The power of positive deviance
http://www.100md.com
《英国医生杂志》
1 Save the Children Federation (USA), Westport, Connecticut, USA, 2 Rollins School of Public Health, Emory University, Atlanta, Georgia, USA, 3 Brigham Young University, Provo, Utah, USA, 4 Positive Deviance Initiative, Tufts University, Medford, Massachusetts, USA, 5 Cambridge, Massachusetts, USA
Correspondence to: D R Marsh, 31 Wildflower Drive, Amherst, Massachusetts, USA dmarsh@savechildren.org
Identifying individuals with better outcome than their peers (positive deviance) and enabling communities to adopt the behaviours that explain the improved outcome are powerful methods of producing change
Introduction
Through a series of increasingly rigorous studies, Save the Children has evaluated the effectiveness of the positive deviance approach to reduce childhood malnutrition in Vietnam (table B on bmj.com). In the early 1990s, Sternin et al showed a 74% reduction in severe malnutrition among children younger than 3 years old who participated in positive deviance programmes.5 6 Mackintosh et al revisited some of these children in 1998, three years after the intervention stopped.16 They found that these children, and especially their younger siblings born after completion of the programme, had better nutritional status than age and sex matched children who did not live in intervention communities. Semistructured interviews with mothers strongly suggested that the superior nutritional status of the younger siblings was due to better care from a younger age—improved practices that their mothers had learnt during the programme.
The strongly positive and consistent results from these programmatic evaluations suggested the approach was successful, but their relatively weak study designs limited our ability to attribute causality to the interventions. We therefore conducted a large, randomised, prospective trial of the approach in 12 communes in northern Vietnam.17 Save the Children conducted monthly measurements on 240 malnourished children (120 in the intervention and non-intervention communes) for six months and then at 12 months. Compared with children in randomly selected non-intervention communes, the intervention children grew better,18 ate and breastfed more often, ate larger portions, consumed more energy,17 experienced less respiratory infection,19 and had mothers who were more likely to confidently share new knowledge about child care and feeding with their neighbours.20 Many effects, such as improved diet and decreased morbidity, occurred among all children, even those not sufficiently malnourished to attend the group learning activities. This finding is consistent with behaviour change through mothers sharing new behaviours with one another.
Use of the positive deviance approach outside nutrition and child survival is limited but growing. It has been used to promote condom use among commercial sex workers in Georgia and Indonesia, improve family planning methods in Guatemala, and improve outcome of pregnancy in Egypt.13 21 It has also been used in efforts to improve educational outcomes in the United Statesw1 to develop a "best practices" tool in Argentina,w2 and in a university donor partnership to identify factors influencing sexual practices in West Africa.w3 The Centre for Development and Population Activities used the positive deviance approach to advocate against female genital cutting in Egypt at the community level and nationally through television using the actual words of the positive deviance individuals,w4 and the Government of Egypt will apply the approach in 60 villages. The US healthcare and business communities are beginning to recognise the power of positive deviance.w5-w8
Advantages and disadvantages
The potential role for positive deviance is vast. For example, which rural Kenyan families optimally use insecticide impregnated bednets, and how can they motivate their neighbours? How can South African policy makers integrate the behaviours and thinking of teenagers who practise "safe sex"? What can we learn from a poor, uninsured Latina mother who succeeds in properly managing her child's diabetes or asthma? What about other intractable, deadly impasses of our time—the Kashmir crisis, Israeli-Palestinian mayhem, or insurgency in Iraq? We believe that positive deviance is a valuable tool that should be part of international health policy makers' toolbox for the 21st century.
Further examples of the use of positive deviance and references w1-w13 are on bmj.com
Contributors and sources: DRM drafted the paper with input from all authors. JS and MS have designed and implemented positive deviance informed projects; DRM, DGS, and KAD have evaluated such projects in many countries. The information in the paper comes from publications and the authors' experiences.
Competing interest: None declared.
References
Wray JD. Can we learn from successful mothers? J Trop Pediatr Environ Child Health 1972;18: 27.
Wishik SM, Van der Vynkt S. The use of nutritional `positive deviants' to identify approaches for modification of dietary practices. Am J Pub Health 1976;66: 38-42.
