Policy Innovations interviews Jerry Sternin of the Positive Deviance Initiative.
What is the origin of the term positive deviance (PD)?
The term has been around for several decades and had been used as a research tool. People have looked at poor kids who are well nourished despite their poverty and the factors that have enabled their families to have well-nourished children despite their poverty. They called these families "positive deviants."
What are your most recent projects?
In the last year we've been working with hospitals in the United States on the problem of Methicillin-resistant Staphylococcus aureus (MRSA). Hospital acquired infections such as MRSA kill 90 to 100,000 people a year. It seemed like an intractable problem, in that all hospitals have it. So we've been working with hospitals both in the Veterans' Administration System and six other hospitals under a grant from the Robert Wood Johnson Foundation to eliminate this terrible bug.
At the same time we are also working on advocating against the trafficking of girls and sex workers in Indonesia. We are working with communities that are very poor who see that as the only alternative. PD asks, "Does everyone who is poor do this, and the answer always is no."
Positive deviance says people are more likely to act their way into a new way of thinking than to think their way into a new way of acting. Can you give us some examples?
Thinking and knowing don't result in behavioral change. Knowledge simply doesn't change behavior. One of the greatest examples is in our MRSA project. The major cause of hospital-acquired infections is due to health care providers not washing their hands. Doctors and nurses have probably heard that it's a good idea to wash your hands, but that knowledge does not translate into practice or behavior change. With PD we focus on getting people to change their practice, which means to start with new practices, and acquiring new habits, and acting their way into a new way of thinking.
In the United States, the development paradigm is called KAP (knowledge, attitude, practice). It's based on the premise that if you change people's knowledge that changes their attitude and that changes their practice, but again that does not really work for behavior change. We know to exercise, not to smoke, etcetera, but it rarely results in behavior change. Positive Deviance reverses that paradigm to PAK. You start by enabling people to change their practice, which then changes their attitude, and ultimately they internalize new knowledge.
Part of the appeal of PD is that is it rests on the individuals in the community in which change is needed. But people can also be reluctant to relinquish old habits. How have you dealt with resistance to change?
It's difficult or virtually impossible to get people to change their habits. We can't get people to want to change their behavior. PD can't get people to change their behavior more than any other approach can. People need to want to change their behavior. PD creates a climate in which demonstrably successful solutions emerge within the community and are discovered by the very people whose behavior needs to change and it's they who decide to change their behavior.
The PD approach has a specific design that enables the community to create an opportunity to enable others to begin to practice those new behaviors. So the whole focus is on the fact that you can't empower people, you can't get people to change their behaviors, which is the problem with all unsuccessful behavior change attempts. People need to want to do something before it can happen.
People empower themselves. You can't empower somebody else.
This whole process begins with an invitation from somebody who is working with the community. The invitation is, "We have this serious problem that we are concerned about." And the first question is, "Is this something you'd like to do something about?" If the answer is "no," then goodbye.
PD observes that 90 percent don't do X, and that means that 10 percent do, and then asks is it that that 10 percent is richer, smarter—do they have more help? And when you ask that question, usually the community that has invited you in the first place thinks back and realizes that there are some folks who don't have any special resources who have already overcome the problem. Before we even come in as "experts" to try and solve the problem, there are some people in the community who already have the solution but it's just hidden from the rest of us.
People whose behavior needs to change are the ones who discover the solution that already exists within their system. For that reason, you don't get the best practice push back. "Best practices" evokes the immune system rejection response to a foreign body, and there is also a social immune system rejection response to outsiders coming in and saying: "Hey, look at the answer here. We have already solved the problem." With PD, the solution and the host in a sense share the same DNA, so you don't get that push back or rejection.
What other challenges do you often encounter?
The biggest challenge isn't from the villagers or the workers in the hospitals. The biggest challenge is for leaders to relinquish their power to enable others to find their own solutions. It's difficult for a doctor or a school principal—whose whole self-image is, "I'm the person who fixes things, who has solutions"—to relinquish that power and to really believe that they, the folk people, have the solutions. It's more of getting people who need to support the project to change their role and be willing to trade in their power for a different kind of power.
