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Notes from the Field> P-Process Withstands the Test of Time and Continues to Evolve and Guide Design of Strategic Health Communication Programs
What makes someone an expert in his or her chosen profession? Often, expertise in a given discipline or profession comes down to knowing the right systematic diagnostic and process tools or frameworks to use to guide analysis and decision-making. This knowledge is what distinguishes physicians from non-physicians or engineers from non-engineers.
In the area of communication, designing a strategic health communication program to encourage healthier behaviors can be a daunting task without the availability of good tools, processes or frameworks. One such tool is the P-Process, which has withstood the test of time and evolved over the past 20 years to become a benchmark and major standard in the design, implementation, monitoring and evaluation of health communication programs worldwide. The P-Process has been adapted and translated in at least six major languages and 30 country versions and is now taught in hundreds of training programs and at premier universities worldwide. It is the heart of an interactive computer-based training and planning software called SCOPE (Strategic Communication Planning and Evaluation) used to train health communication professionals. As the field of health communication has evolved, so has the P-Process. But the P-Process remains a simple, easy-to-follow guide that leads program designers to implement successful projects with positive health outcomes.
Communicating Health – Saving Lives
What exactly is the P-Process? It is a tool that guides users step-by-step through the process of developing strategic communication programs. Using communication strategically does not mean calling in communication expertise only when a project starts to falter or fail. To use a popular analogy, strategic programs use communication as an integral component, not as a "spare wheel" but a "steering wheel" that can help position an intervention, a product, a service or a health behavior. The P-Process helps communication professionals avoid the recurring trap of being forced oftentimes by political imperatives into false dichotomies: radio or TV, community mobilization or mass media, interpersonal communication or group communication, behavioral or dialogue outcomes?
A communication professional can use the P-Process the way a carpenter uses tools. Rather than arguing about whether a hammer is better than a chisel or a saw better than an axe, a good carpenter knows each tool is effective for a different purpose. A communication professional learns to avoid arguing the benefits of interpersonal communication over mass media or whether radio is better than group discussion, because each effort has different strengths. The choice depends on the program's objectives and, often, a combination of different approaches or tools are used.
Today's health communication recognizes the multiple levels that affect health: the socio-political environment, health service delivery systems, community networks, husbands and wives, family members, and individual behavior. The P-Process recognizes these levels too as it leads users through program development. Communication experts with the USAID-funded Population Communication Services (PCS) project developed the original P-Process more than 20 years ago. The new USAID-supported Health Communication Partnership (HCP) – a team of five leading institutions led by Johns Hopkins University Bloomberg School of Public Health/ Center for Communication Programs (CCP) – this year reviewed and revised the P-Process to better reflect the evolution of health communication. Along with CCP, HCP includes the Academy for Educational Development, Save the Children, the International HIV/AIDS Alliance, and Tulane University's School of Public Health and Tropical Medicine.
After USAID awarded HCP, its senior management developed a comprehensive framework called the Pathways Model to respond to strategic objectives in population and family planning, maternal health, child survival, and HIV/AIDS and other infectious diseases (such as TB and malaria). Within HCP programs, the Pathways Model is geared toward broader change across three domains: 1) the social political environment, 2) service delivery systems, and 3) the community and individual. Thus, the revised P-Process now includes and has made salient a number of new features to correspond with the crosscutting concepts inherent in – and the thinking behind – the Pathways Model.
The international public health community may associate the original P-Process with PCS and population and family planning communication, which, given the context in which it was first developed, paid more attention to informed choice especially at the individual and couple levels rather than to collective behavior. Over the years, as the P-Process was used increasingly to address other health issues, the tool was updated to put more emphasis on the role of social and community norms, political advocacy, community participation, and group and collective self-efficacy. The New P-Process not only represents the evolution of health communication but also reflects the major elements of the new Pathways to communication and social change model.
The New P-Process
The New P-Process leads communication professionals through an interlocking series of steps. The five steps are now 1) Analysis, 2) Strategic Design, 3) Development and Testing, 4) Implementation and Monitoring, and 5) Evaluation and Replanning (Figure 1). Major changes include highlighting Participation and Capacity Strengthening as an integral component of each step in the process. These two concepts appear in the revised visual of the P-Process, whereas in the previous version it was only included in the text as principles that need to be observed in designing and implementing communication programs.
The new P-Process also expands the first step – Analysis – by dividing it into a situation analysis and a communication/audience analysis. The situation analysis focuses more on health status or the epidemiology of the particular health problem or disease. The communication/audience analysis focuses more on the analysis of the communication systems, and their strengths, weaknesses and opportunities, as well as the critical component of understanding the audience.
Another change occurs in the actual design of the "P." The original P-Process completed the circle of the "P" by bringing Step Five – Impact Evaluation – back to the design stage. The revised version allows flexibility for communication professionals to use impact evaluation results to return to either the Design or Analysis stage, depending on what the results show. Users go back to the Analysis stage if the program resulted in significantly altered health status and behavior thus changing the original assumptions, or back to the Design stage if the assumptions have not changed significantly.
Step Four – Implementation and Monitoring – is maximized in the design to indicate the relative significance of this step in any program. And while the previous version of the P-Process linked management to implementation and monitoring in Step Four, the revised version no longer includes management in the fourth step because it is central to and inferred in all steps of the communication programming process.
Global Impact
Health communication professionals around the globe will find the new P-Process a valuable tool to help them formulate a clearly designed strategic program leading to healthier behaviors. Health communication professionals have used the P-Process principles in designing, implementing, and evaluating more than 500 country-based programs in the last decade, many of which demonstrated a measurable positive impact. The P-Process has withstood the test of time because of its flexibility and its simplicity. HCP, its numerous partner organizations on the ground in developing countries, thousands of health professionals who have been trained with the P-Process, and universities who have adopted the tool in their curricula will continue to use this flexible tool in developing programs that make a difference and save lives.
The P-Process in Action
In Indonesia, the P-Process was used to design several successful communication interventions. Among them was the Blue Circle program, which successfully shifted the provision of family planning services from the government to the private sector; the Suami Siaga safe motherhood program, which emphasized the role of men and husbands in saving mothers' lives; and a World Bank-funded program to protect coral reefs known as Sekarang. Indonesia's International Training Program managed by the National Family Planning Coordinating Board, uses the P-Process in all their programs funded by JICA, AusAID, and the United Nations Population Fund (UNFPA). Major non-governmental organizations and the departments of communication of key universities also have incorporated the P-Process into their teaching curricula.
For more information, visit www.jhuccp.org
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