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 Table of Contents  
Year : 2019  |  Volume : 6  |  Issue : 4  |  Page : 222-228

Impact of the positive deviance approach on breastfeeding practices among tribal pregnant women: A before – After intervention study

1 Department of Community Medicine, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
2 Department of Community Medicine, IGMC, Nagpur, Maharashtra, India
3 Department of Community Medicine, Lokmanya Tilak Municipal Medical College, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, Maharashtra, India

Date of Submission18-Dec-2018
Date of Decision26-May-2019
Date of Acceptance25-Jun-2019
Date of Web Publication21-Nov-2019

Correspondence Address:
Sudip Bhattacharya
C5/12, HIHT Campus, Dehradun, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_165_18

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Introduction: Breastfeeding is very important for the infant and for the mother. Breastfeeding practices in India and abroad are not up to the mark, and they pose serious health risk to the mothers and the babies. Methodology: This single-group before–after intervention study was conducted to assess the impact of positive deviance (PD) approach on knowledge about exclusive breastfeeding (EBF) practices among tribal pregnant women. The sample size was 376. Data were collected using convenient sampling method. At first, we identified eight positive deviants from that area. They were trained by the investigator regarding EBF practices. They were also motivated to share their knowledge and practices in the community. Results: It was observed that knowledge regarding initiation of breastfeeding (<1 h of birth) increased from 181 (52.2%) to (67.1%) among 347 study participants. Only 81 (23.3%) knew that breastfeeding should be on demand before intervention, which increased by 21% after the intervention. The majority of the study participants, i.e., 286 (82.4%) knew the advantages of breast milk. The proportion of study participants who knew that breastfeeding should not be stopped during mother's illness was 171 (49.3%) before and 229 (66%) after intervention. Before intervention, around one-fourth, that is, 85 (24.5%), knew that if the mother is not producing enough milk, then she should visit a health center which increased to 130 (37.5%) after intervention. The majority of the participants, i.e., 145 (41.8%) knew that bottle feeding should not be done for the babies which increased in proportion to around 55% after intervention. A statistically significant (P < 0.001) increase in knowledge was observed. Conclusion: It is possible to increase the awareness and practice level among the lactating mothers for EBF using the positive deviant approach. Recommendation: The concept of PD approach can be further popularized as they can strengthen our existing health system for better health outcomes in future.

Keywords: Exclusive breastfeeding, intervention study, positive deviance

How to cite this article:
Srivastava A, Gwande K, Bhattacharya S, Singh VK. Impact of the positive deviance approach on breastfeeding practices among tribal pregnant women: A before – After intervention study. CHRISMED J Health Res 2019;6:222-8

How to cite this URL:
Srivastava A, Gwande K, Bhattacharya S, Singh VK. Impact of the positive deviance approach on breastfeeding practices among tribal pregnant women: A before – After intervention study. CHRISMED J Health Res [serial online] 2019 [cited 2021 Mar 6];6:222-8. Available from: https://www.cjhr.org/text.asp?2019/6/4/222/271329

  Introduction Top

For improvement in the state of maternal and child health, the WHO and UNICEF emphasize on the first 1000 days of life beginning with woman's pregnancy and lasting till the child's second birthday. This period offers a unique window of opportunity to build healthy mother-child duo through nutritional interventions.[1]

One important component of nutritional intervention after birth is breastfeeding practices. These are affected by various factors and can be classified into six groups, namely healthcare related, sociodemographic, psychosocial, cultural, community, and policy related. A shorter duration of breastfeeding has been documented as one of the most common reasons for malnutrition in infants. It is attributed to many factors, for example, insufficient milk production, higher socioeconomic status, the influence of paternal education, cultural differences, and working mothers.[2]

A change in behavior of mothers is needed to address this issue. This can play an important role in breastfeeding practice.[3],[4]

Behavior change is of primary importance in low-and-middle-income countries like India where expenditure on health and its interventions are low. The key question in such research is how to predict and modify the adoption and maintenance of health behaviors.[5],[6],[7]

