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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. 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 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.

Positive Deviance Wisdom Series, Number 5, pp. 1-10.   Boston, Tufts University: Positive Deviance Initiative

In a remote mountainous community in Haripur District of Pakistan’s North West Frontier Province (NWFP), a few dozen miles north of the ruins of the ancient Buddhist educational township of Taxila, 19-year old Rahima felt a sharp, painful twitch in her abdomen. Eight months pregnant, Rahima wondered if the labor pains for her first child had begun–four weeks prematurely! As the cold wind blew outside her sparse two-room home in Bagra village, Rahima’s anxiety climbed steeply, much like the full moon gleaming in the sky. Did the full moon represent a good omen? Rahima would accept any kind of assurance, celestial included, for she knew that of the last eight births in Bagra village, two newborns did not make it past the first 40 days. Would her firstborn beat the one-in-four odds of survival in this harsh physical environment that had the dubious distinction of harboring one of the highest rates of infant mortality in the world? The odds for Rahima’s firstborn to face pregnancy complications were stacked high.

She had received no ante-natal care leading up to her impending delivery, no iron or vitamin supplements, and no tetanus toxoid vaccination. Her workload was heavy, and she tired easily cooking, cleaning, and caring for her in-laws, her husband, and his three younger unmarried brothers. While Rahima’s body needed more food and nutrients for the growing fetus, her mother-in-law limited her food portions so that the newborn would not be too big and thus be easily delivered. Rahima’s husband, Mushtaq, a small-time subsistence wheat farmer, was looking forward to becoming a father, wishing for the birth of a male child who could carry on the family name. Although a conscientious husband, Mushtaq, like most other husbands in Bagra village, was not involved in his wife’s pregnancy and ante-natal care. His preoccupation were his wheat fields and providing for the extended family. Mushtaq had no cash savings and made no preparation for any emergencies or pregnancy-related complications for Rahima.

As per Bagra’s social norms, pregnancy, delivery, and child care were exclusively in the women’s domain. Mushtaq’s mother, Shakila Bano, who with her experience of birthing 13 children (10 of whom survived), was Rahima’s primary resource for maternal and newborn care. With the midnight hour approaching and blistery mountainous winds howling, calling the dai, the traditional birth attendant, from a neighboring village was not possible. Shakila would help Rahima deliver the baby with the help of a neighboring aunt. Knowing the messiness of delivering a baby, Shakila spread some jute bags on the cold floor of the animal shed where Rahima would squat holding on to a charpoy, a four legged bed, for support. Writhing in pain, Rahima pushed and pushed until her firstborn—a daughter—was delivered. Shakila sawed the umbilical cord with a bamboo stick and tied a traditional thread around it to stop the bleeding. A dressing of desi ghee (clarified butter) was applied to keep the cord moist and lubricated. The aunt laid the premature newborn girl on the cold floor as Shakila delivered Rahima’s placenta. Mushtaq brought in a bucket of tepid water heated in haste over a wood stove and the aunt bathed the shivering newborn in an attempt to remove the vermix. The baby was then wrapped in a rag blanket and handed to Shakila so she could administer the child gutti, a homemade pre-lacteal concoction made from green tea, buffalo milk, ghee, and sugar. The prevailing belief is that the person who administers the gutti transfers their characteristics (intelligence, disposition, or charm) to the newborn. The thick colostrum, keer, flowing out of Rahima’s breasts,

full of antibodies to boost a newborn’s immunity, was discarded, deemed unfit for the newborn’s consumption. For the first hours, the gutti would suffice. With the newborn washed, wrapped, and fed, Mushtaq’s father, the elder male, was summoned to whisper azan, a prayer from the Holy Quran, in the newborn’s ear on the threshold of the room where Rahima delivered. Rahima prayed silently that her tiny premature baby girl would survive, if not thrive, against overwhelming odds.

Between January 2001 and October 2004, the Positive Deviance approach was implemented in a phased manner in eight villages of Haripur District in Pakistan’s North West Frontier Province to deliver better health outcomes for the likes of Rahimas and their newborns. Positive Deviance (PD) is based on the observation 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 facing similar or worse challenges. In essence, among the thousands of Rahimas, Shakilas, and Mushtaqs of Haripur District, were there a handful of individuals whose uncommon practices resulted in better health outcomes for the mothers and their newborns? Initiated by Save the Children as part of their Saving Newborn Lives (SNL) Initiative in Pakistan, the project represented the first application of the PD approach to address maternal and newborn care issues.

