Melissa Cribbin Transcultural fund recipient
Summer 1999, Bolivia

BACKGROUND 

Positive deviance is an innovative approach towards the rehabilitation of malnourished children through commimity-based and sustainable programs. Positive deviance refers to the ability of some caretakers to encounter successfid practices that enable them to raise well-nourished children in communities where there is poverty and child malnutrition. The Hearth-Nutrition model incorporates the positive deviance concept into a two-week community-based nutrition program built upon locally available foods and discovered child rearing practices from within the community. 

In 1998, Save the Children/ US published a manual based upon these ideas entitled, Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach- A Field Guide in which the steps are (Stemin et al., 1998): 

  • Identification of a village health committee and community health volunteers
  • Situational analysis of malnutrition in children
  • Positive Deviance Inquiry (PDI) 
  • Design of a Nutrition Education and Rehabilitation Sessions (NERS) based on the PDI results
  • Implementation of other Hearth components (de-worming, matemal health programs, etc.) 
Bolivia has some of the highest rates of child malnutrition and mortality in South America. In Bolivia, 8% of the children under five years of age are moderately or severely underweight, 1% are wasted and 29% are stunted (UNICEF 1998). The infant mortality rate in this country is 71 and the under five mortality rate is 102 (UNICEF 1998). A recent study reported that the department of Oruro had a much smaller decrease in its infant mortality rate between 1976-1992 in comparison to the other departments (Darras, 1998). 

Save the Children/ Bolivia initiated a pilot Positive Deviance Inquiry (PDI) in Oruro, Bolivia from June to July, 1999. It was this student researcher's role to coordinate the investigation. This report will summarize the student researcher's objectives in coordination with Save the Children/ Bolivia as well as the methodology used and the results of the PDI. 

AIM AND OBJECTIVES OF THE PROJECT
 
Overall Aim: 
The overall aim of the project was to conduct the PDI in accordance with the field manual to identify the successful practices and behaviors that enable caretakers in poor families and communities to successfully nourish their children

Project Objectives: 
1.  To analyze the contextual information that was gathered prior to the student researcher's arrival for the specific purpose of the PDI
2.  To conduct a PDI in six identified communities of Oruro, Bolivia utilizing the steps as indicated in the field manual 
3 . To assess qualitatively the process and the applicability of the field manual. 

METHODS 
 
PHASE ONE: Analysis of Contextual Information 
The student researcher compiled that PDI assessment information that was gathered previously by Save the Children/Bolivia. The student researcher categorized food 
inventories to assess the food availability in the target communities. The student researcher also transcribed and analyzed focus group information used to assess normal practices in the target communities. Finally, the student researcher organized and assessed weight-for-age data on target age children (6 months- 3 years) in the six selected communities. 

PHASE TWO: Positive Deviance Inquiry (PDI) 
The student researcher was responsible for the coordination of the PDI. The PDI methods consisted of identifying poor families with well-nourished children, poor families with malnourished children, and non-poor families with malnourished children. Home visits were then conducted with thirty-six of these identified families, utilizing two instruments:

  • Observation in the Home- A checklist was used for observing and noting information regarding household members, practices, food availability, and household environment /living quarters. 
  • Guided Interview in the Home- A questionnaire was developed from the field manual with direct and open-ended questions regarding family feeding, caring, and health-seeking practices. 
The successful practices of the poor families with well-nourished children and the hamiful practices of the poor and non-poor families with malnourished children were then compiled and compared 
from the questionnaires and checklists using the matrix method recommended by the field manual. 

PHASE THREE: Assessment of the Field Manual 
The student researcher developed process indicators for the purpose of evaluating the field manual. Since a formal evaluation did not occur, the student researcher kept field notes regarding the steps of the PDT and other processes during the PDI for an assessment of the application of the manual to the field setting. 

RESULTS 
 
PHASE ONE: Analysis of Contextual Information 
The food inventories did not reveal useful information due to the inconsistency of the collection method. Analysis of the focus groups did provide information of customary practices from which PDI identified behaviors could be compared. Weight-for-age 
information revealed a 50% prevalence of malnutrition among children 6 months to 3 years in the six target communities combined. 

PHASE TWO: Positive Deviance Inquiry (PDI) 
The results of the PDI were beneficial. Feeding, caring and health-seeking practices of poor families with well-nourished children were identified. Nutritional foods used by these families included carrot juice and quinoa (high protein grain). One family used songs and games to convince their child with a poor appetite to eat. This and other information may be used to develop a training program (NERS) within the communities. However, the information is not highly confident as it was mainly derived from reported rather than observed behaviors. Therefore, this student researcher recommended that Save the Children/ Bolivia further explore these practices and repeat the PDI during another season. 

PHASE THREE: Assessment of the Field Manual
Assessment of the field manual is still in progress. 

RELATION TO STATED OBJECTIVES 
 
Participation in the Save the Children Positive Deviance program in Bolivia contributed significantly towards the student researcher's learning objectives. The student researcher was successful in applying learned skiffs from the academic setting towards the real-life programmatic setting. The student researcher was able to work with and learn from other 
public health professionals in a cross-cultural environment. The student researcher also gained skills in program assessment and qualitative research methods. 

However, the student researcher was not granted the opportunity to participate in the process evaluation nor the impact evaluation phases as originally intended. Therefore, the student researcher was unable to gain practical experience in program evaluation and quantitative research methods. However, the student researcher will have the chance to provide feedback and assessment information regarding the application of the Positive Deviance field manual to the field setting. 

Top

Home Page | View Profiles By Country | By Last Name | By Year