Positive Deviance as A Strategy

As this is the first systematic review of the Positive Deviance/Hearth program, a broad and inclusive approach to study sampling was used. Studies were identified in 20 databases, including CINAHL and MEDLINE, as well as grey literature from 26 sources including databases (e.g. Open System for Information on Gray Literature) and websites of organizations known to run programs (Appendix 1). The search was limited to articles published in English. There was no restriction on date of publication. The reference lists of all articles were reviewed to identify additional reports. The search term used for both peer reviewed studies and grey literature was ‘Positive Deviance’. ‘Hearth’ was not included in the search term as some programs were only referred to as ‘Positive Deviance’ rather than ‘Positive Deviance/Hearth’. The search term ‘Positive Deviance’ alone was able to identify programs titled ‘Positive Deviance’ and ‘Positive Deviance/Hearth’, and both were included in the review. Some very early programs were referred to only as ‘Hearth’ programs, without the term ‘Positive Deviance’, even though they used a positive deviance approach. These studies were included in the review if they were identified through searches of reference lists. It was not practical to search databases for the term ‘Hearth’ alone, as ‘Hearth’ has multiple meanings, which gave very large number of search results with only a few relevant studies.

To be included in the review, the study or report had to evaluate the effectiveness of a Positive Deviance/Hearth Program for child malnutrition that used similar steps to the CORE manual (Nutrition Working Group, Child Survival Collaborations and Resources Group [CORE] 2002a,Nutrition Working Group, Child Survival Collaborations and Resources Group [CORE] 2002b). No limitations were placed on study design as long as the study reported on program outcomes such as nutrition status or behavior changes. Qualitative, quantitative and mixed-methods studies were included.

Studies were identified by a single researcher, first by examining the title and then the abstract, or in the case of grey literature, the Executive Summary or the first page where the term ‘Positive Deviance’ was mentioned. Data for all studies were extracted independently by two researchers onto a customized form. Initially, the intention was to use a previously validated quality appraisal checklist or form. However, the wide variation in report quality and study design in the grey literature made detailed checklists and appraisal forms impractical. As a result, a more basic form was developed that extracted high-level information on the study design, the completeness of the report sections on setting, population, intervention, study methodology and results, and whether any type of community participation was described for each step in the CORE process. Disagreements between the two researchers were resolved through discussion. Only a few such disagreements occurred, and almost all were because of one of the researchers overlooking a section of the report. This was particularly the case for grey literature reports, which tended to be long and included large amounts of content on other programs not relevant to this study. At the beginning of the review process, there were a small number of differences in opinion when assessing the level of completeness of the reports. These were resolved by better defining what was required to rate the report section as complete.

Because of variations in study design, quality and reporting, qualitative analysis rather than quantitative meta-analysis were used to draw conclusions on effectiveness. Although data were extracted by two researchers, results and analysis were interpreted only by the author.

The search identified 267 peer reviewed articles and 611 grey literature documents containing the term ‘Positive Deviance’ (Figure 1). Of these, 10 peer reviewed studies and 14 grey literature reports met the inclusion criteria. Many documents excluded at the first stage of the search applied the Positive Deviance philosophy to other public health issues and programs, such as Female Genital Mutilation, child protection, hospital acquired infections, HIV/AIDS and cancer risk. Of those that were related to nutrition there were a large number of documents that described or mentioned the positive deviance approach in general terms, but did not report on the results of a positive deviance program.