1 The most efficient way to improve health is to use
locally available, sustainable, and effective
1.1 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?
2.1 an uncommon practice that confers
advantage to the people who practise it
compared with the rest of the
2.1.1 affordable, acceptable, and
sustainable because they are
already practised by at risk people,
22.214.171.124 they do not conflict with local culture
126.96.36.199.1 they work
188.8.131.52.1.1 takes advantage of the
community’s existing assets or
3 The positive deviance
approach involves partnering
with communities to:
3.1 ** 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
5.1 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.
5.1.1 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
184.108.40.206 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
6.1 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
6.1.1 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.
220.127.116.11 Secondly, it introduces a generic
approach for local problem solving.
18.104.22.168.1 Thirdly, positive deviance enhances local
research capacity for controlling disease in
relevant, affordable, sustainable ways.
22.214.171.124.1.1 Lastly, and perhaps most importantly, the
approach reveals at least partial solutions
today to challenges rather than waiting for long
term develop- ment.
7.1 It requires discovering uncommon positive examples,
7.1.1 Rare examples are costly to identify, and common
examples fail to stimu- late new thinking.
126.96.36.199 By extension, the approach is inappropriate for
settings where positive behaviour is impossible due to
non-availability of relevant services or foods.
188.8.131.52.1 Scale-up requires many people with skills in
community mobilisation, participatory research, and
positive deviance, which may limit uptake.
8 Future challenges?
8.1 The potential role for positive deviance is vast.
8.2 We believe that positive deviance is a valuable tool
that should be part of international health policy
makers’ toolbox for the 21st century.