Even though many well-established benefits of exclusive breastfeeding (EBF) are known, sufficient practices do not exist globally. According to the National Family Health Survey-3 (2005–2006), only 46% of children between the age group of 0 and 23 months are breastfed. According to the Rapid Survey on Children (2013–2014), only 44.6% of children between 0 and 23 months of age are breastfed immediately within an hour of birth, and 64.9% of infants between 0 and 5 of age months are exclusively breastfed. Since breastfeeding is a social behavior and not a medical practice, the involvement of the health system for promotion, support, and protection of breastfeeding is different.[8]

Positive deviance (PD) approach is helpful in improving feeding practices focuses on changing behaviors of those who directly (caregivers) or indirectly (extended family members, community members) influence child nutritional status.[7],[8],[9]

PD is based on the observation that in every community there are certain individuals or groups whose uncommon behaviors and strategies enable them to find better solutions to problems than their peers, while having access to the same resources and facing similar or worse challenges.[10],[11]

However, the approach has important limitations. It can only be used to change behavior – not, for example, as a substitute for government aid or vaccines. It requires a high degree of motivation and commitment. Moreover, it is by definition restricted to what is already being done; it excludes brilliant strategies that nobody has tried.[12],[13],[14],[15],[16]

  Methodology Top

This study was conducted to assess the effect of PD approach on knowledge about EBF among the study participants.

It was conducted in the field practice area under Rural Health Training Centre attached to the Department of Community Medicine of a Tertiary Care Municipal Hospital with a population of 8000. Most of the population were tribal, and the main tribes were Varli, Thakur, and Katkari. The study was conceptualized and formulated with the finalization of the study protocol design over 4 months from October 2014 to January 2015. The study protocol was submitted to the Institutional Ethics Committee and its approval was obtained, following which data collection was done over 1 year from March 2015 to March 2016.

Our sample size was calculated using the following method:

Estimating a population proportion with specified absolute precision:

  1. Anticipated population proportion P = 61% (42)
  2. Confidence level: 100 (1−α) = 95%

  3. q = 100−−p = 100 − 61 = 39

  4. Absolute precision required on either side of the proportion (in percentage points) d = 5.

Sample size = n = (Z 1−a/2)2 × p (1−p)/d2

n = (1.96)2 × 61 × 39/25 = 365

However, we took 376 participants to compensate the dropouts.

Pregnant women in the study area were our sampling unit and we used a convenient sampling method. Mixed methods were used (focus group discussion and survey).

Mothers residing in the local area who were willing to participate were included, and mothers who dropped out any time from initiation to 6 months after delivery due to any reason were excluded from the study. Interested mothers residing in the study area who were motivated to practice EBF were included as positive deviants.

During preintervention data collection, subjects who uncommon behaviors (positive deviants) had related to the problems faced during breastfeeding were identified. For example, one of the problems which emerged out after content analysis of focus group discussion was that several mothers do not get privacy at their homes. One of the mothers told us that she used to hide her chest and the baby's body with her “chunni” to overcome this problem. Another mother told us that she will face the wall of the room and breastfeed her child. These mothers were identified as positive deviants and were separated during the process of data collection. A total of eight positive deviants were found in the study area.

Positive deviant mothers were called to the nearby health center and were trained for 2 days by the chief investigator on various aspects of breastfeeding such as latching technique, duration, and benefits of colostrum with the help of a flip chart. Positive deviants were encouraged and motivated to share their knowledge and talk about their deviant behaviors to others so that others can also practice those behaviors to overcome the obstacles confronted in their day-to-day life related to breastfeeding. The investigator helped positive deviants to share whatever they knew and whatever they used to practice. Postintervention data were collected for 347 participants as 29 mothers, who took part during preintervention data collection and were lost to follow-up after intervention due to various reasons, were excluded from the comparative data analysis. Of those 29 mothers, 1 mother had stillbirth, 1 early neonatal death, 2 mothers had abortion, and the remaining 24 mothers were not traceable because of the reasons including not found at home after two visits of follow-up of the subjects [Figure 1]. Some study participants returned back to their in-laws' house or their parents' house. The results were presented for their knowledge, attitude, and practices [Table 1].
Figure 1: Methods used for data collection

