Long-term retention and positive deviant practices in Uganda's community client-led antiretroviral distribution groups (CCLADs): a mixed-methods study

BACKGROUND

HIV testing and starting antiretroviral therapy (ART) are pivotal in treating people living with HIV (PLHIV) but sustaining PLHIV on treatment remains challenging. We assessed retention and attrition in community client-led antiretroviral distribution groups (CCLADs) in Uganda and identified positive deviant practices that foster long-term retention.

METHODS

Using explanatory mixed methods, we collected longitudinal medical data from 65 health facilities across 12 districts in East Central Uganda. Quantitative phase, from 18 April 2021 to 30 May 2021, employed survival analysis and Cox regression to assess retention and identify attrition risk factors. Qualitative inquiry focused on four districts with high attrition from 11 August 2021 to 20 September 2021, where we identified nine health facilities exhibiting high retention in CCLADs. We purposively selected 50 clients for in-depth interviews (n=22) or focus group discussions (n=28). Using thematic analysis, we identified positive deviant practices. We integrated quantitative and qualitative findings into joint displays.

RESULTS

Involving 3055 PLHIV, the study showed retention rates of 97.5% at 6 months, declining to 89.7% at 96 months. Attrition risk factors were lower levels of care (health centre three (adjusted HR (aHR) 2.80, 95% CI 2.00 to 3.65) and health centre four (aHR 3.61, 95% CI 2.35 to 5.54)); being unemployed (aHR 2.21, 95% CI 1.00 to 4.84); enrolment year into CCLAD (aHR 23.93, 95% CI 4.66 to 123.05) and virological failure (aHR 3.41, 95% CI 2.51 to 4.63). Of 22 clients interviewed, 8 were positive deviants. Positive deviants were characterised by prolonged retention in CCLADs, improved clinical outcomes and practised uncommon behaviours that enabled them to find better solutions than their peers. Positive deviant practices included fostering family-like settings, offering financial or self-development advice, and promoting healthy lifestyles.

CONCLUSIONS

Findings underscore the importance of addressing factors contributing to attrition and leveraging positive deviant practices to optimise retention and long-term engagement in HIV care.

Multicriteria Measures to Assess the Sustainability of Diets: A Systematic Review

CONTEXT

Assessing the overall sustainability of a diet is a challenging undertaking requiring a holistic approach capable of addressing the multicriteria nature of this concept.

OBJECTIVE

The aim was to identify and summarize the multicriteria measures used to assess the sustainability characteristics of diets reported at the individual level by healthy adults.

DATA SOURCES

Articles were identified via PubMed, Scopus, and Web of Science. The search strategy consisted of key words and MeSH terms, and was concluded in September 2022, covering references in English, Spanish, and Portuguese.

DATA EXTRACTION

This systematic review followed the PRISMA guidelines. The search identified 5663 references, from which 1794 were duplicates. Two reviewers independently screened the titles and abstracts of each of the 3869 records and the full-text of the 144 references selected. Of these, 7 studies met the inclusion criteria.

DATA ANALYSIS

A total of 6 multicriteria measures were identified: 3 different Sustainable Diet Indices, the Quality Environmental Costs of Diet, the Quality Financial Costs of Diet, and the Environmental Impact of Diet. All of these incorporated a health/nutrition dimension, while the environmental and economic dimensions were the second and the third most integrated, respectively. A sociocultural sustainability dimension was included in only 1 of the measures.

CONCLUSION

Despite some methodological concerns in the development and validation process of the identified measures, their inclusion is considered indispensable in assessing the transition towards sustainable diets in future studies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022358824.

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.

