Impact of Positive Deviance Approach on Breastfeeding Practices Among Tribal Pregnant Women -A Before-After Intervention Study

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Impact of positive deviance approach on breastfeeding practices among tribal pregnant women -A before-after intervention study

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Original Article

Impact of the Positive Deviance Approach on Breastfeeding Practices among Tribal Pregnant Women: A Before – After Intervention Study

Abstract Abhay Srivastava, Introduction: Breastfeeding is very important for the infant and for the mother. Breastfeeding Kanchan Gwande1, practices in India and abroad are not up to the mark, and they pose serious health risk to the Sudip Bhattacharya, mothers and the babies. Methodology: This single‑group before–after intervention study was 2 conducted to assess the impact of positive deviance (PD) approach on knowledge about exclusive Vijay Kumar Singh breastfeeding (EBF) practices among tribal pregnant women. The sample size was 376. Data were Department of Community collected using convenient sampling method. At first, we identified eight positive deviants from that Medicine, Himalayan Institute of Medical Sciences, Dehradun, area. They were trained by the investigator regarding EBF practices. They were also motivated to Uttarakhand, 1Department of share their knowledge and practices in the community. Results: It was observed that knowledge Community Medicine, IGMC, regarding initiation of breastfeeding (<1 h of birth) increased from 181 (52.2%) to (67.1%) among Nagpur, 2Department of 347 study participants. Only 81 (23.3%) knew that breastfeeding should be on demand before Community Medicine, Lokmanya intervention, which increased by 21% after the intervention. The majority of the study participants, Tilak Municipal Medical i.e., 286 (82.4%) knew the advantages of breast milk. The proportion of study participants who College, Lokmanya Tilak knew that breastfeeding should not be stopped during mother’s illness was 171 (49.3%) before Municipal General Hospital, and 229 (66%) after intervention. Before intervention, around one‑fourth, that is, 85 (24.5%), Sion, Mumbai, Maharashtra, India 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

Introduction attributed to many factors, for example, insufficient milk production, higher For improvement in the state of maternal socioeconomic status, the influence of and child health, the WHO and UNICEF paternal education, cultural differences, and emphasize on the first 1000 days of life working mothers.[2] beginning with woman’s pregnancy and lasting till the child’s second birthday. A change in behavior of mothers is needed This period offers a unique window of to address this issue. This can play an Submission: 18-Dec-18 opportunity to build healthy mother‑child important role in breastfeeding practice.[3,4] Revised : 26-May-19 [1] Accepted : 25-Jun-19 duo through nutritional interventions. Behavior change is of primary importance One important component of nutritional in low‑and‑middle‑income countries like intervention after birth is breastfeeding India where expenditure on health and its Address for correspondence: Dr. Sudip Bhattacharya, practices. These are affected by various interventions are low. The key question in C5/12, HIHT Campus, factors and can be classified into six such research is how to predict and modify Dehradun, Uttarakhand, India. groups, namely healthcare related, the adoption and maintenance of health E‑mail: [email protected] sociodemographic, psychosocial, cultural, behaviors.[5‑7] community, and policy related. A shorter Even though many well‑established Access this article online duration of breastfeeding has been benefits of exclusive breastfeeding (EBF) Website: www.cjhr.org documented as one of the most common are known, sufficient practices do not reasons for malnutrition in infants. It is exist globally. According to the National DOI: 10.4103/cjhr.cjhr_165_18 Quick Response Code: This is an open access journal, and articles are Family Health Survey‑3 (2005–2006), distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows How to cite this article: Srivastava A, Gwande K, others to remix, tweak, and build upon the work non‑commercially, Bhattacharya S, Singh VK. Impact of the positive as long as appropriate credit is given and the new creations are deviance approach on breastfeeding practices among licensed under the identical terms. tribal pregnant women: A before – After intervention For reprints contact: [email protected] study. CHRISMED J Health Res 2019;6:222-8.