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Table 1: Knowledge of breastfeeding among the study participants pre- and post-intervention (n=347)

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Quantitative data were analyzed using MS Excel 2007 and Open-Epi software version 3 (Centers for Disease Control and Prevention, Atlanta, USA). The socio-demographic profile and preintervention data were analyzed for 376 participants. The knowledge of the study participants was analyzed using proportions and McNemar's test of significance for paired binary data. For the test to be applicable, preintervention data of only those 347 participants were used whose postintervention data were as available. Hence, the sample size came to be 347. McNemar's test was applied for each individual question of knowledge, and the association was found between before and after intervention data. It was applied at an alpha level of 0.05. Value of P ≤ 0.05 was considered as statistically significant. The scoring system is given with the questionnaire.

The same questionnaire was used for collecting pre- and post-intervention data about breastfeeding. Questions which were based on knowledge of breastfeeding were assigned correct response/s and incorrect response/s; a score of “1” for correct response and “0” for incorrect. The responses were matched before and after intervention, and McNemar's test was applied, which is based on paired binary dichotomous data. A 2 × 2 table for the questions was constructed for pre- and post-data collected.

Ethical approval

The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

  Results Top

Demographic details are described in [Table 2]. There were 224 (59.6%) primigravida and 152 (40.4%) multigravida mothers before intervention. During the postintervention phase, 29 participants were lost to follow-up; a total of 347 participants were left, in which 199 (57.3%) were primigravida, whereas 148 (42.7%) were multigravida mothers. Before intervention, 211 (60.8%) study participants had correct knowledge about the duration of EBF which increased to 237 (68.2%) after intervention.
Table 2: Association between different variables and exclusive breastfeeding practices

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The knowledge of EBF among the study participants is described in [Table 1]. It was observed that knowledge regarding initiation of breastfeeding (<1 h of birth) increased from 181 (52.2%) to (67.1%) among 347 study participants. Around 70% of the study participants had knowledge of colostrum before and after intervention. Only 81 (23.3%) knew breastfeeding should be on demand before intervention which increased by 21% after the intervention. The majority of the study participants, i.e., 286 (82.4%), knew the advantages of breast milk. Only 91 (26.2%) knew that home-based food is more nutritious compared with commercial weaning food which increased to 162 (46.7%) after intervention. Before intervention, 201 (57.9%) of the participants knew that prelacteal feed should not be given, and after intervention, this proportion increased to 228 (65.7%). Sitting with back support (to the baby) is the correct body posture while breastfeeding was known to 155 (44.7%) participants before intervention, whereas 201 (57.9%) knew after intervention.

Similarly, 160 (46.1%) knew correct latching position before intervention and the proportion of which increased to 216 (62.2%) after intervention.

Around 75% of the participants knew that complimentary feeding should be started after 6 months before and after intervention. The proportion of study participants who knew that breastfeeding should not be stopped during mother's illness was 171 (49.3%) before and 229 (66%) after intervention.

Before intervention, around one-fourth, i.e., 85 (24.5%), knew that if a mother is not producing enough milk, then she should visit a health center, which increased to 130 (37.5%) after intervention. Before intervention, 211 (60.8%) study participants knew that a mother should take extra food during lactation which increased by 11% after intervention (71.2%). The majority of the participants, i.e., 145 (41.8%), knew that bottle feeding should not be done for the babies which increased to around 55% after intervention.

On analyzing [Table 3], it is seen that there was a significant increase (P < 0.001) in the overall knowledge of breastfeeding in the participants.
Table 3: Association between knowledge of breastfeeding pre- and post-intervention

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  Discussion Top

Breastfeeding is very important for the child and the mother. Breastfeeding not only prevents the child from various complications but also it prevents the mother from breast cancer. Breastfeeding practices in India and abroad are not up to the mark which pose serious health risks to the mothers and the babies.

Most of the studies conducted globally regarding breastfeeding practices are cross-sectional. Usually, those studies recommend that health workers should work to increase mothers' awareness. This study was unique because we did an interventional study for increasing awareness by the help of positive deviants in that community.

