Author: Sandra Caballero

In one of his many guises, mystical Sufi character Nasirudin appears on Earth as a smuggler, arriving at the customs checkpoint each day leading a herd of donkeys. The customs inspector would feverishly turn the baskets hanging on the donkeys upside down to check the contents to fi nd nothing of interest. Years go by and Nasirudin’s legend as a smuggler grew while the inspector became more frustrated. One day, after Nasirudin and the inspector had retired from their respective occupations, their paths crossed. The former inspector pleaded, “Tell me, Nasirudin. What were you smuggling?” “Donkeys,” Nasirudin said. Nasirudin’s donkey story holds important lessons for educators and educational institutions. Often the solutions to highly intractable problems in schools — e.g. absenteeism, tardiness, gang violence, timely graduation, and others — stare us in the face, but remain invisible in plain sight. To discover these invisible, in-house, innovative practices, educators need to pay attention to the Positive Deviance (PD) approach to social, organizational, and individual change.

Uncovering innovations STRATEGY: Positive deviance that are invisible in plain sight Positive deviants are individuals who face the same challenges as others and have the same resources but still manage to fi nd ways to effectively address problems. By Arvind Singhal ARVIND SINGHAL ([email protected]) is a professor of communication and director of the social justice initiative at the University of Texas at El Paso. SPREADING INNOVATION The Positive Deviance (PD) approach assumes that every community has individuals or groups whose uncommon behaviors and strategies enable them to find better solutions to problems than their peers although everyone has access to the same resources and challenges (Pascale, Sternin, & Sternin, 2010). However, these people and groups are ordinarily invisible to others in the community, and especially to expert change agents. These implausible outliers are deviants because their uncommon behaviors are not the norm; they are positive deviants because they have found ways to effectively address the problem, while most others have not. Over the past two decades, the PD approach has been employed in over 40 countries to address a wide variety of intractable and complex social problems, including solving endemic malnutrition in Vietnam, decreasing neonatal and maternal mortality in Pakistan, reducing school dropouts in Argentina and in the U.S., reintegrating returned child soldiers in northern Uganda, and drastically reducing the spread of hospital-acquired infections in U.S. healthcare institutions (Pascale, Sternin, & Sternin, 2010; Singhal, Buscell, & Lindberg, 2010; Singhal & Dura, 2009). PD & malnutrition In December 1990, Jerry and Monique Sternin arrived in Hanoi to open an office for Save the Children. Their mission: Implement a large-scale program to combat childhood malnutrition in a country where 65% of all children under age 5 were malnourished (Singhal, Sternin, & Dura, 2009). Vietnamese officials challenged the Sternins to come up with an approach that enabled the community, without much outside help, to improve children’s nutritional status. They were given six months to show results. Tasked with the impossible, the Sternins wondered if the concept of positive deviance, codified by Tufts University nutrition professor Marian Zeitlin, might hold promise. Zeitlin was investigating why some children in poor households were better nourished than others (Zeitlin, Ghassemi, & Mansour, 1990). What were they doing that others were not? Positive deviance sounded good in theory but no roadmaps existed to design an intervention. Working with local resource persons, the Sternins decided to survey families in four village communities in Quang Xuong District in the Thanh Hoa province, south of Hanoi, where childhood malnutrition was high. V95 N3 kappanmagazine.org 29 30 Kappan November 2013 emphasized doing more than seeing or hearing? So, they designed a two-week nutrition program around the notion of “doing” in each of the four intervention villages. They asked caregivers whose children were malnourished to forage for shrimps, crabs, and sweet potato greens. The focus was on action, picking up the shrimps, crabs, and sweet potato shoots. They recruited local women to host cooking sessions where the caregivers learned how to cook new recipes using the foraged ingredients. Again, the emphasis was on doing, not simply on information transfer. Before feeding their children, mothers weighed them. No food was wasted as the children were actively fed. Upon returning home, the non-PD mothers were encouraged to feed their children three or four small meals a day. Such feeding and monitoring continued for two weeks. Mothers could actually see their children becoming noticeably healthier. The scales were tipping! From the original four communities in Thanh Hoa, the project was first expanded to another 10 adjacent communities, and then, over the next several years, nationwide. Each time, the Sternins insisted that the community engage in a process of self-discovering the PD behaviors rather than importing them from other communities. This process of selfdiscovery was as important, if not more, than the actual PD behaviors that were uncovered. Overall, the PD program helped over 2.2 million people, including over 500,000 Vietnamese children improve their nutritional status (Pascale, Sternin, & Sternin, 2010). A decade later, a study showed that successive generations of impoverished Vietnamese children in the program villages were well-nourished (Mackintosh, Marsh, & Schroeder, 2002). Community members weighed about 2,000 children under age 3, compiled a growth chart for each child, and mapped their locations. About 64% of the weighed children were malnourished. The