Srivastava, et al.: Positive deviance approach on breastfeeding practices

only 46% of children between the age group of 0 and However, we took 376 participants to compensate the 23 months are breastfed. According to the Rapid Survey dropouts. on Children (2013–2014), only 44.6% of children between Pregnant women in the study area were our sampling 0 and 23 months of age are breastfed immediately within an unit and we used a convenient sampling method. Mixed hour of birth, and 64.9% of infants between 0 and 5 of age methods were used (focus group discussion and survey). months are exclusively breastfed. Since breastfeeding is a social behavior and not a medical practice, the involvement Mothers residing in the local area who were willing to of the health system for promotion, support, and protection participate were included, and mothers who dropped out of breastfeeding is different.[8] any time from initiation to 6 months after delivery due to any reason were excluded from the study. Interested Positive deviance (PD) approach is helpful in improving mothers residing in the study area who were motivated to feeding practices focuses on changing behaviors of those practice EBF were included as positive deviants. who directly (caregivers) or indirectly (extended family members, community members) influence child nutritional During preintervention data collection, subjects who status.[7‑9] uncommon behaviors (positive deviants) had related to the problems faced during breastfeeding were identified. PD is based on the observation that in every community For example, one of the problems which emerged out there are certain individuals or groups whose uncommon after content analysis of focus group discussion was that behaviors and strategies enable them to find better solutions several mothers do not get privacy at their homes. One to problems than their peers, while having access to the of the mothers told us that she used to hide her chest [10,11] same resources and facing similar or worse challenges. and the baby’s body with her “chunni” to overcome this However, the approach has important limitations. It can problem. Another mother told us that she will face the wall only be used to change behavior – not, for example, as of the room and breastfeed her child. These mothers were a substitute for government aid or vaccines. It requires a identified as positive deviants and were separated during high degree of motivation and commitment. Moreover, it the process of data collection. A total of eight positive is by definition restricted to what is already being done; it deviants were found in the study area. [12‑16] excludes brilliant strategies that nobody has tried. Positive deviant mothers were called to the nearby health center and were trained for 2 days by the chief investigator Methodology on various aspects of breastfeeding such as latching This study was conducted to assess the effect of PD technique, duration, and benefits of colostrum with the approach on knowledge about EBF among the study help of a flip chart. Positive deviants were encouraged and participants. motivated to share their knowledge and talk about their deviant behaviors to others so that others can also practice It was conducted in the field practice area under Rural those behaviors to overcome the obstacles confronted Health Training Centre attached to the Department of in their day‑to‑day life related to breastfeeding. The Community Medicine of a Tertiary Care Municipal investigator helped positive deviants to share whatever they Hospital with a population of 8000. Most of the population knew and whatever they used to practice. Postintervention were tribal, and the main tribes were Varli, Thakur, and data were collected for 347 participants as 29 mothers, who Katkari. The study was conceptualized and formulated with took part during preintervention data collection and were the finalization of the study protocol design over 4 months lost to follow‑up after intervention due to various reasons, from October 2014 to January 2015. The study protocol were excluded from the comparative data analysis. Of those was submitted to the Institutional Ethics Committee and 29 mothers, 1 mother had stillbirth, 1 early neonatal death, its approval was obtained, following which data collection 2 mothers had abortion, and the remaining 24 mothers was done over 1 year from March 2015 to March 2016. were not traceable because of the reasons including Our sample size was calculated using the following not found at home after two visits of follow‑up of the method: subjects [Figure 1]. Some study participants returned back to their in‑laws’ house or their parents’ house. The results Estimating a population proportion with specified absolute were presented for their knowledge, attitude, and practices precision: [Table 1]. a. Anticipated population proportion P = 61% (42) b. Confidence level: 100 (1−α) = 95% Quantitative data were analyzed using MS Excel q = 100−−p = 100 − 61 = 39 2007 and Open‑Epi software version 3 (Centers for c. Absolute precision required on either side of the Disease Control and Prevention, Atlanta, USA). The proportion (in percentage points) d = 5. socio‑demographic profile and preintervention data were analyzed for 376 participants. The knowledge of the study Sample size = n = (Z1−a/2)2 × p (1−p)/d2 participants was analyzed using proportions and McNemar’s n = (1.96)2 × 61 × 39/25 = 365 test of significance for paired binary data. For the test to be

