Using the role model approach to optimise caregiver administration of sulfadoxine-pyrimethamine amodiaquine to children aged 3-59 months in Burkina Faso, Chad and Togo: findings from an evaluation.

BACKGROUND: Seasonal malaria chemoprevention (SMC) is a World Health Organization-recommended intervention for the prevention of malaria among children at high risk in areas with seasonal transmission. During the coronavirus disease 2019 (COVID-19) pandemic, SMC drug distribution was rapidly adapted to reduce contact and mitigate the risk of transmission between communities and community distributors, with caregivers administering doses. To address the challenges and find local solutions to improve administration and adherence, the role model approach was designed, implemented and evaluated in selected communities of Burkina Faso, Chad and Togo. This paper describes the results of this evaluation. METHODS: Focus group discussions were held with primary caregivers in all three countries to understand their perceptions of the approach's acceptability and feasibility. In Burkina Faso and Togo, household surveys assessed the characteristics of caregivers reached by role model activities. Key indicators on SMC coverage and adherence allowed for an assessment of caregiver engagement outcomes related to participation in activities. Statistical associations between participation in study's activities and caregiver beliefs related to SMC had been tested. RESULTS: The majority of caregivers believed the approach to have a positive effect on drug administration, with most adopting the promoted strategies. Greater involvement of fathers in drug administration and acknowledgement of their joint responsibility was a notable positive outcome. However, several barriers to participation were noted and there was criticism of the group approach. In Burkina Faso and Togo, end-of-round survey results revealed that 98.4% of respondents agreed the approach improved their knowledge and skills in malaria prevention, while 100% expressed a desire to continue practicing the behaviours learned. However, there was a relatively low level of awareness of the approach among communities. Participation was strongly associated with participants' self-reported belief in ease of remembering to administer, and ease of administering, SMC medicines. CONCLUSION: Caregivers perceived the role model approach to be beneficial in aiding drug administration, with other positive impacts also reported. Replication and scale-up should utilize the most popular communication channels and existing community structures to ensure activities are promoted effectively. A mixture of group and one-on-one approaches should be used where appropriate and feasible.

A trans-Canadian positive deviance seminar for paraesophageal hernia surgery: Reporting national postoperative outcomes and consensus recommendations.

BACKGROUND: The incidence of adverse events (AEs) and length of stay (LOS) varies significantly following paraesophageal hernia surgery. We performed a Canadian multicenter positive deviance (PD) seminar to review individual center and national level data and establish holistic perioperative practice recommendations. METHODS: A national virtual PD seminar was performed in October 2021. Recent best evidence focusing on AEs and LOS was presented. Subsequently, anonymized center-level AE and LOS data collected between 01/2017 and 01/2021 from a prospective, web-based database that tracks postoperative outcomes was presented. The top two performing centers with regards to these metrics were chosen and surgeons from these hospitals discussed elements of their treatment pathways that contributed to these outcomes. Consensus recommendations were then identified with participants independently rating their level of agreement. RESULTS: Twenty-eight surgeons form 8 centers took part in the seminar across 5 Canadian provinces. Of the 680 included patients included, Clavien-Dindo grade I and II/III/IV/V complications occurred in 121/39/12/2 patients (17.8%/5.7%/1.8%/0.3%). Respiratory complications were the most common (effusion 12/680, 1.7% and pneumonia 9/680, 1.3%). Esophageal and gastric perforation occurred in 7 and 4/680, (1.0% and 0.6% respectively). Median LOS varied significantly between institutions (1 day, range 1-3 vs. 7 days, 3-8, p < 0.001). A strong level of agreement was achieved for 10/12 of the consensus statements generated. CONCLUSION: PD seminars provide a supportive forum for centers to review best evidence and experience and generate recommendations based on expert opinion. Further research is ongoing to determine if this approach effectively accomplishes this objective.

Red Ribbon Club inculcation of positive deviance approach to promote blood donation among undergraduate medical college students.

