The positive deviance hearth approach to reducing child malnutrition: systematic review

Transcription

1 Tropical Medicine and International Health doi: /j x volume 16 no 11 pp november 2011 Systematic Review The positive deviance hearth approach to reducing child malnutrition: systematic review Piroska A. Bisits Bullen Walden University, Minneapolis, USA Summary objectives The Positive Deviance Hearth approach aims to rehabilitate malnourished children using practices from mothers in the community who have well-nourished children despite living in poverty. This study assesses its effectiveness in a range of settings. methods Systematic review of peer reviewed intervention trials and grey literature evaluation reports of child malnutrition programs using the Positive Deviance Hearth approach. results Ten peer reviewed studies and 14 grey literature reports met the inclusion criteria. These described results for 17 unique Positive Deviance Hearth programs in 12 countries. Nine programs used a pre- and post-test design without a, which limited the conclusions that could be drawn. Eight used more robust designs such as non-randomized trials, non-randomized cross-sectional sibling studies and randomized led trials (RCTs). Of the eight programs that reported nutritional outcomes, five reported some type of positive result in terms of nutritional status although the improvement was not always as large as predicted, or across the entire target population. Both the two RCTs demonstrated improvements in carer feeding practices. Qualitative results unanimously reported high levels of satisfaction from participants and recipient communities. conclusions Overall this study shows mixed results in terms of program effectiveness, although some Positive Deviance Hearth programs have clearly been successful in particular settings. Sibling studies suggest that the Positive Deviance Hearth approach may have a role in preventing malnutrition, not just rehabilitation. Further research is needed using more robust study designs and larger sample sizes. Issues related to community participation and consistency in reporting results need to be addressed. keywords positive deviance, hearth, child malnutrition, systematic review Introduction It is estimated that 125 million children are underweight because of inadequate nutrition, with 195 million suffering from stunting (United Nations Children s Fund [UNICEF] 2009). The majority of these children live in Africa and Asia. Progress in reducing child malnutrition is not fast enough to meet the Millennium Development Goal of halving the prevalence of underweight children by 2015 (United Nations 2010). The Positive Deviance Hearth approach provides community-based rehabilitation for moderate and severely malnourished children (Pascale et al. 2010). More than 30 years ago, Wishik and Van Der Vynckt (1976) proposed an approach that identified families whose children were well nourished despite living in the same conditions and at the same level of poverty as other families. The approach documented the feeding and care practices of these families, such as feeding special foods, active feeding, and hygiene practices, which could then be incorporated into a nutrition program knowing that they were both affordable and culturally acceptable. The term Positive Deviance was first used to describe this approach by Marian Zeitlin, as part of her pioneering works in the 1990s documenting positive deviance in child nutrition (Zeitlin et al. 1990; Positive Deviance Initiative 2010). In the 1990s, this Positive Deviance approach was combined with small group Hearth sessions for delivering nutrition education to mothers in a community setting (Wollinka et al. 1997). The result was the Positive Deviance Hearth Program, which has since been implemented by Save the Children (Sternin et al. 1998), the Peace Corps (2008), USAID (McNulty & Pambudi 2008) and UNICEF (Shibpur People s Care Organisation [SPCO] n.d.) ª 2011 Blackwell Publishing Ltd

2 The Positive Deviance Hearth Program manual, produced by the Nutrition Working Group, Child Survival Collaborations and Resources Group [CORE] (2002a), states as key steps in the following order: (1) Decide whether the Positive Deviance Hearth Program is feasible. (2) Begin community mobilization and train community resources. The Positive Deviance Hearth Program is intended to be highly participatory. (3) Determine current practices in the community affecting child nutritional status. (4) Conduct a Positive Deviance Inquiry to identify wellnourished children in the community, and investigate the successful feeding and child care practices that their families use. (5) Use the information from the Positive Deviance Inquiry to design educational messages and menus for the Hearth sessions. (6) Conduct a series of Hearth sessions over 2 weeks. During these sessions, small groups of mothers with malnourished children meet in one of their homes with a volunteer facilitator. They jointly prepare a nutritious meal for their children using food they have contributed. (7) Regularly weigh all children to monitor their progress and make follow-up home visits. (8) Hearth sessions are repeated as necessary until children are rehabilitated. Although variations of this Positive Deviance Hearth program have been implemented in many countries, there have been no published