The power of positive devianceBMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7475.1177 (Published 11 November 2004) Cite this as: BMJ 2004;329:1177
Table A Illustrative Positive Deviance Behaviors and Enablers
Positive deviant behaviours
Reduce childhood malnutrition
Higher consumption of fish, crab, shrimps, snails, breastmilk, clams, beans, peanuts
Boiling drinking water; 5-6 meals/day; active feeding; mosquito bednet; full immunisation; daily bath
Early care seeking for illness
Higher consumption of sugar, flour, oil, wild vegetables.
Exclusive breastfeeding; intention to breastfeed for 2 years; increased feeding during illness; active feeding; ≥3 meals/day
Greater paternal involvement; supportive family; early care seeking for illness
Improve pregnancy weight gain and birth weight
Higher consumption of meats and vegetables
More antenatal visits; more daytime rest
Care-seeking to decrease painful urination or discolored urine
Improve household maternal and newborn care
Saving funds and obtaining transport for emergency; tetanus vaccination
Assuring clean delivery surface, attendant’s hands, and blade
Receiving blanket; leaving cord stump undressed
Danger sign recognition with prompt care-seeking
Reduce girl trafficking
Fear of losing contact with daughter, of disease, or of a bad experience; shame from sex work or violating religious tenets
Planting multiple crops (beyond coffee); reducing family expenses so daughter does not have to work outside village; establishing daughter in small local business
Discussing risks of entertainment industry work; identifying and avoiding neighborhood brokers; monitoring daughter’s friends; reiterating family values; investigating out-of-village work possibilities; requiring daughter to report home regularly
Table B Evaluation of Positive Deviance-Informed Integrated Nutrition Projects in Vietnam: Selected Results
Design and study setting
Retrospective analysis of project weights (n=1893); Thanh Hoa Province, 1993-1995
Nutritional status of all children improved (d-WAZ +0.36, from - 2.14 to - 1.78, P<0.001). Nutritional status of severely malnourished children (<−3 Z) improved dramatically (d-WAZ +1.44, from -3.58 to -2.14, p<0.001)5
Comparison of former project children and their younger siblings with age and sex matched sibling pairs in non-intervention commune (n=71), three years after project stopped; Thanh Hoa Province, 1998, 1999
Older former program children were somewhat better nourished than their non-program counterparts; and their younger siblings, born after the intervention ceased, were much better nourished than their non-program counterparts (WAZ -1.82 vs. -2.45, P=0.007; WHZ -0.71 vs. -1.45, p<0.001).16 Former program mothers fed their younger children more than non-program mothers (2.9 vs. 2.2 meals/day, p<0.001).
Prospective, randomised, evaluation of the effectiveness of a positive deviance informed integrated nutrition project. Weight measured monthly for first 7 months and at 12 months. (n=240); Phu Tho Province, 1999-2000
Younger (<15 months of age) malnourished (WAZ <-2) children at baseline (n=35) had less deterioration than comparison children (d-WAZ in first four months -0.05 vs. -0.20, p=0.02; and d-HAZ over 12 months -0.10 vs. -0.23, p=0.01).18 Intervention children consumed intervention-promoted foods more frequently (PD food/day 4.1 vs. 3.6, p<0.05), ate more food (410 vs. 340g, p<0.01), consumed more energy 827 vs. 718 kcal/d, p<0.05), and were more likely to meet their daily energy requirements (49 vs. 35%, p<0.01) than comparison children.w14 Intervention children experienced less respiratory illness than comparison children (adjusted odds ratio 0.5, p=0.001).19
*d-HAZ= change in height-for-age Z score; d-WAZ=change in weight-for-age Z score; PD=positive deviant
- National Staff Development Council, http://www.nsdc.org/connect/projects/positivedeviance.cfm and http://www.nsdc.org/library/publications/results/res4-02spar.cfm, 2004.
- Institute for Women’s Leadership, http://www.womensleadership.com/alumnaesubpage/coachtip_8_1_01.html, 2004
- Stella Babalola, Claudia Vondrasek, Jane Brown, Factors Affecting Sexual Practices in West Africa – A Positive Deviant Approach, APHA, Atlanta, October 21-35, 2001 (JHU, CCP).
- Promoting Women in Development, http://www.cedpa.org/publications/PROWID/AFRICA/Egypt1_rib.pdf, 2004
- Macklis RM, Successful Patient Safety Initiatives: Driven from Within, Group Practice Journal, November/December 2001: 1-5.
- Dorsey D. Positive Deviant. Fast Company Magazine 2000;41: 284.
- R Mathews, W. Wacker, The Deviant’s Advantage – How Fringe Ideas Create Mass Markets, New York: Crown Business, 2002.
- Sternin J, Positive Deviance: A New Paradigm for Addressing Today’s Problems Today, Journal of Corporate Citizenship, Issue 5, Spring 2002, 57-62.
- Evans T, Whitehead M, Diderichsen F, Bhuiya A, Wirth M. Challenging inequities in health: from ethics to action. Oxford: Oxford University Press; 2001.
- Sternin M, Sternin J, Marsh DR, Field Guide: Designing a Community-Based Nutrition Education & Rehabilitation Program Using the "Positive Deviance" Approach, Westport: Save the Children and BASICS, December, 1998.
- Marsh, DR, Monitoring and Evaluation, p 157-187, chapter in Nutrition Working Group, Child Survival and Collaborations and Resources Group (CORE), Positive Deviance/Hearth: A Resource Guide of Sustainably Rehabilitating Malnourished Children, Washington, D.C.: December 2002.
- PD/Hearth – Finding Community-based Solutions to Malnutrition, Arlington: BASICS II and Save the Children, 2001.
- Lapping K, Marsh DR, Rosenbaum J, et al., The positive deviance approach: Challenges and opportunities for the future, Food and Nutrition Bulletin 2002;23 (4 suppl):130-137.
- Pachón H, Schroeder DG, Marsh DR, Dearden KA, Ha TT, Lang TT, Effect of an integrated child nutrition intervention on the dietary intake of children less than 24 mo in rural north Vietnam, Food and Nutrition Bulletin, 2002;23 (4 suppl):62-69.
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