Positive Deviance Wisdom Series, Number 1, pp. 1-8. Boston, Tufts University: Positive Deviance Initiative
Positive Deviance Grows Roots in Vietnam¹ in the Land of a Thousand Rice Fields Combating Malnutrition by Arvind Singhal, Jerry Sternin, & Lucía Durá Positive Deviance Wisdom Series, Number 1, 2009 www.positivedeviance.org Rice farming in Vietnam photo: Modified from original by Chris Feser @ flickr.com CC POS IT IVE DEVIANCE I N I T I A T I V E
“Sternin, you have six months to show results,” noted Mr. Nuu, a high-ranking official in the Vietnamese Ministry of Foreign Affairs. “What? Six months? Six months to demonstrate impact?”
Jerry Sternin could not believe his ears. “Yes, Sternin, six months to show impact, or else, I will not be able to extend your visa.” malnutrition would not yield quick and sustainable results, the Sternins wondered if the construct of Positive Deviance, coined a few years previously by Tufts University nutrition professor Marian Zeitlin,¹ might hold promise. Zeitlin broached the notion of PD as she tried to understand why children in some poor households, without access to any special resources, were better nourished than children in other households. What were the parents of these children doing? Perhaps combating malnutrition called for an assets-based approach: that is, identifying what’s going right in a community and finding ways to amplify it, as opposed to the more traditional deficit-based approach of focusing on what’s going wrong in a community and fixing it from the outside. PD sounded good in theory. But no one, to date, had operationalized the construct to actually design a field-based nutrition intervention. Might it work in a community-setting? How? The Sternins had no road maps or blueprints to consult. Where to begin? Beginning close to Hanoi, their home base, made sense. Childhood malnutrition rates were high in Quang Xuong In December 1990, Jerry Sternin, accompanied by his wife Monique and ten-year old son Sam, arrived in Hanoi to open an office for Save the Children, a U.S.-based NGO. His mission: To implement a large scale program to combat childhood malnutrition in a country where two thirds of all children under the age of five suffered from malnutrition. The Vietnamese government had learned from experience that results achieved by traditional supplemental feeding programs were not sustainable. When the programs ended, the gains usually tapered off. The Sternins had to come up with an approach that enabled the community, without much outside help, to take control of their nutritional status. And quickly! Mr. Nuu had given the Sternins six months!
CRISIS OR OPPORTUNITY
From years of studying Mandarin, Jerry knew that the Chinese characters for “crisis” were represented by two ideograms: danger and opportunity. Perhaps there was an opportunity to try something new in Vietnam. Necessity is the mother of invention. If old methods of combating Crisis Danger Opportunity 1
POSITIVE DEVIANCE enables communities to discover the wisdom they already have, and then to act on it. district in Thanh Hóa province, south of Hanoi. After a four-hour ride on Highway One in a Russian car the Sternins arrived on locale. The Ho Chi Minh trail, the major supply route for the Vietcong guerillas during U.S. hostilities in Vietnam, snaked through Quang Xuong, so suspicion of Americans, was noticeably high. The Sternins’ first task was to build trust with all stakeholders. The rest would follow. After several days of consultation with local officials, four village communities were selected for a nutrition baseline survey. Armed with six weighing scales and bicycles, health volunteers weighed some 2,000 children under the age of three in four villages in a record 3.5 days. A very, very poor families who are healthy!” These poor families in Thanh Hóa who had managed to avoid malnutrition without access to any special resources represented the Positive Deviants. things right, and “Deviants” because they engaged in behaviors that most others did not. What behaviors were these PD families engaging in that others were not? To answer this question, community members decided to visit with six of the poorest families with well-nourished children in each of the four villages. The Sternins believed that if the community self-discovered the solution, they were more likely to implement it. photo: PDI Women weighing children in an interventional village growth card for each child, with a plot of their age and weight, was compiled. Some 64% of the weighed children were found to be malnourished. No sooner was the data tallied, with abated breath the Sternins asked, “Are there any well-nourished children who come from very, very poor families?” The response: “Yes, yes, there are some children from Palpable excitement bathed the community hall. The self-discovery process yielded the following key PD practices among poor households with well-nourished children: Family members added greens of sweet potato plants to their children’s meals. These greens are rich in beta carotene, the miracle vitamin, and other essential micro nutrients e.g. iron and calcium. 2 POSITIVE DEVIANCE is based on the premise that if the community self-discovers the solution, they are more likely to implement it. “Positive” because they were doing (powered by a noisy tractor engine), Family members collected tiny shrimps and crabs from paddy fields adding them to their children’s meals. These foods are rich in protein and minerals. Family members and villagers did not have this nutritional scientific knowledge, but that wasn’t important. Interestingly, these foods were accessible to everyone, but most community members believed they were inappropriate for young children. Further, besides feeding their children uncommon food, PD caregivers were feeding their children three to four times a day, rather than the customary two meals; PD caregivers were actively feeding their children, making sure there was no food wasted; and PD caregivers washed the hands of the children before and after they ate.
