The Positive Deviance Approach: Challenges and Opportunities for the Future

Abstract

The positive deviance (PD) approach offers an alternative to needs-based approaches for development. The “traditional” application of the PD approach for childhood malnutrition involves studying children who grow well despite adversity, identifying uncommon, model practices among PD families, and designing an intervention to transfer these behaviors to the mothers of malnourished children. A common intervention for child malnutrition, the so-called “hearth,” brings mothers together to practice new feeding and caring behaviors under the encouragement of a village volunteer. Hearths probably work because they modify unmeasured behavioral determinants and unmonitored behaviors, which, in turn, result in better child growth. Some health outcomes require a better understanding of behavioral determinants and are not best served by hearth-like facilitated group skills-building. We propose testing “booster PD inquiries” during implementation to confirm behavioral determinants and efficiently focus interventions. We share early experience with the PD approach for HIV/AIDS and food security. The attributable benefit of the PD approach within a program has not been quantified, but we suspect that it is a catalyst that accelerates change through the processes of community attention getting, awareness raising, problem-solving, motivating for behavior change, advocacy, and actual adopting new behaviors. Program-learners should consider identifying and explicitly attempting to modify the determinants of critical behavior(s), even if the desired outcome is a change in health status that depends on multiple behaviors; measure and maintain program quality, especially at scale; and creatively expand and test additional roles for PD within a given program.

Variation in Formula Supplementation of Breastfed Newborn Infants in New York Hospitals

“…[45][46][47] Research into these exemplar hospitals by using community-based participatory methodology and/or a positive deviance approach might provide insight into important but hitherto undocumented maternal behaviors, family characteristics, staff or community attitudes, and cultural determinants (beyond the recognized hospital policies and practices and socioeconomic, infant, and maternal factors) that are contributing to their better breastfeeding outcomes. 48,49 Recent community-based efforts, sensitive to the cultural determinants and focused on changing social norms, are proving to be successful in improving breastfeeding rates, particularly in disadvantaged communities. 50,51 The finding that formula supplementation is much lower (30%-40%) at level 1 hospitals compared with level 2, level 3, or RPC hospitals is striking.…”

HIV and the Ramifications for Food Security and Child Health in Affected Communities

“…With the improbability of new external resources for care being brought to bare on already destitute communities, a 'positive deviance' (PD) approach to care has been raised [105][106][107] and explored. A PD inquiry identifies uncommon, model caretaker and/or household behaviors that result in positive child outcomes in a community [106] .…”

“…The specific and express merger of caring and caregiver competence to the HIV/AIDS epidemic are beginning to appear [105,107,108] . Lapping et al [105] share early experience with the PD approach for the topic of this review (i.e.…”

Editorial

“…Promoting a positively deviant lifestyle, beyond being a catchy slogan, is a good start: for example, providing practical advice to parents on how to promote nutritious eating habits in their children 5 , or sponsoring "hearths" to encourage good feeding practices among mothers 6 . But we might also hold onto a belief in a trickle-down effect for the food environment: policies that promote a healthy food environment on a larger level will make it easier for parents to promote a healthy food environment in the home.…”