Positive Deviance Research Articles

Identifying Factors that Support the Delivery of Exceptional Care in General Practice and Development of the IDEAL Framework: A Qualitative Study.

The positive deviance approach seeks to identify and learn from those that perform exceptionally well. Positive deviance as an approach to quality improvement is gaining traction in general practice. This study aimed to explore and compare stakeholders' perceptions of the factors that support the delivery of exceptional care in general practice and to refine a previously developed theoretical framework of factors associated with positively deviant care in general practice: the Identifying and Disseminating the Exceptional to Achieve Learning (IDEAL) framework. Semi-structured interviews were conducted with 33 purposively sampled patients, general practitioners, practice nurses, and practice managers in Irish general practice. Subsequently, a directed content analysis approach was employed to deductively analyse interview data using the IDEAL framework, and newly emerging factors were inductively analysed and abstracted into the framework. Several distinct strategies (e.g. patient activation and team collaboration), structures (e.g. facilities and staffing), and contextual factors (e.g. communication and rapport, and culture) were found to support the delivery of exceptional care, and differences in perceptions, values, and expectations emerged between patients and practice staff. Interview data largely supported the pre-determined factors posited by the IDEAL framework, and new factors were abstracted into the framework (e.g. facilities and infrastructure). Stakeholder engagement regarding the factors supporting exceptional care in general practice supported and extended the IDEAL framework, contributing to a more comprehensive understanding of how exceptional care is delivered in general practice. The refined framework will support researchers, policymakers, and teams looking to support, measure, and achieve exceptionally good patient care in general practice.

Eastern Australian Farmers Managing and Thinking Differently: Innovative Adaptation Cycles.

The uncertainty of climate change is a significant challenge prompting Australian farmers to create different thinking and different management systems that ensure sustained farm business viability and continuity, particularly in extreme environments. The purpose of this study was to explore the conditions and adaptive processes for managing farm resilience and cyclic adaptation pathways, in response to climate change. A positive deviance sample of farmers was interviewed, and data was collected from a cohort of twenty-two climate change innovators across Eastern Australia. Grounded theory analysis of data identified three processes and two transactional maps of climate change adaptation, in this under studied farmer cohort. The development of the transactional maps found the resilience and preparedness processes as adaptive learning responses to the stressors of climate change. The processes of managing the business and resources were identified as markers of preparedness and resilience that ensured business viability and continuity. Farmers prepared for climate change through transforming make-over processes as an adaptive learning response to climate challenges. Mapping the cycle of adaptation identified the processes of socio-cognitive agency, learning from feedback and consequences, and contextual variables as critical elements of adaptation. The intervening socio-ecological processes of intelligence gathering and influencing, and socio-cognitive precursors, were found to regulate the adaptation cycle. The cycle was found to have both incremental and transformative transmission processes, and intervening processes of climate and contextual variables. The changing patterns and extremes of climate change were found to impact the growing season, and its potential, as unique variables that demand farm adaptation. Ultimately, this study identified potential points of influence for leveraging preparedness behaviours.

Effect of Positive Deviance Approach on Promotion of Safe Disposal of Child’s Faeces in Rural Tamil Nadu: A Community-Based Quasi-Experimental Study

Background: Unsafe disposal of child’s faeces plays a crucial role in disease transmission and environmental pollution. These areas are overlooked by many sanitation promotion interventions. The objective was to determine the effect of Positive Deviance (PD) approach on safe disposal of child’s faeces among households who owned a toilet. Methodology: A community-based quasi-experimental study was carried out in the four field practice villages of UHTC, Villupuram for 18 months. Households who owned a toilet and had a child <5 years were included. After IEC clearance, information was collected from a representative sample of 100 households before intervention and another 100 households after intervention. PD approach was applied for six months to promote safe disposal practices. Data was analyzed in SPSS 24 software. Chi square test and Effect size (Cramer’s V) were employed. Results: Before intervention, only 3% households disposed the faeces into a toilet. While, after intervention, almost 38% households disposed in the toilet (c2=37.39; df=1; p=0.001). Effect size was found to be 0.43. Conclusion: PD approach demonstrated considerable improvements in safe disposal of child’s faeces in rural settings. Further, in order to sustain the behaviour, change frequent reinforcement of key messages at frequent intervals need to emphasized.