Sternins asked the quintessential PD question: Are there any well-nourished children who come from very, very poor families? Indeed, there were some children from very poor families who were well nourished. Those who had managed to avoid malnutrition without access to any special resources were the positive deviants. Through a process of community-led self-discovery, the Sternins learned that the PD families were practicing a few simple behaviors that others were not (Singhal, Sternin, & Dura, 2009): • Families collected tiny shrimps and crabs from paddy fields and added them to their children’s meals. These foods are rich in protein and minerals. • Families added greens of sweet potato plants to their children’s meals. These greens are rich in essential micronutrients. Both the shrimp and the greens were accessible to everyone, but most community members believed they were inappropriate for young children. • Families were feeding their children smaller meals three to four times a day, rather than the customary two a day. • Families were actively feeding their children, rather than placing food in front of them, making sure no food was wasted. With best practices discovered, the natural urge was to disseminate this knowledge. Initially, such was done through local resource persons who visited homes, made posters, and presented informational and educational sessions. But these solutions encountered resistance from most households because they didn’t fit their established practices. In one of the community meetings, a village elder offered some advice; “A thousand hearings isn’t worth one seeing, and a thousand seeings isn’t worth one doing.” The Sternins dwelled on the sagacity of the elder’s remark. Could a nutrition program be designed that Every community has individuals or groups who manage to find better solutions to problems than their peers although everyone has access to the same resources and challenges. V95 N3 kappanmagazine.org 31 visiting those six PD schools (Sternin, 2003). The process of self-discovery is not just about looking at what is going right. Several groups reported that teachers in the PD schools showed unusual respect for their students, rather than identifying the specifi c uncommon behaviors or practices through which that respect could be observed. The groups were challenged to identify specifi c, verifi able practices that led to good outcomes. The PD inquiry yielded specifi c and verifi able practices (Sternin, 2003; Singhal & Dura, 2009). In PD schools, teachers warmly greeted parents whenever they visited the school. In turn, parents felt comfortable approaching the child’s teacher and were heavily involved in the school’s activities, providing skills workshops (i.e. sewing, woodworking), mending fences, and volunteering. Teachers also asked parents to RSVP to invitations for meetings, and when parents did not respond, teachers went out of their way to contact them. In PD schools, teachers felt supported to break up their class into smaller groups and modify lessons and assignments to cater to students’ abilities. Further, PD schools served breakfast to students, recognizing that hungry children have diffi culty in learning. Serving breakfast also meant that students showed up at the beginning of the school day, resulting in higher attendance and higher attention. The common practice in the nonPD schools was to serve lunch. In a fourth step, the Sternin team designed a PD intervention that would make knowledge and solutions actionable across schools in Alem and other communities. For instance, teachers, parents, and students entered into learning contracts, defi ning their respective roles and responsibilities to ensure the students made steady progress. These were assessed routinely so no one fell through the cracks. A subsequent World Bank report noted that school dropout rates in Misiones, Argentina, dropped signifi cantly (Sternin, 2003). Student performance in U.S. schools Inspired by the Sternins’ work, the National Staff Development Council conducted the fi rst-ever study of positive deviance in U.S. schools (Richardson, 2004). Six school districts were investigated that achieved above-average student results without access to any additional resources. Richardson (2004) reviewed several salient PD practices, including the ones that follow. Mary Dunbar Barksdale, a 3rd-grade teacher in Velasco Elementary School in Brazosport, Texas, was an implausible outlier among her peers. Although 94% of her students lived in poverty, all of her students scored highly on the statewide assessments. A PD inquiry revealed that Barksdale’s moBorn out of necessity, this pioneering experience in Vietnam paved the way for other PD applications to follow. The fi rst systematic use of PD in educational settings occurred in Argentina, inspiring other PD investigations in the U.S. and elsewhere. Reducing dropouts in Argentina In 2000, a 1st grader in Argentina’s rural Misiones province had no more than a one in two chance of making it past 6th grade. Students routinely dropped out to help with agricultural tasks. For most parents, school attendance for their children was a relatively low priority. Survival took precedence over education. To explore the potential of the PD approach in combating high rates of school dropouts, Jerry Sternin was invited to Misiones. In Alem and San Pedro, two communities in Misiones, Sternin worked with a team of school offi cials, teachers, and parents to conduct a PD inquiry (Dura & Singhal, 2009). Perhaps there were some elementary schools in Misiones that had higher graduation rates and no access to any extra resources. The fi rst step in a PD inquiry is to defi ne the problem. The participants defi ned the problem as “Schools in Alem retain only 56% of students through grade three.” Then they specifi ed a desired outcome: Schools in Alem would achieve retention rates of 75% or higher (Dura & Singhal, 2009, p. 3). The next step was determining if Alem had schools that did not have a dropout problem. With school enrollment and attendance data at hand for 63 schools, the team identifi ed eight schools with retention rates ranging from 78% to 100%. The team eliminated two schools because they had access to extra resources. Six schools were identifi ed as PD schools (Dura & Singhal, 2009). Teams of teachers, parents, and school administrators set out to discover uncommon practices by Those are the positive deviants. 