Zeitlin M, Ghassemi H, Mansour M. Positive deviance in child nutrition—with emphasis on psychosocial and behavioral aspects and implications for development. Tokyo: United Nations University, 1990.
Shekar M, Habicht J-P, Latham M. Positive-negative deviant analyses to improve programme targeting and services: example from Tamil Nadu Integrated Nutrition Project. Int J Epidemiol 1992;21: 707-13.
Sternin M, Sternin J, Marsh D. Rapid, sustained childhood malnutrition alleviation through a "positive deviance" approach in rural Vietnam: preliminary findings. In: Keeley E, Burkhalter BR, Wollinka O, Bashir N, eds. The hearth nutrition model: applications in Haiti, Vietnam, and Bangladesh, Report of a Technical Meeting at World Relief Corporation, Wheaton, IL, June 19-21, 1996. Arlington: BASICS, 1997.
Sternin M, Sternin J, Marsh D. Scaling up a poverty alleviation and nutrition program in Viet Nam. In: Marchione T. Scaling up, scaling down: capacities for overcoming malnutrition in developing countries. Amsterdam: Gordon and Breach, 1999.
Bolles K, Speraw C, Berggren G, Lafontant JG. Ti Foyer (hearth) community-based nutrition activities informed by the positive deviance approach in Leogane, Haiti: A programmatic description. Food Nutr Bull 2002;23 (suppl 4): 11-17.
Food for the Hungry International. FY2001 annual report. http://gme.fhi.net/fse/R2/docs/ISA%20FY%202001%20Report.doc2004 (accessed 6 Oct 2004).
EcoYoff. Positive deviance—take 2. Living and learning newsletter 2003 Sep 21 http://ifnc.tufts.edu/pdf/ecoyoff21.pdf (accessed 11 Oct 2004).
Sethi V, Kashyap S, Seth V, Agarwal S. Encouraging appropriate infant feeding practices in slums: a positive deviance approach. Pakistan J Nutr 2003;2: 164-6.
Dearden K, Quan N, Do M, Marsh DR, Schroeder G, Pachón H, et al. What influences health behavior? Learning from caregivers of young children in Vietnam, Food Nutr Bull 2002;23(suppl 4): 119-29.
Marsh DR, Sternin M, Khadduri R, Ihsan T, Nazir R, Bari A, et al. Identification of model newborn care practices through a positive deviance inquiry to guide behavior change interventions in Haripur, Pakistan. Food Nutr Bull 2002;23(suppl 4): 109-18.
Ahrari M, Kuttab A, Khamis S, Farahat AA, Darmstadt GL, Marsh DR, et al. Socioeconomic and behavioral factors associated with successful pregnancy outcomes in upper Egypt: a positive deviance inquiry. Food Nutr Bull 2002;23: 83-8.
Berggren WL, Wray JD. Positive deviant behavior and nutrition education. Food Nutr Bull 2002;23(suppl 4): 9-10.
Marsh DR, Schroeder DG, The positive deviance approach to improve health outcomes: experience and evidence from the field: preface. Food Nutr Bull 2002;23(suppl 4): 5-8.
Mackintosh AT, Marsh DR, Schroeder DG, Sustainable positive deviant child care practices and their effects on child growth in Viet Nam. Food Nutr Bull 2002;23(suppl 4): 18-27.
Marsh DR, Pachón H, Schroeder DG, Ha TT, Dearden K, Lang TT, et al. Design of a prospective, randomized evaluation of an integrated nutrition program in rural Viet Nam. Food Nutr Bull 2002;23(suppl 4): 36-47.
Schroeder DG, Marsh DR, Ding B, Pachón H, Ha TT, Dearden KD, et al. Impact of an intervention on Vietnamese children's growth. Food Nutr Bull 2002;23(suppl 4): 53-61.
Sripaipan T, Schroeder D, Marsh DR, Pachón H, Dearden K, Ha TT, et al. Do community-based nutrition programs reduce morbidity? A case from Vietnam. Food Nutr Bull 2002;23(suppl 4): 70-7.
Hendrickson JL, Dearden KA, Pachon H, An NH, Schroeder DG, Marsh DR. Empowerment in rural Viet Nam: Exploring changes in mothers and health volunteers in the context of an integrated nutrition project, Food Nutr Bull 2002;23(suppl 4): 86-94.