In this study, an overall increase in knowledge was found in study participants after intervention. Knowledge regarding initiation increased from 52.2% to 67.1% after intervention. Regarding the duration of EBF, there was an increment of 7% (from 61% to 68%).

In a study, it was documented that 81.2% of mothers had knowledge about benefits of breastfeeding.[17] In another study conducted among college girls of Ludhiana, it was seen that 35% of participants had average knowledge, 28% had below average knowledge, whereas 14% and 23% of girls had good and excellent knowledge about EBF, respectively.[18]

In another quasi-experimental study, among 200 primigravida in a maternity hospital, a statistically significant difference was observed between knowledge scores of two groups after applying a planned health education tool.[19]

In this study, 65.7% of mothers followed EBF for 6 months; nearly 60% of mothers initiated breastfeeding within 1 h of delivery, and 69% of mothers gave colostrum to their babies.

In a cross-sectional study, it was found that 67.4% of mothers were practicing breastfeeding exclusively, which was similar to our study; around 35.1% of mothers initiated breastfeeding within 1 h of birth and 84.8% of mothers gave colostrum to their babies. It was also found in 38.6% of cases that breastfeeding was done when the baby cried, and in our study 56.1% of mothers were feeding on demand of the baby, that is, whenever the baby cried.[20]

In this study, the majority (72.8%) of study participants were in the age group of 21–30 years who were following EBF. About 40% of mothers (<18 years of age) practiced EBF. In another study, it was found that a majority (76.4%) of the study participants up to 25 years of age were practicing EBF. Nearly half (46.6%) of the study participants less 20 years of age were practicing EBF, and the difference was found statistically insignificant which is similar to our study. This similarity might be due to the fact that both studies were conducted in the same study area.[21]

In our study, of 173 mothers who completed their education up to secondary level, 122 (70.53%) were practicing EBF. Of 123 subjects with primary education level, 69.11% were practicing EBF. Among 46 illiterate subjects, 17 (36.96%) were practicing EBF.

  Conclusion Top

It is possible to increase the awareness and practice level among pregnant mothers for EBF using the positive deviant approach.


The following are the limitations of our study:

  1. The results of the study are based on the subjective responses
  2. Since the majority of the study participants were primigravida, EBF practices were studied only after intervention
  3. We cannot ignore the Hawthorne effect
  4. EBF practices of the subjects could have been determined in a better way if a longer period of follow of at least a year was done. Due to time constraints, this was not possible.


