An Adaptable Communication Strategy for Demand Generation: Misoprostol

This roadmap for communication design focuses on advocacy for use of misoprostol, one of 13 "Life-Saving Commodities." The commodity is used for postpartum hemorrhage (PPH) , a leading cause of maternal deaths, along with another underutilised commodity, oxytocin, as recommended by the World Health Organization (WHO) for cases of PPH when needed in settings of active management of the third stage of labour.

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, misoprostol, is presented.

The illustrative strategy for misoprostol advocacy communication (beginning on page 28) details each step for this specific commodity used to treat PPH. The health and commodity context are detailed with information on standard treatment, use as a second choice to oxytocin, cost, and availability. Barriers to uptake include its possible lack of availability and its possible use to cause abortion - a cultural barrier to introduction in some countries. The audience and communication analysis section details key determinants from an evidence review:

• Knowledge and attitudes of PPH and misoprostol among women, community members, and providers, including skilled and traditional birth attendants (TBAs) and community health worker (CHWs), are a determinant of misoprostol use. For example, in Bangladesh, lack of knowledge and misperception were reasons given by women interviewees for lack of use. In India, providers were concerned about community misperceptions. However, "[c]ommunity mobilization interventions to increase access to misoprostol for PPH prevention have shown some success..." including in Zaire. In a pilot in Ethiopia, health extension worker (HEW) training increased demand for mistoprosal; however, "the evaluation highlighted the need for sensitization of decision-makers at the district level, community education campaigns to raise awareness, and training TBAs (who already have communities' trust) to distribute misoprostol as well."
• Social/normative barriers are included in studies identifying traditional beliefs and practices that prevent women from "seeking timely modern health care because it would be seen as a sign of weakness - illnesses, including problems during childbirth, are seen as having spiritual causes and thus would not respond to modern medicine - or the cultural 'protocol' is to seek health solutions from the ancestors/traditional practitioner first, and modern medicine as a last resort."
• Demand, in a study in India, was driven by pregnant women and their families (usually mothers-in-law).
• Availability was shown to have a positive effect on demand in Bangladesh; whereas, in a Nigerian study, lack of supply reduced demand. Regulatory issues can impact the availability.

The illustrative vision is: "Providers, women, their partners, and gatekeepers see misoprostol as a valuable tool to prevent and treat PPH, and they easily obtain and use it consistently at facilities and at community level (when oxytocin is not available)."

The primary audiences are: 1) pregnant women planning to deliver at home and 2) community-level providers - CHWs, TBAs, social workers, and pharmacists. Influencing audiences are: 1) male partners, mothers, and mothers-in-law; 2) facility-based providers; and 3) community leaders, including religious leaders. The document gives case study examples of potential audience members.

Message design strategy is elaborated through charts beginning on page 41, by designated audience. For example, an objective for pregnant women is to increase the number who would recommend misoprostol to a relative or friend to prevent excessive bleeding after childbirth. Message positioning: "Knowledgeable mothers who deliver at home ask for misoprostol so they can live to raise their children." Key promise: "Taking misoprostol immediately after childbirth can prevent excessive bleeding and could save your life. Saving your own life is the best way to help your baby live and be healthy." A key message: "If you have shivering after taking misoprostol, cover yourself with a blanket."

Many approaches, activities, and interventions are charted beginning on page 52 and include the following categories, with an example for each:

• Mass Media, for example: for print media, develop/adapt take home brochures/leaflets on misoprostol (including where to get it), stickers to remind women when to take misoprostol, posters.
• Clinic‐Based Services, for example: develop posters for awareness, teaching, and reminding, and develop safe birth video for clinic waiting room.
• Community‐Based Services, Outreach, and Community Approach, for example: for CHWs, develop and produce radio distance learning programme on safe birth, including misoprostol for PPH, for community workers that model positive behaviors and relationships with communities and referral clinics.
• Structural, for example: to address policies and guidelines, develop a twitter feed or other social media on international, national, and local progress toward making misoprostol available at community level, local impact, studies/reports published, implementation tips, and other relevant information.

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 providers trained to use misoprostol for PPH or number of individual education/counseling sessions held with men/gatekeepers.

The foundational guidance section: Materials associated with the I-Kit, like this commodity-specific strategy document for misoprostol, 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 magnesium sulfate). 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"