DOING NOT TELLING
With the “truth” discovered, the natural urge was to go out and tell the people what to do. Various ideas for posters, educational sessions, and others. However, from previous field-based experience in other countries, the Sternins knew that old habits die hard; new ones, even when they hold obvious advantages, are hard to cultivate. Their experience suggested that such “best practice” solutions almost always engendered resistance from the people. The Sternins coined a phrase for it, the “natural human immune system rejection” response to being told what to do by others. As the brainstorming wound down, a skeptical village elder volunteered quietly: “A thousand hearings isn’t worth one seeing, and a thousand seeings isn’t worth one doing.” 3 Shrimps and crabs for the taking in Vietnamese rice paddies “A thousand hearings isn’t worth one seeing, and a thousand seeings isn’t worth one doing.” PD emphasizes “doing.” “telling” were brainstormed: household visits, attractive photo: Modified from orig. by Intl. Rice Research Inst., CC On the car ride back to Hanoi, the Sternins talked about the wisdom inherent in the elder’s remark. Could they help design a nutrition program which emphasized “doing” more than “seeing” or “hearing?” A two-week nutrition program was designed in each of the four intervention villages. Mothers, other family members, or caregivers whose children were malnourished, were asked to forage for shrimps, crabs, and sweet potato greens. The focus was on action. Armed with small nets and containers, mothers waded the paddy fields picking up tiny shrimps and crabs. Caregivers learned how to cook new recipes using the foraged ingredients. Again, the emphasis was on “doing.” Before the caregivers sat down to feed the children, they weighed their children, and plotted the data points on their growth chart. The children’s hands were washed, and the caregivers actively fed the children, ensuring no food was wasted. Some caregivers noted how their children seemed to eat more in the company of other children. When returning home, mothers were encouraged to break the traditional two-meal-a-day practice into three or four smaller portions. Such feeding and monitoring continued for two weeks. Caregivers could visibly see the children becoming healthier. The scales were tipping! After the pilot project, which lasted two years, malnutrition had decreased by an amazing 85 percent in the communities where the PD approach was implemented. 4 photo: PDI Children’s weight was plotted on charts to map their growth THE POSITIVE DEVIANCE approach is informed by and bathed in data. Data is collected at every step and openly posted for the community to monitor the progress. Data informs where problems and solutions lie. 5 attitude, practice) framework on its head. As opposed to subscribing to the notion that increased knowledge changes attitudes, and attitudinal changes influence practice, PD believes in changing practice. PD believes that people change when that change is distilled from concrete action steps. Second, the PD approach questions the traditional role of outside expertise, believing that the wisdom to solve the problem lies inside. While social change experts usually make a living discerning community deficits and then implementing outside solutions to change them, in the PD approach, the role of experts is framed differently. The community members are the experts. The facilitator’s role is to help the community find the Positive Deviants, identify their uncommon but effective practices, and then design a community intervention to make those practices accessible to everyone. Over the next several years, the PD intervention became a nationwide program in Vietnam, helping over 2.2 million people, including over 50,000 children improve their nutritional status. Born out of necessity, this pioneering PD operationalization experience in Vietnam, with all its struggles and learnings, yielded several key insights. First, the PD approach turns the dominant A cooking session in progress in an intervention village Third, in the PD approach, the change is led by internal change agents who present the social proof to their peers. As the PD behaviors are already in practice, the solutions can be implemented without delay or access to outside resources. Further, the benefits can be sustained, since the solution resides locally. Six months after the Sternins’ arrival in Vietnam, a beaming Mr. Nuu from the Vietnamese Ministry of Foreign Affairs handed them their renewed visa. They photo: PDI “transmission” interventional KAP (knowledge, In the PD approach, the change is led by internal change agents who present the social proof to their peers. would end up living in Vietnam for six years. The PD approach had found Vietnam to be a fertile ground to grow roots. Now the saplings could travel places, finding nurturance in other soils. ¹This pioneering Vietnam story draws upon numerous conversations and audiotaped interviews with both Monique and the late Jerry Sternin. To learn more read (1) Pascale, R.T., and Sternin, J. (2005). Your company’s secret change agents. Harvard Business Review. May, 1-11; (2) Sternin J. and Choo R. (2000).The power of Positive Deviance. Harvard Business Review, January-February: 14-15; and (3) Zeitlin, M., Ghassemi, H., and Mansour, M. 1990. Positive deviance in child nutrition. New York: UN University Press. 6 photo: PDI Monique Sternin listening to a discussion on nutrition Research shows that many younger siblings born several years after the project were able to avoid malnutrition altogether – a clear demonstration that the change in behavior had stuck with family members and caregivers. Design Team: Arvind Singhal, Lucía Durá, Robert Gutierrez, and Sarah Ontiveros Department of Communication The University of Texas at El Paso Email: [email protected] The Positive Deviance Initiative Tufts University 150 Harrison Avenue, Room 135 Boston, MA 02111 tel (617) 636-2195 fax (617) 636-3781 www.positivedeviance.org POS IT IVE DEVIANCE I N I T I A T I V E
