The Power of Positive Deviants

A promising new tactic for changing communities from the inside

A version of this article was originally published November 29, 2009 in The Boston Globe

In 2001, Muhammad Shafique arrived in the Haripur District in Pakistan, a region known for its traditionalism and wariness of outsiders. As part of a team from Save the Children, Shafique was seeking to improve outcomes for newborns. Immediate breast-feeding is recommended for babies, but infants in the region were typically fed ghutti, an herbal mixture, before nursing. By tradition, the umbilical cord was cut with a bamboo stick, which put babies at risk for tetanus. And fathers were seldom involved in pregnancy and delivery. These and other factors had contributed to high rates of infant illness and mortality.

In similar places, aid groups had tried to tackle this problem by training midwives or distributing information to mothers at health clinics. But Shafique and his colleagues took another approach. They talked at length with the villagers, and soon discovered that these customs, while prevalent, were not universal. A few mothers breast-fed their newborns before giving them ghutti, calling their milk “the first gift of God for my child.” One father had bought a clean razor blade, which he asked the attendant to use instead of a bamboo stick to cut the cord. Several men had taken steps to provide their pregnant wives with extra food and had saved money in case of emergency.

In general, the children of these parents were flourishing. At a series of well-attended meetings, the Save the Children staffers shared these success stories, describing how unorthodox practices within the community were producing healthy babies. Others began to adopt these strategies. Six months after Save the Children left, men from the villages reported that no newborns had died since the group’s departure.

According to Shafique, the husbands said to themselves, “If he can do it, why can’t I?…The solution to the problem lies within the community. There are people who have the same resources, but they’re doing something differently.”

This initiative is an example of “positive deviance,” an approach to behavioral and social change. Instead of imposing solutions from without, the method identifies outliers in a community who, despite having no special advantages, are doing exceptionally well. By respecting local ingenuity, proponents say, the approach galvanizes community members and is often more effective and sustainable than imported blueprints.

The concept was first applied to reduce malnutrition in the early 1990s in Vietnam. Since then, programs in developing countries have used it widely for the same purpose. But more recently, it has been invoked in a broader range of contexts, beyond public health, and in rich countries, including the United States. Organizations are now turning to positive deviance to address a dizzying variety of challenges, from female genital cutting and human trafficking in Asia and Africa, to school dropouts and diabetes in the United States. The business world has also begun to take an interest in using the tactic to maximize performance.

In New England, Maine Medical Center has launched an initiative to target Methicillin-resistant Staphylococcus aureus, known as MRSA, a dangerous hospital-acquired infection. Waterbury Hospital in Connecticut, which used the approach to enhance communication with patients regarding medication, has now begun a positive deviance inquiry into end-of-life care. And the Massachusetts Coalition for the Prevention of Medical Errors just received federal funding to fight hospital-acquired infections with the method.

Last year, the Rockefeller Foundation funded a new program at Tufts University’s Friedman School of Nutrition Science and Policy, the Positive Deviance Initiative, to advance the idea. Monique Sternin, who helped pioneer the approach in Vietnam, runs the program, which documents projects and offers training and mentoring. It is also organizing a conference to be held in Bali in January.

In a culture that distrusts self-appointed experts and frowns on imperialism, while lauding community and democracy, positive deviance is a powerful concept. But the approach has important limitations. It can only be used to change behavior – not, for example, as a substitute for government aid or vaccines. It requires a high degree of motivation and commitment. And it is by definition restricted to what is already being done; it excludes brilliant strategies that nobody has tried.

While positive deviance has yielded impressive results in international public health and in American hospitals, it may be too soon to assess how well it can work in other scenarios. Proponents say it’s easiest to implement in cohesive communities, which are relatively uncommon in the United States. And most of the cutting-edge experiments here are too new to be evaluated. Even much of the available data should be taken with a grain of salt. Positive deviance is often employed in conjunction with other improvement efforts, making its impact difficult to isolate.

But the core idea – relying on local wisdom, capitalizing on the hidden genius of ordinary people – is deeply appealing. Unlike a lab experiment or “best practices” transferred from elsewhere, the strategies have already been shown to work in context. As it takes root, positive deviance could instill a new way of looking at hard problems.

In 1991, Sternin was sitting in the home of a poor Vietnamese rice farmer when she spotted a crab. She and her husband, Jerry, were working with Save the Children to combat malnutrition in rural Vietnam. (Jerry died in 2008.) Malnutrition was widespread, and attempts to solve the problem, such as importing food, had proved unsustainable or insufficient.

The idea of examining thriving outliers had been floating around in the nutrition literature since the 1960s. A 1990 book by Tufts professor Marian Zeitlin, “Positive Deviance in Child Nutrition,” expanded on the notion. Inspired by this book, the Sternins decided to apply its insights in practice. In Vietnam, they would identify children who had somehow managed to be well nourished. Then they would try to figure out what those families were doing right.

During this process, which Monique Sternin refers to as a “treasure hunt,” the Sternins went to the families’ homes, looked closely for clues, and asked many questions. One home did not even have full walls, but it housed healthy children. Seeing a crab crawling out of a basket, Sternin said, as she recently recalled, “Oh! What about that? Do you by any chance feed your children crab?” Reluctantly, the father admitted that yes, he scavenged for shrimp and crabs while he was farming in the rice paddies.

