Positive deviance in context. Positive Deviance: The difference between coping and adapting
Positive Deviance in situations of failure to thrive as opposed to situations of hunger and malnutrition
Positive Deviance and Poverty
Gaining weight by behaving in a positively deviant manner
What is behind positive deviant attitudes?
Conclusion
References
Ecol. of Food and Nutrition, Vol. 30, No. 2, 1993.
CLAUDIO SCHUFTAN
schuftan@gmail.com
Positive deviance in context
Positive deviance: the difference between coping and adapting
Positive deviance in situations of failure to thrive as opposed to situations of hunger and malnutrition
Positive deviance and poverty
Gaining weight by behaving in a positively deviant manner
What is behind positive deviant attitudes?
Conclusion
Defined loosely, for the purposes of this paper, positive deviance studies examine the performance of mothers who are successful in maintaining their children’s nutrition and health under conditions of poverty in which most children are failing to do so. Positive deviants are children of those mothers who grow and develop adequately living in impoverished environments where the majority of peers suffer from growth retardation and malnutrition.
Positive deviance has been seen as a form of social, behavioral and physiologic adaptability to nutritional stress in a process that apparently overcomes adversity. Positive deviance, therefore, focuses on psycho-social and behavioral considerations. This places it in an evolutionary context as a form of adaptation and implies that attitudinal problems may be at the root of malnutrition and ill-health.
The Zeitlin et al. (1990) monograph has presented the nutrition community with a model for conducting “program-relevant” research into positive deviance based on the premise that since socioeconomic development will not alleviate poverty over wide areas of the Third World during the next few decades, a search for “feasible approaches” (practicable solutions) to improve child survival has been necessitated. Positive deviance research thus sets out to identify which factors in these positive approaches are predominantly behavioral, which are biological and environmental, which are innate and which are acquired. It attempts to learn from adaptive child care and feeding behaviors as well as from social networks that support them as a means of designing policies and programs that reinforce and extend these adaptive behaviors to more mothers. It looks for affordable methods and interim solutions in that realm to reduce existing inequities.
As professionals, we are asked to maintain a healthy nucleus of survivors by making policy recommendations that can be incorporated in household education activities using approaches that include commercial and social marketing techniques to achieve major positive changes
Positive deviance in context. Positive Deviance: The difference between coping and adapting
The neo-Malthusian view that increases in mortality are a first form of adaptation to limited food supply is in my view a fallacy. Rather than an adaptation. It is a tragic consequence. Moreover, at the next level, stunting is also stricto-sensu a coping response, not an adaptation. I further contend that positive deviance is less an adaptation mechanism (carrying a positive connotation) than it is a coping mechanism (with a less positive connotation). Coping is adaptation at a very sub-optimal level. According to Webster’s dictionary, adaptation is concerned with accommodating or adjusting to a new situation while coping has to do with dealing with and attempting to overcome problems and difficulties Coping strategies are less transferable than adaptive strategies. Adaptation is much more general with coping being more restricted to very concrete situations. Furthermore coping may entail grave costs to the individual and society in the medium and long-run.
Positive deviance cannot, therefore, be strictly considered as an adaptation to limited food availability and in addition it is obviously not the solution for poor environmental and health conditions.
Positive Deviance in situations of failure to thrive as opposed to situations of hunger and malnutrition
In affluent societies, failure to thrive (FTT) denotes the undernutrition seen when overall food availability is not a constraint. Here, psycho-social dysfunction may occur in households potentially leading to FTT of the offspring.