systematic reviews of it. There have been a number of non-systematic reviews and working groups to identify successful practices from existing programs (Zeitlin et al. 1990; Nutrition Working Group, Child Survival Collaborations and Resources Group [CORE] 2002b; Schooley & Morales 2007). Methods Identification of studies As this is the first systematic review of the Positive Deviance Hearth program, a broad and inclusive approach to study sampling was used. Studies were identified in 20 databases, including CINAHL and MEDLINE, as well as grey literature from 26 sources including databases (e.g. Open System for Information on Gray Literature) and websites of organizations known to run programs (Appendix 1). The search was limited to articles published in English. There was no restriction on date of publication. The reference lists of all articles were reviewed to identify additional reports. The search term used for both peer reviewed studies and grey literature was Positive Deviance. Hearth was not included in the search term as some programs were only referred to as Positive Deviance rather than Positive Deviance Hearth. The search term Positive Deviance alone was able to identify programs titled Positive Deviance and Positive Deviance Hearth, and both were included in the review. Some very early programs were referred to only as Hearth programs, without the term Positive Deviance, even though they used a positive deviance approach. These studies were included in the review if they were identified through searches of reference lists. It was not practical to search databases for the term Hearth alone, as Hearth has multiple meanings, which gave very large number of search results with only a few relevant studies. To be included in the review, the study or report had to evaluate the effectiveness of a Positive Deviance Hearth Program for child malnutrition that used similar steps to the CORE manual (Nutrition Working Group, Child Survival Collaborations and Resources Group [CORE] 2002a, Nutrition Working Group, Child Survival Collaborations and Resources Group [CORE] 2002b). No limitations were placed on study design as long as the study reported on program outcomes such as nutrition status or behaviour changes. Qualitative, quantitative and mixed-methods studies were included. Study quality and data extraction Studies were identified by a single researcher, first by examining the title and then the abstract, or in the case of grey literature, the Executive Summary or the first page where the term Positive Deviance was mentioned. Data for all studies were extracted independently by two researchers onto a customized form. Initially, the intention was to use a previously validated quality appraisal checklist or form. However, the wide variation in report quality and study design in the grey literature made detailed checklists and appraisal forms impractical. As a result, a more basic form was developed that extracted high-level information on the study design, the completeness of the report sections on setting, population, intervention, study methodology and results, and whether any type of community participation was described for each step in the CORE process. Disagreements between the two researchers were resolved through discussion. Only a few such disagreements occurred, and almost all were because of one of the researchers overlooking a section of the report. This was particularly the case for grey literature reports, which tended to be long and included large amounts of content on other programs not relevant to this study. At the ª 2011 Blackwell Publishing Ltd 1355

3 beginning of the review process, there were a small number of differences in opinion when assessing the level of completeness of the reports. These were resolved by better defining what was required to rate the report section as complete. Because of variations in study design, quality and reporting, qualitative analysis rather than quantitative meta-analysis were used to draw conclusions on effectiveness. Although data were extracted by two researchers, results and analysis were interpreted only by the author. Results Selection of studies The search identified 267 peer reviewed articles and 611 grey literature documents containing the term Positive Deviance (Figure 1). Of these, 10 peer reviewed studies and 14 grey literature reports met the inclusion criteria. Many documents excluded at the first stage of the search applied the Positive Deviance philosophy to other public health issues and programs, such as Female Genital Mutilation, child protection, hospital acquired infections, HIV AIDS and cancer risk. Of those that were related to nutrition there were a large number of documents that described or mentioned the positive deviance approach in general terms, but did not report on the results of a positive deviance program. In some cases, a single Positive Deviance Hearth program had multiple studies and reports related to it. In total, 17 unique Positive Deviance Hearth programs were identified in 12 countries. Six of the 10 peer reviewed studies were on one program. The decision of what counted as a single program was based on the number of evaluation reports. For example, USAID funded five NGOs to implement the program in Indonesia using a standardized approach. A final evaluation covered the work of all five NGOs, and so, all were