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Table 1: Knowledge of breastfeeding among the study participants pre‑ and post‑intervention (n=347) Question Subjects, frequency (%) Comments Preintervention Postintervention Knows that initiation of breastfeeding is within 1 h 181 (52.2) 233 (67.1) Increase Knows exclusive breastfeeding is for 6 months 211 (60.8) 237 (68.2) Increase Knows colostrums should be given 235 (67.7) 250 (72.0) Increase Knows breastfeeding should be on demand 81 (23.3) 153 (44.1) Increase Knows the advantages of breast milk 286 (82.4) 308 (88.8) Increase Knows home based food is more nutritious compared to commercial 91 (26.2) 162 (46.7) Increase weaning food Knows prelacteal feed should not be given 201 (57.9) 228 (65.7) Increase Knows the correct body position of baby while breastfeeding 155 (44.7) 201 (57.9) Increase Knows the correct latching position 160 (46.1) 216 (62.2) Increase Knows that complimentary feeding should be started after 6 months 255 (73.5) 268 (77.2) Increase Knows breastfeeding should not be stopped during mothers’ illness 171 (49.3) 229 (66.0) Increase Knows that a mother should visit a health center if not producing 85 (24.5) 130 (37.5) Increase adequate milk Mother should take extra food during lactation 211 (60.8) 247 (71.2) Increase Bottle feeding should not be done for the babies 145 (41.8) 189 (54.5) Increase

Ethical approval 2 FGDs with 8 participants The permission was taken from Institutional Ethics each Committee prior to starting the project. All procedures performed in studies involving human participants Pre-Intervention 29 patients lost data collection were in accordance with the ethical standards of the to follow up n = 376 • One early institutional and/or national research committee and with neonatal death the 1964 Helsinki declaration and its later amendments or • One still birth • 2 Abortions comparable ethical standards. • 25 not found at n = 347 place after Results 2 home visits Demographic details are described in Table 2. There were 224 (59.6%) primigravida and 152 (40.4%) multigravida Post-Intervention data collection mothers before intervention. During the postintervention n = 347 phase, 29 participants were lost to follow‑up; a total of 347 participants were left, in which 199 (57.3%) were Figure 1: Methods used for data collection primigravida, whereas 148 (42.7%) were multigravida mothers. Before intervention, 211 (60.8%) study applicable, preintervention data of only those 347 participants participants had correct knowledge about the duration of were used whose postintervention data were as available. EBF which increased to 237 (68.2%) after intervention. Hence, the sample size came to be 347. McNemar’s test was applied for each individual question of knowledge, and the The knowledge of EBF among the study participants is association was found between before and after intervention described in Table 1. It was observed that knowledge data. It was applied at an alpha level of 0.05. Value of regarding initiation of breastfeeding (<1 h of birth) P ≤ 0.05 was considered as statistically significant. The increased from 181 (52.2%) to (67.1%) among 347 study scoring system is given with the questionnaire. participants. Around 70% of the study participants had knowledge of colostrum before and after intervention. Only The same questionnaire was used for collecting pre‑ and 81 (23.3%) knew breastfeeding should be on demand before post‑intervention data about breastfeeding. Questions intervention which increased by 21% after the intervention. which were based on knowledge of breastfeeding were The majority of the study participants, i.e., 286 (82.4%), assigned correct response/s and incorrect response/s; knew the advantages of breast milk. Only 91 (26.2%) knew a score of “1” for correct response and “0” for that home‑based food is more nutritious compared with incorrect. The responses were matched before and after commercial weaning food which increased to 162 (46.7%) intervention, and McNemar’s test was applied, which is after intervention. Before intervention, 201 (57.9%) of based on paired binary dichotomous data. A 2 × 2 table the participants knew that prelacteal feed should not be for the questions was constructed for pre‑ and post‑data given, and after intervention, this proportion increased to collected. 228 (65.7%). Sitting with back support (to the baby) is