32 Kappan November 2013 dents, especially the Vietnamese and Hmong, bore the burden of household tasks that took time from classes and assignments (Po, 2011). Further, students were also falling off track because of absenteeism, gang participation, drug use, and abuse at home. Although resource constraints made it impossible to implement a “pure” PD progress in Merced, Munger was able to work with at-risk students to identify and develop several PD strategies to get students back on track. For students who were gang members, this meant walking away from a fight without losing face with the opposing gang while maintaining loyalty and membership in their own gang. The simple act of walking away ensured physical safety for all and soothed tensions rather than incite them. Further, many students said they would actively seek a “reflective pause” when engaging in any action that might land them in detention. This allowed them to uphold their familial responsibilities and also to continue with their after-school parttime jobs. Teachers who participated in the Merced PD project invested time to meet among themselves to identify and implement solutions for students who were in difficulty. They also met with these students individually, offering support, guidance, and mentoring. Enough trust was generated that participating students felt comfortable disclosing problems to each other and to sympathetic teachers and administrators. Through such conversations, participating students at Merced learned what their successful peers were doing differently. Within two years of the PD program being implemented, graduation rates at Merced increased by about 25%. Absenteeism in Clairton City Close on the heels of Merced, the Clairton City dus operandi included a close examination of all her students’ tests in order to identify problem areas, retooling her classes to plug these gaps, and retesting students until they achieved the desired level. Over the next seven years, Barksdale’s process was shared widely across Brazosport Independent School District schools, and further refined, honed, and standardized for implementation. Each teacher in Brazosport received reports for how each student in their class performed on tests. They noted which questions students missed, which wrong answers they chose, and what remedial action was needed for which student on which question (Richardson, 2004). Only when all students met the required testing standard did the class move forward. Students who needed additional learning time were regrouped and retaught for what they missed. Students who needed substantial help were tutored one-on-one by instructional aides in learning labs. No child was to fall through the cracks! Given that several teachers in a school in Brazosport taught the same class, if one teacher’s students did particularly well on a standardized exam, other teachers were enabled to learn what their colleague was doing differently. He or she may simply have passed out a weekly review sheet of the critical concepts covered in class; this would have served as a study guide and helped with subject retention. Once identified, such “hidden” PD practices were widely shared and amplified. Richardson’s (2004) analysis also found that the Mason School District in Ohio scored significantly higher than its peers. Their secret sauce was a judicious use of review sheets, pacing charts, and common assessment protocols. Curriculum leaders for each subject in a Mason school jointly developed a pacing chart for each course, ensuring that “students taking the same course from different instructors get an equal amount of instruction in each topic” (Richardson, 2004, p. 85). The pacing chart broke down the instructional walls between classrooms, allowing for implementing common in-time assessments across classrooms. Student performances on tests allowed curriculum leaders to determine what worked and what remedial actions were needed. PD at Merced High School In 2009, Merced High School in Merced, Calif., engaged Mark Munger, a longtime colleague of the Sternins, to serve as a PD coach to address its graduation rate — a dismal 56% (Po, 2011). The odds of graduating were stacked heavily against students: Most hailed from poor families (75% were eligible for free and reduced-price meals), English was a second language to many (Spanish and Hmong were the predominant first languages), and many female stuBarring a few exceptions, outside experts introduce most innovations in schools, even while innovative and effective solutions lie hidden in plain sight. V95 N3 kappanmagazine.org 33 has been tapped thus far. Barring a few exceptions, most innovations in schools are introduced from the outside by experts, while innovative and effective solutions lie hidden in plain sight. Possibilities abound to use the Positive Deviance approach in schools across the U.S. and elsewhere. I hope that Positive Deviance becomes the norm to solve complex intractable problems in educational institutions which defy simplistic, expert-driven solutions. K References Dura, L. & Singhal, A. (2009). Will Ramon finish 6th grade? Positive deviance for student retention in rural Argentina. Positive Deviance Wisdom Series, 2, 1-8. Mackintosh, U., Marsh, D., & Schroeder, D. (2002). Sustained