Positive Deviance

This week, an eight-year-old blog post from Oxfam about ‘Positive Deviance’ came to my attention about reversing a common approach to public health programmes (based on the Ladder of Intervention) and instead, changing people’s practice first, and then working backwards to the education and knowledge.

The Ladder of Intervention assumes that we start from the bottom rung – that of least intervention – and then work upwards, with each rung resulting in a greater level of intervention (and less autonomy). This process also aligns with the KAP approach; Knowledge, Attitude, Practice.

The basic premise of KAP is that, by changing knowledge, you change attitudes and practices. However, the failures in this approach are obvious: millions still smoke, overeat, and so on.

Aid on the Edge of Chaos, Ben Ramalingam

The reverse process uses something known as Positive Deviance. This approach still operates with the assumption that we know what is the best outcome for an individual or community but drops the assumption that we know how best to achieve that behaviour change.

Much in the way that Solution Focused Brief Therapy builds on existing capability within someone and their previous outliers of positive behaviour, Positive Deviance looks to the community themselves to identify positive outliers – people for whom the ‘problem’ is less pronounced or is not affecting them at all.

The next stage is to observe and evaluate what makes these people positive outliers (known as positive deviants)? What behaviours, genetics, or environmental variables have enabled these people to have more positive outcomes.

Marian Zeitlin, had been supported by the UN Children’s Fund and the (WHO) Organisation to examine the phenomenon of positive deviance: the off-the-chart performance— in health, growth, and development—of certain children in a community compared with others.

Zeitlin trialled a version of positive deviance in Bangladesh, working with BRAC, to examine diarrhoeal infection and malnutrition in infants. The approach focused on mothers’ wisdom and knowledge, especially in relation to positive deviants: Zeitlin and her colleagues used scientific behavioural trials to identify the factors that led to positive deviance, then used this knowledge in the design and roll-out of interventions.

In Vietnam, in December 1991, Jerry and Monique Sternin (Save the Children) were allowed to work in four communities with 2,000 under-three-year-olds, 63 per cent of whom were malnourished. Driven ‘more by faith than by proof’, and armed with their belief in the evolutionary principles of positive deviance, the Sternins told the heads of the major village committees that the approach was going to be about finding solutions that were already in the community, which would have to take responsibility for their identification and application.

To their considerable surprise, the villagers were very keen on the idea. They had previously experienced only short-term aid projects after which they had watched their children’s health gains deteriorate again. This sounded different and more beneficial. After the children were weighed, they were ranked according to their family’s economic status.

Volunteer groups then identified the positive deviants. Sternin remembers asking the volunteers, ‘Is it possible for a child to be very poor and still well-fed?’ and the answer was YES.

It turned out that much of what was being done differently in the positive deviant families was tacit and unconscious: the individuals in question weren’t even consciously aware they were doing anything different or new.

Aid on the Edge of Chaos, Ben Ramalingam

Through building on the existing positive behaviours within the community, they enabled the community to help change the behaviours of their peers. From this point, they worked backwards from the practical behaviours to help the communities appreciate that these behaviours led to positive outcomes, and then to understand why their behaviours were resulting in positive outcomes.

This, therefore, was the reverse of our normal Public Health Approach of Educate, Motivate, Action and led to a new approach of Practice, Attitude, Knowledge.

You can read more about Positive Deviance here.