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Table 2: Association between different variables and intervention. The proportion of study participants who exclusive breastfeeding practices knew that breastfeeding should not be stopped during Breastfeeding practices Total mother’s illness was 171 (49.3%) before and 229 (66%) Yes (%) No (%) after intervention. Age Before intervention, around one‑fourth, i.e., 85 (24.5%), <18 4 (40) 6 (60) 10 knew that if a mother is not producing enough milk, 19‑20 48 (71.65) 19 (28.35) 67 then she should visit a health center, which increased 21‑30 166 (65.09) 89 (34.91) 255 to 130 (37.5%) after intervention. Before intervention, 31‑40 10 (66.67) 5 (33.33) 15 211 (60.8%) study participants knew that a mother should Total 228 (65.71) 119 (34.29) 347 take extra food during lactation which increased by 11% 2 χ , Df, P 4.028, 3, 0.2584 after intervention (71.2%). The majority of the participants, Education level i.e., 145 (41.8%), knew that bottle feeding should not be Illiterate 17 (36.96) 29 (63.04) 46 done for the babies which increased to around 55% after Primary 85 (69.11) 38 (30.89) 123 intervention. Secondary 122 (70.53) 51 (29.47) 173 Higher secondary and above 4 (80) 1 (20) 5 On analyzing Table 3, it is seen that there was a significant Total 228 (65.71) 119 (34.29) 347 increase (P < 0.001) in the overall knowledge of χ2, Df, P 19.74, 3, 0.0001 breastfeeding in the participants. SES Upper class 2 (100) 0 (0.00) 2 Discussion Upper middle class 79 (73.84) 28 (26.16) 107 Breastfeeding is very important for the child and the Middle class 46 (56.09) 36 (43.91) 82 mother. Breastfeeding not only prevents the child from Lower middle class 87 (67.45) 42 (32.55) 129 various complications but also it prevents the mother from Lower class 14 (51.85) 13 (48.15) 27 breast cancer. Breastfeeding practices in India and abroad Total 228 (65.71) 119 (34.29) 347 are not up to the mark which pose serious health risks to χ2, Df, P 10.01, 4, 0.04 the mothers and the babies. Occupation Housewife 207 (71.13) 84 (28.87) 291 Most of the studies conducted globally regarding Semi‑skilled worker 3 (21.42) 11 (78.58) 14 breastfeeding practices are cross‑sectional. Usually, those Skilled worker 5 (55.56) 4 (44.44) 9 studies recommend that health workers should work to Unskilled worker 11 (61.11) 7 (38.89) 18 increase mothers’ awareness. This study was unique because Clerk, shop owner, and farm owner 2 (13.33) 13 (86.67) 15 we did an interventional study for increasing awareness by Total 228 119 347 the help of positive deviants in that community. χ2, Df, P 34.82, 4, 0.0000005 Type of family In this study, an overall increase in knowledge was found in Nuclear 116 (57.71) 85 (42.28) 201 study participants after intervention. Knowledge regarding Joint 108 (76.59) 33 (23.40) 141 initiation increased from 52.2% to 67.1% after intervention. Extended 4 (80) 1 (20) 5 Regarding the duration of EBF, there was an increment of Total 228 (65.70) 119 (34.29) 347 7% (from 61% to 68%). 2 χ , Df, P 13.57, 2, 0.0011 In a study, it was documented that 81.2% of mothers had Gravidity knowledge about benefits of breastfeeding.[17] In another Primigravida 127 (63.81) 72 (36.18) 199 study conducted among college girls of Ludhiana, it was Multigravida 101 (68.24) 47 (31.75) 148 seen that 35% of participants had average knowledge, 28% Total 228 (65.70) 119 (34.29) 347 had below average knowledge, whereas 14% and 23% 2 χ , Df, P 5.785, 1, 0.016 of girls had good and excellent knowledge about EBF, SES: Socioeconomic status respectively.[18] the correct body posture while breastfeeding was known In another quasi‑experimental study, among to 155 (44.7%) participants before intervention, whereas 200 primigravida in a maternity hospital, a statistically 201 (57.9%) knew after intervention. significant difference was observed between knowledge scores of two groups after applying a planned health Similarly, 160 (46.1%) knew correct latching position education tool.[19] before intervention and the proportion of which increased In this study, 65.7% of mothers followed EBF for to 216 (62.2%) after intervention. 6 months; nearly 60% of mothers initiated breastfeeding Around 75% of the participants knew that complimentary within 1 h of delivery, and 69% of mothers gave colostrum feeding should be started after 6 months before and after to their babies.