positive deviant child care practices and their effects on child growth in Vietnam. Food and Nutrition Bulletin, 23 (4), 16-25. Niederberger, M. (2011, March 31). Clairton district’s ‘positive’ initiative shows results. Pittsburgh Post-Gazette. www.postgazette.com/pg/11090/1135793-55.stm?cmpid=news.xml Pascale, R.T., Sternin, J., & Sternin, M. (2010). The power of positive deviance: How unlikely innovators solve the world’s toughest problems. Boston, MA: Harvard University Press. Po, V. (2011, March 7). Positive deviance: Combating high school dropouts. New America Media. http:// newamericamedia.org/2011/03/positive-deviance-a-programto-combat-high-drop-out-rate.php Richardson, J. (2004). From the inside out: Learning from the positive deviance in your organization. Oxford, OH: National Staff Development Council. Singhal, A., Buscell, P., & Lindberg, C. (2010). Inviting everyone: Healing healthcare through positive deviance. Bordentown, NJ: PlexusPress. Singhal, A. & Dura, L. (2009). Protecting children from exploitation and trafficking: Using the Positive Deviance approach in Uganda and Indonesia. Washington DC: Save the Children. Singhal, A., Sternin, J., & Dura, L. (2009). Combating malnutrition in the land of a thousand rice fields: Positive Deviance grows roots in Vietnam. Positive Deviance Wisdom Series, 1, 1-8. Sternin, J. (2003). Positive deviance and student retention and educational enhancement program. Unpublished report. Washington, DC: The World Bank. Zeitlin, M., Ghassemi, H., & Mansour, M. (1990). Positive deviance in child nutrition. New York, NY: U.N. University Press. School District in Pennsylvania used a PD approach to address absenteeism among 7th to 9th graders, as well as address late arrivals and disruptive classroom behavior (Niederberger, 2011). Initially designed to address gang violence and street crime in Clairton, the PD program morphed into a school-based program when it became clear that keeping youth in school meant keeping them off the streets. With the active engagement of a local church group and a core group of parents, students, and school officials, a PD inquiry assessed what enabled at-risk students to attend school, arrive on time, and display no disruptive behavior. Some of the PD practices that were uncovered were astonishingly simple. PD students used alarm clocks to wake up on time. Some placed these alarms across the room from their beds so they had to get out of bed to turn them off. Those practices made it easier for them to get ready and make it to school in a timely manner. Another group of students implemented a regular peer-based texting system each morning to make sure they were all awake and getting ready for school. The PD inquiry also showed that children of parents for whom school attendance was “non-negotiable” were unlikely to be tardy or absent. The Clairton PD program showed remarkable results: From 2009-10 to 2010-11, both in-school and out-of-school suspensions dropped by 50%, disruptive class behavior decreased by 57%, and tardy arrivals dropped by 45% (Niederberger, 2011). Parental involvement in school affairs, slow to catch on, increased significantly over time. A call to educators The Positive Deviance approach holds important implications for U.S. schools and institutions of higher learning. However, very little of this potential Some of the PD practices that were uncovered were astonishingly simple.

A chapter in Roger Hiemstra and Philippe Carré (Eds.) A Feast of Learning: International Perspectives on Adult Learning and Change (pp. 141-159). Charlotte, NC: Information Age Publishing.

MONTHLY DEVELOPMENTS JUNE 2013 17 AFTER PUBLISHING

Its 2010 edition, packaged in 32 leather-bound volumes that weighed 130 pounds, Encyclopedia Britannica ended its 244-year print-run rather unceremoniously. Its competitive disrupter: the web-based Wikipedia.

In early 2013, Wikipedia offered 26 million articles in 286 languages free of cost to anyone who could access its site. In contrast to Britannica’s cadre of centralized editors and “expert” writers, Wikipedia is edited and authored by tens of thousands of volunteers from across the globe. This allows Wikipedia to both expand and update its offerings in real time. Wikipedia’s disruptive dominance holds important lessons for social change practitioners. Its success reminds us that wisdom lies with ordinary people and is distributed widely; that there is value in inviting and including all constituents; and that the dominant hegemony of expert-driven command and control systems should be questioned. Simply stated, old normal ways of doing things should pave the way for a new normal. Social change practitioners need to question normative ways of thinking, especially the bell curve. What is needed instead is an alternative conceptualization of social change: one that turns the classical expert-driven approaches on their head, valuing the wisdom that lies with unusual suspects. This alternative is known as the positive deviance (PD) approach to social, organizational and individual behavior change. It is premised on the belief that in every community there are certain individuals or groups whose uncommon behaviors and strategies enable them to find better solutions to problems than their peers, while having access to the same resources and often facing worse challenges. Over the past two decades, the PD approach has been employed in over 40 countries to address a wide variety of complex social problems: solving endemic malnutrition in Vietnam; decreasing neo-natal and maternal mortality in Pakistan; reducing school dropouts in Argentina; reintegrating returned child soldiers in northern Uganda; and controlling the spread of hospital-acquired infections in U.S. hospitals. Childhood malnutrition in Vietnam In 1990, Save the Children U.S. sent