385. HOSPITAL COSTS OF POSTOPERATIVE ADVERSE EVENTS FOLLOWING ESOPHAGECTOMY: RESULTS FROM 10 CANADIAN INSTITUTIONS

Abstract Background Surgical resection plays a central role in the multimodal curative intent management of esophageal cancer. Despite advances in peri-operative care, 60% of patients undergoing esophagectomy experience postoperative adverse events (AEs), if AEs are prospectively collected by surgeons. We recently performed a systematic review documenting the published index hospital costs of AEs, yet the overall costs of AEs in Canadian esophageal centres remains unknown. Methods Between 2017–2021, prospectively collected data from 10 Canadian esophageal centres were included. Volumes of esophagectomy, incidence of postoperative AEs (anastomotic leak (AL), pneumonia, respiratory failure), graded using the Ottawa TM&M system [ottawatmm.org], and obtained from 2 Canadian Association of Thoracic Surgeons (CATS) National Positive Deviance Seminars were included. Using literature-derived index hospitalization costs of AEs, estimates of annual costs were obtained (2023 Cdn$). Results Data from 795 esophagectomies performed in Canada between 2017–2019 revealed an average AL rate of 15% (8.7–22%). This led to an estimated yearly hospital cost of $6.63 M. Additional data from 863 esophagectomies performed between 2018–2021 revealed an average yearly pneumonia rate of 10.2% (2.4–20.3%)., with an estimated cost of $1.44 M, and respiratory failure (requiring ICU admission) of 7.8% (0–13.8%), with an estimated cost of $1.83 M. When all 10 centres are combined, these 3 AEs equate to over $9.9 M in hospital expenditures/year. A 1% reduction/year in the 3 AEs would lead to a cost-savings of $816,738. Conclusion Our analysis of only 3 post-operative AEs highlights the staggering costs to hospitals across Canada individually, and collectively, and emphasizes the need to support value-based QI research. Direct financial support from hospitals to support value-based QI in esophageal surgery has the potential to simultaneously improve care and provide valuable cost savings.

How did local wisdom and practice make schools thrive during the pandemic? Evidence from a positive deviance study in rural Uganda

PurposeThis research explores the impact of the locally grown strategies for learning support, as a positive deviance (PD) study, during the COVID-19 pandemic in rural Uganda.Design/methodology/approachThe researchers employed a randomized control trial (RCT) as an original design whereby 50 schools received a full package of SMS and WhatsApp peer groups of head teachers, 50 schools received SMS only and another 50 served as a control group. As an analytical method, this study adopted a difference-in-difference (DID) model to analyze the impact of the radio talk shows promoted through SMS followed by discussion among WhatsApp peer groups. The data collected in June 2021 and February 2022 were used due to the COVID-19-related data limitation of the baseline survey collected in 2019.FindingsThe authors found that the local radio talk shows as a PD intervention had a humble impact on preventing pupils’ dropout during the school closures for two years in Uganda. However, the authors did not obtain a significant result on the impact of the PD intervention on pedagogical support or learning outcomes at the school level. The authors also found that the pupils have significantly dropped their level of proficiencies in literacy and numeracy during the pandemic.Originality/valueThe findings could be of value for the leaders, educators and policymakers to understand the most recent update of learning situation in Uganda and the potential impact of locally grown strategies for learning which does not require external inputs.

P24-054-23 Applying Positive Deviance To Improve Nutrition and Health-Focused Policy, Systems, and Environmental Change Implementation

P24-054-23 Applying Positive Deviance To Improve Nutrition and Health-Focused Policy, Systems, and Environmental Change Implementation

Efficiency, quality, and management practices in multidisciplinary and traditional diabetes healthcare services in Mexico