“These are protein bombs,” says Dirk Schroeder, a professor of global health at Emory University who later conducted a study showing the project’s effectiveness. “When parents were first asked, they were really embarrassed about it. It was considered a low-class food, rather than buying Nestle baby food in a jar. In fact, it was a perfect thing to do.”

This Vietnamese father was one of the “positive deviants” identified by the Sternins. Other strategies emerged too: distributing the available food into more portions; keeping chickens outdoors, which is more hygienic. Once these behaviors were discovered, the outliers shared them with their neighbors. They all ate together at the homes of the positive deviants. “As the price of admission you would have to bring shrimp,” Sternin says. The community developed its own system for weighing and monitoring the children. Based on encouraging early results, this pilot project was expanded to other villages.

When the two-year intervention ended, rates of malnutrition had declined substantially. One evaluation found that in four of the communities, severe malnutrition had dropped from 23 percent to 6 percent. The change was durable: When Schroeder and his colleagues conducted a study three years later, they found that children in participating villages were doing better than their counterparts in a similar village. Strikingly, younger children, who were born after the initiative concluded, enjoyed an even more pronounced edge than their older siblings.

According to one of the Sternins’ favorite mottos, “it’s easier to act your way into a new way of thinking than to think your way into a new way of acting.” Facilitators try to introduce new behaviors instead of trying to change minds. Once people see the value of these strategies, they revise their views. Often, the positive deviants are unaware of the benefits of their habits, and are, in fact, ashamed of them because they violate cultural norms. The approach also works best, ironically, with the most formidable problems, perhaps after other solutions have failed, because the community must be highly motivated to solve the problem, Sternin says.

After the success in Vietnam, the approach to malnutrition quickly attracted the attention of USAID, UNICEF, and many nongovernmental organizations. It has been used in Guinea, Mozambique, Haiti, Bolivia, India, and Tajikistan, among other countries. Intrigued by the results, the Sternins and other groups began to appropriate the idea for different ends. They have reported progress in preventing female circumcision in Egypt, lowering elementary school dropout rates in Argentina, and reintegrating girls who had been abducted by rebel forces in Uganda.

In the United States, the most celebrated triumph has come in the fight against MRSA. The bacteria cling to surfaces and can live without a human host for days. MRSA kills approximately 19,000 people annually and sickens many more, and the vast majority of victims contract the disease as a result of their stays in medical facilities. In a hospital, everyone – doctors, nurses, patient transporters, and maintenance workers – plays a role in contributing to (or stopping) its spread.

Previous tactics to reduce MRSA rates consisted of educational campaigns, posters, pamphlets, and lectures. A VA hospital in Pittsburgh tried a model based on Toyota’s methods of maximizing efficiency. In this system, designated problem-solvers receive intensive training and other staffers consult them. Dr. Jon Lloyd, then the medical adviser for the Pittsburgh Regional Healthcare Initiative, recalls that these efforts achieved gains, but progress was slow and the training was costly.

In 2004, Lloyd came across an article about the Sternins in Fast Company and instantly thought to borrow their brainchild. In 2006, pilot projects were launched at six American hospitals, including Billings Clinic in Montana and Albert Einstein Medical Center in Philadelphia. By 2008, all of these hospitals had demonstrated remarkable success. According to data from the Plexus Institute, a nonprofit that collaborated on the initiative, reduction rates ranged from 32 percent to 83 percent. Since then, about 30 more US hospitals have introduced positive deviance inquiries.

In places known for their rigid pecking orders, these interventions often disrupt long-established dynamics: Managers listen and ask questions, and the support staff generate many of the answers. At Albert Einstein, for example, a patient transporter named Jasper Palmer had a technique for removing his gown, balling it up into a small package, and stuffing it inside his inverted gloves for disposal. A highly effective way of thwarting germs, it has since been deemed the Palmer method and widely adopted. The hierarchies reportedly lessened their hold in other ways, too: Nurses, for instance, began to feel more comfortable reminding doctors to wash their hands.

“They’ll walk up and say, ‘Here, let me help you, let me squirt some Purell on your hands’,” says Lloyd, who is now a senior clinical adviser at the Plexus Institute. The efficacy of positive deviance, he believes, is “related to the issue of ownership. The solutions tend to last longer because it’s just human nature that we don’t turn our backs on what we create.”

While some of the solutions are ingenious, many are actually quite obvious, but for whatever reason they were previously ignored. It’s the process of engagement and mobilization that seems to enable people to change their behavior. The same principles pertain to other areas, such as education. Starting in December 2008, Asbury Park High School in New Jersey has been working to ferret out positive deviants among teachers and students with the goal of improving academic performance. They discovered that a few teachers greet students at the door to foster a friendly classroom atmosphere and build relationships. Some students, they found, had strong adult role models in their lives, and they started a mentoring program to replicate that asset for others.

It’s too early to say whether the changes will boost test scores, but Christine DeMarsico, a teacher at the school, says the undertaking has already had beneficial effects on the school community.

“Through the process, you’re having dialogue,” she says. Typically, by contrast, “Teachers are pretty much islands.”

At bottom, positive deviance amounts to simple common sense. But that may be what’s most revelatory about it. Instead of throwing money at a problem or devising grand solutions, it urges us to look a little more closely at what’s already happening. As the approach starts to be used increasingly in the United States – especially in health care, but also in education, to reduce gang violence, and to promote exercise – many creative solutions will no doubt emerge. And more unwitting experts, like Jasper Palmer, will get their due. “Here I am,” Palmer says, “becoming a big star.”

Source: The Boston Globe

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