Positive Deviance Initiative. Projects. www.positivedeviance.org/projects (accessed 11 Oct 2004).(David R Marsh, senior chi)
Correspondence to: D R Marsh, 31 Wildflower Drive, Amherst, Massachusetts, USA dmarsh@savechildren.org
Identifying individuals with better outcome than their peers (positive deviance) and enabling communities to adopt the behaviours that explain the improved outcome are powerful methods of producing change
Introduction
Through a series of increasingly rigorous studies, Save the Children has evaluated the effectiveness of the positive deviance approach to reduce childhood malnutrition in Vietnam (table B on bmj.com). In the early 1990s, Sternin et al showed a 74% reduction in severe malnutrition among children younger than 3 years old who participated in positive deviance programmes.5 6 Mackintosh et al revisited some of these children in 1998, three years after the intervention stopped.16 They found that these children, and especially their younger siblings born after completion of the programme, had better nutritional status than age and sex matched children who did not live in intervention communities. Semistructured interviews with mothers strongly suggested that the superior nutritional status of the younger siblings was due to better care from a younger age—improved practices that their mothers had learnt during the programme.
The strongly positive and consistent results from these programmatic evaluations suggested the approach was successful, but their relatively weak study designs limited our ability to attribute causality to the interventions. We therefore conducted a large, randomised, prospective trial of the approach in 12 communes in northern Vietnam.17 Save the Children conducted monthly measurements on 240 malnourished children (120 in the intervention and non-intervention communes) for six months and then at 12 months. Compared with children in randomly selected non-intervention communes, the intervention children grew better,18 ate and breastfed more often, ate larger portions, consumed more energy,17 experienced less respiratory infection,19 and had mothers who were more likely to confidently share new knowledge about child care and feeding with their neighbours.20 Many effects, such as improved diet and decreased morbidity, occurred among all children, even those not sufficiently malnourished to attend the group learning activities. This finding is consistent with behaviour change through mothers sharing new behaviours with one another.
Use of the positive deviance approach outside nutrition and child survival is limited but growing. It has been used to promote condom use among commercial sex workers in Georgia and Indonesia, improve family planning methods in Guatemala, and improve outcome of pregnancy in Egypt.13 21 It has also been used in efforts to improve educational outcomes in the United Statesw1 to develop a "best practices" tool in Argentina,w2 and in a university donor partnership to identify factors influencing sexual practices in West Africa.w3 The Centre for Development and Population Activities used the positive deviance approach to advocate against female genital cutting in Egypt at the community level and nationally through television using the actual words of the positive deviance individuals,w4 and the Government of Egypt will apply the approach in 60 villages. The US healthcare and business communities are beginning to recognise the power of positive deviance.w5-w8
Advantages and disadvantages
The potential role for positive deviance is vast. For example, which rural Kenyan families optimally use insecticide impregnated bednets, and how can they motivate their neighbours? How can South African policy makers integrate the behaviours and thinking of teenagers who practise "safe sex"? What can we learn from a poor, uninsured Latina mother who succeeds in properly managing her child's diabetes or asthma? What about other intractable, deadly impasses of our time—the Kashmir crisis, Israeli-Palestinian mayhem, or insurgency in Iraq? We believe that positive deviance is a valuable tool that should be part of international health policy makers' toolbox for the 21st century.
Further examples of the use of positive deviance and references w1-w13 are on bmj.com
Contributors and sources: DRM drafted the paper with input from all authors. JS and MS have designed and implemented positive deviance informed projects; DRM, DGS, and KAD have evaluated such projects in many countries. The information in the paper comes from publications and the authors' experiences.
Competing interest: None declared.
References
Wray JD. Can we learn from successful mothers? J Trop Pediatr Environ Child Health 1972;18: 27.
Wishik SM, Van der Vynkt S. The use of nutritional `positive deviants' to identify approaches for modification of dietary practices. Am J Pub Health 1976;66: 38-42.
Zeitlin M, Ghassemi H, Mansour M. Positive deviance in child nutrition—with emphasis on psychosocial and behavioral aspects and implications for development. Tokyo: United Nations University, 1990.