Identifying nutrition-sensitive development options in Madagascar through a positive deviance approach

Context-adapted interventions are needed to alleviate the burden of food and nutrition insecurity on resource-poor rural households in southeastern Madagascar. The Positive Deviance approach implies identifying locally viable development solutions by focusing on particularly successful, innovative individuals. To identify promising practices that could be promoted as part of food and nutrition security (FNS) interventions in the Atsimo Atsinanana region of southeastern Madagascar, positive deviance was searched among smallholder farmers. Positive deviants are defined as households with overall optimal performance across four aspects of FNS: household-level food security, women’s diet quality, child’s diet quality, and low diarrhea incidence. To identify positive deviants, a two-step procedure was followed. Based on quantitative survey data from 413 rural smallholder households (mother-child pairs) with a child aged between 6 and 23 months, each household’s four performance scores were adjusted by removing the average effects of household resources. Then, households with Pareto-optimal performance were identified regarding the four aspects. Subsequently, 16 positive deviants were revisited and positive deviant practices were identified through in-depth interviews. A set of practices were validated through focus group discussions with local nutrition and agriculture experts. Positive deviant practices include the adoption of agricultural innovation, such as new cash crops, as well as nutrition-sensitive market behaviors and reliance on off-farm activities. In addition, some ethno-cultural factors help to explain positive deviance. These diverse positive deviant practices may serve as examples and inspiration for locally grounded development interventions targeting FNS in southeastern Madagascar.

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.

Program Impact Pathway of the Positive Deviance/Hearth Interactive Voice Calling Program in a Peri-Urban Context of Cambodia

Background

Positive Deviance/Hearth (PDH) is an internationally recognized nutrition rehabilitation program. However, nutritional improvements are inconsistent across contexts. It is unclear if variations are due to differences in program design, implementation, utilization, or other contextual factors. Furthermore, few PDH programs have addressed the high time and work burdens of caregivers and volunteers. To address this, the study integrated interactive voice calling (IVC) with PDH.

Objectives

A program impact pathway (PIP) analysis was used to evaluate the secondary outcomes of facilitators, barriers, and contextual factors that influenced the design, implementation, and utilization of a Positive Deviance/Hearth-Interactive Voice Calling program to improve the nutritional status of children in Cambodia.

Methods

A PIP analysis was done on data collected through in-depth interviews with caregivers (n = 32), key informant interviews with volunteers (n = 16) and project staff (n = 3), and surveys of project staff (n = 5).

Results

In the design phase, facilitators included quality training, technical support and design tools, community mobilization, and linkage to existing health services. Barriers included poor community mobilization. For the implementation phase, facilitators were good volunteer knowledge, follow-up tools and guidance, supervision, and spot checks of volunteers. Barriers were lack of time and overworked older caregivers. For the utilization phase, facilitators included family and volunteer support and access to phones, whereas barriers were lack of support, time, and financial resources; low levels of education and old age of caregivers; and inconsistent phone use. Contextual factors included food insecurity and increased childcare responsibilities of grandmothers due to migration of mothers.

Conclusions

The PIP analysis identified facilitators, barriers, and contextual factors that may affect the design, intervention, and utilization of IVC interventions for health and nutrition behavior change and elements to consider when designing and implementing them. When implementing child nutrition programs in Cambodia, supporting interventions addressing mental health and time and resource constraints of elderly caregivers should also be included.This trial was registered at clinicaltrials.gov as NCT03399058.

Associations of Enteric Protein Loss, Vaccine Response, Micronutrient Deficiency, and Maternal Depressive Symptoms with Deviance in Childhood Linear Growth: Results from a Multicountry Birth Cohort Study