AbstractDiabetes is a major health issue in middle-income countries like Mexico. Multidisciplinary healthcare (MHC) models aim to improve diabetes care and reduce costs. However, the relationship between management practices, efficiency, and quality of care in MHC and traditional healthcare (THC) models is unclear. This study evaluates the efficiency and quality of diabetes healthcare models in Mexico, identifying associated management practices. Methodology. Data from a retrospective longitudinal analysis were used to compare 20 THC and 20 MHC. Technical efficiency (TE) scores were estimated using data envelopment analysis (DEA), quality scores were calculated based on provider competence and patient performance. The relationship between efficiency, quality, and management practices was analyzed using positive deviance regression. Results. DEA analysis indicate higher TE in MHC units (mean score: 65, SD = 19) compared to THC units (mean score: 24, SD = 23). MHC units scored 78.55 (SD = 18.71) in performance score, while THC units scored 37.7 (SD = 18.97). MHC units also outperformed THC units in competence scores (mean: 68.71, SD = 18.31 vs. 49.97, SD = 23.31). Several management practices were associated with best performance in terms of both efficiency and quality strategic thinking, human resource management, financial management, operations management, performance management, and governance. Conclusion. This study highlights the higher efficiency of MHC models in diabetes care compared to THC models in Mexico. However, both models require improvement in quality. Understanding the relationship between management practices, efficiency, and quality can guide policymakers in enhancing diabetes care in low- and middle-income countries.

The persistence of cognitive biases in financial decisions across economic groups

While economic inequality continues to rise within countries, efforts to address it have been largely ineffective, particularly those involving behavioral approaches. It is often implied but not tested that choice patterns among low-income individuals may be a factor impeding behavioral interventions aimed at improving upward economic mobility. To test this, we assessed rates of ten cognitive biases across nearly 5000 participants from 27 countries. Our analyses were primarily focused on 1458 individuals that were either low-income adults or individuals who grew up in disadvantaged households but had above-average financial well-being as adults, known as positive deviants. Using discrete and complex models, we find evidence of no differences within or between groups or countries. We therefore conclude that choices impeded by cognitive biases alone cannot explain why some individuals do not experience upward economic mobility. Policies must combine both behavioral and structural interventions to improve financial well-being across populations.

Success in Education by Defying Great Odds: A Positive Deviance Analysis of Educational Policies

EEducation is seen as a resource at a global level but is currently considered to be in crisis in many parts of the world. This constitutes a significant drawback in terms of humanity’s prosperity and well-being since education is the key not only to an educated workforce but also to humane, collaborative, and caring societies. Even within this dim landscape, there are certain educational systems that defy the odds and perform significantly higher than their otherwise comparable systems. This paper proposes using an unusual lens for educational policy comparative studies, that of positive deviance, to aid us in progressing towards a more stable educational state of affairs. Using a positive deviance methodology, which focuses on learning what is working well in systems that defy and overcome substantial challenges, this study investigates the patterns, attitudes, and actions of three selected cases: Massachusetts as a positive deviant in the US, Estonia as a positive deviant in Europe, and Castile-Leon as a positive deviant in Spain. The purpose is, by analysing educational policies, laws, and other related documents, to find commonalities that explain why these systems outperform others. The results of the comparative analysis pinpoint areas and strategies informative to those leading struggling educational systems, such as a strong commitment to equity and justice, placing teachers at the centre of reforms, using assessment as a tool for process monitoring and summative inquiry, and making preschool education accessible to all.

Public finance management architecture in Tajikistan: International reform advice and domestic reform practice

AbstractDebates persist on the effectiveness of externally driven Public Finance Management (PFM) reforms in developing countries, with limited empirical research and field investigations in the Central Asian region. This study collected evidence through Solution and Leader Driven Change (SLDC) and Problem Driven Iterative Adaptation (PDIA) theoretical framework explanations, policy documents review, interview and survey results and Public Expenditure and Financial Accountability (PEFA) framework assessments to find that not all of the World Bank's advice on PFM improvement was adopted in the first phase of reforms in Tajikistan. Blending SLDC and PDIA arguments, the study investigates both positive deviants and reform failures.

A new method to assess sustainability of agricultural systems by integrating ecosystem services and environmental impacts