BACKGROUND: Blood is an essential part of human life and blood donation has become a necessity that every society must take into consideration. Health care professionals have a major responsibility in raising community awareness on blood donation. OBJECTIVE: This study aims to find out the knowledge and attitude of undergraduate medical students on blood donation and to determine the effectiveness of positive deviance (PD) approach. METHODOLOGY: This institutional based cross-sectional study was conducted as a part of World AIDS Days celebration by Red Ribbon club among 414 undergraduate students using convenient sampling technique. A baseline and endline survey were conducted using a pre-structured validated questionnaire. To address the knowledge gap PD approach was used for the students who had voluntarily donated blood, volunteered in providing health education, and shared their experience to their peers. Ethical principals were adhered. RESULTS: The mean age of the students was 20.4 ± 1.2 years. Most respondents had moderate knowledge on blood donation and positivity attitude towards the same. The key finding of our study is that about 45 students (10.9%) have donated blood till now. As a result of PD training session more than half of them volunteered to donate blood in the future. CONCLUSION: This study shows that awareness about blood donation were minimal among the medical students with misconceptions. After PD approach, the willingness was increased from 10% to 66%. Thus, PD approach builds capacity and leadership in volunteers is considered as the best approach for behavior change among their own peers.

The use of positive deviance approach to improve health service delivery and quality of care: a scoping review.

BACKGROUND: Quality has been a persistent challenge in the healthcare system, particularly in resource-limited settings. As a result, the utilization of innovative approaches is required to help countries in their efforts to enhance the quality of healthcare. The positive deviance (PD) approach is an innovative approach that can be utilized to improve healthcare quality. The approach assumes that solutions to problems are already available within the community and identifying and sharing those solutions can help others to resolve existing issues. Therefore, this scoping review aimed to synthesize the evidence regarding the use of the PD approach in healthcare system service delivery and quality improvement programs. METHODS: Articles were retrieved from six international databases. The last date for article search was June 02, 2023, and no date restriction was applied. All articles were assessed for inclusion through a title and/or abstract read. Then, articles that passed the title and abstract review were screened by reading their full texts. In case of duplication, only the full-text published articles were retained. A descriptive mapping and evidence synthesis was done to present data with the guide of the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews checklist and the results are presented in text, table, and figure formats. RESULTS: A total of 125 articles were included in this scoping review. More than half, 66 (52.8%), of the articles were from the United States, 11(8.8%) from multinational studies, 10 (8%) from Canada, 8 (6.4%) from the United Kingdom and the remaining, 30 (24%) are from other nations around the world. The scoping review indicates that several types of study designs can be applied in utilizing the PD approach for healthcare service and quality improvement programs. However, although validated performance measures are utilized to identify positive deviants (PDs) in many of the articles, some of the selection criteria utilized by authors lack clarity and are subject to potential bias. In addition, several limitations have been mentioned in the articles including issues in operationalizing PD, focus on leaders and senior managers and limited staff involvement, bias, lack of comparison, limited setting, and issues in generalizability/transferability of results from prospects perspective. Nevertheless, the limitations identified are potentially manageable and can be contextually resolved depending on the nature of the study. Furthermore, PD has been successfully employed in healthcare service and quality improvement programs including in increasing surgical care quality, hand hygiene practice, and reducing healthcare-associated infections. CONCLUSION: The scoping review findings have indicated that healthcare systems have been able to enhance quality, reduce errors, and improve patient outcomes by identifying lessons from those who exhibit exceptional practices and implementing successful strategies in their practice. All the outcomes of PD-based research, however, are dependent on the first step of identifying true PDs. Hence, it is critical that PDs are identified using objective and validated measures of performance as failure to identify true PDs can subsequently lead to failure in identifying best practices for learning and dissemination to other contextually similar settings.

Reducing Overuse by Healthcare Systems: A Positive Deviance Analysis.