  1. The concept of PD provides an unconventional manner through which knowledge can be transformed into practices. Inhabitants of the community who because of their uncommon behavior are doing well can be identified by health workers (Anganwadi Workers, ASHA, Multi-Purpose Workers, etc.,) of that area who can be trained and motivated to share their intentions and viewpoint to other people in the community
  2. Incentives can be given to the health workers by local governing bodies to promote discovering more positive deviants from the community.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Office of Research-Innocenti. The First 1,000 Days of life: The Brain's Window of Opportunity. United Nations Children's Fund-Innocenti Research Centre. Available from: https://www.unicef-irc.org/article/958-the- first-1000-days-of-life-the-brains-window-of-opportunity.html. [Last accessed on 2018 Dec 05].  Back to cited text no. 1
Chudasama RK, Patel PC, Kavishwar AB. Determinants of exclusive breastfeeding in South Gujarat region of India. J Clin Med Res 2009;1:102-8.  Back to cited text no. 2
Grant C. Behaviour Change Approaches for Social Norms Regarding Gender. K4D Helpdesk Report. Brighton, UK: Institute of Development Studies; 2017.  Back to cited text no. 3
Kumar R, Bhattacharya S, Sharma N, Thiyagarajan A. Cultural competence in family practice and primary care setting. J Family Med Prim Care 2019;8:1-4.  Back to cited text no. 4
[PUBMED]  [Full text]  
Bhattacharya S, Singh A, Prakas K. Does stream of education affect the knowledge and attitude regarding breastfeeding among adolescent students? Indian J Community Health 2016;28:337-43. Available from: https://www.iapsmupuk.org/journal/index.php/IJCH/article/view/701. [Last accessed on 2019 May 26].  Back to cited text no. 5
Bhattacharya S, Sharma N, Singh A. Designing culturally acceptable screening for breast cancer through artificial intelligence-two case studies. J Family Med Prim Care 2019;8:760-2.  Back to cited text no. 6
[PUBMED]  [Full text]  
Bhattacharya S, Singh A. Using the concepts of positive deviance, diffusion of innovation and normal curve for planning family and community level health interventions. J Family Med Prim Care 2019;8:336-41.  Back to cited text no. 7
[PUBMED]  [Full text]  
Hoddinott J, Ahmed I, Ahmed A, Roy S. Behavior change communication activities improve infant and young child nutrition knowledge and practice of neighboring non-participants in a cluster-randomized trial in rural Bangladesh. PLoS One [Internet] 2017;12. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5479588/. [Last cited on 2019 Jun 29].  Back to cited text no. 8
US Agency for International Development. Behavior Change Interventions and Child Nutritional Status: Evidence from the Promotion of Improved Complementary Feeding Practices. US Agency for International Development; 2011.  Back to cited text no. 9
Black RE, Victora CG, Walker SP, Bhutta Z, Christian P, de Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle income countries. Lancet Maternal and Child Nutrition Series. Lancet 2013;382:427-51.  Back to cited text no. 10
Greenland K, Chipungu J, Curtis V, Schmidt WP, Siwale Z, Mudenda M, et al. Multiple behaviour change intervention for diarrhoea control in Lusaka, Zambia: A cluster randomised trial. Lancet Glob Health 2016;4:e966-77.  Back to cited text no. 11
Zeitlin MF, Ghassemi H, Mansour M. United Nations University, Programme JWNS. Positive Deviance in Child Nutrition: With Emphasis on Psychosocial and Behavioural Aspects and Implications for Development. Tokyo: Tokyo: United Nations University Press; 1990. Available from: http://apps.who.int/iris/handle/10665/39406 [Last accessed on 2018 Nov 12].  Back to cited text no. 12
Marsh DR, Schroeder DG, Dearden KA, Sternin J, Sternin M. The power of positive deviance. BMJ 2004;329:1177-9.  Back to cited text no. 13
Bisits Bullen PA. The positive deviance/hearth approach to reducing child malnutrition: Systematic review. Trop Med Int Health 2011;16:1354-66.  Back to cited text no. 14
Singhal A. Communicating what works! Applying the positive deviance approach in health communication. Health Commun 2010;25:605-6.  Back to cited text no. 15
Sreeramoju P, Dura L, Fernandez ME, Minhajuddin A, Simacek K, Fomby TB, et al. Using a Positive Deviance Approach to Influence the Culture of Patient Safety Related to Infection Prevention. Open Forum Infect Dis [Internet] 2018;5. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6166267/. [Last cited on 2019 Jun 29].  Back to cited text no. 16
Nigam R, Sinha U. Assessment of knowledge and attitude of antenatal mothers towards breastfeeding. Natl J Community Med 2012;3:381-4.  Back to cited text no. 17
Lata S, Kishore J, Barnabas S, Victor B. Knowledge and attitude regarding breastfeeding among college girls of a selected college of Ludhiana. J Nurs Sci Pract 2012;2:1-10.  Back to cited text no. 18
Shanthakumari K, Tamrakar A, Kotian M. Effectiveness of planned health education on ideal breastfeeding among primigravidae in a selected hospital at Mangalore, South Karnataka. Nurs Health Sci 2014;3:54-8.  Back to cited text no. 19
Bobhate PS, Shrivastava SR. Breastfeeding practices and factors associated with it: Across sectional study among tribal women in Khardi primary health centre, Thane, India. Int J Public Health Res 2012;2:115-21.  Back to cited text no. 20
Wadde SK, Vedpathak VL, Yadav VB. Breast feeding practices in rural mothers of Maharashtra. Int J Recent Trends Sci Technol 2011;1:115-9.  Back to cited text no. 21


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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