Beginning with an experimental PD process in two villages—Bagra and Banda Muneer Khan, followed by a pilot phase in Kaag and Chanjiala villages, where various PD processes, tools, and strategies were further refined, a larger four-village intervention was implemented in Garamthone, Nilorepaeen, Bhaira, and Chambapind villages. Baseline and end-line data were collected in these four interventional villages and in four comparison control villages to rigorously assess the effects of the PD intervention.

The use of the PD approach in these eight communities of Haripur District followed an iterative, well-defined process in two phases. In Phase one, activities were initiated to foster community dialogue about the problem of newborn mortality and morbidity among community members (separately between male and female groups) in order to identify PD newborns and their families, discover what were their demonstrably successful strategies (through a PD inquiry), and develop a plan of action. Phase two was dedicated to community action via community-designed neighborhood activities undertaken by both male and female groups.

The PD process, designed to build strong rapport with the community members, helped the intervention team learn about the local contexts of understanding with respect to maternal and newborn care. For instance, the concept of “newborn” was extended to babies under 40 days to match the cultural mindset in which babies have a special moniker for up to 40 days. Because in the NWFP of Pakistan, safe motherhood, pregnancy, and delivery are highly taboo subjects, a step by step approach was employed with various participatory activities such as transect walks, focus group discussions, social network maps, newborn mapping, and in-depth interviews. During the community orientation and feedback sessions, facts and figures about newborn and maternal care were shared, including powerful, emotive testimonies from family members who had lost a newborn or a wife, daughter-in-law, or niece during labor and delivery.

A baseline about newborns in the community was established working with both women and men’s groups. A newborn mapping activity was conducted by both groups to determine how many babies had been born the year before, how many had been stillborn or died immediately after birth, after 7 days, after 28 days and within 40 days. Concurrently, explorations of common practices with women’s groups around pregnancy, delivery, and immediate and subsequent post-partum care were explored using stuffed dolls as props. The dolls provided a visual representation of how the newborn was handled during the delivery process and post-delivery.

A baseline about newborns in the community was established working with both women and men’s groups. A newborn mapping activity was conducted by both groups to determine how many babies had been born the year before, how many had been stillborn or died immediately after birth, after 7 days, after 28 days and within 40 days. Concurrently, explorations of common practices with women’s groups around pregnancy, delivery, and immediate and subsequent post-partum care were explored using stuffed dolls as props. The dolls provided a visual representation of how the newborn was handled during the delivery process and post-delivery.

Besides the newborn, family members related to the newborn were identified as PD persons, such as a father who saved money in case of obstetric emergency at delivery, a mother-in-law who prepared a delivery kit for the arriving newborn, a dai who successfully resuscitated newborns who were not breathing and practiced clean cord cutting and appropriate cord care.

The inquiry also helped discern household behaviors that increased the chances of newborn survival, including tetanus toxoidd vaccination and antenatal care for the mother, delivery preparedness on part of mothers-in-law and dais, emergency-preparedness on part of husbands, the use of clean surface for delivery, clean hands while delivering, clean cutting of umbilical cord, thermal care of newborns, exclusive breastfeeding, timely care-seeking for premature or sick babies, paternal involvement in spouse and childcare, increase in postpartum maternal diet, and others.

The PD inquiry also yielded rich insights on messaging strategies used by the misali kirdars. For example, a religious leader noted: “we don’t need to bathe the baby for azan as when we listen to azan (a prayer from the Holy Quran) five times a day, we are not clean most of the time, so in the same way newborns need not be bathed before saying azan in their ears.” This religious leader, and his message about delaying the bathing rituals of a newborn, was then given play in mohallah (neighborhood) sessions and in community Healthy Baby Fairs, thus multiplying its effects.

To advocate for paternal involvement in maternal health pre and post delivery, a father noted: “Giving panjiri, a nutritionally-rich protein bar, to the pregnant woman can lead to a healthy baby and also keep mother’s life out of danger. If we provide food for the mother, it will ensure the health of the baby.” A mother-in-law explained the benefits of exclusive breastfeeding for her daughters-in-law: “The baby has no disease in the mother’s womb. If breast milk were dangerous, the baby would become ill in the womb. So mother’s milk is safe for the baby because it comes from the mother’s body.” Different channels of communication were used to repeat and reinforce the PD messages through different media, including religious and secular leaders and popular, culturally appropriate tools, such as street theatre to validate the messages given by the PD volunteers. However, the PD methodology focuses not just on the message delivery but also creates an enabling environment at the household level by involving husbands, mothers-in-law, the village health committee members, and members of the Village Action Team (VAT), who collectively facilitate and support the process of behavior change.