BACKGROUND: Healthcare in the USA is increasingly delivered by large healthcare systems that include one or more hospitals and associated outpatient practices. It is unclear what role healthcare systems play in driving or preventing overutilization of healthcare services in the USA. OBJECTIVE: To learn how high-value healthcare systems avoid overuse of services DESIGN: We identified "positive deviant" health systems using a previously constructed Overuse Index. These systems have much lower-than-average overuse of healthcare services. We confirmed that these health systems also delivered high-quality care. We conducted semi-structured interviews with executive leaders of these systems to validate a published framework for understanding drivers of overuse. PARTICIPANTS: Leaders at select healthcare systems in the USA. INTERVENTIONS: None APPROACH: We developed an interview guide and conducted semi-structured interviews. We iteratively developed a code book. Paired reviewers coded and reconciled each interview. We analyzed the interviews by applying constant comparative techniques. We mapped the emergent themes to provide the first empirical data to support a previously developed theoretical framework. KEY RESULTS: We interviewed 15 leaders from 10 diverse healthcare systems. Consistent with important domains from the overuse framework, themes from our study support the role of clinicians and patients in avoiding overuse. The leaders described how they create a culture of professional practice and how they modify clinicians' attitudes to facilitate high-value practices. They also described how their patients view healthcare consumption and the characteristics of their patient populations allowed them to practice high-value medicine. They described the role of quality metrics, insurance plan ownership, and alternative payment model participation as encouraging avoidance of overuse. CONCLUSIONS: Our qualitative analysis of positive deviant health systems supports the framework that is in the published literature, although health system leaders also described their financial structures as another important factor for reducing overuse and encouraging high-value care delivery.

Identifying Strategies for Improving Pre-exposure Prophylaxis Adherence: Perspectives from a Sample of Highly Adherent Young Men Who have Sex with Men.

Most research on pre-exposure prophylaxis (PrEP) adherence and persistence uses a deficit-based approach to identify negative influences on PrEP adherence; however, an alternative set of approaches (such as resilience, asset-based, and positive variation) may identify equally important positive influences on PrEP adherence. Thus, the current study presents qualitative perspectives of PrEP adherence strategies from a sample of adherent YMSM. PrEP-using YMSM living in the Chicago area from a larger cohort study were recruited into a 90-day diary study that measured sexual health behaviors including PrEP use. A subset (n = 28) were then recruited for in-depth interviews between April and September 2020 covering topics of PrEP use and adherence. Thematic analysis was used to interpret patterns within the data. The analytic sample (n = 19) consistently reported high levels of adherence. Adherence strategies were organized into three broader categories: psychological (e.g. mindfulness, pill auditing), technical/instrumental (e.g. automated reminders, pill organizers), and social strategies (e.g. checking in with friends, or getting suggestions from friends). The majority of participants described using multiple strategies and changing strategies to respond to barriers to adherence. Other themes that were related to adherence included having a daily medication history and a generally positive outlook toward the PrEP regimen. Those who had medication histories were able to draw from experience to develop strategies for PrEP adherence. Findings suggest the need for pre-emptive counseling for PrEP-initiators on the use of multiple strategies, how to prepare for PrEP adherence, to adapt to challenges, and to adopt a range of potential strategies for adherence.

RESUMEN: La mayoría de las investigaciones sobre el cumplimiento y la persistencia de la profilaxis pre-exposición (PrEP) utiliza un enfoque basado en el déficit para identificar las influencias negativas en el cumplimiento de la PrEP; sin embargo, un conjunto alternativo de enfoques (como resiliencia, basado en en las capacidades o recursos, y variación positiva) puede identificar influencias positivas igualmente importantes en la adherencia a la PrEP. Por lo tanto, el estudio actual presenta perspectivas cualitativas de las estrategias de adherencia a la PrEP de una muestra de los hombres jóvenes que tienen sexo con hombres (YMSM) adherentes. Los YMSM que usaban PrEP que vivían en la región de Chicago de un estudio de cohorte más grande fueron reclutados en un estudio diario de 90 días que midió los comportamientos de salud sexual, incluido el uso de PrEP. Luego se reclutó un subconjunto (n = 28) para entrevistas en profundidad entre abril y septiembre de 2020 que cubrieron temas de uso y adherencia a la PrEP. El análisis temático se utilizó para interpretar patrones dentro de los datos. La muestra analítica (n = 19) reportó consistentemente altos niveles de adherencia. Las estrategias de adherencia se organizaron en tres categorías más amplias: psicológicas (p. ej., atención plena, auditoría de píldoras), técnicas/instrumentales (p. ej., recordatorios automáticos, organizadores de píldoras) y estrategias sociales (p. ej., ponerse en contacto con amigos o recibir sugerencias de amigos). La mayoría de los participantes describieron el uso de múltiples estrategias y el cambio de estrategias para responder a las barreras a la adherencia. Otros temas relacionados con la adherencia incluyeron tener un historial de medicación diario y una perspectiva generalmente positiva hacia el régimen de PrEP. Aquellos que tenían antecedentes de medicación pudieron aprovechar la experiencia para desarrollar estrategias para la adherencia a la PrEP. Los hallazgos sugieren la necesidad de asesoramiento preventivo para los iniciadores de la PrEP sobre el uso de múltiples estrategias, cómo prepararse para la adherencia a la PrEP, cómo adaptarse a los desafíos y adoptar una variedad de posibles estrategias para la adherencia.