treated as part of one USAID program. One study in Bangladesh used the Positive Deviance approach to identify successful behaviours, but then used group peer education and individual counselling to disseminate the behaviours rather than a Hearth. While this program does not strictly adhere to the CORE manual, it was included in the review as one of only two randomized led trials (RCTs) identified. Study quality Table 1 summarizes the study designs used for each program. Nine of the programs, all grey literature reports, used a pre- and post-test design without a. Three used a non-randomized trial with a comparison group and two used an RCT. Three programs included a nonrandomized cross-sectional survey of younger siblings and a comparison group. These sibling studies involved identifying families who had previously had their elder children participate in the program. The studies compared the nutritional status of their younger siblings to similarly aged children who had not had an older sibling participate. The purpose of these studies was to determine whether the Positive Deviance Hearth program was able to prevent malnutrition as the mother applied the behaviours she had learnt to her next children. Nine programs included specific qualitative methods, mainly interviews and or focus groups with one or more stakeholder groups. In terms of study quality, only a small number of studies used highly rigorous designs with a group and only some of those used an appropriate matching strategy for selecting the group. However, nine programs used a combination of both qualitative and quantitative evaluation techniques, which improves validity and provides a more accurate picture of program effectiveness. In many cases, assessing the quality of the study was difficult because of the large variation in the completeness of reports. Only two reports, one peer reviewed and one grey literature, provided a complete description of the setting, population, intervention, study methodology and results. Seven reports had incomplete information in all of these areas. Community participation Only one program described community participation during all stages of the process (Maslowsky et al. 2008). All programs except one involved community members in the delivery of the Hearth sessions. However, community involvement in defining the problem, determining existing behaviours, identifying positive deviants and monitoring the program was usually either not reported or limited to the involvement of a small number of community volunteers or representatives. Quantitative results The outcome variables reported by studies varied widely and included weight gain, nutritional status, weight for age Z scores (WAZ), feeding practices, hygiene practices and breastfeeding rates. Even when the same outcome variable was used, such as nutritional status, the reference standards used to determine a child s status were often not reported. Some grey literature reports failed to report statistical significance. Because of the heterogeneity in outcome variables and report quality, a quantitative meta-analysis could not be performed. Table 2 summarizes the quantitative results from the more robust study designs. Table ª 2011 Blackwell Publishing Ltd

4 Peer reviewed journals Gray literature 231 excluded on the basis of title and abstract. Most common reasons: Study not related to child nutrition. Brief mention of positive deviance unrelated to a specific study. 267 potentially relevant on the basis of including the term positive deviance 611 potentially relevant on the basis of including the term positive deviance 473 excluded on the basis of a brief assessment. most common reasons: Program not related to child nutrition. Brief mention of positive deviance unrelated to a program. Insufficient detail to determine program methodology. 36 retrieved for further assessment 138 retrieved for further assessment 24 excluded: 12 formative research 7 general PD reviews/essays 3 preliminary or duplicate results 1 insufficient detail 1 other reason 119 excluded: 35 preliminary or duplicate results 22 program manual/description 8 could not be located 11 formative research 11 insufficient detail 9 outcome data not reported 19 general PD reviews/essays 4 other reason 12 studies included in data extraction 19 reports included in data extraction 2 excluded: 1 pilot study with full program evaluated in another report 1 pilot study with only process evaluation, no outcome data 5 excluded: 1 process evaluation 2 preliminary reports with full results in a later report 2 insufficient detail to complete majority of data extraction form 10 studies included in data extraction 14 reports included in data extraction Total of 24 studies/reports evaluating 17 unique Positive Deviance/Hearth programs (results for some programs were spread across multiple studies/reports.) Figure 1 Identification of positive deviance hearth studies and reports. shows the total number of studies with positive and negative results for each study design. All studies that used a pre- and post-test design without a showed that the malnourished children who participated in the program gained weight between day 0 and the end of the Hearth sessions. The amount of weight gained and the proportion of children rehabilitated varied significantly between and within programs. For example, the percentage of children gaining at least 400 g in 1 month in the USAID funded program in Indonesia range ª 2011 Blackwell Publishing Ltd 1357