We identified the determinants of positive (children who had a birth weight < 2.5 kg and/or maternal height < 145 cm but were nonstunted at 24 months of age) and negative (children who had a birth weight ≥ 2.5 kg and maternal height ≥ 145 cm but were stunted at 24 months of age) deviance in childhood linear growth. We found that socioeconomic status (β = 1.54, P < 0.01), serum retinol (β = 0.05, P < 0.01), hemoglobin (β = 0.36, P < 0.01), length-for-age Z-score (LAZ) at birth (β = 0.47, P < 0.01), and tetanus vaccine titer (β = 0.182, P < 0.05) were positively and maternal depressive symptom (β = -0.05, P < 0.01), serum ferritin (β = -0.03, P < 0.01), male sex (β = -1.08, P < 0.01), and α1-antitrypsin (β = -0.81, P < 0.01) were negatively associated with positive deviance. Further, diarrhea episodes (β = 0.02, P < 0.01), male sex (β = 0.72, P < 0.01), and α1-antitrypsin (β = 0.67, P < 0.01) were positively and hemoglobin (β= -0.28, P < 0.01), soluble transferrin receptor level (β = -0.15, P < 0.01), and LAZ score at birth (β = -0.90, P < 0.01) were negatively associated with negative deviance. To summarize, enteric protein loss, micronutrient deficiency, vaccine responses and maternal depressive symptoms were associated with linear growth deviance in early childhood. In such a background, public health approaches aimed at reducing the risk of intestinal inflammation and altered gut permeability could prove fruitful in ensuring desired linear growth in children. In addition, maternal mental health issue should also be considered, especially for promoting better nutritional status in children in the context of linear growth deviance.

Advantages and limitations of the methodological approaches used to study dietary shifts towards improved nutrition and sustainability

Acting on diet is one of the changes required - in combination with actions on food production, transformation, and waste - to address the challenges of reducing the environmental impact of our food systems and eliminating all forms of malnutrition. The number of studies exploring how to move towards a more sustainable diet has exploded over the past decades, but there is a need to facilitate their understanding and use by policy makers and all other stakeholders possibly influencing diet sustainability. The aim of the present article is to propose a categorization of studies into 4 approaches, based on the type of methodology used to explore diet sustainability, and to highlight the principles, advantages, and limitations of each approach in order to help study users in their interpretation. The 4 approaches are: assessment of sustainability characteristics of hypothetical diets (approach 1) or existing diets (approach 2), identification of existing "positive deviants" (approach 3), and design of more sustainable diets with constrained optimization (approach 4). Specificities and key findings drawn from each approach are described, and challenges for future studies are discussed.

Effectiveness of Positive Deviance, an Asset-Based Behavior Change Approach, to Improve Knowledge, Attitudes, and Practices Regarding Dengue in Low-Income Communities (Slums) of Islamabad, Pakistan: A Mixed-Method Study

Simple Summary

Dengue is a mosquito-borne infection caused by the Aedes mosquito, expanding at an alarming pace around the world. Recently, Pakistan has witnessed some major dengue outbreaks, affecting thousands of individuals across the country. As there is no specific cure or vaccine, prevention and vector control remain the key methods to avoid dengue infection. In Pakistan, dengue control activities are mainly focused on information-sharing through mass media and communication materials such as pamphlets and posters. The main challenge is a lack of community participation that can create an enabling environment for communities to follow the desired behaviors. There is a strong need to design and implement community-led behavior change approaches to ensure community participation and translate the knowledge into practices. This study was conducted to better understand the effectiveness of a community engagement approach, ‘positive deviance’, on dengue prevention and control. The study was carried out in two slums affected by the recent dengue outbreak in Islamabad, Pakistan. A total of 112 persons participated in the study, which was conducted from June–October 2020. The community discovered already-existing positive behaviors surrounding dengue prevention and control, which were shared with other participants through interactive activities. The study demonstrated positive changes in knowledge, attitudes, and practices, and could be a potential tool for dengue prevention and control programs worldwide.