What constitutes brilliant aged care? A qualitative study of practices that exceed expectation.

AIM: This study aimed to explore what constitutes brilliant aged care. BACKGROUND: Although many aged care services do not offer the care that older people and carers need and want, some perform better. Rather than focus on problems with aged care, this study examined brilliant aged care-practices that exceeded expectation. DESIGN: The methodology for this study was informed by grounded theory, underpinned by constructionism to socially construct meaning. METHODS: This study invited nominations for a Brilliant Award via a survey, and interviews with the nominees via web conference. After receiving survey responses from 10 nominators, interviews were conducted with 12 nominees. Data were analysed using reflexive thematic analysis and documented according to COREQ guidelines to optimise rigour and transparency. RESULTS: According to participants, brilliant aged care involved being relationally attuned to older people, a deep understanding of the older person, recognition of aged care as more than a job, innovative practices and permission to reprioritise. CONCLUSIONS: This study suggests that, in aged care, brilliance happens. It emphasises the importance of meaningful connections and relationships in aged care, where thoughtful acts acknowledge an older person's value and humanity as well as creativity and innovation. RELEVANCE TO CLINICAL PRACTICE: For those who manage and deliver aged care, the findings suggest that small practice changes can make a positive difference to older people. Brilliant aged care can involve acts of empathy; enthusiasm for aged care; innovative practices, even those that are small scale; and reprioritising workplace tasks to spend time with older people. For policymakers, this study highlights the need to recognise and raise the profile of the pockets of brilliance within the aged care sector. This might be achieved via awards and other initiatives that serve to celebrate and learn from brilliance in its myriad forms. PATIENT OR PUBLIC CONTRIBUTION: The nominees, who included carers, were invited to participate in workshops with other carers and older people to co-design a model of brilliant aged care, during which workshop participants discussed and critiqued the findings constructed from the data.

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.

Understanding rebel nurse leadership-as-practice: Challenging and changing the status quo in hospitals.

Some nurses are responding rebelliously to the changing healthcare landscape by challenging the status quo and deviating from suboptimal practices, professional norms, and organizational rules. While some view rebel nurse leadership as challenging traditional structures to improve patient care, others see it as disruptive and harmful. These diverging opinions create dilemmas for nurses and nurse managers in daily practice. To understand the context, dilemmas, and interactions in rebel nurse leadership, we conducted a multiple case study in two Dutch hospitals. We delved into the mundane practices to expand the concept of leadership-as-practice. By shadowing rebel nurse practices, we identified three typical leadership practices which present the most common "lived" experiences and dilemmas of nurses and nurse managers. Overall, we noticed that deviating acts were more often quick fixes rather than sustainable changes. Our research points to what is needed to change the status quo in a sustainable manner. To change unworkable practices, nurses need to share their experienced dilemmas with their managers. In addition, nurse managers must build relationships with other nurses, value different perspectives, and support experimenting to promote collective learning.

Beyond transformational leadership in nursing: A qualitative study on rebel nurse leadership-as-practice.

