BackgroundHealth care–associated infections (HAIs) are a socio-technical problem. We evaluated the impact of a social change intervention on health care personnel (HCP), called “positive deviance” (PD), on patient safety culture related to infection prevention among HCP.MethodsThis observational study was done in 6 medical wards at an 800-bed public academic hospital in the United States. Three of these wards were randomly assigned to receive PD intervention on HCP. After a retrospective 6-month baseline period, PD was implemented over 9 months, followed by 9 months of follow-up. Patient safety culture and social networks among HCP were surveyed at 6, 15, and 24 months. Rates of HAI were measured among patients.ResultsThe measured patient safety culture was steady over time at 69% aggregate percent positive responses in wards with PD vs decline from 79% to 75% in wards without PD (F statistic 10.55; P = .005). Social network maps suggested that nurses, charge nurses, medical assistants, ward managers, and ward clerks play a key role in preventing infections. Fitted time series of monthly HAI rates showed a decrease from 4.8 to 2.8 per 1000 patient-days (95% confidence interval [CI], 2.1 to 3.5) in wards without PD, and 5.0 to 2.1 per 1000 patient-days (95% CI, –0.4 to 4.5) in wards with PD.ConclusionsA positive deviance approach appeared to have a significant impact on patient safety culture among HCP who received the intervention. Social network analysis identified HCP who are likely to help disseminate infection prevention information. Systemwide interventions independent of PD resulted in HAI reduction in both intervention and control wards.
The Positive Deviance (PD) approach is based on the premise 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. In contrast to traditional problem-solving approaches that begin with an expert-driven analysis of “what is not working” with people—their explicit needs, deficits, problems, and risks—followed by attempts to plug those gaps, the PD approach focuses on identifying “what is working.” PD offers a systematic framework to identify assets, indigenous knowledge, and home-grown solutions, and to amplify them for wider adoption. The PD approach was operationalized and systematized in the early 1990s in Vietnam to address malnutrition. At the time, 65% of children under five were malnourished. Instead of looking for the causes and applying best practices, PD pioneers looked for children from very poor families who were well-nourished. Through community-led efforts, they determined the existence of positive deviants, identified their behaviors and strategies, and amplified them. The process was replicated across 14 villages—each identifying its own batch of local practices—and malnutrition decreased by 85%. These actions led to PD as we know it today in the form of the “6 Ds”: Define, Determine, Discover, Design, Discern, and Disseminate. PD has been used widely to address a large number of intractable social problems—many of them dealing with health and risk: reducing endemic malnutrition, decreasing neonatal and maternal mortality, reducing goiter and diseases of micronutrient deficiency, boosting organ transplantation rates and cancer screenings, increasing mental well-being and psychological resilience, preventing and controlling malaria and Chagas, and reducing hospital-acquired infections in healthcare. From 2004 to 2008, six U.S. hospitals pioneered the use of PD to address the growing incidence of infections caused by the antibiotic resistant bacteria Methicillin-resistant Staphylococcus aureus (MRSA). PD was used to identify and amplify evidence-based infection prevention practices. Pilot outcomes included a 73% average reduction in healthcare-associated MRSA infections units and a subsequent decrease of between 33 and 84% at the different hospitals. The PD approach to problem-solving holds important implications for public health scholars and practitioners, risk communicators, and message designers. The cases of Vietnam and one of the pilot hospitals are used to illustrate the ways that through language- and action-based strategies PD challenges traditional risk and health messaging, proposing instead an asset-based, participatory, and sustainable framework.
This article analyzes the communicative practices that undergird the Positive Deviance approach to social change and its contributions to the curbing of girls’ trafficking in rural Indonesia. Positive Deviance hinges on the premise that in every community there are individuals whose uncommon practices enable them to find better solutions to problems than their neighbours with access to the same resources. Our archival and field research in Indonesia indicates that Positive Deviance is time and skills intensive, yet it is also rich in communication and relational practices. It facilitates a unique vantage point to build human capital and sustain positive impacts.
In design thinking, extreme users have found work-arounds for common problems, but they are few in number and often overlooked in toolkits and write-ups. This article posits that positive deviance, an approach to social and behavioral change that is compatible with design thinking, offers technical and professional communicators an accessible and innovative methodology for engaging extreme users. The authors analyze a case study of how the positive deviance approach was used to address federal recidivism on the U.S.–Mexico border. They conducted a positive deviance inquiry to arrive at the everyday replicable behaviors that enabled released individuals to complete their terms of supervised release successfully, despite the odds against them and without access to special resources. The authors conclude by discussing the value and implications of focusing on extreme users.
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