In the Third World, most undernutrition seen is still due to household food insecurity. Hence, under situations of household food insecurity, can “positive behavior” be manipulated on a grand enough scale to reverse the effects of malnutrition without improving household food availability? In my view anyone who proposes manipulating positive behavior without first eliminating the other factors causing hunger and malnutrition deserves to he (at least) strongly criticized and refuted by all development professionals
Three major types of variable relate to good growth: socio-economic correlates, physiological determinants, and psycho-social and behavioral patterns (Zeitlin et al. 1990) This is agreed but, is it not a fallacy to put these three types of variable on an equal footing and at the same level of causality carrying the same relative weight? Jonsson (1988) has suggested that it is indeed a fallacy when postulating a conceptual framework of ill-health and malnutrition now adopted as pan of the official UNICEF nutrition policy; (see also Schuftan, 1979). A further fallacy often perpetuated and not dispelled in the positive deviance literature is that the socioeconomic and physiological correlates of malnutrition have already been reasonably addressed by the major Child Survival interventions (Zeitlin et al. 1990). I have strongly argued otherwise in two previous papers (Schuftan. 1989. 1990). This is not to say that no health and nutrition measures are worthwhile without prior economic improvements: some can lead to income improvements through increased take-home pay or by freeing money spent otherwise for the purchase of more food. Other measures are justified on humanitarian grounds alone, as for example immunization programs.
Believing that once positive deviance behaviors are identified and reinforced by programs is in my view, the wrong long-term focus to solve the global problem of malnutrition. The psycho-social and behavioral aspects of infant and child feeding are still overshadowed by the concrete local economic and political constraints, even white agreeing that positive deviance type interventions can result in a differential benign attention, concern and care for the child. These are desirable, but certainly not sufficient.
In underdeveloped societies, sustained/redistributive socioeconomic interventions are the key to revert situations of widespread malnutrition. Achieving these alone would be a significant quantum leap forward from the current situation in the Third World.
Since economic determinants do underlie behavioral determinants of malnutrition the question is whether there is a threshold socioeconomic cut-off point. This must be a little above mere survival and minimal food security, but sufficient to allow social support systems and psycho-social and behavioral stimulation to at least have a chance to revert malnutrition as a public health problem. I am not aware of research results that address this issue.
Positive Deviance and Poverty
The positive deviance approach may imply that we are continuing to simply do nothing about the major underlying socioeconomic constraints. When searching for feasible approaches and practical solutions to combat malnutrition, why are we invited (yet again) to seek these outside the realm of socioeconomic and political constraints? Is it because it is less “messy” or more comfortable and secure for we professionals (Schuftan, 1987)? In this context, perhaps choosing to concentrate on positive deviance interventions may be more interesting than important. Why should we continue to feel helpless about the prospects of socioeconomic change? It is high time we show positive deviance ourselves. We must cope better with this major adversity, particularly since “solutions” many of us have helped put in place in the past have failed.
“In the name of equity, we cannot divert our attention and energy away from efforts to change the economic, social and political conditions of the poor” (Zeitlin et al. 1990). My response is to ask how can positive deviance interventions reduce deep underlying inequities in need of redressal for example, income maldistribution and disempowerment of the poor, if they concentrate on fostering positively deviant behaviors that do not touch or even scratch these major underlying inequities? For how much longer con we buy insurance against critics by starting out with a statement like the one quoted at the beginning of this paragraph and then discussing other lesser matters with impunity? I see this too often in the nutrition literature (positive deviance being no exception in the long list) and I have almost made a writing career out of denouncing this fact (Schuftan 1982, 1985 and 1988 a.b).
Can tinkering with social, behavioral and attitudinal tools of change, prominently represented by commercial and now social marketing techniques, achieve major changes in the long-run if is ignores, lakes for granted or considers the above inequities as un-removable? Am I alone in being afraid that such tinkering does not add up sufficiently to reach a significant break-through point in the battle against malnutrition?
Solutions need to be embedded in a context or framework, and the one we mostly see used now requires change. However, the main change required is not primarily the context that fosters dysfunctional infant feeding and care practices” (Zeitlin et al. 1990) It is, in contrast, the total socioeconomic and political framework in which the above context is immersed that needs to be changed so that it can guarantee lasting positive changes in the feeding and care of the majority of children.
For the proponents of positive deviance focusing on the malnourished alone lacks scientific methodological rigor (Zeitlin et al. 1990). I agree but where is the same scientific rigor when the food and nutrition literature elegantly brushes-off, for others to take care of the major determinants of hunger and malnutrition?
If the most significant problem in the Third World remains the low food availability in vulnerable (poor) households, how can it be a sufficient goal “to maintain a healthy nucleus of survivors using better-coping child rearing practices” (Zeitlin et al. 1990)? Should we not strive for more than survival? Concentrating on changing dysfunctional infant-feeding and infant-care practices as a first priority seems therefore to be doing things backwards in the Third World.