Abstract

Dengue is a mosquito-borne, viral disease that has emerged as a global health concern in recent years. In the absence of specific antiviral treatment and vaccines, prevention remains the key strategy for dengue control. Therefore, innovative and community-driven approaches are required to improve the vector control practices. This study applied and evaluated the positive deviance (PD) approach on dengue prevention and control in selected slums of Islamabad during June–October 2020. The two most dengue-affected slums, the Faisal colony and France colony, were purposively selected as intervention and control groups, respectively. A total of 112 participants (56 for the intervention and 56 for the control group) participated in the study. The intervention group was exposed for two months to locally identified role model behaviors through weekly interactive sessions, dengue sketch competitions, and role plays. Another two months enabled the community to practice these behaviors without any external support in order to explore the intervention’s sustainability. Three surveys were conducted: before the intervention, after two months, and after four months, to assess any changes in the knowledge, attitudes, and practices of participating communities. Results found that the PD intervention had a significant positive impact on dengue knowledge, attitudes, and practices in the intervention group. PD could offer an empowering and efficient community engagement tool for future dengue prevention and control, both in Pakistan and more globally.

Disruptive Technologies for Achieving Supply Chain Resilience in COVID-19 Era: An Implementation Case Study of Satellite Imagery and Blockchain Technologies in Fish Supply Chain

In supply chains where stakeholders belong to the economically disadvantaged segment and form an important part of the supply chain distribution, the complexities grow manifold. Fisheries in developing nations are one such sector where the complexity is not only due to the produce being perishable but also due to the livelihood dependence of others in the coastal regions that belong to the section of economically disadvantaged. This paper explains the contextual challenges of fish supply chain in a developing country and describes how integrating disruptive technologies can address those challenges. Through a positive deviance approach, we show how firms can help unorganized supply chains with economically disadvantaged suppliers by carefully redesigning the supply chain through the integration of satellite imagery and blockchain technology. With COVID-19 in the backdrop, we highlight how such technologies significantly improves the supply chain resilience and at the same time contributes to the income generating opportunities of poor fisherfolks in developing nations. Our study has important implications to both developing markets and food supply chain practitioners as this paper tackles issues such as perishability, demand-supply mismatch, unfair prices, and quality related data transparency in the entire value chain.

Effectiveness of Positive Deviance Approach to Promote Exclusive Breastfeeding Practice: A Cluster Randomized Controlled Trial

Background

Suboptimal breastfeeding (BF) contributes to a significant number of infant deaths. A positive deviance approach (PDA) was not studied in Ethiopia, whether it improve exclusive breastfeeding (EBF) practice. Therefore, we determined the effectiveness of positive deviant approached intervention in increasing the proportion of EBF practice.

Methods

A cluster-randomized controlled trial was employed in Jimma town from February 01 to September 30, 2018. Six randomly selected clusters (kebeles) were randomized into two arms. Then, 260 mothers who met the eligibility criteria were enrolled in either the intervention or control arm depending on where they lived. Women in the intervention group received counseling and social support in addition to the usual service to promote EBF, from women identified and trained as positive deviants in their community, while those in the control groups received the usual community-based services from urban health extension professionals. Data on primary and secondary outcome variables were collected at three points, and statistical difference was estimated using Chi-X² or Fisher exact test. The net effect of the intervention was calculated. The magnitude of the intervention effect was estimated using the relative risk. For all statistical tests, 95% CI with a P-value of <0.05 was used.

Results

The overall response rate at the endline was 98.8%. Exclusive BF was significantly different between the groups at mid and end points, while no difference at baseline. A higher proportion of mothers in the intervention group reported EBF compared to the control group at mid and end-line. The rate of EBF increased by 18.5% (P=0.01) in the intervention group while 0.2% in the counterparts, with a net effect of +18.2%. The probability of practicing EBF was significantly higher for the intervention group compared to the control group. At baseline, the relative risk of avoiding EBF (RR:1.112) was similar among the two groups. However, at follow-up, mothers in the intervention group were 2 times more likely to practice EBF (RR: 2.294) compared to those in the control group.

Conclusion and Recommendation

The PD approach is an effective intervention to promote EBF and also positively affected frequency and duration of BF. Therefore, we recommend the promotion and use of positive deviance approach as a strategy to improve EBF practice in urban settings.

Trial Registration Number

Clinical trial PACTR201805003379263, 23 May 2018.