Most nurse leadership studies have concentrated on a classical, heroic, and hierarchical view of leadership. However, critical leadership studies have argued the need for more insight into leadership in daily nursing practices. Nurses must align their professional standards and opinions on quality of care with those of other professionals, management, and patients. They want to achieve better outcomes for their patients but also feel disciplined and controlled. To deal with this, nurses challenge the status quo by showing rebel nurse leadership. In this paper, we describe 47 nurses' experiences with rebel nurse leadership from a leadership-as-practice perspective. In eight focus groups, nurses from two hospitals and one long-term care organization shared their experiences of rebel nurse leadership practices. They illustrated the differences between "bad" and "good" rebels. Knowledge, work experience, and patient-driven motivation were considered necessary for "good" rebel leadership. The participants also explained that continuous social influencing is important while exploring and challenging the boundaries set by colleagues and management. Credibility, trust, autonomy, freedom, and preserving relationships determined whether rebel nurses acted visibly or invisibly. Ultimately, this study refines the concept of rebel nurse leadership, gives a better understanding of how this occurs in nursing practice, and give insights into the challenges faced when studying nursing leadership practices.

The power of positive deviance behaviours: From panic-gogy to effective pedagogy in online teaching.

This study examines university faculty members' successful behaviours and the factors influencing these behaviours, when dealing with the issues posed by emergency remote teaching during the COVID-19 pandemic. Data was gathered through interviews with 12 carefully chosen instructors who competently prepared and implemented their first online classes despite various challenges encountered during the crisis. Interview transcripts were analysed by applying the theoretical concepts of the positive deviance approach to identify exemplary behaviours in the face of crisis. The results revealed that the participants performed three unique but effective behaviours, called 'positive deviance behaviours', in their online teaching: philosophy-driven decision making informed planning and ongoing performance monitoring. These behaviours were affected by individual factors (e.g., community engagement and emotion management during different phases of emergency remote teaching) and organisational factors (e.g., networks/hardware and training/support). By examining the positive deviance behaviours of instructors who delivered effective classes, this study offers online teaching and faculty development strategies in both crisis and non-crisis situations.

Uptake of postnatal care and its determinants in Ethiopia: a positive deviance approach.

BACKGROUND: Postnatal care (PNC) services are an essential intervention for improving maternal and child health. In Ethiopia, PNC service has been poorly implemented, despite the governments and partners' attempt to improve maternal and child health service utilization. Moreover, many literatures identified that women with no education are significantly underutilized the PNC services. Thus, this study aimed to assess the PNC service uptake among women at high risk for underutilization of PNC services and to identify the individual and community level determinants of PNC services uptake in Ethiopia using the positive deviance approach. METHODS: Data from the Ethiopia Demographic and Health Survey 2016 were used. A total of 2417 deviant women (women with no education) were identified through a two-stage stratified sampling technique and included in this analysis. A multilevel mixed-effect binary logistic regression analysis was computed to identify the individual and community-level determinants of PNC services uptake among deviant women. In the final model, a p-value of less than 0.05 and adjusted odds ratio (AOR) with 95% confidence interval (CI) were used to declare statistically significant determinants of PNC services uptake. RESULTS: In this analysis, the uptake of PNC service among deviant women was 5.8% [95% CI: 4.9-6.8]. Working in the agriculture (AOR = 2.15, 95% CI: 1.13-3.52), being Orthodox religion follower (AOR = 2.56, 95% CI: 1.42-4.57), living in the highest wealth quantile (AOR = 2.22, 95% CI: 1.25-3.91) were the individual level determinants, whereas residing in the city administration (AOR: 3.17, 95% CI: 1.15-8.71), and living closer to health facility (AOR: 1.57, 95% CI: 1.03-2.39) were the community level determinants. CONCLUSION: The study highlighted a better PNC service uptake among deviant women who are working in the agriculture, follows orthodox religion, lives in highest household wealth status, resides in city administration, and living closer to the health facility. The positive deviance approach provides evidences for health policy makers and program implementers to improve health behavior in specific target population, and ultimately to bring better maternal and child health outcomes, despite acknowledged adverse risk profile. Such strategy and knowledge could facilitate targeted efforts aimed at achieving national goals of maternal and newborn mortality reduction in the country.

A behavioural study of obedience in health professional students.

