Part 3: The Power of Positive Deviance

Part 3: The Power of Positive Deviance

1. The most efficient way to improve health is to use locally available, sustainable, and effective approaaches

   • In the 1970s policy developers tested the concept that public health interventions could be designed around uncommon, beneficial health behaviours that some community members already practised.

2. How does positive deviance work?

   • an uncommon practice that confers advantage to the people who practise it compared with the rest of the community.
     • affordable, acceptable, and sustainable because they are already practised by at risk people,
       • they do not conflict with local culture
         • they work
           • takes advantage of the community’s existing assets or strengths

3. The positive deviance approach involves partnering with communities to:

   • ** Develop case definitions ** Identify four to six people who have achieved an unexpected good outcome despite high risk ** Interview and observe these people to discover uncommon behaviours or enabling factors that could explain the good outcome ** Analyse the findings to confirm that the behaviours are uncommon and accessible to those who need to adopt them ** Design behaviour change activities to encourage community adoption of the new behaviours ** Monitor implementation and evaluate the results.

4. Positive deviance Positive deviance is the observation that in most settings a few at risk individuals follow uncommon, beneficial practices and consequently experience better outcomes than their neighbours who share similar risks

5. The approach facilitates three important processes: social mobilisation, information gathering to craft interventions, and behaviour change.

   • Social mobilisation—Participants have said that they are motivated by learning that they are doing something right and that a successful solution to their problem already exists within their community, instead of receiving criticism for their inadequacies.
     • Information gathering—In-depth inquiries, community norms studies, and community vetting are used to identify the transferable behaviours and enabling factors that are likely to account for the good outcome of the identified individual or family
       • Behaviour change—Some behaviours are so afford- able and accessible (such as a clean blade to cut a new- born baby’s cord) that enthusiasm for immediate adoption ripples through the community, even before the formal intervention starts. Other behaviours change more slowly through interventions that encourage new behaviours.

6. Advantages

   • The success of the approach rests on its ability to mobilise the community to identify role models within its midst who use uncommon, but demonstrably successful, strategies to tackle common problems.
     • Firstly, it serves equity, in that it is informed by the wisdom of disadvantaged “doers” of healthy behaviours and provides solutions accessible to those with similar socioeconomic constraints.
       • Secondly, it introduces a generic approach for local problem solving.
         • Thirdly, positive deviance enhances local research capacity for controlling disease in relevant, affordable, sustainable ways.
           • Lastly, and perhaps most importantly, the approach reveals at least partial solutions today to challenges rather than waiting for long term develop- ment.

7. Disadvantages

   • It requires discovering uncommon positive examples,
     • Rare examples are costly to identify, and common examples fail to stimu- late new thinking.
       • By extension, the approach is inappropriate for settings where positive behaviour is impossible due to non-availability of relevant services or foods.
         • Scale-up requires many people with skills in community mobilisation, participatory research, and positive deviance, which may limit uptake.

8. Future challenges?

   • The potential role for positive deviance is vast.
   • We believe that positive deviance is a valuable tool that should be part of international health policy makers’ toolbox for the 21st century.