FROM INQUIRY TO CREATIVE IMPLEMENTATION OF A COMMUNITY-DESIGNED ACTION PLAN 

The PD practices that were discovered were openly shared with community members in community-wide meetings, albeit separately, because of cultural mores, with male and female members. Here the community members had an opportunity to discuss the PD behaviors, seeing their relevance, usefulness, and practicality. Moreover, this community meeting served as a springboard for action and the development of a community led initiative. 

The action plan was developed with the consensus of the whole community and displayed in a common social place to ensure transparency of roles and responsibilities to achieve the objectives. This basic plan was further developed or modified by the community-identified activists in the VAT workshop. The VAT was formed to manage the project and members were asked how they could measure the impact of the initiative (e.g. survival of newborns, adoption of new PD behaviors, lasting change, and others) and how they would monitor the progress of the program. These village health activists developed a six month plan, deciding that in cooperation with the community members, a plethora of activities would be undertaken at the neighborhood level with regular bi-monthly group interaction mohallah (neighborhood) sessions. 

These meetings were facilitated by local social activists, who volunteered to carry out the community action plan. Each bi-monthly session was focused on a newborn and maternal care topic and highlighted certain specific PD behaviors and strategies that had been discovered during the recent PD inquiries. One of the fun activities in the male mohallah sessions was to set up a mock bazaar where men were asked to buy what they considered a clean delivery kit for pregnant women. Discussion on each participant’s purchase followed and resulted in men declaring, some anonymously, that a new razor blade was the best tool for cutting the umbilical cord. The community’s respect and open support for the men’s contributions and decisions helped enhance their self and collective efficacy, leading to the emergence of a new and innovative leadership. Scores of new male volunteers signed up to run the mohallah sessions. Similarly, in the female mohallah sessions, community volunteers set up a bazaar, laying out several objects on a table and asking pregnant mothers, mothers-in-law, and dais, to select the five or six objects (e.g. soap bar, clean blade, clean plastic sheet, etc.) that were essential for a clean delivery kit. The selection of each object, essential or non-essential, sparked a healthy discussion about the object’s relevance in delivery preparedness. New leadership emerged from these sessions to serve as volunteers and activists in improving the quality of lives of newborns and their mothers.

MEN TAKE CHARGE 

The initial community dialogue in intervention villages unequivocally revealed that male involvement in maternal and newborn care was minimal. In this dominant Pashtun culture of patriarchy, male bonding with infants or caring for one’s wife is perceived as not being “manly.” A popular local folktale emphasizes this norm of paternal-detachment: Once upon a time a father who was going for work in another village directed his wife not to pick-up the newborn baby too often and advised her to hold a hen instead. When he came back after a few weeks, he saw that the hen had become weak and the baby was thriving!” The PD processes employed several interactive games and simulated role plays to help the local Pashtun men to become more involved in the care of their wives and newborn children. One of the games used to pass on responsibility to the male Village Action team was the balloons-as-newborn game. Men blew air into balloons and floated them over their heads. They were told that newborns are happy and alive as long as they are floating, but if they fall to the ground that means they are sick and may die. So, what could they do individually, as well as collectively, to minimize newborn deaths? By floating balloons, and keeping them in the air, they were “acting” on their communal, parental and spousal responsibilities: if they stayed together as a team and continue their PD work the newborn would survive and be safe; if they discontinued their collective effort the newborn would be endangered.

The PD project in Haripur District used a variety of interactive exhibits and artifacts to improve delivery preparedness and newborn care. In addition to the objects (e.g. new razor blade, soap bar, etc.) used during the mohallah bazaars, a big hit were homemade dolls, filled with rice or sand, and with detachable umbilical cord and placenta. These dolls were used to elicit accurate information from female community members on current practices regarding how the cord was cut, how the placenta was delivered, where the newborn is laid down, how the newborn was handled, and how he or she was resuscitated. The stuffed dolls were used to train female community volunteers in appropriate delivery and post-delivery practices, including the learning of new, improved newborn life saving behaviors. The dolls allowed mothers, mothers-in-law, fathers, and dais (the traditional birth attendants) to engage in learning by doing. 