Interprofessional Education and Collaborative Practice (IPECP) is a field of study suggested to improve team functioning and patient safety. However, even interprofessional teams are susceptible to group pressures which may inhibit speaking up (positive deviance). Obedience is one group pressure that can inhibit positive deviance leading to negative patient outcomes. To examine the influence of obedience to authority in an interprofessional setting, an experimental simulated clinical scenario was conducted with Respiratory Therapy (RT) (n = 40) and Advanced Care Paramedic (ACP) (n = 20) students. In an airway management scenario, it was necessary for students to challenge an authority, a senior anesthesiologist, to prevent patient harm. In a 2 × 2 design cognitive load and an interventional writing task designed to increase positive deviance were tested. The effect of individual characteristics, including Moral Foundations, and displacement of responsibility were also examined. There was a significant effect for profession and cognitive load: RT students demonstrated lower levels of positive deviance in the low cognitive load scenario than students in other conditions. The writing task did not have a significant effect on RT or ACP students' behaviour. The influence of Moral Foundations differed from expectations, In Group Loyalty was selected as a negative predictor of positive deviance while Respect for Authority was not. Displacement of responsibility was influential for some participants thought not for all. Other individual variables were identified for further investigation. Observational analysis of the simulation videos was conducted to obtain further insight into student behaviour in a compliance scenario. Individual differences, including experience, should be considered when providing education and training for positive deviance. Simulation provides an ideal setting to use compliance scenarios to train for positive deviance and for experimentation to study interprofessional team behaviour.

Identification of positive parenting practices among parents of young children living in low-income and racially, ethnically, and culturally diverse households.

Using the positive deviance approach, the purpose of this study was to identify parent feeding practices that might be protective against early childhood obesity among children with lower weight status (BMI percentile ≥5th-<85th) relative to higher weight status (BMI percentile ≥85th). Qualitative interviews were conducted with 71 parents of children aged 2-5 years old (48% girls) enrolled in the Minnesota Special Supplemental Nutrition Program for Women Infants and Children (WIC). Children were identified as having lower weight status (defined as 'positive deviants') (n = 36) or 'higher weight status' (n = 35), and were African American [n = 22], Hispanic [n = 23], or Hmong [n = 26]). Parents were asked about approaches to child feeding and health- and weight-related practices. Findings indicated that relative to caregivers of children with higher weight status, parents of children identified as positive deviant were more likely to report having a consistent routine for providing meals, using a guided choices approach, serving small portions of food during mealtimes, and trusting their child hunger and satiety cues. Moreover, parents of children identified as positive deviant were more likely to promote healthful eating and physical activity engagement and implement clear rules and limits for screen time than parents of children with higher weight status. Results suggest specific parent feeding behaviors and health-related practices that may influence child weight status among children living in low-income and racialized households. The findings of this study also provide research evidence and support the tenets of the Satter Division of Responsibility in Feeding framework. Parenting practices and strategies among parents of children identified as positive deviant are expected to be feasible and should be explored and communicated in future interventions to support age- and sex-recommended weight and health-related outcomes among young children to promote health equity.

Beyond the Sociocultural Rhetoric: Female Genital Mutilation, Cultural Values and the Symbolic Capital (Honor) of Women and Their Family in Conakry, Guinea-A Focused Ethnography Among "Positive Deviants".

Female genital mutilation (FGM) is justified by sociocultural arguments, including that it guarantees girls'/women's appropriate sexual behavior, thus preserving family honor. We explored the perspectives of Guineans who do not practice FGM ("positive deviants"), as well as of Guineans who still practice FGM but who are supportive of abandoning the practice ("reluctant adherents"). We conducted a "focused ethnographic" study in Conakry, Guinea with a sample of 58 people. Individual semi-structured interviews were undertaken to explore the views and experiences of 18 women and 12 men of different generations who abandoned the practice of FGM. Group interviews with an additional 16 women and 12 men (half of whom were "positive deviants" and the other half "reluctant adherents") validated and enriched the data. Participants consider that FGM has deleterious consequences as it: (1) does not prevent girls or married women from being sexually active outside of marriage; (2) may impair couples' sexual satisfaction, and thus lead to divorce, men's infidelity or polygamy; and (3) may reduce women's ability to have multiple children, because of the increased risk of infertility or obstetric complications. In addition, participants reported that many Guineans fear that the promotion of FGM abandonment is a Western plot to eradicate their culture. We conclude that Guineans who practice and do not practice FGM share the same cultural values about the importance of culturally appropriate sexual behavior, being married, and having many children, which are central sources of honor (symbolic capital) to women and their families. They, however, have opposing views on how to achieve these objectives. Based on our participants' perspectives, the harmful consequences of FGM can potentially sabotage these sources of honor. Recommendations for messages aimed at promoting FGM abandonment are discussed.