Agricultural stakeholders disagree on how to put the general concept of sustainability into practice. But most recognize the need for assessment methods to characterize the current situation and gauge progress yet to be made. Many sustainability assessment methods for agricultural systems have been published, but very few integrate ecosystem services (ES). And yet, ES indicators are key to better integrating biological processes to support the agroecological transition. Although researchers have attempted to link the concept of environmental impact (EI) and ES through life cycle analysis (LCA), gaps remain when it comes to doing so within a sustainability assessment method. Here a new method based on an original conceptual indicator framework embedding new predictive indicators of EI and ES indicators was developed. This framework covers 22 environmental themes and integrates few basic economic and social indicators. The method was implemented on 33 farms with different certifications and production specifications. All farms were members of an agricultural cooperative in north-eastern France. We selected 250 plots to cover the farms’ crop rotations. The correlation analysis showed no systemic trade-off between EI or ES and economic indicators. Meanwhile, the joint assessment of ES and EI (like the multivariate analysis), delivered more nuanced results than a classical opposition between intensive and organic farming. Some farms with a moderate or even good level of ES often do not leverage them, as shown by their high EI. The principle component analysis and subsequent hierarchical ascendant classification allowed us to distinguish five clusters providing a more complex picture than simply opposing conventional and organic agriculture. Finally, the positive deviance analysis revealed that economic, environmental and social considerations can be balanced in a way that seems to be more sustainable than, for example, an organic farm that has very successfully reduced EI but at a cost of several economic and social trade-offs.

Pendekatan Positive Deviance Dalam Mereduksi Kejadian Malaria Di Kota Jayapura

Malaria is still a public health problem in the world, including in Indonesia. Positive deviation behavior is one of the factors that influence the incidence of malaria. So this study aims to determine the effect of positive deviation on the incidence of malaria in Jayapura City. This community service was carried out in the Mandala Village area, Jayapura City, Papua Province. The community service method uses the Community Empowerment method using Focus Group Discussion (FGD). Sampling using Exautive sampling (sampling technique when all members of the population are used as samples). The data collected will be analyzed using SPSS version 21.0. The results of the quantitative analysis showed that the most influential factor on the incidence of malaria was positive deviation (p=0.000). The results of the qualitative analysis show that positive deviation behaviors to prevent malaria are using mosquito nets when sleeping, wearing long sleeves when working and when going out at night, and burning trash and coconut belts. The positive deviation approach can be used as an effort to prevent and control malaria through the active role of health cadres or community leaders. Keywords: Malaria, Positive Deviance, Behavior, Prevention

The Development of Children’s Learning Assistance Strategy in The Covid-19 Pandemic with a Positive Deviance Approach

This study aims to help parents develop effective learning assistance strategies for their children's distance learning during COVID-19 pandemic. This study applies action research with a positive deviance approach, involving the transfer of knowledge and experiences of positive deviants, namely parents who have previously found adaptive assisting strategies. The participants consisted of parents of elementary school students, with children who are carrying out full learning from home. Data collection was carried out through interviews, focus group discussions, observation, and the use of documents via a google form, while the data analysis used thematic analysis techniques. The results obtained are in the form of a formulation of effective learning assistance strategies applied at home based on good parental practices during the COVID-19 pandemic, consisting of steps to overcome four specific challenges. All strategic steps formulated have a positive impact on both parents and children.

Health service quality in 2929 facilities in six low-income and middle-income countries: a positive deviance analysis

Primary care is of insufficient quality in many low-income and middle-income countries. Some health facilities perform better than others despite operating in similar contexts, although the factors that characterise best performance are not well known. Existing best-performance analyses are concentrated in high-income countries and focus on hospitals. We used the positive deviance approach to identify the factors that differentiate best from worst primary care performance among health facilities across six low-resource health systems. This positive deviance analysis used nationally representative samples of public and private health facilities from Service Provision Assessments of the Democratic Republic of the Congo, Haiti, Malawi, Nepal, Senegal, and Tanzania. Data were collected starting June 11, 2013, in Malawi and ending Feb 28, 2020, in Senegal. We assessed facility performance through completion of the Good Medical Practice Index (GMPI) of essential clinical actions (eg, taking a thorough history, conducting an adequate physical examination) according to clinical guidelines and measured with direct observations of care. We identified hospitals and clinics in the top decile of performance (defined as best performers) and conducted a quantitative, cross-national positive deviance analysis to compare them with facilities performing below the median (defined as worst performers) and identify facility-level factors that explain the gap between best and worst performance. We identified 132 best-performing and 664 worst-performing hospitals, and 355 best-performing and 1778 worst-performing clinics based on clinical performance across countries. The mean GMPI score was 0·81 (SD 0·07) for the best-performing hospitals and 0·44 (0·09) for the worst-performing hospitals. Among clinics, mean GMPI scores were 0·75 (0·07) for the best performers and 0·34 (0·10) for the worst performers. High-quality governance, management, and community engagement were associated with best performance compared with worst performance. Private facilities out-performed government-owned hospitals and clinics. Our findings suggest that best-performing health facilities are characterised by good management and leaders who can engage staff and community members. Governments should look to best performers to identify scalable practices and conditions for success that can improve primary care quality overall and decrease quality gaps between health facilities. Bill & Melinda Gates Foundation.