Gaining weight by behaving in a positively deviant manner
The most important cause of the shift to the left in the weight distribution curve of children in the Third World is low household income, or paraphrasing Zeitlin et al. (1990): “excessively deficient income”.
Positive deviance type interventions attempt to change the shape of the normal curve by bringing the non-positive deviants more to the center of the curve. This skewing is unnatural in contrast to shifting the entire curve to the right. The latter is what would happen if household food security were permanently strengthened for the majority. I remain skeptical that the curve could he shifted to the right by changing behavioral patterns. This would be especially true for patterns such as those derived from maternal experiences during childhood and marital experiences which figure prominently in the Zeitlin et al. (1990) monograph.
The socioeconomic status of the poorest children in developed countries mostly explains their weights falling below 1.5 or 2 standard deviations from the median even if the persistence of negative deviant behaviors may explain a part of their being at the far left end of the curve.
The additional outreach components of a program to achieve positive deviance goals in the Third World can become prohibitively expensive. So far networks of village health workers have not proven to be capable of doing this effectively and massively enough in the absence of strong empowerment and redistributive measures.
Should we not, therefore, recognize that positive deviance interventions may be more appropriate to situations where household food security has been achieved? This can then move the far-left deviants of the weight curve more towards the center
What is behind positive deviant attitudes?
Parents of positive deviants are said to upwardly mobile, non-fatalistic, to take initiatives, adopt modernizing practices, to be more enterprising (with the mother often also being employed), to effectively use health and family planning services and educational facilities, to have higher aspirations and to invest more in each child (Zeitlin et al. 1990). A question remains as to whether parents with all (or most of) the opposite characteristics or traits, but having significantly improved income, would not have better nourished children. Would positive deviance arguments withstand the evidence of a study that would double the monthly income of deprived families for a year or two as the sole intervention activity? Here child growth outcomes would be compared with matched families who only received a variety of different psycho-social stimulation interventions.
I refuse to believe that, as a sustainable line of action to combat malnutrition in the future, the diffusion of the positively deviant parental attitudes alone can significantly protect young children, in spite of poverty.
An improved socio-economic status usually leads to modernization. This is another of the concepts found in the positive deviance monograph that is rather subjective and difficult to define But does modernization (as an objective for intervention) lead to an improved socioeconomic status? It often does not, Modernization per-se must be considered a mixed blessing as for example, with the nutritional consequences of urban migration, bottle feeding, and of the decreased role and support of extended families.
Thus the view that attitudinal problems are at the root of malnutrition and ill-health (Zeitlin et al. 1990) is considered as far from true. Social marketing and other stimulation or motivation techniques cannot, by changing wrong attitudes, get at the root causes of malnutrition. Under existing conditions, the quality of psycho-social stimulation given to low income children will almost always be lower than that provided to children of higher social class and better nutritional status within the same culture (Zeitlin et al. 1990). If social class is mainly determined by income and social and economic power, is this not a statement supporting my basic argument that redistributive socioeconomic interventions are fundamental? Furthermore, children of positive deviants are said to be protected from high levels of infection but this also true for the more well-to-do children.
Zeitlin et al. 1990 also claim that investing in improving positive deviant behavior might be more effective in fostering child growth and development than investing in direct food distribution programs. But then, who are still advocating that these latter programs are successful long-term solutions to solve the problems of hunger and malnutrition?
Mother-child interactions and the technology used in weaning, feeding and in the provision of health care have fundamental effects on food intake. Here I agree with the authors of the monograph but the food has, first of all, to be there. We thus have the obligation to undertake general actions that improve household food security. Simple protein-energy-malnutrition, here defined as cases where the mother does provide adequate stimulation for her infant, but as a result of lack of resources does not provide adequate nutrition, predominates in the Third World and has to be addressed frontally and first. Thereafter, or even concomitantly (but not before), we can treat the behavioral disorders of mother/child interaction as needed.