Motivating healthcare professionals (nurses, nurse assistants, physicians) to integrate new practices for preventing healthcare-associated infections into the care continuum: turning Positive Deviance into positive norms.

BACKGROUND: The literature examining healthcare-associated infections (HAI) points to two main problems in conforming to infection prevention and control (IPC) guidelines among healthcare professionals (HP). One is the discrepancy between HPs' behavioral intentions and their implementation in practice. The other refers to how HPs maintain these practices after the intervention stage ends. The method proposed in this study seeks to address both these issues by using the Positive Peviance (PD) approach to focus on the dissemination stage of interventions. The study seeks to offer a method for disseminating 27 PD practices to 135 HPs, among them nurses, nurse assistants and physicians, so as to help them maintain IPC guidelines, offer feedback on the dissemination process and examine the impact of the dissemination stage on changes in their behavior. METHODS: The theoretical model underlying this qualitative research was the Recognition-Primed dDecision (RPD) model, which we implemented in the field of healthcare-associated infections (HAIs). Moreover, we used the Discovery & Action Dialogue (DAD) and Think Aloud (TA) techniques to describe the methodological development of simulations for HPs. Feedback from the HP demonstrators underwent content analysis, while descriptive statistics were used to characterize behavioral changes. RESULTS: HPs' information processing regarding infection prevention shifts from peripheral/automatic processing to intuition and analytical/central processing, turning PD practices into positive norms. The HPs personally experienced finding a solution and made repeated corrections until they overcame the barriers. Most of the HPs (69.4%) reported that the practices were fully implemented, together with additional practices. CONCLUSIONS: Implementation of the dissemination stage indicates that in order for HPs to integrate and assimilate practices that are not in the official guidelines, merely observing simulations is not sufficient. Rather, each staff member must personally carry out the procedures.

Age differences in the impact of a Positive Deviance/Hearth programme on the nutritional status of children in rural Bangladesh.

OBJECTIVE: To examine the difference in the rehabilitation rate from underweight by child age at enrolment in the Positive Deviance (PD)/Hearth programme. DESIGN: This secondary data analysis used programme monitoring records of underweight children aged 6-60 months attending a 2-week PD/Hearth session and followed up for 6 months from September 2018 to March 2019. Data were analysed using multilevel mixed-effect regression and Poisson regression with robust variance. SETTING: Rajshahi Division, Bangladesh. PARTICIPANTS: A total of 5227 underweight (weight-for-age Z-score (WAZ) <-2) children attended the PD/Hearth sessions. RESULTS: From enrolment to 6 months follow-up, the mean WAZ improved from -2·80 to -2·09, and the percentage of underweight children decreased to 54·5 %. Compared to the enrolment age of 6-11 months, the estimated monthly change in WAZ at 6 months of follow-up were 0·05 lower for 12-23 months, 0·06 lower for 24-35 months, and 0·09 lower for 36-60 months of the enrolment age (all P < 0·001). The probability of rehabilitation at 6 months of follow-up were lower by 16·7 % for 12-23 months (RR = 0·83; 95 % CI 0·77, 0·91), 15·5 % for 24-35 months (RR = 0·84; 95 % CI 0·78, 0·92), and 34·9 % for 36-60 months of the enrolment age (RR = 0·65; 95 % CI 0·59, 0·72), compared to the enrolment age of 6-11 months. CONCLUSIONS: Enrolment in the PD/Hearth programme at a younger age had the advantage of greater rehabilitation from underweight than older age. Our findings provide a better understanding of the successes and failures of the PD/Hearth programme to achieve more sustainable and cost-effective impacts.

Using Narrative Evidence to Convey Health Information on Social Media: The Case of COVID-19.

