacy, community mobilisation, entertainment education, information and communication technologies (ICTs), and mass and traditional media. The conceptual framework for the strategy is structured as a multi-directional continuum of social and environmental contexts: the individual level family and peer networks, community, and social and structural. The communication strategy includes 6 steps:

• "Analyze the Situation
• Define a Vision
• Choose Intended Audiences
• Select Key Messages
• Determine Activities and Interventions
• Plan for Monitoring and Evaluation"