Education and debate Future challenges? The potential role for positive deviance is vast. For example, which rural Kenyan families optimally use insecticide impregnated bednets, and how can they motivate their neighbours? How can South African policy makers integrate the behaviours and thinking of teenagers who practise “safe sex”? What can we learn from a poor, uninsured Latina mother who succeeds in properly managing her child’s diabetes or asthma? What about other intractable, deadly impasses of our time—the Kashmir crisis, Israeli-Palestinian mayhem, or insurgency in Iraq? We believe that positive deviance is a valuable tool that should be part of international health policy makers’ toolbox for the 21st century. Contributors and sources: DRM drafted the paper with input from all authors. JS and MS have designed and implemented positive deviance informed projects; DRM, DGS, and KAD have evaluated such projects in many countries. The information in the paper comes from publications and the authors’ experiences. Competing interest: None declared.
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Wray JD. Can we learn from successful mothers? J Trop Pediatr Environ Child Health 1972;18:27. Wishik SM, Van der Vynkt S. The use of nutritional ‘positive deviants’ to identify approaches for modification of dietary practices. Am J Pub Health 1976;66:38-42. Zeitlin M, Ghassemi H, Mansour M. Positive deviance in child nutrition—with emphasis on psychosocial and behavioral aspects and implications for development. Tokyo: United Nations University, 1990. Shekar M, Habicht J-P, Latham M. Positive-negative deviant analyses to improve programme targeting and services: example from Tamil Nadu Integrated Nutrition Project. Int J Epidemiol 1992;21:707-13. Sternin M, Sternin J, Marsh D. Rapid, sustained childhood malnutrition alleviation through a “positive deviance” approach in rural Vietnam: preliminary findings. In: Keeley E, Burkhalter BR, Wollinka O, Bashir N, eds. The hearth nutrition model: applications in Haiti, Vietnam, and Bangladesh, Report of a Technical Meeting at World Relief Corporation, Wheaton, IL, June 19-21, 1996. Arlington: BASICS, 1997. Sternin M, Sternin J, Marsh D. Scaling up a poverty alleviation and nutrition program in Viet Nam. In: Marchione T. Scaling up, scaling down:
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capacities for overcoming malnutrition in developing countries. Amsterdam: Gordon and Breach, 1999. Bolles K, Speraw C, Berggren G, Lafontant JG. Ti Foyer (hearth) community-based nutrition activities informed by the positive deviance approach in Leogane, Haiti: A programmatic description. Food Nutr Bull 2002;23 (suppl 4):11-17. Food for the Hungry International. FY2001 annual report. http:// gme.fhi.net/fse/R2/docs/ISA%20FY%202001%20Report.doc2004 (accessed 6 Oct 2004). EcoYoff. Positive deviance—take 2. Living and learning newsletter 2003 Sep 21. http://ifnc.tufts.edu/pdf/ecoyoff21.pdf (accessed 11 Oct 2004). Sethi V, Kashyap S, Seth V, Agarwal S. Encouraging appropriate infant feeding practices in slums: a positive deviance approach. Pakistan J Nutr 2003;2:164-6. Dearden K, Quan N, Do M, Marsh DR, Schroeder G, Pachón H, et al. What influences health behavior? Learning from caregivers of young children in Vietnam, Food Nutr Bull 2002;23(suppl 4):119-29. Marsh DR, Sternin M, Khadduri R, Ihsan T, Nazir R, Bari A, et al. Identification of model newborn care practices through a positive deviance inquiry to guide behavior change interventions in Haripur, Pakistan. Food Nutr Bull 2002;23(suppl 4):109-18. Ahrari M, Kuttab A, Khamis S, Farahat AA, Darmstadt GL, Marsh DR, et al. Socioeconomic and behavioral factors associated with successful pregnancy outcomes in upper Egypt: a positive deviance inquiry. Food Nutr Bull 2002;23:83-8. Berggren WL, Wray JD. Positive deviant behavior and nutrition education. Food Nutr Bull 2002;23(suppl 4):9-10. Marsh DR, Schroeder DG, The positive deviance approach to improve health outcomes: experience and evidence from the field: preface. Food Nutr Bull 2002;23( suppl 4):5-8. Mackintosh AT, Marsh DR, Schroeder DG, Sustainable positive deviant child care practices and their effects on child growth in Viet Nam. Food Nutr Bull 2002;23( suppl 4):18-27. Marsh DR, Pachón H, Schroeder DG, Ha TT, Dearden K, Lang TT, et al. Design of a prospective, randomized evaluation of an integrated nutrition program in rural Viet Nam. Food Nutr Bull 2002;23(suppl 4):36-47. Schroeder DG, Marsh DR, Ding B, Pachón H, Ha TT, Dearden KD, et al. Impact of an intervention on Vietnamese children’s growth. Food Nutr Bull 2002;23(suppl 4):53-61. Sripaipan T, Schroeder D, Marsh DR, Pachón H, Dearden K, Ha TT, et al. Do community-based nutrition programs reduce morbidity? A case from Vietnam. Food Nutr Bull 2002;23(suppl 4):70-7. Hendrickson JL, Dearden KA, Pachon H, An NH, Schroeder DG, Marsh DR. Empowerment in rural Viet Nam: Exploring changes in mothers and health volunteers in the context of an integrated nutrition project, Food Nutr Bull 2002;23(suppl 4):86-94. Positive Deviance Initiative. Projects. www.positivedeviance.org/projects (accessed 11 Oct 2004).
(Accepted 11 August 2004)
Kangaroo Mother Care, an example to follow from developing countries Juan Gabriel Ruiz-Peláez, Nathalie Charpak, Luis Gabriel Cuervo Caring for low birthweight infants imposes a heavy burden on poor countries. An effective healthcare technique developed in 1978 may offer a solution to this problem and additionally be of use in wealthy countries too
Introduction Each year about 20 million infants of low birth weight are born worldwide, which imposes a heavy burden on healthcare and social systems in developing countries.1 w1 Medical care of low birthweight infants is complex, demands an expensive infrastructure and highly skilled staff, and is often a very disruptive experience for families.2 w2 w3 w4 Premature babies in poorly resourced settings often end up in understaffed and ill equipped neonatal care units, that may be turned into potentially deadly traps by a range of factors colluding— for example, malfunctioning incubators, broken monitors, overcrowding, nosocomial infections, etc. In 1978 Edgar Rey, a Colombian paediatrician concerned with the problems arising from a shortage BMJ VOLUME 329
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of incubators and the impact of separating women from newborns in neonatal care units, developed Kangaroo Mother Care (KMC),3 a healthcare technique for low birthweight infants that is at least as effective as traditional care in a neonatal care unit.4 5
What does KMC entail? In KMC, babies weighing 2000 g or less at birth and unable to regulate their body temperature remain with their mothers as incubators, main source of stimulation, and feeding. Newborns are attached to mothers
Clinical Epidemiology and Biostatistics Unit, School of Medicine, Javeriana University, Bogotá, Colombia Juan Gabriel Ruiz-Peláez professor continued over BMJ 2004;329:1179–82
Additional references w1-w20 are on bmj.com
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