During disease outbreaks or pandemics, policy makers must convey information to the public for informative purposes (eg, morbidity or mortality rates). They must also motivate members of the public to cooperate with the guidelines, specifically by changing their usual behavior. Policy makers have traditionally adopted a didactic and formalistic stance by conveying dry, statistics-based health information to the public. They have not yet considered the alternative of providing health information in the form of narrative evidence, using stories that address both cognitive and emotional aspects. The aim of this viewpoint paper is to introduce policy makers to the advantages of using narrative evidence to provide health information during a disease outbreak or pandemic such as COVID-19. Throughout human history, authorities have tended to employ apocalyptic narratives during disease outbreaks or pandemics. This viewpoint paper proposes an alternative coping narrative that includes the following components: segmentation; barrier reduction; role models; empathy and support; strengthening self-efficacy, community efficacy, and coping tools; preventing stigmatization of at-risk populations; and communicating uncertainty. It also discusses five conditions for using narrative evidence to produce an effective communication campaign on social media: (1) identifying narratives that reveal the needs, personal experiences, and questions of different subgroups to tailor messaging to produce targeted behavioral change; (2) providing separate and distinct treatment of each information unit or theory that arises on social networks; (3) identifying positive deviants who found creative solutions for stress during the COVID-19 crisis not found by other members of the community; (4) creating different stories of coping; and (5) maintaining a dialogue with population subgroups (eg, skeptical and hesitant groups). The paper concludes by proposing criteria for evaluating the effectiveness of a narrative.

Financial sustainability strategies of public primary health care centres in the Republic of Srpska, Bosnia and Herzegovina.

BACKGROUND: The literature on the functioning of public health facilities in health systems with significant arrears is limited. The growing liabilities of health facilities and the accumulating arrears have been a challenge in the Republic of Srpska. Most public primary healthcare (PHC) centres generated a gross loss in 2018. METHOD: Guided by the 'positive deviance' approach, we used an exploratory case study design to identify strategies used by managers to achieve financial sustainability in eight top-performing PHC centres. Qualitative data were collected through face-to-face in-depth semistructured interviews with key informants from the PHC centres that reported positive financial results in 2018. RESULTS: Seven organisational goals, comprising 34 financial sustainability strategies, were recognised during the data analysis and were used to build an organisational-level model for a PHC centre. CONCLUSION: Managers concurrently used multiple strategies to ensure financial sustainability. Each centre tailored its range of strategies to the organisational context, local context, and wider environment of the health system. The strategies were conceived and implemented by managers operating at different organisational levels under the leadership of top-level managers. Managers of indebted health facilities can learn from the positively deviant peers who manage facilities that achieved satisfactory financial performance.

Evaluation of mobile phone-based Positive Deviance/Hearth child undernutrition program in Cambodia.

Child undernutrition in Cambodia is a persistent public health problem requiring low-cost and scalable solutions. Rising cellphone use in low-resource settings represents an opportunity to replace in-person counselling visits with phone calls; however, questions remain on relative effectiveness. Our objective was to evaluate the impact of two options for delivering a World Vision infant and young child feeding (IYCF) counselling programme: (1) traditional Positive Deviance/Hearth (PDH) programme with in-person visits or (2) PDH with Interactive Voice Calling (PDH-IVC) which integrates phone calls to replace 62.5% of face-to-face interaction between caregivers and volunteers, compared to the standard of care (SOC). We conducted a longitudinal cluster-randomised controlled trial in 361 children 6-23 months. We used an adjusted difference-in-difference approach using baseline, midline (3 months) and endline (12 months) surveys to evaluate the impact on child growth among the three groups. At baseline, nearly a third of children were underweight, and over half were food insecure. At midline the PDH group and the PDH-IVC groups had improved weight-for-age z-scores (0.13 DID, p = 0.011; 0.13 DID, p = 0.02, respectively) and weight-for-height z-score (0.16 DID, p = 0.038; 0.24 DID, p = 0.002), relative to SOC. There were no differences in child height-for-age z-scores. At endline, the impact was sustained only in the PDH-IVC group for weight-for-age z-score (0.14 DID, p = 0.049), and the prevalence of underweight declined by 12.8 percentage points (p = 0.036), relative to SOC. Integration of phone-based IYCF counselling is a potentially promising solution to reduce the burden of in-person visits; however, the modest improvements suggest the need to combine it with other strategies to improve child nutrition.