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Table 3: Association between knowledge of breastfeeding pre‑ and post‑intervention Question Subjects Comments After Knows that initiation of Before Response Correct Incorrect <0.0001 breastfeeding is within 1 h Correct 179 2 Incorrect 54 112 Knows exclusive breastfeeding Before Response Correct Incorrect <0.0001 is for 6 months Correct 207 4 Incorrect 30 106 Knows colostrum should be Before Response Correct Incorrect 0.0093 given Correct 228 7 Incorrect 22 90 Knows breastfeeding should be Before Response Correct Incorrect <0.0001 on demand Correct 81 0 Incorrect 72 194 Knows the advantages of breast Before Response Correct Incorrect <0.0001 milk Correct 284 2 Incorrect 24 37 Knows home based food is Before Response Correct Incorrect <0.0001 more nutritious compared to Correct 86 5 commercial weaning food Incorrect 76 180 Knows prelacteal feed should Before Response Correct Incorrect <0.0001 not be given Correct 201 0 Incorrect 27 119 Knows the correct Before Response Correct Incorrect body position of baby while Correct 154 1 <0.0001 breastfeeding Incorrect 47 145 Knows the correct latching Before Response Correct Incorrect <0.0001 position Correct 160 0 Incorrect 56 131 Know that complimentary Before Response Correct Incorrect 0.0019 feeding should be started after 6 Correct 254 1 months Incorrect 14 78 Knows breastfeeding should Before Response Correct Incorrect <0.0001 not be stopped during mothers’ Correct 169 2 illness Incorrect 60 116 Knows that a mother should visit Before Response Correct Incorrect <0.0001 a health centre if not producing Correct 85 0 adequate milk Incorrect 45 217 Mother should take extra food Before Response Correct Incorrect <0.0001 during lactation Correct 211 0 Incorrect 36 100 Bottle feeding should not be Before Response Correct Incorrect <0.0001 done for the babies Correct 145 0 Incorrect 44 158

In a cross‑sectional study, it was found that 67.4% of In this study, the majority (72.8%) of study participants mothers were practicing breastfeeding exclusively, which were in the age group of 21–30 years who were following was similar to our study; around 35.1% of mothers EBF. About 40% of mothers (<18 years of age) practiced initiated breastfeeding within 1 h of birth and 84.8% of EBF. In another study, it was found that a majority (76.4%) of the study participants up to 25 years of age were mothers gave colostrum to their babies. It was also found practicing EBF. Nearly half (46.6%) of the study in 38.6% of cases that breastfeeding was done when the participants less 20 years of age were practicing EBF, and baby cried, and in our study 56.1% of mothers were the difference was found statistically insignificant which is feeding on demand of the baby, that is, whenever the baby similar to our study. This similarity might be due to the fact cried.[20] that both studies were conducted in the same study area.[21]

