“In my fifty years of life, I have never heard the word deviance used in a positive context”, one of my colleagues remarked when I talked to her about my interest in positive deviance. I heard the term positive deviance for the first time in 2007 when the veterans’ affairs health care system decided to utilize this approach as a culture transformation strategy and improve hand hygiene and ultimately reduce methicillin resistant staphylococcal infections. One thing led to the other and I found myself engaging in deep conversations with my colleagues Brad Doebbeling, Anthony Suchman, Arvind Singhal and Lucia Dura, and learning about positive deviance.

Positive deviance is a social change strategy that has been used successfully to solve seemingly intractable and complex social and public health problems. The approach has found application in healthcare as well in recent years. It is based on the observation that there are certain individuals or groups (positive deviants) within a community, whose uncommonly positive behaviors and strategies enable them to find better solutions to problems than their peers, while having similar access to resources. This intervention was successfully used by Jerry and Monique Sternin in Vietnam to solve child malnutrition. When this couple measured the weights of all children in the Vietnamese villages they found that not all children were underweight. Instead of focusing on what the families with underweight children were doing wrong, they set out to identify what the families with normal weight children were ‘doing right’.

Jerry and Monique didn’t just ask the families of normal weight children how they fed their children. They actually had teams make home trips to observe how food is prepared and how the children are fed. What they found is that although the families couldn’t quite articulate what they were doing different from other families that resulted in their children being normal weight (remember the last time you asked grandma for a recipe and you tried to recreate the taste?), they were doing some things differently. For example, they observed that these families added shrimp and greens (considered to be non-edibles by most of these villagers) from the paddy fields to the stew they made at home. While serving their children to eat, they reached the ladles deep into the stewpot to actually pick up these cooked shrimp and greens. They also fed the children more frequently. It’s little surprise then that these children were normal weight, but Jerry and Monique didn’t just stop with identifying these ‘positive deviants’ and their ‘positively deviant practices’. They harnessed these families to serve as social proof to other families (“If we can do it, you can do it too, and this is how we did it”) and the conversations, learning and sharing that followed resulted in reducing the percentage of underweight children significantly in these villages.

Applying these principles and lessons from public health in health care is both interesting as well as tricky. Positive deviance has been used in recent years in health care to improve hand hygiene, to reduce infections caused by methicillin resistant Staphylococcus aureus, to improve antimicrobial use, and to reduce surgical site infections in different hospitals. However, its use in health care is not yet widespread. I will write about the application of positive deviance in health care (Part II of this topic) in the coming weeks. Stay tuned.


  1. Pascale RS, Sternin J, Sternin M. The Power of Positive Deviance: How Unlikely Innovators Solve the World’s Toughest Problems. Boston, MA: Harvard Business Press; 2010.
  2. Picture for this blogpost from: http://completecoach.pro/tag/deviant/ Image labeled for noncommercial reuse.