Jerry and Monique Sternin to Vietnam to implement a large-scale program to combat child- Look beyond the curve and you’ll find the real key to social change lies at the edge. By Arvind Singhal, Samuel Shirley and Edna Holt Marston Professor and Director of Social Justice Initiative at The University of Texas at El Paso Photo: marekuliasz/Shutterstock.com The Value of Positive Deviations Simply stated, old normal ways of doing things should pave the way for a new normal. Figure 1. The new normal for social change interventions means focusing on what can be learned from the positive deviants 3-plus more standard deviations away from the average. The numbers on the x-axis represent the number of standard deviations (σ) away from the mean (μ). The area under the curve shows that 68% of all cases fall within 1 standard deviation of the mean, 95% of cases within 2 standard deviations, and almost all cases within 3 standard deviations. POSITIVE DEVIANCE 18 MONTHLY DEVELOPMENTS JUNE 2013 POSITIVE DEVIANCE hood malnutrition. With 65% of all Vietnamese children under the age of five malnourished, Vietnamese officials challenged the Sternins to come up with a sustainable solution, and to show positive results within six months. Tasked with the impossible, the Sternins wondered if the concept of positive deviance, codified by Tufts University nutrition professor Marian Zeitlin, might hold promise. Zeitlin was investigating why some children in poor households were better nourished than others. What were they doing that others were not? Because childhood malnutrition rates were high in Quong Xuong District south of Hanoi, four of its village communities were selected for a nutrition survey. Some 2,000 children under the age of three were weighed and their locations mapped. The Sternins posed the quintessential whodunit PD question: are there any well-nourished children who come from very, very poor families? The response: Yes. Indeed, there were some children from very poor families who were well-nourished. Those that had managed to avoid malnutrition without access to any special resources represented the positive deviants. Through a process of community-led self-discovery, it became apparent that the PD families were practicing a few simple behaviors that others were not: • Family members collected tiny shrimps and crabs from paddy fields and added them to their children’s meals. These foods are rich in protein and minerals. • Family members added greens of sweet potato plants to their children’s meals. These greens are loaded with micronutrients. While these foods were accessible to everyone, most community members believed they were inappropriate for young children. • PD mothers and caregivers were feeding their children smaller meals three to four times a day, rather than the customary two big meals twice a day; and • PD mothers and caregivers were actively feeding their children, rather than just placing food in front of them. This made sure there was no food wasted. After some trial and error, a two-week nutrition program was designed in each of the four intervention villages. Mothers whose children were malnourished were asked to forage for shrimps, crabs and sweet potato greens. The focus was not on informationtransfer, but rather on action, practice and embodied experience. In the company of positive deviants, non-PD mothers of malnourished children learned how to cook new recipes using the foraged ingredients. These mothers practiced the behaviors that the PD families had discovered on their own. Before feeding their children, mothers weighed them. No food was wasted as the children were actively fed. Upon returning home, the non-PD mothers were encouraged to feed their children three or four small meals a day instead of the traditional two meals. Such feeding and monitoring continued throughout the twoweek program. Mothers could actually see their children becoming noticeably healthier. The scales were tipping! Then the project expanded to another 10 adjacent communities. Community members engaged in a process of self-discovering the PD behaviors, as opposed to importing them from neighboring communities. The process of self-discovery was found to be as important as the actual behaviors that were uncovered. Research showed that malnutrition decreased by an amazing 85% in the first 14 PD communities. The program was scaled up by building a living university around these 14 PD communities. Teams from other communities with high rates of malnutrition spent up to two weeks directly experiencing the essential elements of the PD process. When they returned home, they would implement the PD nutrition program in at least two local communities. Through this lateral expansion, the PD intervention became a nationwide program in Vietnam, helping over 2.2 million people improve their nutritional status, including over 500,000 children. A later study, conducted by researchers at Emory University, showed successive generations of impoverished Vietnamese children in the program villages were well-nourished. Centralized distributions and standard deviations The normal (or Gauss) distribution, signified by the bell curve, is the most important distribution in the social sciences. Symmetrical and clustered around the mean, the curve allows us to specify the number of observations that fall under specific secIllustration: Ersin Kurtdal/Shutterstock.com “We dance round in a ring and suppose, but the secret sits in the middle and knows.” —Robert Frost MONTHLY DEVELOPMENTS JUNE 2013 19 tions (see Figure 1 on page 17). While initially applied to describe measurement errors, the normal curve is now routinely used to describe variation in human phenomena such as weight, height, IQ or other health and lifestyle parameters. Social scientists use the normal curve to make inferences about populations from