In the first hospital we worked with, which was the Pittsburgh Veteran's Administration, a year an a half ago when we had a kick-off meeting with 100 people, the question was asked, "Who in this room is responsible for infection control?" And everybody pointed to the four people who were called infection control specialists. About a month ago we had a meeting again with 128 people from the hospital and the same question was asked, and 128 hands went up. So it isn't that the people in charge of infection control are relinquishing their power but they are getting 128 people to help them with their job.
So the biggest challenge always is to get those people whose self-image is wrapped up in being the person who knows the answer to become the ones who know the questions.
In your experience when is PD most useful?
PD is most useful when you have something that feels like an intractable problem. That's where PD has its greatest power.
The best example (there's more information on this on our website) is the issue of female circumcision in Egypt. This is a 4000-year-old practice, from the time of the Pharaohs, with about a 90 percent prevalence rate. People ask, how you begin to dream about changing a 4000-year-old practice with 90 percent prevalence? But PD turns that question on its head and says: "Hold on. At his moment, you have between 300,000 to 500,000 women not carrying out this practice. They are the 10 percent that we should be looking at."
PD works best for seeming intractable problems that have not responded to other solutions, number one.
Number two: It's only useful when it's a problem whose solution requires behavior or social change. It's not about technical change. If you're trying to make a better vaccine, you would never use PD.
Bill Easterly has written about the flaws of aid and the difference between the "planners" working from the top down and the "seekers" looking for answers from the bottom up. Do you see a parallel in the work carried out by PD?
Generally that's absolutely what PD is about. PD says that the world's greatest expert on how to solve the problem of malnutrition despite poverty in this village is a poor woman who has a well-nourished kid. It's that the solution already exists within the community and that the world's experts on how to solve any problem are the people who live with the problem and have already solved it.
That's the key: somebody who is demonstrably successful and already solving it is obviously where we should be getting our wisdom from.
The only distinction I would make is that PD takes it one step beyond what Bill Easterly is saying, in that the job of that external seeker isn't to find the solution herself because then it is her discovery. Her job is to create the space in which the community itself discovers their own solution and then it is not the seekers solution. The seeker is still someone from the outside but that's a fine distinction.
How did PD move into the corporate sector?
I've written two articles in the Harvard Business Review talking about PD as a management tool. Based on those, as well as an article in Fast Company, a couple of years ago some corporate folks said, "Hey as we think about the tool, we also have positive deviance. We have 100 sales forces and the median for selling a product is 50 a day or a year. But when we look at that 50 that is the median, it belies the reality, which is that of those 100 sales forces 30 of them are selling 20, and 15 of them are selling 95. What's going on? And how do we amplify that positive deviance?"
Corporations have said that we have a huge problem with diversity in hiring. We know as a company that we have this problem, but one of our five units has 30% minorities and the other units have 5%.
It's the recognition that there is a bell curve that exists in every situation. And corporations have realized that PD is a tool to harvest and amplify the positive outliers, who usually aren't examined.
What general advice can you give to organizations?
At this very moment in your corporation there are those who are doing things differently in a positive sense. If you could just line up those arrows that are already pointing in the direction that you want to go, it's a tremendous resource. Don't be blinded by the tyranny of averages because it belies the reality of resources that at this very moment are there to be picked or amplified.
What lies ahead for PD?
Well, I don't know. We constantly get inquiries from people around the world but for different applications. What lies ahead I think is that this is perhaps reaching a tipping point. More and more people are becoming aware of the approach. When you think of it, it's just exquisitely simple. There are all of these people and groups out there with no special resources and the same barriers constraints who are succeeding. Wouldn't it be great if we could figure out what they are doing before anyone comes in and changes anything else—and learn how to amplify their success?