Design thinking approach to simplify monetary transactions for the visually challenged

Design thinking, having applications in many fields, is emerging to be a pragmatic technique for facilitating Human Centred Design (HCD), a modern-day necessity, through a well-defined systematic process. This paper presents a case study detailing the application of design thinking principles to approach and develop solutions for the visually challenged to recognize the denomination of Indian currencies. Throughout the paper, specific implementations of design thinking principles have been detailed with emphasis on the key takeaways from the various stages. A comprehensive review of our approach compared to existing and unconventional applications has been provided to underline the importance of incorporating design thinking into emergent consumer-oriented solutions. A lot of research has been done in developing denomination classification models, however, there seems to be a lack of solutions designed through the perspective of a blind person who plays the critical factor in determining effectiveness once deployed. The design procedure helped us realize the importance of developing a simple user-friendly interface with a single input button and audio relays to guide the blind user during operation. Establishing a good platform for interaction and feedback was found to be critical in helping us modify and prioritize aspects such as achieving a low false-positive percentage and the addition of a high threshold Softmax function which made the solution design effective.

Positive Deviance for Dual-Method Promotion among Women in Uganda: A Qualitative Study

Dual-method use is the most reliable form of protection against unintended pregnancies and human immunodeficiency virus/sexually transmitted infections (HIV/STIs). Although dual-method use remains uncommon among women in stable relationships, some women do practice it. In this study, we explored the barriers that make dual-method use rare and the behaviors of women who practice dual-method use using a positive deviance framework in Uganda. We screened 150 women using highly effective contraceptives at five health facilities. We identified nine women who practiced dual-method use and 141 women who did not. In a qualitative study, we conducted in-depth interviews with all nine women practicing dual-method use and 10 women randomly selected out of the 141 who did not. We performed a thematic analysis using the positive deviance framework. Regardless of practicing dual-method use or not, women faced perceived barriers against dual-method use, such as partner’s objection, distrust, shyness about introducing condoms into marital relationships, and limited access to condoms. However, women practicing dual-method use had higher levels of risk perception about unintended pregnancies and HIV/STIs. They also engaged in unique behaviors, such as influencing their partners’ condom use by initiating discussions, educating their partners on sexual risks and condom use, and obtaining condoms by themselves. These findings will be useful in developing effective community-led and peer-based interventions promoting dual-method use to reduce the dual burden of unintended pregnancies and HIV/STIs among women in Uganda.

The Importance of the Social Environment in Achieving High Levels of Physical Activity and Fruit and Vegetable Intake in African American Church Members

PURPOSE

African Americans experience a high burden of chronic diseases and cancers that are prevented and ameliorated with physical activity (PA) and fruit and vegetable (FV) intake. The purpose of this study is to identify individual, social, and neighborhood variables associated with African Americans attaining high levels of both behaviors.

DESIGN

This study is a cross-sectional analysis.

SETTINGS AND PARTICIPANTS

Cohort of African Americans adults recruited from black churches in the Greater Houston area.

MEASURES

Self-administered questionnaires collected in 2012 assessed correlates and behavioral outcome variables (PA and FV consumption). A combined 4-category behavioral outcome was created: high PA/high FV, low PA/high FV, high PA/low FV, and low PA/low FV.

ANALYSIS

Standard and stepwise multinomial logistic regression examined the association between the various variables and the behavioral outcome.

RESULTS

This sample (n = 1009) had a mean age of 49 years, was mostly female, and obese. Compared to the low PA/low FV intake group, the high PA/high FV intake group had significantly lower odds of individual-level variables (worrying about getting cancer, perceived stress, loneliness, and financial strain) and higher odds of social-level variables (social status, social cohesion, social organization involvement, and social norms). Only social-level variables remained significantly associated with higher odds of high PA/high FV intake in stepwise regression.

CONCLUSION

These findings indicate that social influences may be most critical for high PA and FV intake in African Americans adults.