5 Table 1 Positive Deviance Hearth studies and program evaluations included in the review Country Reference Reported timeframe Setting Study evaluation type Quantitative design Bangladesh* Parvanta et al Rural Mixed-methods Randomized led trial Vietnam Hendrickson et al. 2002; Marsh et al. 2002; Schroeder et al. 2002; Pachón et al. 2002; Sripaipan et al. 2002; Dickey et al Rural Haiti Bolles et al Rural Mixed-methods Randomized led trial Mixed-methods trial Haiti Burkhalter & Northrup Rural Mixed-methods trial India Sethi et al. 2007; Positive Deviance Initiative n.d. Indonesia McNulty & Pambudi Rural Various, including rural and peri-urban slums Rwanda Brackett Rural Vietnam Mackintosh et al. 2002; Sternin et al Afghanistan Save the Children n.d Rural Rural Quantitative trial Mixed-methods Pre- and post-test without cross-sectional survey of younger siblings and comparison group Mixed-methods Pre- and post-test without cross-sectional survey of younger siblings and comparison group Quantitative Pre- and post-test without cross-sectional survey of younger siblings and comparison group Mixed-methods Pre- and post-test without Qualitative methodology Source type Interviews with project staff, group leaders and small number of participants. Interviews on empowerment with program health volunteers and mothers in intervention and comparison communes. Peer reviewed Peer reviewed Follow-up survey of participant and non-participant mothers. Focus groups with participating mothers who had the largest and smallest weight gain children. Peer reviewed Grey literature N A Peer reviewed and grey literature Interviews with community leaders, volunteers, program staff, and other stakeholders. Grey literature Focus groups with program participants and healthcare workers. Grey literature N A Peer reviewed and grey literature Interviews with Community Health Council members, MCH Promoters, female volunteers, and caregivers Grey literature 1358 ª 2011 Blackwell Publishing Ltd

6 Table 1 (Continued) Country Reference Reported timeframe Setting Study evaluation type Quantitative design Qualitative methodology Source type Bangladesh Filoramo Rural Quantitative Pre- and post-test without Guinea Maslowsky et al India Jeevan Daan Maternal and Child Survival Program, Ahmedabad n.d. India Shibpur People s Care Organisation [SPCO] n.d Rural Mixed-methods Pre- and post-test without Urban slum Quantitative Pre- and post-test without Rural Quantitative Pre- and post-test without Madagascar Berggren Rural Mixed-methods Pre- and post-test without Nigeria USAID BASICS n.d Not described Quantitative Pre- and post-test without Tajikistan McNulty & Baboeva Rural Quantitative Pre- and post-test without Zambia Crespo et al Rural Quantitative Pre- and post-test without N A Grey literature Focus group discussions and individual interviews with a wide range of stakeholders. Grey literature N A Grey literature N A Grey literature Interviews with participating parents. Grey literature N A Grey literature N A Grey literature N A Grey literature *Program used group peer education and individual counselling to disseminate the behaviours rather than the Hearth approach. ª 2011 Blackwell Publishing Ltd 1359

7 Table 2 Quantitative results from randomized and non-randomized led trials and sibling studies of the positive deviance hearth program Country Reference Quantitative design Sample size Outcome variables Results Bangladesh* Parvanta et al Randomized led trial 432 mothers assigned to three treatment options: no intervention, group peer education and individual education. Self-reported feeding of vegetables to children under 2 years in the past 48 h, including quantity. Percentage of mothers who reported feeding any vegetables in past 48 h (P = 0.003): Individual education, 74%; Group peer education, 75%; Control, 58%. Vietnam Hendrickson et al. 2002; Marsh et al. 2002; Schroeder et al. 2002; Pachón et al. 2002; Sripaipan et al. 2002; Dickey et al Randomized led trial 120 children in six intervention communes. 120 children in six comparison communes. Nutrition status and mean WAZ measured every 2 months for 6 months, and then again at 12 months (Ministry of Health growth-monitoring charts used as reference standard) Children s food consumption in grams and proportion of children meeting daily energy requirements (kcal kg) based on 24 h dietary recall. Breastfeeding prevalence based on 24 h recall. Respiratory and diarrhoeal disease rates based on 14 day recall. Percentage of mothers who reported feeding recommended portion of green vegetables (P = 0.001): Individual education, 33%; Group peer education, 52%; Control, 17%. Children in the intervention communes did not show statistically significant better growth than comparison children. Intervention children who were younger (15 months or less) and more malnourished (less than 2 Z) at baseline, deteriorated less than comparable children in the comparison communes. Intervention children consumed more food per day and were more likely to meet their daily energy requirements than comparison children. There were no statistically significant differences for breastfeeding prevalence. Children in the intervention communes had approximately half the respiratory illness experienced by those in comparison communes (AOR = 0.5; P = 0.001). No statistically significant difference in diarrhoeal disease ª 2011 Blackwell Publishing Ltd