Shekar M, Habicht J-P, Latham M. Positive-negative deviant analyses to improve programme targeting and services: example from Tamil Nadu Integrated Nutrition Project. Int J Epidemiol 1992;21: 707-13.
Sternin M, Sternin J, Marsh D. Rapid, sustained childhood malnutrition alleviation through a "positive deviance" approach in rural Vietnam: preliminary findings. In: Keeley E, Burkhalter BR, Wollinka O, Bashir N, eds. The hearth nutrition model: applications in Haiti, Vietnam, and Bangladesh, Report of a Technical Meeting at World Relief Corporation, Wheaton, IL, June 19-21, 1996. Arlington: BASICS, 1997.
Sternin M, Sternin J, Marsh D. Scaling up a poverty alleviation and nutrition program in Viet Nam. In: Marchione T. Scaling up, scaling down: capacities for overcoming malnutrition in developing countries. Amsterdam: Gordon and Breach, 1999.
Bolles K, Speraw C, Berggren G, Lafontant JG. Ti Foyer (hearth) community-based nutrition activities informed by the positive deviance approach in Leogane, Haiti: A programmatic description. Food Nutr Bull 2002;23 (suppl 4): 11-17.
Food for the Hungry International. FY2001 annual report. http://gme.fhi.net/fse/R2/docs/ISA%20FY%202001%20Report.doc2004 (accessed 6 Oct 2004).
EcoYoff. Positive deviance—take 2. Living and learning newsletter 2003 Sep 21 http://ifnc.tufts.edu/pdf/ecoyoff21.pdf (accessed 11 Oct 2004).
Sethi V, Kashyap S, Seth V, Agarwal S. Encouraging appropriate infant feeding practices in slums: a positive deviance approach. Pakistan J Nutr 2003;2: 164-6.
Dearden K, Quan N, Do M, Marsh DR, Schroeder G, Pachón H, et al. What influences health behavior? Learning from caregivers of young children in Vietnam, Food Nutr Bull 2002;23(suppl 4): 119-29.
Marsh DR, Sternin M, Khadduri R, Ihsan T, Nazir R, Bari A, et al. Identification of model newborn care practices through a positive deviance inquiry to guide behavior change interventions in Haripur, Pakistan. Food Nutr Bull 2002;23(suppl 4): 109-18.
Ahrari M, Kuttab A, Khamis S, Farahat AA, Darmstadt GL, Marsh DR, et al. Socioeconomic and behavioral factors associated with successful pregnancy outcomes in upper Egypt: a positive deviance inquiry. Food Nutr Bull 2002;23: 83-8.
Berggren WL, Wray JD. Positive deviant behavior and nutrition education. Food Nutr Bull 2002;23(suppl 4): 9-10.
Marsh DR, Schroeder DG, The positive deviance approach to improve health outcomes: experience and evidence from the field: preface. Food Nutr Bull 2002;23(suppl 4): 5-8.
Mackintosh AT, Marsh DR, Schroeder DG, Sustainable positive deviant child care practices and their effects on child growth in Viet Nam. Food Nutr Bull 2002;23(suppl 4): 18-27.
Marsh DR, Pachón H, Schroeder DG, Ha TT, Dearden K, Lang TT, et al. Design of a prospective, randomized evaluation of an integrated nutrition program in rural Viet Nam. Food Nutr Bull 2002;23(suppl 4): 36-47.
Schroeder DG, Marsh DR, Ding B, Pachón H, Ha TT, Dearden KD, et al. Impact of an intervention on Vietnamese children's growth. Food Nutr Bull 2002;23(suppl 4): 53-61.
Sripaipan T, Schroeder D, Marsh DR, Pachón H, Dearden K, Ha TT, et al. Do community-based nutrition programs reduce morbidity? A case from Vietnam. Food Nutr Bull 2002;23(suppl 4): 70-7.
Hendrickson JL, Dearden KA, Pachon H, An NH, Schroeder DG, Marsh DR. Empowerment in rural Viet Nam: Exploring changes in mothers and health volunteers in the context of an integrated nutrition project, Food Nutr Bull 2002;23(suppl 4): 86-94.
Positive Deviance Initiative. Projects. www.positivedeviance.org/projects (accessed 11 Oct 2004).(David R Marsh, senior chi)