sample statistics. By paying attention to the mean values and standard deviations with a representative sample, one can predict—with a high degree of confidence—the odds of solving a problem. Normal bell curves, for instance, can tell social change practitioners that most African-American children who grow up in poor inner-city neighborhoods in a single parent household are highly unlikely to finish high school in a timely manner. Or that most Pashtun women living in mountainous communities of Pakistan’s Khyber Pakhtunkhwa Province are at high risk for pregnancy-related complications. Or that most poor, uneducated and newly-married women in rural areas of India’s Bihar State are highly unlikely to control their use of contraceptives. In other words, social change practitioners can gain insights on the nature and scope of a social problem in a population, including what is normative—that is, what is the most likely case, scenario or outcome for most of people. Such data, when collected and analyzed before designing an intervention, can help social change practitioners gauge the severity of a problem in a community. Actionable intervention strategies can then be employed to plug gaps and deficits. Unfortunately, our record in solving social problems is highly dismal when normal distributions are used to gauge what ails most of the population. Nassim N. Taleb, author of The Black Swan, has extensively written about the pitfalls of overly relying on the bell curve, especially in social spheres. The bell curve glorifies mediocrity, disregarding the promise lurking in large deviations and outliers. By focusing attention on what is most probable, the unusual, the implausible and the exceptional are routinely ignored. In contrast, in the positive deviance approach, the identification of the exceptional represents a starting point. In PD, the normal and normative are of secondary interest. The seemingly impossible and implausible are of most interest. In calling for a new normal to solve complex social problems we ask to focus not on what is wrong with most people, but rather what is working with the very few, the exceptional, the positive deviants. In Vietnam, this new normal was exemplified in the implausible TO ORDER: CALL 1-800-232-0223 FAX 703-661-1501 E-MAIL [email protected] WEBSITE www.styluspub.com Toward Resilience is an introductory resource for development and humanitarian practitioners working with populations at risk of the impacts of climate change and other hazards. The book provides practical guidance on how to integrate disaster risk reduction and climate change adaptation into the program management cycle and adapt activities to a range of contexts and development and humanitarian sectors. TOWARD RESILIENCE: A Guide to Disaster Risk Reduction and Climate Change Adaptation Released February 2013 Paper: 978 1 85339 786 8, $25.95 Distributed in the U.S. by About The Author Duncan Green is Oxfam GB’s Senior Strategic Adviser. He was Oxfam’s Head of Research from 2004-12. He is the author of several books on Latin America, including Faces of Latin America (third edition 2006) and Silent Revolution: The Rise and Crisis of Market Economics in Latin America (2003). He has been a Senior Policy Advisor on trade and development at the UK’s Department for International Development (DFID) and Policy Analyst on trade and globalization at CAFOD. May 6th, 3:00–6:00pm: SIT/World Learning Center May 7th, 10am–Noon: Society for International Development, DC Chapter May 7th, 6:30–8:00pm: World Affairs Council May 9th, 5:30–7pm: GWU – The Elliott School of International Affairs Meet Author Duncan Green in Washington, DC: May 6–9, 2013 at these FREE events! (Receive 20% off From Poverty to Power, 2nd Edition on-site.) New Guide from Emergency Capacity Building Project published by Practical Action Publishing POSITIVE DEVIANCE 20 MONTHLY DEVELOPMENTS JUNE 2013 POSITIVE DEVIANCE question: are there well-nourished children who come from very, very poor families? In the past two decades, this type of implausible PD question has been asked repeatedly to tackle a large number of intractable social problems. For instance, in summer 2012, in collaboration with a dozen field researchers, I led a formative research inquiry in the urban slums of New Delhi. Our purpose was to provide data-driven inputs to the design of a mass media health campaign to promote small family size, emphasizing delay of first child and spacing between children, countering the preference for male children, and encouraging adoption of contraceptive methods. Instead of gathering deficit-based “normative” data, we used new normal sensibilities to guide our fieldwork. Were there individuals, couples, or health workers who had found better family planning solutions than most of their peers without access to any extra resources? If so, what did they do? By analyzing archival data and key informant interviews we identified several positive deviants. What were they doing that resulted in highly successful outcomes? One respondent, a married woman, significantly reduced the risk of pregnancy by closely tracking her menstrual cycle and avoiding sex during the days she was likely to conceive. During these “no, no days” she employed a variety of excuses to avoid penetrative intercourse. She would tell her husband, “I am keeping a fast for a few days for your health.” On her “yes, yes days” she coyly noted, “I go out of my way to please him.” While most married women in this setting would be unable to negotiate sex, our positive deviant had found a creative, culturallyappropriate way to reduce the risk of pregnancy. After all, how could a husband overrule his wife’s sacred fast—one undertaken for his sake! We also met a health worker who employed certain uncommon practices that yielded high rates of male vasectomy. When he organized