8 Table 2 (Continued) Country Reference Quantitative design Sample size Outcome variables Results Haiti Bolles et al trial Haiti Burkhalter & Northrup 1997 India Sethi et al. 2007; Positive Deviance Initiative n.d. trial trial 50 malnourished children participating in the program. 55 malnourished children in the comparison group. 192 malnourished children in the intervention group. 185 malnourished children in the group. 148 children in three intervention. 138 children in four comparison Percentage of children growing at or better than the international weight-for-age median rate at 1, 2 and 6 months after completing the program. Comparison group only measured at 1 month. Average WAZ gain from baseline to 12 months after completion of the program (reference standard not specified). Nutritional status 6 months after the implementation of the program (National Center for Health Statistics international reference standards). 1 month: Intervention, 68%; Comparison, 0%. 2 months: Intervention, 40%; Comparison, Not measured. 6 months: Intervention, 60%. Comparison, Not measured. No statistically significant differences between intervention and comparison group. Larger gains for mildly malnourished children were predicted when multivariate analysis was used to for confounders. Fewer intervention infants, as com pared to comparison infants in the, were underweight (42.9% vs. 53.7%), wasted (18.6% vs. 31.4%), and stunted (44.3% vs. 56.7%). Indonesia McNulty & Pambudi 2008 cross-sectional survey of younger siblings and comparison group Rwanda Brackett 2007 cross-sectional survey of younger siblings and comparison group 62 younger siblings from five intervention communities, three communities 128 children who had an older sibling participate in the program; 156 children who did not have an older sibling participate (comparison group) Mean weight gain from baseline to 6 months after implementation. Nutritional status of former participants and their younger siblings (WHO reference standards) Percentage of children with good nutritional status (>)2 WAZ) (WHO reference standards). Mean weight gain in intervention infants was 360 grams greater than comparison infants. Intervention: 22% moderate malnutrition, 9.8% severe malnutrition. Comparison: 43% moderate malnutrition, 9.5% severe malnutrition. (Statistically significant, p value not reported) Wasting was higher in the intervention than community. No significant difference between intervention and comparison groups. ª 2011 Blackwell Publishing Ltd 1361

9 Table 2 (Continued) Quantitative design Sample size Outcome variables Results Country Reference No statistically significant difference in WAZ of participant children compared to comparison group. Younger siblings of participant children had better WAZ compared to the comparison group: Age-adjusted mean WAZ 1.82 vs. 2.47, respectively, P < Age-adjusted mean WAZ of participant children and younger siblings measured 3 and 4 years after the end of the program in intervention and comparison communes (NCHS WHO CDC reference standards). 46 households in four intervention communes and 25 households one comparison commune. cross-sectional survey of younger siblings and comparison group Vietnam Mackintosh et al. 2002; Sternin et al Behaviours: Breastfeeding, meal frequency, snacking, hand washing, and healthcare seeking behaviours were all improved in the intervention community compared to the community. Behaviours of mothers in intervention and comparison communes 3 and 4 years after the end of the program. from 36 to 54% between NGOs and 21 92% between program sites (McNulty & Pambudi 2008). The results from these studies must be treated with caution in the context of a systematic review. While the study designs were appropriate for their intended use in the field, they have many internal threats to validity, which make them inappropriate for drawing overall conclusions on the effectiveness of the Positive Deviance Hearth approach. Of the three non-randomized trials, one reported a positive result: substantially fewer children in the intervention community suffered from underweight, wasting or stunting 6 months after program implementation; one reported a positive result 1 month after program implementation, and one reported no significant difference between the intervention and comparison groups, although multivariate analysis suggested that this may have been due to confounding effects. Sample sizes ranged from 50 to 192 children in the intervention group. Only one study had a clear matching strategy for the comparison group. Three studies used a non-randomized cross-sectional survey of younger siblings and a comparison group to assess the potential for the program to prevent malnutrition. Of these, two reported that younger siblings in the intervention group had substantially lower rates of malnutrition than the comparison group, although one of these studies also showed that wasting rates were higher in the intervention group. One reported no significant difference. One reported improvements in behavioural practices among mothers in the comparison group. All three studies matched the comparison communities on one or more variable. Sample sizes ranged from 46 to 128 