Positive deviance for dual-method promotion among women in Uganda: study protocol for a cluster randomized controlled trial

Background

Dual-method use is known as the most reliable protection against unintended pregnancies and sexually transmitted infections, including HIV. However, it is not commonly used in sub-Sharan Africa, especially among women using highly effective contraceptives. This article describes a protocol to evaluate the effect of an intervention formulated under the positive deviance approach for promoting dual-method use in Uganda.

Methods

A total of 150 women will be interviewed using a structured questionnaire to find those practicing dual-method use. In-depth interviews will then be conducted with all women using the dual method and 10 women using only highly effective contraceptives to identify their unique practice. Then, a cluster randomized controlled trial will be conducted to examine the effect of an intervention formulated under the positive deviance approach on dual-method uptake and adherence. Twenty health facilities will be randomized to an intervention or control arm and 480 women will be enrolled in each group. The participants will be followed up for 8 months.

Discussion

This trial focuses on women who already adapted dual-method use and identifies their unique solutions to promote dual-method use. This trial could tackle barriers for dual-method use, which expert outsiders may fail to recognize, by analyzing and promulgating their unique behaviors. This study could provide evidence that the positive deviance approach can address unintended pregnancies and sexually transmitted infections as well as other health problems which usual approaches have failed to address.

Trial registration

UMIN-CTR Clinical Trial, UMIN000037065. Registered on 14 June 2019.

Mentor Mothers Zithulele: exploring the role of a peer mentorship programme in rural PMTCT care in Zithulele, Eastern Cape, South Africa

Background: The majority of global HIV infections in children under 10 years of age occur during pregnancy, delivery or breastfeeding, despite improved coverage of 'prevention of mother-to-child transmission' (PMTCT) guidelines to reduce vertical transmission. This article looks closer at one community-based peer mentorship programme [Mentor Mothers Zithulele (MMZ)] in the Eastern Cape, South Africa which aims to supplement the existing heavily burdened antenatal programmes and improve PMTCT care.Methods: Semi-structured interviews were undertaken with HIV-positive women participating in MMZ and women receiving standard PMTCT care without any intervention. A focus group discussion (FGD) was conducted with women working as Mentor mothers (MMs) for MMZ to explore their experience of the impact of peer mentoring on the rural communities they serve.Results: Six main themes were identified in the interviews with antenatal patients: (i) MMs were a key educational resource, (ii) MMs were important in promoting exclusive breastfeeding, (iii) encouraging early HIV testing during pregnancy and (iv) providing psychosocial support to patients in their homes, thereby reducing stigma and sense of alienation. Respondents requested (v) additional focus on HIV education. MMs can (vi) function as a link between patients and health-care providers, improving treatment adherence. During the FGD two themes emerged; MMs fill the gap between patients and health services, and MMZ should focus on HIV awareness and stigma reduction.Conclusion: Peer mentoring programmes can play an important role in reducing vertical HIV transmission in resource-limited, rural settings by providing participants with education, psychosocial support, and a continuum of care.

A Mixed-Methods Exploration of Barriers and Facilitators to Evidence-Based Practices for Obesity Prevention in Head Start

OBJECTIVE

To identify positive and negative deviant cases using quantitative fidelity data from a previous implementation of a nutrition intervention, Together, We Inspire Smart Eating (WISE), and to determine barriers and facilitators to fidelity by conducting qualitative interviews with deviant cases.

DESIGN

Explanatory sequential mixed methods.

SETTING

Head Start Program agencies in 2 southern US states.

PARTICIPANTS

Quantitative fidelity data were collected in 42 Head Start classrooms. Recruitment for qualitative interviews prioritized those who were positive or negative deviants across fidelity components (African American, n = 21; white, n = 19; and Hispanic, n = 3).

INTERVENTION

WISE introduces children to fruits and vegetables using evidence-based practices of role modeling, positive feeding, mascot use, and hands-on exposure.