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In our study, of 173 mothers who completed their education unicef-irc.org/article/958-the-first-1000-days-of-life-the-brains- up to secondary level, 122 (70.53%) were practicing EBF. window-of-opportunity.html. [Last accessed on 2018 Dec 05]. Of 123 subjects with primary education level, 69.11% were 2. Chudasama RK, Patel PC, Kavishwar AB. Determinants of practicing EBF. Among 46 illiterate subjects, 17 (36.96%) exclusive breastfeeding in South Gujarat region of India. J Clin Med Res 2009;1:102‑8. were practicing EBF. 3. Grant C. Behaviour Change Approaches for Social Norms Regarding Gender. K4D Helpdesk Report. Brighton, UK: Conclusion Institute of Development Studies; 2017. It is possible to increase the awareness and practice level 4. Kumar R, Bhattacharya S, Sharma N, Thiyagarajan A. Cultural among pregnant mothers for EBF using the positive deviant competence in family practice and primary care setting. J Family Med Prim Care 2019;8:1‑4. approach. 5. Bhattacharya S, Singh A, Prakas K. Does stream of education Limitations affect the knowledge and attitude regarding breastfeeding among adolescent students? Indian J Community Health 2016;28:337‑43. The following are the limitations of our study: Available from: https://www.iapsmupuk.org/journal/index.php/ 1. The results of the study are based on the subjective IJCH/article/view/701. [Last accessed on 2019 May 26]. responses 6. Bhattacharya S, Sharma N, Singh A. Designing culturally acceptable 2. Since the majority of the study participants were screening for breast cancer through artificial intelligence‑two case primigravida, EBF practices were studied only after studies. J Family Med Prim Care 2019;8:760‑2. intervention 7. Bhattacharya S, Singh A. Using the concepts of positive deviance, diffusion of innovation and normal curve for planning 3. We cannot ignore the Hawthorne effect family and community level health interventions. J Family Med 4. EBF practices of the subjects could have been Prim Care 2019;8:336‑41. determined in a better way if a longer period of follow 8. Hoddinott J, Ahmed I, Ahmed A, Roy S. Behavior change of at least a year was done. Due to time constraints, this communication activities improve infant and young child was not possible. nutrition knowledge and practice of neighboring non-participants in a cluster-randomized trial in rural Bangladesh. PLoS One Recommendations [Internet] 2017;12. Available from: https://www.ncbi.nlm.nih. gov/pmc/articles/PMC5479588/. [Last cited on 2019 Jun 29]. 1. The concept of PD provides an unconventional manner 9. US Agency for International Development. Behavior Change through which knowledge can be transformed into Interventions and Child Nutritional Status: Evidence from the practices. Inhabitants of the community who because Promotion of Improved Complementary Feeding Practices. US of their uncommon behavior are doing well can be Agency for International Development; 2011. identified by health workers (Anganwadi Workers, 10. Black RE, Victora CG, Walker SP, Bhutta Z, Christian P, de ASHA, Multi‑Purpose Workers, etc.,) of that area who Onis M, et al. Maternal and child undernutrition and overweight can be trained and motivated to share their intentions in low-income and middle income countries. Lancet Maternal and viewpoint to other people in the community and Child Nutrition Series. Lancet 2013;382:427-51. 11. Greenland K, Chipungu J, Curtis V, Schmidt WP, Siwale Z, 2. Incentives can be given to the health workers by local Mudenda M, et al. Multiple behaviour change intervention for governing bodies to promote discovering more positive diarrhoea control in Lusaka, Zambia: A cluster randomised trial. deviants from the community. Lancet Glob Health 2016;4:e966‑77. Declaration of patient consent 12. Zeitlin MF, Ghassemi H, Mansour M. 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Financial support and sponsorship 15. Singhal A. Communicating what works! Applying the positive Nil. deviance approach in health communication. Health Commun 2010;25:605‑6. Conflicts of interest 16. Sreeramoju P, Dura L, Fernandez ME, Minhajuddin A, Simacek K, There are no conflicts of interest. 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 References from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6166267/. 1. Office of Research-Innocenti. The First 1,000 Days of life: The [Last cited on 2019 Jun 29]. Brain’s Window of Opportunity. United Nations Children’s 17. Nigam R, Sinha U. Assessment of knowledge and attitude of Fund-Innocenti Research Centre. Available from: https://www. antenatal mothers towards breastfeeding. Natl J Community Med

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2012;3:381‑4. 20. Bobhate PS, Shrivastava SR. Breastfeeding practices and factors 18. Lata S, Kishore J, Barnabas S, Victor B. Knowledge and attitude associated with it: Across sectional study among tribal women in regarding breastfeeding among college girls of a selected college Khardi primary health centre, Thane, India. Int J Public Health of Ludhiana. J Nurs Sci Pract 2012;2:1‑10. Res 2012;2:115‑21. 19. Shanthakumari K, Tamrakar A, Kotian M. Effectiveness of planned health education on ideal breastfeeding among 21. Wadde SK, Vedpathak VL, Yadav VB. Breast feeding practices primigravidae in a selected hospital at Mangalore, South in rural mothers of Maharashtra. Int J Recent Trends Sci Technol Karnataka. Nurs Health Sci 2014;3:54‑8. 2011;1:115‑9.

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