vasectomy camps in rural areas, several men who previously had agreed to a vasectomy either did not show up on the appointed day or hesitated to be the first to undergo the procedure. Their dilly-dallying negatively impacted other participants’ motivation and many assembled men would dissipate to the chagrin of camp organizers. To overcome this problem, our health worker arranged for a few men who were already highly motivated vasectomy seekers to stride up—in open view of other men—and demand that they be the first to undergo the procedure. Post-procedure, they were purposely urged to stride out like a stallion, boasting about the ease and painless nature of the vasectomy. Such purposive planning and orchestration of vasectomy prospects by the health worker delivered significantly better vasectomy completion rates, in comparison to his peers. While most health workers would shrug their shoulders when vasectomy prospects walked away, the PD health worker had hit upon an effective practice: present examples of proud, confident men in full view of others as social proof of the value of the procedure. The important point here is that the fasting strategy of the married woman and the purposive social proof practice of the health worker represent exceptional, non-normal actions. These practices were discovered because we actively sought to find the statistical outliers, the positive deviants. Our understanding of how to solve complex social problems faces an epistemological crisis. Existing ways of knowing and intervening have proved highly inadequate in addressing intractable problems. Normal distributions hold social scientists in their seductive stranglehold. In glorifying the normative and the most probable, they disregard the exceptions, the improbable outliers. Thus social change practitioners are unsuspecting victims of their own trained incapacities. The new normal, exemplified by the positive deviance approach, acknowledges that wisdom to solve complex social problems exists locally, albeit hidden from plain view. In seeking the exceptional among the ordinary and the improbable among the probable, social change practitioners hold the promise to uncover tacit wisdom and solutions that cost little and are more inclusive, adaptable and culturally appropriate. MD Learn from experts, share experience, connect with colleagues from InsideNGO’s 300 member organizations. 75+ sessions addressing the core challenges faced by international development and relief operations staff. Leave with ideas, solutions, tools and resources to do your job better – help your organization achieve its programmatic mission. To learn more, go to: www.InsideNGO.org/AC13 July 30 – August 1 Walter E. Washington Convention Center, Washington DC It’s Time to Register! “The conference exceeded my expectations. I had three truly excellent days with lots of networking, learning, re-learning, understanding and enjoyment in general.” “Good mix of people with different perspectives and experiences coming together to discuss relevant and important issues that impact the effectiveness of our work.”

 The diffusion of innovations: A Communication Science Perspective (pp. 192-205). New York: Peter Lang Publishers.

Leading Change in Healthcare: Transforming Organizations Using Complexity, Positive Psychology, and Relationship Centered-Care (pp. 177-209).   New York: Radcliffe Publishing.

It [positive deviance] is the most fascinating idea anyone has had to solve the problem [of hospital-acquired infections] in a century. (Gawande, 2007, p. 27) Most health communication campaigns, especially those that draw upon the diffusion of innovations tradition, are premised on the following tenets (Rogers, 2003; Singhal & Dearing, 2006; Singhal, 2010): that new health information or ideas come from the outside and are promoted by a change agency through expert change agents, who use persuasive communication strategies to educate their client audience. In this short essay, an alternative conceptualization of diffusing health innovations is broached whose premise is that innovative ideas are often lurking within the system, where the change agents’ primary role is to facilitate a process whereby which the community can self-discover these ideas, and where dialogue and “social proof” result in an organic spread of the innovation, in contrast to passive adopters buying into a change agency’s prescription. This alternative approach to diffusing health information or ideas is known as the positive deviance (PD) approach. PD is an approach that enables communities to discover the wisdom they already have, and finds a way to amplify it (Pascale & Sternin, 2005; Singhal & Dura, 2009). We illustrate the key tenets of the PD approach through an example of its application in dramatically reducing hospital-acquired infections in U.S. health care settings. Despite being 100% preventable, hospital-acquired infections (HAIs) kill 100,000 people each year in the United States, mainly because hygiene protocols are compromised. That is more deaths than breast cancer, HIV/AIDS, and road accidents combined. Adherence to hand hygiene protocols Correspondence should be addressed to Arvind Singhal, Department of Communication, University of Texas, El Paso, 202 Cotton Memorial, El Paso, TX 79968. E-mail: [email protected] in U.S. hospitals is pitifully low—averaging between 35 and 40% (Singhal & Greiner, 2008). That means an interaction between a health care worker and a patient in a U.S. hospital, more than likely, carries the risk of infection transfer. A leading bacterial source of HAIs is methicillin-resistant Staphylococcus aureus (MRSA), a deadly pathogen resistant to commonly used antibiotics. MRSA infections have quintupled in the United States in the past decade, and MRSA is a formidable enemy, for it can survive for up to 6 weeks on surfaces