ANALYSIS

A directed content analysis approach informed by the integrated Promoting Action on Research Implementation in Health Service framework.

PHENOMENON OF INTEREST

Barriers and facilitators to WISE evidence-based practices implementation.

RESULTS

Qualitative analyses identified themes of culture, leadership support, and mechanisms for embedding change as key contextual factors. Key findings related to recipient characteristics were beliefs about what works, personalized strategies to use WISE, and classroom management. Primary themes for the innovation construct were time and preparation, degree of fit, and WISE advantage. Finally, findings relative to the construct of facilitation included trainer support and desire for additional training.

CONCLUSIONS AND IMPLICATIONS

The study of cases at the extreme ends of the fidelity spectrum can provide unique perspectives on barriers and facilitators to implementation of interventions.

Why some children from poor families do well-an in-depth analysis of positive deviance cases in Singapore

Purpose: Research documents that children from low-income families face higher risks in many areas of their development including academic performance. However, some children from low-income homes excel academically despite their disadvantaged environment. Method: Using Positive Deviance methodology (PD), audio-diary and interview data were collected from ten children who scored at least 70 percentile in school examinations in spite of their financial deprivation.Results: This paper uncovers specific dimensions of agency in these children that stemmed from the relational contexts they had with their mothers. Combining the PD methodology and sensitizing lens from Social Relational Theory, this study provided evidence that PD children are connected agents within their family. It suggests that children's awareness of their family circumstances motivated them to work hard and enabled them to devise creative ways to manage their limited financial resources.Conclusions: The findings challenge dominant discourses on poor children as passive victims and suggest new ways for practitioners to examine the relationship contexts that support children's capacity as agents rather than focusing on individual traits.

Learning From the Community to Improve Maternal—Child Health and Nutrition: The Positive Deviance/Hearth Approach

The "traditional" use of the Positive Deviance approach to behavior change involves studying children who thrive despite adversity, identifying uncommon model behaviors among Positive Deviant families, and then designing and implementing an intervention to replicate these behaviors among mothers of malnourished children. This article presents the results of a literature review designed to gather information on the role of the Positive Deviance/Hearth methodology in social and behavior change. Examples of how the methodology has been applied beyond infant and child malnutrition to address other health areas, such as improving pregnancy outcomes, are explored. An analysis of Positive Deviance programming being carried out by Project Concern International in Guatemala and Indonesia is conducted. The role of cultural context in the design and implementation of Positive Deviance/Hearth, as well as the role of Positive Deviance in affecting social and behavior change, require further exploration. The issues related to cultural context and the challenges for monitoring and evaluation of program outcomes are presented.

Perchlorate in dairy milk. Comparison of Japan versus the United States

Perchlorate has been considered a potential threat to human health, especially to developing infants and children due to its ability to inhibit iodide uptake by the sodium iodide symporter (NIS) of the thyroid. Although the U.S. has been the prime focus of perchlorate contamination, at least some of the similar sources of perchlorate exist across the world, and it has been detected in many types of foods and beverages worldwide. We present here perchlorate data from cow's milk samples from Japan (mean 9.4 +/-2.7 microg/L, n = 54), which are higher on average than those found in U.S. dairy milk samples reported by a 2004 Food and Drug Administration (FDA) study (5.9+/-1.8 microg/L, n= 104).

Identifying Healthy Eating Strategies in Low-Income Pregnant Women: Applying a Positive Deviance Model

Using positive deviance methodology, we identified strategies that enabled some low-income pregnant women to eat healthy meals while others did not. We used a descriptive design consisting of small group interviews of low-income pregnant women and identified 6 of 18 women as eating healthy diets. Women with healthy diets knew to eat balanced meals, had family support, were willing to prepare foods that were different than other family members, and ate at home more frequently than women with unhealthy diets. Health care providers can use the positive deviance approach to guide the development of interventions to improve women's diets using community-specific solutions to enhance the health of mothers and infants.