Positive deviance as a novel tool in malaria control and elimination: methodology, qualitative assessment and future potential

Abstract

Background: Positive deviance (PD) is an asset-based, community-driven approach to behaviour change that has successfully been applied to address many health and social problems. It is yet to have been assessed for malaria control but may represent a promising tool for malaria elimination given its suitability in targeting small and remote population groups, apparent sustainability and ability to instil a high amount of community mobilisation. Here, the PD methodology as applied to malaria is explained, with focus upon and qualitative assessment of a proof of concept study in Cambodia.

Methods: Three villages in Battambang, northwestern Cambodia were selected for the intervention, with an estimated population of 5036 including both residents and migrant workers. In August 2010, field teams conducted a 1 week PD process to sensitise and mobilise the community, establish normative behaviours in relation to malaria control and prevention, identify positive deviant behaviours from within the community, and identify PD volunteers. Until March 2011, PD volunteers were supported by field teams via monthly meetings to conduct activities in their respective communities to increase practice of PD behaviours. In February 2012, 1 year following the end of external support, evaluative interviews were conducted with community members to qualitatively assess community acceptance and interpretation of the PD intervention, perceived behaviour changes, and perceived positive outcomes.

Results: Qualitative data from focus group discussions and in-depth interviews showed that the PD approach was well-accepted into the communities and created a strong sense of community empowerment. Positive behaviour change was linked to the PD intervention, including greater usage of nets by forest goers, and use of public health facilities for malaria diagnosis and treatment. One year following the end of external assistance, PD volunteers were still conducting activities in their respective communities.

Conclusions: PD offers a promising tool in malaria control and elimination settings. Work is ongoing to quantitatively measure impact of PD on behaviours and malaria transmission and once gathered, national malaria control programmes should be encouraged to look at including PD as part of their national strategies. Feasibility of scale-up, cost-effectiveness, and applicability to other settings and diseases is also currently being explored.

Fig. 1

Map of Cambodia displaying province and district of study site

Fig. 2

Conceptual game played during community orientation meeting

Fig. 3

An IDI being held with a community member. Purposive and convenience sampling was used to ensure IDIs were held with individuals from different groups within the communities and to ensure gender balance

Fig. 4

Participatory analysis. Project staff and community members participated in joint analysis of the data from IDIs and FGDs to ensure validation of findings and community participation

Fig. 5

Sharing positive behaviours with the community

Fig. 6

Village malaria map created by PD volunteers. PD volunteers mapped houses in the village, the coverage of PD activities, and houses with confirmed and suspect malaria cases

Fig. 7

Community handover seminar. A symbolic handover of the project to the community to encourage them to continue the intervention without external help