EVIDENCE OF OVERCOMING ODDS

A pre-post, interventional control research design pointed to significant gains in maternal and newborn care indicators. In comparison to control villages where the gains were insignificant, in the intervention villages:

The percentage of mothers giving home made pre-lactal feeds in the first 3 days decreased significantly from 70% to 25%

The percentage of mothers giving home made pre-lactal feeds in the first 3 days decreased significantly from 70% to 25%

The percentage of newborns whose cords did not receive unhygenic homemade remedies increased significantly from 7% to 19%

The percentage of fathers who saved money and arranged for transport to tackle pregancy emergencies increased significantly from 45% to 62%  

The percentage of families that used a new blade to cut the baby’s cord increased significantly from19% to 33% 

The percentage of families that delayed bathing the newborn for the first 24 hours increased significantly from 18% to 32% 

It is useful to highlight that, in contrast to adopting the relatively simple behavior of using a new blade for cord cutting, the delayed bathing of a newborn represents a far more complex behavioral change, given its religious and cultural significance. Post-delivery bathing of a newborn is undertaken in most communities of Haripur District within minutes of delivery; an azan (a Quranic prayer) is whispered by a male elder in the ear of the newborn, and the child needs to be “clean” for this purpose. However, early bathing causes hypothermia—a major killer of newborns. The PD approach also helped in changing certain social norms in the intervention villages. In the North West Frontier Province, a highly conservative part of Pakistan, communication about maternal and newborn health is virtually absent. Infant and maternal mortality are couched in fatalistic terms—“as God’s will.” Women, by tradition, are not allowed to participate in health education meetings. However, the introduction of the PD approach, which began by building trust with the community’s male elders, led to more open household, neighborhood, and community discussions on such “taboo” topics between men and women. The Positive Deviants identified by the community (mothers, mothers-in-law, dais, husbands, religious leaders, and others) found a forum to advocate their uncommon yet effective behavioral practices at community levels. The odds of survival for the yet-to-be-born in Rahima’s village have gone up significantly since the PD approach to maternal and newborn care was implemented.

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

Positive Deviance Wisdom Series, Number 2, pp. 1-8.   Boston, Tufts University: Positive Deviance Initiative

While all 24 students in Ramón’s first grade class await their birthdays, they are unaware of how bleak their future might be. Within two years, by the time they are in third grade, it is likely that 5 out of the 24 will have stopped going to school. By the sixth grade, another 7 out of the remaining 20 will have dropped out.1 In 2000, a first grader in San Pedro and, more generally, in Argentina’s rural province of Misiones would have had a 3 in 4 chance of getting to third grade and a 1 in 2 chance of making it past the sixth grade. Ramón’s entering class of 24 would have become a class of 12 students by seventh grade. Ramón’s entering class of 24 would have become a class of 12 students by seventh grade.

What explains this sharp drop in school enrollment rates in Misiones? Why do so many Ramóns drop out of school, missing out on learning basic literacy and numeracy skills? The answers, in part, lie in the traditional roles that young children in Misiones play in subsistence agriculture. For instance, Ramón may drop out of school:

To help his parents plant cassava branches, a staple food in Northeastern Argentina.

To help with the tobacco harvest. Children like Ramón are well equipped to pick tobacco leaves
as one has to squat low in order to pluck them from the bottom, keeping the upper ones intact.

To help with weeding, a non-complex task which children carry out with relative ease. Weeding, much like tobacco harvesting, requires long hours of squatting in the fields.

In essence, young children in Misiones play a key role in generating family livelihoods.For them, and their parents, school attendance is a relatively low priority. Survival takes precedence over education. However, not every elementary school in Misiones has high dropout rates. Some schools do better.

Consider Mr. García’s school. Mr. García is a teacher in
a school in Misiones which has higher student retention rates. After school hours, Mr. García can often be seen at his students’ home sipping a cup of mate, a local beverage made of herbs. He may ask parents about the well-being of the family pig that appears to be pregnant and about the tobacco harvest: “How much are they selling it for per kilo?” Mr. García may encourage Manuel and Lydia, the parents of Sylvia whom he knows on a first name basis, to continue sending their child to school. “Education is a great equalizer,” he emphasizes. “Sylvia is a good student and has a bright future ahead.”

The boys and girls in Mr. García’s class, as well as their parents, know that Mr. García believes in their potential and will go the extra mile to encourage their continued presence in school, even when they are absent.

In Misiones, teachers like Mr. García are beacons of hope for the Ramóns and Sylvias, who otherwise would not make it past third grade.