and transmits easily through contact. Amidst this alarming reality, a handful of U.S. hospitals—Billings Clinic in Montana, VA hospitals in Pittsburgh, Albert Einstein in Philadelphia, Franklin Square Hospital Center in Baltimore, and the University of Louisville Hospital Center—have shown sharp, almost unbelievable, declines in MRSA infections in the past three years, ranging from 84 to 30% (Buscell, 2008; Lloyd, Buscell, & Lindberg, 2008; Singhal, Buscell, & McCandless, 2009; Singhal & Greiner, 2008). What are these hospitals doing differently? As opposed to the traditional approach of focusing on what does not work, and communicating with, motivating, and rewarding employees to fix those problems, these hospitals are focusing on what works, believing that among its employees are individuals who practice certain simple yet uncommon behaviors that prevent MRSA transmission. For instance, in these hospitals, the following uncommon behaviors were observed: – A patient who refuses to make eye contact with a doctor or nurse if he does not hear the tap run or the sanitizer’s dispensing swish. He then alternatively looks at the wash basin and the health care provider until the nonverbal equivalent of “please wash your hands” is understood. – A pediatric anesthesiologist who carries her little patients in her arms to the operation theater. She notes that the 606 SINGHAL act of carrying a child, in contrast to wheeling the child in, has a calming effect on the baby, is highly reassuring to the parents, and creates a compassionate ambience in the surgical theater. Further, a calm baby means that it is easier to administer anesthesia, hook IVs, and such. – An intensive care unit (ICU) nurse who is not afraid to hand a sanitized gown and a pair of gloves to a surgeon who drops in to check on his patient. While most nurses dare not verbally confront a surgeon, she knows that a cordial attitude and warm smile helps her overcome the power differentials. These individuals are “positive deviants” because their “deviant” behaviors, many of them communicative, are not the norm, and “positive” as they model the desirable MRSAprevention behaviors. These positive deviants—patients, doctors, and nurses—make distinctive and valuable contributions to enhancing quality of care and patient safety. In the PD approach, through a set of dialogue and discovery processes, essentially communicative processes, the multiple identities and contributions of the positive deviants are collectively mobilized and amplified for the larger public good. As more people discover these positive deviants among them (social proof) and learn how they practice safety, the norm across the institution begins to shift (Singhal, 2010). Evaluations of PD initiatives in the United States and in more than three dozen countries show that one of the main reasons why PD works is because the community owns the solution, self-discovers it through dialogic inquiry, and there is “social proof” that those ideas can be implemented locally with no extra resources (Dura & Singhal, 2009; Pascale, Sternin, & Sternin, 2010; Singhal & Dura, 2009). Positive deviance is now being applied widely in U.S. hospitals to address such diverse issues as medication reconciliation, diabetes control, end-of-life diagnosis, and HIV/AIDS prevention. In overseas contexts, PD has been used to address malnutrition, childhood anemia, the eradication of female genital mutilation, curbing the trafficking of girls, increasing school retention rates, and promoting higher levels of condom use among commercial sex workers. Health communication scholars and practitioners can gain much from further incorporating this asset-based approach in their quest to improve the quality of life of individuals and communities. REFERENCES Buscell, P. (2008, Autumn). Mapping the positive deviance/MRSA prevention networks at Pennsylvania and Montana health care facilities shows promise. Prevention Strategist, pp. 41–45. Dura, L., & Singhal, A. (2009). Will Ramon finish sixth grade? Positive deviance for student retention in rural Argentina. Positive deviance wisdom series, Number 2, pp. 1–8. Boston: Tufts University, Positive Deviance Initiative. Gawande, A. (2007). Better: A sugeon’s notes on performance. New York: Metropolitan. Lloyd, J., Buscell, P., & Lindberg C. (2008, Spring). Staff driving cultural transformation diminishes MRSA. Prevention Strategist, pp. 10–15. Pascale, R. T., & Sternin, J. (2005, May). Your company’s secret change agents. Harvard Business Review, pp. 1–11. Pascale, R. T., Sternin, J., & Sternin, M. (2010). The power of positive deviance: How unlikely innovators solve the world’s toughest problems. Boston: Harvard University Press. Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York: Free Press. Singhal, A. (2010). Turning the diffusion of innovations paradigm on its head. In A. Vishwanath & G. Barnett (Eds.), Advances in the study of the diffusion of innovations: Theory, methods, and application. New York: Peter Lang. Singhal, A., Buscell, P., & McCandless, K. (2009). Saving lives by changing relationships: Positive deviance for MRSA prevention and control in a U.S. hospital. Positive deviance wisdom series, Number 3, pp. 1–8. Boston: Tufts University, Positive Deviance Initiative. Singhal, A., & Dearing, J. W. (Eds.). (2006). Communication of innovations: A journey with Ev Rogers. Thousand Oaks, CA: Sage Singhal, A., & Dura, L. (2009). Protecting children from exploitation and trafficking: Using the positive deviance approach in Uganda and Indonesia. Washington, DC: Save the Children. Singhal, A., & Greiner, K. (2008). Do what you can, with what you have, where you are: A quest to eliminate MRSA at the Veterans Health Administration’s hospitals in Pittsburgh. Deep Learning, 1(4), pp. 1–14. Complexity-in-Action Series. Allentown, NJ: Plexus Institute.