When there is no household food security, the social structure is always destabilized and there is poor satisfaction with life. In dire poverty, is it not safe to say (hat level of wealth (or poverty) is the primary determinant of satisfaction? Can therefore, maternal joy in living be increased through positive deviance interventions alone?
Conclusion
A certain limited usefulness in further studying differences in the ability of Third World poor women to cope must be recognized. This however, will be mostly in the future There are things to learn from the degree of maternal competency and the ability of some women in the some apparent low socioeconomic situation to maintain the nutrition and health of their children. There are however, limitations on what can be operationally achieved in applying the information gained from these positive deviance studies while conditions of household food insecurity prevail and dominate. It is disturbing that the information gained in this area has been and can be further misused, particularly by people, agencies or governments that have vested interests in not changing underlying conditions of poverty.
Positive deviance can hardly explain individuals’ and households’ successes in beating the system of poverty and the deprivations that go with it (Zeitlin et al. 1990) This because there is only “so much” the poor can do as individuals and there are only “so many” that are allowed to beat the system until the opportunities set by the system, controlled by the rich and powerful, are closed.
Entitlements to food and the legal and political rights deemed necessary to support poor communities (at least nutritionally) are mostly non-existent and continue to be trampled-on, abused with impunity or are simply ignored in the Third World. They are generally overrun or bypassed because of the disempowerment of the poor. (Only very limited de facto support to revert these injustices is available from our Western-financed food and nutrition projects; they do not explicitly aim to change these social and political constraints to people’s entitlement to food)
The passing of more equitable social legislation (see World Declaration on Nutrition Ed.), in which we should be far more actively involved, is not however the main problem for the future. Enforcement must be the priority This will only be achieved by empowering people at the base. The limited effect of anti-slavery legislation in Mauritania or of anti-discriminatory laws against untouchables in India and Nepal must be kept in mind in this regard More than moral authority is required for effective action.
In summary, therefore, many children in the Third World will recover and he prevented from becoming malnourished only when the economic and food security situations of households are permanently improved. What is left of malnutrition may then be amenable to positive deviance interventions in my view positive deviance studies and praxis, have the potential to (mis)lead our emphases towards further limited, minimalist interventions in attempting to comprehensively solve the problems of hunger and malnutrition in the world. The have the potential, indeed, to set us up for yet another failure that we may only recognize ten years down the road.
References
Jonsson. U. (1988). A conceptual approach to the understanding and explanation of hunger and malnutrition in society. In: M. Latham et al. (Eds.) Hunger and Society: An understanding of the causes. Cornell International Nutrition Monograph Series Vol. 1 No. 17. pp. 20-43.
Schuftan. C. (1979). Household purchasing power deficit: A more operational indicator to express malnutrition. Ecol. of Food Nutr. 8.1. 29-35.
Schuftan. C. (1982). Viewpoint: Ethics, ideology and nutrition. Food Policy 7.2. 159-164.
Schuftan. C. (1985). Hunger and malnutrition: Outlook for changes in the Third World. J. Trop. Pediatrics. 31.6. 299-300.
Schuftan. C. (1987). Food and nutrition interventions: The missing link between technology, ethics and ideology. World Rev Nutr. and Dietetics. 53.
Schuftan. C. (1988a). Macro and micro causes of malnutrition. In M. Latham et al. (Eds.) Hunger and Society: An understanding of the causes. Cornell International Nutrition Monograph Series. Vol. 1 No 17. pp. 20-43.
Schuftan. C. (1988b). Multidisciplinarity, paradigms and ideology in national development work. Scand. J. of Devpt. Alternatives. VII. 2 + 3. 241-290.
Schuftan. C (1989) Health still only for some by the year 2000? J. Trop. Pediatrics. 35.4. 197-198.
Schuftan. C. (1990) The Child Survival Revolution: A revolution that isn’t? Family Practice 7.4. 329-332.
Zeitlin. M. H. Ghassemi and M. Mansour. (1990). Positive Deviance in Child Nutrition with Emphasis on Psychosocial and Behavioural Aspects and Implications for Development. WHO/UNICEF Joint Nutrition Support Programme. The United Nation University. (Food and Nutrition Bulletin Supplement 14).
Claudio Schuftan MD
SAIGON-VIETNAM.