DEFIANT WELCOME

“Señor, Argentina no es Vietnam (Sir, Argentina is not Vietnam). Your Positive Deviance approach that may have worked in Vietnam will not work here in Misiones! We, the teachers, haven’t been paid in months. The parents of these children who drop-out are worthless and disinterested. And you Señor, you know nothing of our situation or problems,” noted a senior female teacher. Other teachers, with crossed arms and defiant looks, nodded in agreement.

“Señora, lo que usted dice es absolutamente la verdad!” (Madam, what you say is absolutely true), replied Jerry

Sternin, co-founder of the Positive Deviance Initiative. “It is also true that some of you, sitting in this room at

this very moment, have been able to retain over 85% of your students. So, yes, I know nothing about your situation. But I do know that the solution to your problem already lurks in this room.”2

After a long pause, an elder teacher noted, “Yes, Señor, that is correct.” She added, “but we are so often blamed for student drop-outs by both the parents and school administrators.”

“Is that the case every time?” asked Jerry. “At every school?” There was a long pause. Some teachers leaned in. Some appeared to drop their frowns. Some seemed to be smiling.

“PD is not a magic bullet,” Jerry noted with humility, “but by looking at elementary schools in Misiones that
are able to retain and graduate more students without access to any special resources, we might get somewhere.”

More folded arms began to open and Jerry’s suggestions received affirmation…

Positive Deviance Wisdom Series, Number 3, pp. 1-8.   Boston, Tufts University: Positive Deviance Initiative.

A tragedy of such appalling magnitude unfolds itself daily in U.S. hospitals. On average, hospital acquired infections (HAIs) kill about 275 patients in U.S. hospitals a day. This is largely because their doctors, nurses, therapists, ambulance drivers, and other health care workers did not follow hand hygiene protocols, were too busy to properly gown and glove, or were, simply, in a hurry. 

A leading bacterial source of HAIs is Methicillin Resistant Staphylococcus Aureus (MRSA), a deadly pathogen resistant to most commonly-used antibiotics, that can live up to six weeks on environmental surfaces and transmits easily through contact. MRSA infections have increased 32-fold in the U.S. in the past three decades. Amidst this alarming reality, a handful of U.S. hospitals have shown sharp declines in MRSA infections. At Billings Clinic, a multi-specialty physician practice in Billings, Montana, healthcare-associated MRSA infections have dropped by a whopping 84% in the past 2.5 half years.

What is Billings Clinic doing differently? As opposed to the traditional approach of focusing on what does not work, and rewarding or punishing employees to practice safety, Billings Clinic’s approach to MRSA prevention focuses on what works, believing that among its vast pool of employees, doctors, nursing staff, housekeepers, therapists, technicians, pastors, and social workers, there are individuals who practice certain simple yet uncommon behaviors that prevent MRSA transmission. For instance: A physician purposely sees his MRSA patients last during rounds, a simple practice that greatly reduces the risk of transmitting MRSA. An ICU nurse disinfects a patient’s side rails several times during her shift to keep MRSA from being picked up and spread. A nurse places a clean sheet between herself and a MRSA patient to avoid direct microbial transfer. 

 A physician stops wearing his tie, his white coat, and long sleeves, all vectors for the spread of MRSA infections. Many others adopt his practice.

These individuals, and dozens of others like them, at Billings Clinic are Positive Deviants. They are “Deviants” because their behaviors are not the norm and “Positive” as they model the desirable MRSA-prevention behaviors. As more people discover how to practice safety, the norm across the institution begins to shift.

TRACKING INTRACTABLE BEHAVIORAL PROBLEMS In the summer of 2004, Billings Clinic CEO Nick Wolter, MD attended a workshop in Durham, NH, where Jerry Sternin, co-founder of the Positive Deviance Initiative at Tufts University, made an impromptu 15 minute presentation on the topic. Sternin emphasized that the Positive Deviance (PD) approach was especially suited to address intractable social and behavioral problems.

Following basic hand hygiene protocols, Wolter knew, was an intractable behavioral problem in U.S. hospitals, including his own. Adherence to hand hygiene protocols for every patient encounter in U.S. hospitals ranged from 29 to 48 percent. This meant that, more than likely, the interaction between a health care worker and a patient carried the risk of infection transfer. This figure was highly problematic as patients expect hospitals to be safe environments, not transmission vectors of deadly pathogens. As a physician, Wolter knew that if he washed his hands before examining a patient, it would be cumbersome to wash them again just because he answered his pager during the process. When one’s hands feel clean, the behavioral tendency is to resume interrupted work, not fully grasping the implications for infection transfer…