children and four to five communities in the intervention group. Two studies used an RCT design and both used appropriate tests for statistical significance. One reported no statistically significant difference in terms of nutrition status, although intervention children who were younger (up to 15 months) and more malnourished (less than )2 Z) at baseline, deteriorated less than comparable children in the comparison communities. The study also showed a reduced rate of respiratory illness in the intervention group compared with the comparison group, but no difference in the rate of diarrhoeal disease. The sample size for the study was six intervention and six comparison communities. The other study did not measure nutritional status or weight as an outcome. Both studies showed statistically significant improvements in child feeding practices in the intervention group compared with the group. Qualitative results Studies using qualitative methods unanimously reported that the program was considered success by mothers and 1362 ª 2011 Blackwell Publishing Ltd

10 Table 3 Summary of positive deviance hearth program results by study design Type of study design Number of studies showing positive effect on nutrition and or associated behaviours Number of studies showing no effect on nutrition and or associated behaviours Randomized led trial (n = 2) 2* 0 trial (n = 3) 2 1 cross-sectional survey of younger 2 1 siblings and comparison group (n = 3) Pre- and post-test without (n = 9) 9 0 *One study reported no statistically significant difference in terms of nutrition status, although younger and more malnourished intervention children deteriorated less than comparison children and there were improvements in feeding behaviours. program staff. Most also reported a high level of community enthusiasm and engagement. The managers of the program in Gujarat, India, said it was the most popular program being run by Integrated Child Development Services (Jeevan Daan Maternal and Child Survival Program, Ahmedabad n.d.). Some studies reported that participant mothers were sharing the information they had learnt with their neighbours. In the Indonesian program, this appeared to be more common in rural rather than urban areas (McNulty & Pambudi 2008). Both mothers and fathers reported visible improvements in the children who participated in the program: they were more active, looked healthier and were cleaner (Burkhalter & Northrup 1997; Berggren 2004; Maslowsky et al. 2008). This visible change appeared to motivate the mothers and volunteers to continue with the program. One study found that mothers in the intervention group reported a greater increase in empowerment than comparison mothers (Hendrickson et al. 2002). Discussion Overall, this study shows mixed results in terms of Positive Deviance Hearth program effectiveness. The nine studies that used a pre- and post-test design without a cannot be used to draw definitive conclusions because of the study design, although they do show a wide range in rehabilitation rates between programs and sites. Of the seven more robust study designs that measured nutritional outcomes, five reported some type of positive result in terms of nutritional status, although not always as dramatic as hoped. Both the two RCTs reported improvements in feeding behaviour, and two of three sibling studies reported positive results for nutrition status and behaviour change in younger siblings up to 3 4 years after the mothers and older siblings participated in the program. This is encouraging as it suggests that the program may have a role in preventing malnutrition, not just rehabilitation. More studies are needed to confirm the sibling effect. The qualitative results suggest that the program is both feasible and acceptable to communities in a range of developing country settings both urban and rural. The conclusions that could be drawn from this study are limited by the small number of studies using robust designs, the small sample sizes in most studies, inconsistent reporting of results. The results may also have been affected by publication bias if researchers and practitioners chose not to publish studies showing negative results. Many reports did not state the reference standards used or report results of statistical tests. This prevented a metaanalysis being conducted as part of this review. Future studies should seek to report results using the WHO reference standards and relevant statistical tests. The grey literature search clearly enhanced the results of this review. If the review had been limited to peer reviewed studies, only four programs would have been identified and two of them would only have partial results. With grey literature included 17 programs were identified. Although many of the grey literature reports had variable quality and used a pre- and post-test design without a, some used more robust designs including non-randomized trials and sibling studies. These reports contributed substantially to the results and suggest that including grey literature in reviews of other practical field programs may be beneficial. Programs were included if they followed steps similar to those outlined in the CORE manual, which includes community participation (Nutrition Working Group, Child Survival Collaborations and Resources Group [CORE] 2002a, Nutrition Working Group, Child Survival Collaborations and Resources Group [CORE] 2002b). While most programs involved community members in the implementation of the Hearth sessions, community participation in the other program steps was rarely reported or was superficial and limited to a small number of community volunteers or representatives. Future research should investigate how important the depth of community participation is for program effectiveness. ª 2011 Blackwell Publishing Ltd 1363

