Identification of Model Newborn Care Practices through a Positive Deviance Inquiry to Guide Behavior-Change Interventions in Haripur, Pakistan

Abstract

A positive deviance (PD) inquiry identifies uncommon, model practices that a follow-on program can spread. PD has been used to rehabilitate malnourished children, but not for improving newborn health. Save the Children Federation/US (SC) conducted newborn PD cycles in communities (total population about 5,000 each) in two project areas in Haripur District, Pakistan among Afghan refugees and among local Pakistanis. Each PD cycle included planning, community orientation, situation analysis, PD inquiries, and community feedback with action planning. PD inquiries were in-depth interviews to identify uncommon behaviors among surviving asphyxiated newborns, thriving low birthweight babies, surviving newborns who had danger signs, and normal newborns. The Afghan caregivers showed better use of services and some household practices than their Pakistani counterparts, consistent with duration of SC presence (15 years vs. 18 months, respectively). The practices of both groups for clean delivery, thermal control, immediate and exclusive breastfeeding, and fathers' involvement were weak. But PD individuals, families, and/or birth attendants modeled good maternal care and immediate, routine and special newborn care. Communities enthusiastically committed to change behavior and form neighborhood support groups for better newborn care, including a demand for hygienic delivery. The PD approach for the newborn is more complex than for child nutrition. Yet this pilot-test proposed a conceptual framework for household newborn care, suggested tools and methods for information gathering, identified PDs in two settings of different risk, galvanized SC staff to the potential of the approach, mobilized communities for better newborn health, and drafted a newborn PD training curricula.

A systematic review of newborn health interventions in humanitarian settings

“…The controlled pre-post studies were considered medium-quality 47 57 and high-quality, 29 despite two not accounting for confounders in the design or analysis. The qualitative studies were medium-quality 38 62 and high-quality 28 56 61 despite only one considering their own role in creating potential bias.…”

“…These positive deviance findings were shared but there was no assessment of changed behaviour following this exercise. 38 …”

Effectiveness of Positive Deviance, an Asset-Based Behavior Change Approach, to Improve Knowledge, Attitudes, and Practices Regarding Dengue in Low-Income Communities (Slums) of Islamabad, Pakistan: A Mixed-Method Study

“…The successful nutrition experience was later replicated in over 40 countries all over the world [25][26][27][28]. The PD approach has recently been employed on a variety of public health issues which include maternal and newborn health, diabetes care, and malaria prevention and control [29][30][31].…”

Unearthing local forms of child protection: Positive deviance and abduction in Ethiopia

“…In traditional programs, typically the monitoring and evaluation that occurs at the end of the project expects clear and measurable results. In PD, often immediate results are less emphasized because the action learning process starts the behavior change that “continues to play out, but involves shifts in internal determinants (knowledge, recognition that norms may not be healthy) as well as decisions to do things differently next time and to tell others to do likewise” (Marsh et al., 2002, p. 112). Monique Sternin explained to me that these shifts occur over time because PD is “latent, it’s a ripple effect with undetermined consequences.…”