Factors associated with syndemic anemia and stunting among children in Myanmar: A cross-sectional study from a positive deviance approach

BackgroundAnemia and stunting in children are detrimental to the prospects of a normal, healthy upbringing. Having similar risk factors and serious consequences, the syndemic aspect of these two ailments is mostly underrated, and positive deviant (PD) factors that ensure non-anemic status in stunted children have not been studied to date. MethodsThis study aimed to identify PD factors that have potential to prevent syndemic anemia among stunted children aged 6–59 months in Myanmar. This was a cross-sectional secondary analysis of the Myanmar Demographic and Health Survey (DHS) data conducted in 2016, applying the PD concept, where children who were stunted without anemia were considered as PDs. ResultsAmong 1248 stunted children, those who had the syndemic condition were compared with their PD peers in terms of maternal characteristics as well as socioeconomic and health-related factors. Multivariable logistic regression analyses were used to identify the determinants of syndemic state. The results showed that three out of every five stunted children were anemic. The syndemic risk was decreased among children of maternal age groups 20–34 years and 35–44 years: [aOR] = 0.19, 95% CI = 0.05–0.69; p = 0.012, and aOR = 0.19, 95% CI = 0.05–0.75; p = 0.018, respectively. Moderately stunted children (aOR = 0.53, 95% CI = 0.34–0.81; p = 0.004) and children who were not currently breastfed (aOR = 1.56, 95% CI = 1.01–2.41; p = 0.044) were less likely to develop the syndemic condition. ConclusionMaternal age, stunting severity, breastfeeding duration, and maternal anemic status are strong predictors in determining hemoglobin concentrations among stunted children. This study suggests that nutritional interventions targeting PD factors could represent syndemic action in improving child health.

Dual Schooling for Low-Resource Families: An Exploratory Study From a Positive Deviance Perspective

Parent education programs are important avenues through which parents of children with developmental delays can learn new skills to help them with child-rearing challenges. However, those in economic hardship often face problems with applying these skills at home where the child’s learning and/or behavioral problems commonly occur. In this exploratory qualitative study, we adopted a positive deviance (PD) lens to explore strategies six economically disadvantaged parents used to support their children who were attending special and mainstream preschools concurrently. The PD perspective was first used in public health research with low-resource communities where a few individuals have been observed to adopt uncommon practices and behaviors that enable them to find better ways to prevent social or health problems than their neighbors facing similar constraints and risks. We identified adaptive parental behaviors, thoughts and feelings that helped them navigate daily hassles faced with “dual schooling” their children in Singapore. The study highlights important implications in the development and refinement of future parent training programs.

Perspectives on National Institutes of Health Funding Requirements for Racial and Ethnic Diversity Among Medical Scientist Training Program Leadership

Since 1964, the National Institutes of Health (NIH) has funded the Medical Scientist Training Program (MSTP) MD-PhD program at medical schools across the US to support training physician-scientists. Recent studies have suggested that MSTPs have consistently matriculated more students from racial and ethnic backgrounds historically underrepresented in science than MD-PhD programs without NIH funding; however, the underlying basis for the increased diversity seen in NIH-funded MSTPs is poorly understood. To investigate how administrators and faculty perceive the impact of MSTP status on MD-PhD program matriculant racial and ethnic diversity. This qualitative study used a positive deviance approach to identify 9 high-performing and 3 low-performing MSTPs based on the percentage of students underrepresented in science who matriculated into the program between 2014 and 2018. This study, a subanalysis of a larger study to understand recruitment of students underrepresented in science at MSTPs, focused on in-depth qualitative interviews, conducted from October 26, 2020, to August 31, 2022, of 69 members of MSTP leadership, including program directors, associate and assistant program directors, and program administrators. The association of NIH funding with institutional priorities, programs, and practices related to MD-PhD program matriculant racial and ethnic diversity. The study included 69 participants (mean [SD] age, 53 [10] years; 38 women [55%]; 13 African American or Black participants [19%], 6 Asian participants [9%], 12 Hispanic participants [17%], and 36 non-Hispanic White participants [52%]). A total of 51 participants (74%) were in administrative roles, and 18 (26%) were faculty involved in recruitment. Five themes emerged from the data: (1) by tying MSTP funding to diversity efforts, the NIH created a sense of urgency among MSTP leadership to bolster matriculant diversity; (2) MD-PhD program leadership leveraged the changes to MSTP grant review to secure new institutional investments to promote recruitment of students underrepresented in science; (3) MSTPs increasingly adopted holistic review to evaluate applicants to meet NIH funding requirements; (4) MSTP leadership began to systematically assess the effectiveness of their diversity initiatives and proactively identify opportunities to enhance matriculant diversity; and (5) although all MSTPs were required to respond to NIH criteria, changes made by low-performing programs generally lacked the robustness demonstrated by high-performing programs. This study suggests that NIH funding requirements may be a powerful incentive to promote diversity and positively affect representation of students underrepresented in science in the biomedical scientific workforce.