11 The large number of programs screened for inclusion clearly demonstrates that many NGOs and governments are currently using the Positive Deviance Hearth program. More research using larger sample sizes, more rigorous designs and longer timeframes is required. Program managers should be encouraged to use robust designs to evaluate their programs and to report their results in high quality peer reviewed or grey literature reports, using standard outcome measures. Acknowledgement Paul Bullen. References Berggren G (2004). Report on positive deviance hearth workshop in Benin. Available at: projects/benin_west_africa_workshop_2004.pdf Accessed 19th December [Accessed 28 January 2011]. Bolles K, Speraw C, Berggren G & Lafontant JG (2002) Ti Foyer (hearth) community-based nutrition activities informed by the positive deviance approach in Leogane, Haiti: a programmatic description. Food and Nutrition Bulletin 23(4 Suppl), Brackett C (2007) Malnutrition Interventions in Developing Nations: strengths and Weaknesses of the Positive Deviance Hearth Program in Rural Rwanda. California State University, Fullerton. Burkhalter BR & Northrup RS (1997). Hearth program at the hôpital Albert Schweitzer in Haiti. In: Hearth Nutrition Model: Applications in Haiti, Vietnam, and Bangladesh (ed. O Wollinka, E Keeley, BR Burkhalter & N Bashir) Published for the U.S. Agency for International Development and World Relief Corporation by the Basic Support for Institutionalizing Child Survival (BASICS) Project, Arlington, pp Available at: PNACA868.pdf [Accessed 28 Jan 2011]. Crespo R, Boswell C, Klick R & Summer A (2008). Third annual midterm evaluation report: the salvation army Zambia Chikankata child survival project. Available at: usaid.gov/pdf_docs/pdacm961.pdf [Accessed 19 December 2010]. Dickey VC, Pachón H, Marsh DR et al. (2002) Implementation of nutrition education and rehabilitation programs (NERPs) in Viet Nam. Food and Nutrition Bulletin 23(4 Suppl), Filoramo L (1997). Initiation of the Shishu Kabar program in Southwestern Bangladesh. In: Hearth Nutrition Model: Applications in Haiti, Vietnam, and Bangladesh (ed. O Wollinka, E Keeley, BR Burkhalter & N Bashir) Published for the U.S. Agency for International Development and World Relief Corporation by the Basic Support for Institutionalizing Child Survival (BASICS) Project, Arlington, pp Available at: [Accessed 28 January 2011]. Hendrickson JL, Dearden K, Pachón H, An NH, Schroeder DG & Marsh DR (2002) Empowerment in rural Viet Nam: exploring changes in mothers and health volunteers in the context of an integrated nutrition project. Food and Nutrition Bulletin 23(4 Suppl), Jeevan Daan Maternal and Child Survival Program, Ahmedabad (n.d.) Available at: NGOs_working_in_slums_using_PD-HEARTH.pdf [Accessed 19 December 2010]. Mackintosh U, Marsh D & Schroeder D (2002) Sustained positive deviant child care practices and their effects on child growth in Viet Nam. Food and Nutrition Bulletin 23(4 Suppl), Marsh D, Pachón H, Schroeder D et al. (2002) Design of a prospective, randomized evaluation of an integrated nutrition program in rural Viet Nam. Food and Nutrition Bulletin 23(4 Suppl), Maslowsky S, Sidibé S & Traoré BB (2008) The success of the hearth model in Guinea. Africare Food Security Review 12. Available at: ASFRintro.php#paper12 [Accessed 19 December 2010]. McNulty J & Baboeva G (2007). Save the children final evaluation report: Zarafshan partnerships. Available at: usaid.gov/pdf_docs/pdack740.pdf [Accessed 19 December 2010]. McNulty J & Pambudi ES (2008). Report of the Pos Gizi assessment: suggestions for expanding the approach in Indonesia. Available at: Report_for_DEPKES_FINAL.pdf [Accessed 19 December 2010]. Nutrition Working Group, Child Survival Collaborations and Resources Group [CORE] (2002a). Positive deviance hearth: a resource guide for sustainably rehabilitating malnourished children. Available at: PNADG191.pdf [Accessed 3 January 2011]. Nutrition Working Group, Child Survival Collaborations and Resources Group [CORE] (2002b). Positive deviance hearth for nutrition technical advisory group meeting. Washington, DC. December Available at: pdf/publications/core.pdf [Accessed 3 January 2011]. Pachón H, Schroeder DG, Marsh DR, Dearden KA, Ha TT & Lang TT (2002) Effect of an integrated child nutrition intervention on the complementary food intake of young children in rural north Viet Nam. Food and Nutrition Bulletin 23(4 Suppl), Parvanta CF, Thomas KK & Zaman KS (2007) Changing nutrition behavior in Bangladesh: successful adaptation of new theories and anthropological methods. Ecology of Food and Nutrition 46, DOI: / Pascale R, Sternin J & Sternin M (2010) The Power of Positive Deviance. Harvard Business Press, Boston, MA. Peace Corps (2008). Hearth nutrition guide. Available at: [Accessed 3 January 2011]. Positive Deviance Initiative (2010). History. Available at: [Accessed 19 December 2010] ª 2011 Blackwell Publishing Ltd