Can US Medical Schools Teach About Structural Racism?

Since the beginning of COVID-19 and the rise of social justice movements sparked by the murders of George Floyd and Breonna Taylor in the summer of 2020, many medical schools have made public statements committing themselves to become antiracist institutions. The notions that US society generally, and medicine, are rife with structural racism no longer seems as controversial in the academic community. Challenges remain, however, in how this basic understanding gets translated into medical education practice. Understanding where the profession must go should start with understanding where we currently are. Prior to the events of 2020, in the spring of 2018, we conducted nine key informant interviews to learn about the challenges and best practices from schools deemed to be positive deviants in teaching about structural racism. Our interviews showed that even those schools deemed positive deviants in the amount of teaching done about structural racism faced significant barriers in providing a robust education. Significant structural change, perhaps far beyond what most schools consider themselves willing and able to engage in, will be necessary if future US physicians are to fully understand and address structural racism as it affects their profession, their practice, and their patients.

Effectiveness of Positive Deviance Approach to Reduce Malnutrition among under Five Children: A Systematic Review and Meta-Analysis of Interventional Studies.

The high malnutrition rate in children under five makes this problem one of the public health problems. Various efforts have been made to reduce malnutrition in children under five, one of which is the implementation of community programs with a positive deviance approach which is considered an effective way because the solution to the problem comes from the local community. Thus, we conducted a systematic review and meta-analysis to determine the effect of interventions with a positive deviance approach to reducing under-five children's malnutrition. Systematic searches were conducted using the following journal databases: Science Direct, Pubmed, Proquest, SAGE journal, Web of Science, and Scopus. The article was included if using an intervention design. Data analysis used Review Manager 5.4 software, random effect model, outcome mean of difference, and 95% confidence interval. There were no significant differences between the intervention and control groups on the length for age z-scores (LAZ), weight for age z-scores (WAZ), and weight for height z-scores (WHZ) indicators. There was an increase in LAZ, WAZ, and WHZ scores in the intervention group, with a greater z-score than in the control group. In conclusion, interventions with the positive deviance approach can be used as an alternative to improving the nutritional status of under-five children. However, further research is needed to determine the effective duration of interventions in improving the nutritional status of children.

When Abusive Supervision Increases Workplace Deviance: The Moderating Role of Psychological Safety and Organizational Identification

This study offers new insights into the moderators between abusive supervision and workplace deviance. Building on the conservation of resources theory, the study introduces coping resources as moderators between abusive supervision and the two dimensions of workplace deviance, that is, interpersonal and o rganizational deviance. The study identifies psychological safety, an intrapsychic state, as a moderator between abusive supervision and interpersonal deviance. Similarly, the research tests organizational identification as a moderator between abusive supe rvision and organizational deviance. The study tests the hypotheses by collecting two source of data from various Pakistani organizations. The two source data from 122 supervisor subordinate dyads provide support for the results. The study finds that low p sychological safety strengthens the positive link between abusive supervision and interpersonal deviance. Besides, a low level of identification with an organization strengthens the positive association between abusive supervision and organizational devian ce. Thus, the study extends the literature by highlighting the importance of several personal and coping resources for employees at work.