12 Positive Deviance Initiative (n.d.). PD hearth project in Uttar Pradesh, India urban health resource center. Available at: [Accessed 19 December 2010]. Save the Children (n.d.). Final evaluation provincial strengthening in Northern Afghanistan: capacity building and innovation to support the basic package of health services and sustainably improve access, quality and use of essential MCH services throughout Jawzjan province. Available at: pdf_docs/pdacm809.pdf [Accessed 22 December 2010]. Schooley J & Morales L (2007) Learning from the community to improve maternal child health and nutrition: the positive deviance hearth approach. Journal of Midwifery and Women s Health, 52, DOI: /j.jmwh Schroeder DG, Pachón H, Dearden KA, Ha TT, Lang TT & Marsh DR (2002) An integrated child nutrition intervention improved growth of younger, more malnourished children in northern Viet Nam. Food and Nutrition Bulletin 23, Sethi V, Kashyap S, Aggarwal S, Pandey R & Kondal D (2007) Positive deviance determinants in young infants in rural Uttar Pradesh. Indian Journal of Pediatrics 74, Shibpur People s Care Organisation [SPCO] (n.d.). Progress report of the Banchete Shekhar process (PD) five years ( ). Available at: FIVE_YEARS_PROGRESS_REPORT_SPCO_.pdf [Accessed 19 December 2010]. Sripaipan T, Schroeder DG, Marsh DR et al. (2002) Effect of an integrated nutrition program on child morbidity due to respiratory infection and diarrhea in northern Viet Nam. Food and Nutrition Bulletin 23(4 Suppl), Sternin M, Sternin J & Marsh DL (1997). Rapid, sustained childhood malnutrition alleviation through a positive-deviance approach in Rural Vietnam: preliminary findings. In: Hearth Nutrition Model: Applications in Haiti, Vietnam, and Bangladesh (ed. O Wollinka, E Keeley, BR Burkhalter & N Bashir) Published for the U.S. Agency for International Development and World Relief Corporation by the Basic Support for Institutionalizing Child Survival (BASICS) Project, Arlington, pp Available at: PNACA868.pdf [Accessed 28 January 2011]. Sternin M, Sternin J & Marsh D (1998). Designing a communitybased nutrition program using the hearth model and the positive deviance approach a field guide for save the children. Available at: [Accessed 3 January 2011]. United Nations (2010). The millennium development goals report. Available at: MDG%20Report%202010%20En%20r15%20-low% 20res% %20-.pdf#page=13 [Accessed 3 January 2011]. United Nations Children s Fund [UNICEF] (2009). Tracking progress on child and maternal nutrition: a survival and development priority. Available at: publications/files/tracking_progress_on_child_and_maternal_ Nutrition_EN_ pdf [Accessed 3 January 2011]. USAID BASICS (n.d.). Improving child health in Nigeria: basics III. Available at: BASICSNigeriaFinalReport.pdf [Accessed 19 December 2010]. Wishik SM. & Van Der Vynckt S (1976) The use of nutritional positive deviants to identify approaches for modification of dietary practices. American Journal of Public Health 66, Wollinka O, Keeley E, Burkhalter BR & Bashir N, eds (1997) Hearth nutrition model: applications in Haiti, Vietnam, and Bangladesh. Published for the U.S. Agency for International Development and World Relief Corporation by the Basic Support for Institutionalizing Child Survival (BASICS) Project. Arlington, VA. Available at: usaid.gov/pdf_docs/pnaca868.pdf [Accessed 28 January 2011]. Zeitlin M, Ghassemi H & Mansour M (1990) Positive Deviance in Child Nutrition: With Emphasis on Psychosocial and Behavioral Aspects and Implications for Development. The United Nations University, Tokyo. Available at: [Accessed 19 December 2010]. Appendix 1: Databases and grey literature sources searched Peer reviewed journal databases searched Academic Search Complete CINAHL Plus with Full Text Communications & Mass Media Complete MEDLINE Political Science Complete ProQuest Central ProQuest Health and Medical Complete ProQuest Nursing & Allied Health ProQuest Psychology Journals ProQuest Research Library ProQuest Science Journals ProQuest Social Science Journals PsycARTICLES ª 2011 Blackwell Publishing Ltd 1365

13 Appendix 1: (Continued) Peer reviewed journal databases searched PsycINFO ResearchNow SAGE Health Sciences SAGE Social Science & Humanities Science Direct SocIndex with Full Text Web of Science Grey literature sources searched: BASICS CARE Caritas International Copac National, Academic, and Specialist Library Catalogue CORE Group Family Health International Networked Digital Library of Theses and Dissertations Open System for Information on Grey Literature (SIGL) OXFAM PLAN International Positive Deviance Initiative Positive Deviance Project Canada Positive Deviance Resource Center ProQuest Dissertations and Theses Save the Children The Australian Government s overseas aid program (AusAID) The British Library Integrated Catalogue, which includes the index of conference proceedings The Plexus Institute The Power of Positive Deviance book (Pascale et al. 2010). UK Department for International Development (DFID) UNICEF United Nations University United States Agency for International Development (USAID) Walden University Library Catalogue World Health Organization World Vision Corresponding Author Piroska A. Bisits Bullen, No.104, Street 472, Phnom Penh, Cambodia. Tel.: ; s: piroska.bisits-bullen@waldenu.edu, u.want.piroska@gmail.com 1366 ª 2011 Blackwell Publishing Ltd